HNY Policy and Pathway Repository - York

MSK and CCG co-working on public health

• Media campaign promoting positive lifestyle change and MSK health and role of regular activity for low grade tendon symptoms.
• Promotional materials at strategic locations
• Appropriately targeted community initiatives particularly in relation to work related upper limb disorders (WRULD)
• SEO of web hub

Diagnose clinically without investigation if a person

• Is 40 or over AND Has activity related elbow pain AND Has no restriction of flexion/extension AND no morning stiffness OR morning stiffness that persists for >30 minutes
• No history of trauma
• Symptoms are located over the common flexor or common extensor origin

Primary care

Patient presents to primary care with elbow tendon pain

Primary care team to optimise pre MSK management using the MSK web hub for patient education and management or alternative offline resources.

Non - pharmacological management strategies:

• Check BMI/ smoking/ exercise status:
• If lifestyle factors highlighted discuss as risk factors for MSK ill health/ tendon pain.
• Refer to MSK web hub for lifestyle advice.
• Recommend relative rest if acute onset.
• Refer to MSK tenis elbow/ golfers elbow pages

Pharmacological management

• For acute onset or chronic presentations where there is evidence of ongoing inflammation (e.g. night pain) consider NSAIDs + PPI or topical NSAIDS
• Consider a corticosteroid injection only in conjunction with other treatment e.g physiotherapy as a corticosteroid injection will not on its own resolve the patients tendon dysfunction.
• Exercise caution if considering a second corticosteroid injection- evidence exists that suggests repeated injection may be linked to persistent symptoms.
   

MSK physiotherapy

Physiotherapy team to assist primary care in management of patients where web hub information and primary care strategies have not helped, where patients have self referred, or where patient is experiencing flair up.

All patients regardless of access point should have a discussion of expectations and functional goals to support planned management pathway.

1:1 treatment:

• Should include patient education on tendinopathy, and lifestyle factors that can contribute to tendon disorders. Activity modification strategies and a review of working practices should be included where a Work Related Upper Limb Disorder (WRULD) is suspected.
• For patients with clinically suspected medial or lateral epicondylitis management should consist of a progressive eccentric loading program over a minimum period of 3 months AND provision of an epiclasp
• Landmark guided corticosteroid injection may be considered as part of a package of care, although the evidence base suggests caution in ofering this treatment for this condition.
   

MSK extended scope practitioner

To support primary care and physiotherapy teams in managment and diagnosis of complex case presentations. To support patients in their decisions regarding surgery and ensure alternative treatment options have been explored and optimised.

Diagnostic uncertainty:

• to utilise clinical skills and experience supported by diagnostic imaging and procedures to propose a primary diagnosis or diagnoses for patients with complex upper limbpresentations or advanced disability.

Assurance of optimised conservative management:

• To ensure conservative management pathways have been fully optimised for patients with elbow tendon pain: medication, exercise, pacing, and lifestyle factors AND ensure expectations have been discussed.

Extended Scope treatment options:

• Consider role of ultrasound guided injection
• Consider role of shockwave therapy for recalcitrent tendinopathy.
• Consider role of PRP injection

 

Onward referral options (following primary care):

• X-ray not required prior to referral unless diagnostic uncertainty
• Understand/manage expectations prior to referral- what are the goals of onward referral?
• Physiotherapy: patients will be offered 1:1 physiotherapy intervention.
• Patients should trial at least 6 months of conservative treatments (specifically exercise based therapies) prior to consideration of secondary treatment options i.e PRP/ shockwave.
• Referrals for secondary interventions to be initiated by ESP team following clinical review.
   

Onward referral options (following MSK physiotherapy):

• Medication management: refer to primary care team or Physio independent prescriber if medication optimisation required.
• Lifestyle management: Consider local referral options- smoking cessation, weight management, HEAL programme, water based exercise oppertunities.
• Complex condition management/ failure to respond to treatment: refer to MSK ESP team in cases of diagnostic uncertainty,or if guided injection, or secondary care management is to be considered
   

Onward referral options (following MSK extended scope practitioner):

• Medication management: refer to primary care team or Physio independent prescriber if medication optimisation Condition management: refer to MSK Physiotherapy team.
• Lifestyle management: Consider local referral options- smoking cessation, weight management, HEAL programme.
• Shockwave therapy: refer to CTC physiotherapy department.
• PRP refer to Simon Boyle at tertiary centre with PRP capability.