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 joint symptoms.
• Promotional materials at strategic locations
• Appropriately targeted community initiatives
• SEO of web hub

Diagnose clinically without investigation with clear history of injury mechanism and presentation of symptoms. Ensure patient asked about speed of knee swelling, any ‘pop or snapping’ sensation, giving way or locking post trauma. Confirm with objective assessment. Tests can be false negative due to apprehension and muscle guarding.

Symptoms of pain can be localised in collateral ligament injury or more diffuse

True mechanical symptoms involve joint instability due to ligament laxity - particularly associated with ACL injury

Primary care

Patient presents to primary care with knee ligament injury
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. Refer to MSK web hub for lifestyle advice.
• Refer to MSK web hub section on managing a soft tissue injury

Pharmacological management
Optimise medication management

Radiology:
X-ray not required prior to referral unless there is history of acute injury when a fracture is suspected.

If patient presents with signs and symptoms of clear knee ligament instabilty or possible significant injury following acute trauma REFER DIRECTLY TO SECONDARY CARE ORTHOPAEDIC ACUTE KNEE INJURY CLINIC and don't delay by asking for any radiology

Condition management:
MSK serviceconsider self management for minor injury through MSK web resources before referral

Complex condition management:
Refer to MSK ESP team or in cases of diagnostic uncertainty
 

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 Physiotherapy
Ensure thorough assessment of mechanism of injury, history and knee ligament stability. Seek senior physiotherapy clinician/ESP opinion if unstable knee.

• education and reassurance acute soft tissue management
• advice supported by web hub content
• exercise management and rehabilitation through 1:1 or gym classes
   

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 lower limb presentations or advanced disability.

Investigations

• Plain film x ray of knee - AP, lateral and skyline views
• Consider MRI if mechanical symptoms and/or ligament instability on assessment.
• Assurance of optimised conservative management:
  • To ensure conservative management pathways have been fully optimised for patients with knee ligament injury including: medication, exercise, pacing, and lifestyle factors AND ensure expectations have been discussed.
• Support decision making:
  • Support patients in their decision making as to whether to proceed with appropriate surgery. Refer appropriately (either direct to List or orthopeadic opinion) to secondary care.

Onward referral options (following MSK physiotherapy):

Medication management: refer to primary care team if medication optimisation required.

Complex condition management: refer to MSK ESP team in cases of diagnostic uncertainty, or significant disabiltiy, or if orthopaedic referral needs to be considered.

If patient presents with signs and symptoms of clear knee ligament instabilty following acute injury arrange referral to secondary care orthopaedic acute knee injury clinic.
 

Onward referral options (following MSK extended scope practitioner):

Medication management: refer to primary care team if medication optimisation required.

Condition management: refer to MSK Physiotherapy team.

Orthopaedics: direct to list/ outpatient opinion to specialist knee surgeon.