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

None provided

Most common clinical presentation is 1st extensor compartment tendinopathy (Dequervain’s) however other common presentations include extensor carpi ulnaris tendinopathy (6 th extensor compartment), and intersection syndrome (2nd and 3rd extensor compartments).

Trigger finger/thumb presentations usually respond well to relative rest/ splinting/ corticosteroid injection. Consider rheumatiological involvement where patient is presenting with multiple triggers in hands.
 

Primary care

Patient presents to primary care with wrist and hand tendon problem

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 wrist and Hand tendon pages
• For trigger finger advise relative rest .

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 corticosteroid injection for Dequervains or trigger finger if appropriately skilled to offer
   

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 Dequervains tenosynovitis or trigger finger appropriate splinting modalities should be trialled prior to considering injection therapy.
• Landmark guided corticosteroid injection may be considered as part of a package of care.

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 wrist and hand tendon pathology i.e. medication, exercise, pacing, and lifestyle factors AND ensure expectations have been discussed.

Extended Scope treatment options:
Consider role of ultrasound guided injection

Onward referral options (following primary care)

• X-ray not required prior to referral
• Understand/manage expectations prior to referral- what are the goals of onward referral?
• Physiotherapy: patients will be offered 1:1 physiotherapy intervention.
• 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 / ultrasound guided injection required: 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.
• Orthopaedic management: Referral for release of A1 pulley in recalcitrent trigger finger cases.