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 and presentation of symptoms. Ensure patient asked about site of pain, pattern of symptoms, neurological features and nature of aggravating factors. Confirm with objective assessment.

Primary care:

Patient presents to primary care with Heel 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. Refer to MSK web hub for lifestyle advice.
• Refer to MSK web hub section on managing plantar fasiitis
• Ensure patient wearing appropriate footwear

Pharmacological management
Optimise medication management

Radiology:
Imaging not required prior to referral unless medical differentials need to be considered
 

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

• Educate regarding nature of condition, discuss self directed management strategies / activity modification and rest.
• Medication management: refer to primary care team if medication optimisation required.
• Specific soft tissue stretches to calf complex and plantar fascia
• Consider concurrent podiatry/orthotic referral if biomechanical factors are a contributing factor
   

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
Consider MRI or USS if failed conservative treatment or diagnostic uncertainty

Assurance of optimised conservative management:
To ensure conservative management pathways have been fully optimised for patients with plantar fasciitis 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/orthopaedic input. Refer appropriately (either direct to List or orthopeadic opinion) to secondary care.

Onward referral options (following primary care)

• MSK service- consider self management through MSK web resources before referral for 3 months
• Consider referral to physiotherapy
• Consider referral to community podiatry biomechanics department if patient previously had physiotherapy intervention
• Complex condition management: Refer to MSK ESP team or in cases of diagnostic uncertainty

Onward referral options (following MSK physiotherapy)

• If failed conservative management options consider referral for shock wave therapy to Clifton park Hospital physiotherapy department
• Complex condition management: refer to MSK ESP team in cases of diagnostic uncertainty, or significant disabiltiy, or if orthopaedic referral needs to be considered.

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: outpatient opinion to specialist foot and ankle surgeon.