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 subacromial pain/ rotator cuff disorder clinically without investigation if a person

• Is 40 or over AND Has activity related shoulder pain AND Has no restriction of lateral rotation AND no morning stiffness OR morning stiffness that persists for >30 minutes
• No history of trauma
• Symptoms are located in the upper arm, not the AC joint or trapezius muscle.
• Increasing incidence of degenerative rotator cuff pathology (i.e degenerative tears) with increasing age. Cuff tears associated with more pronounced weakness and night pain cf. sub-acromial pain syndrome.

Primary care

Patient presents to primary care with subacromial pain/ rotator cuff disorder.

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 Subacromial pain or rotator cuff 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
• Only consider subacromial corticosteroid injection (not joint or supraspinatus muscle) in conjunction with physiotherapy referral as high recurrence rate in cases only managed with injection.
• Exercise caution in offering repeated subacromial injection where degenerative rotator cuff tear is suspected.

Radiology

• X-ray not required prior to referral unless there has been signficant trauma and a fracture is suspected
• If there is a history of previous calcific tendinitis please refer these urgently and state this on the referral.
• ULTRASOUND IS NOT COMMISSIONED FOR PRIMARY CARE ACCESS AS THE MSK AND RADIOLOGISTS DO RECOMMENDED IT AT THIS STAGE.
   

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 subacromial pain core treatment should consist of a progressive eccentric loading program over a minimum period of 3 months AND exercise based symptom modification procedures.
• For patients with clinically suspected degenerative rotator cuff syndrome the Moon Group01. Protocol should be followed. Consider if this can be delivered in a cohort environment.
• Landmark guided subacromial injection may be considered as part of a package of care.

Class based management: The moon Group Protocol
Patients with suspected degenerative rotator cuff tears should be offered exercise based management in line with the moon group protocol in the first instance due to the high level of efficacy of this approach at satisfactorily settling symptoms over 6 months. Class based input should be offered for up to 3 months wiith the option of further monitoring on a monthly basis up to 6 months.
 

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 subacromial pain and rotator cuff disorders: medication, exercise, pacing, and lifestyle factors AND ensure expectations have been discussed.

Extended Scope treatment options:
Consider role of ultrasound guided procedures including Subacromial/subdeltoid bursa injection, barbotage for calcific tendinopathy.

Consider role of shockwave therapy for recalcitrent calcific tendinopathy.

Support Surgical decision making:
Support patients in their decision making and ensure patients are informed about the likely outcomes of Arthroscopic subacromial decompression and rotator cuff repairs, including post operative protocols.

Recognise cohort of patients for whom rotator cuff repair is not going to be possible or effectively improve symptoms and discuss alternative options e.g reverse geometry arthroplasty/ suprascapular nerve block.

Arrange direct to list/ orthopeadic opinion

Onward referral options (following primary care)

• Understand/manage expectations prior to referralwhat are the goals of onward referral?
• Physiotherapy: patients will be offered 1:1 physiotherapy or class based intervention.
• Patients should trial at least 6 months of conservative treatments (specifically exercise based therapies) prior to consideration of operative management strategies.
• Investigations for potential operative cases to be arranged by the ESP team.

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 surgical management are 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 required.
• If secondary care pain services are required i.e. for suprascapular nerve block make recommendation for that referral to GP. Condition management: refer to MSK Physiotherapy team.
• Lifestyle management: Consider local referral optionssmoking cessation, weight management, HEAL programme.
• Orthopaedics: direct to list/ outpatient opinion.
• Orthotics Knee bracing ***TBC following evidence r/w***