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.
• Health promotion regarding Work related upper limb disorders.
• Promotional materials at strategic locations
• Appropriately targeted community initiatives
• SEO of web hub

 

Diagnose Osteoarthritis clinically without investigation if a person:

• Is 45 or over AND Has activity related joint pain AND Has either no morning joint related stiffness OR morning stiffness that lasts for no more than 30 minutes and has some observable reduction in joint range.
• No history of trauma
• Mechanical symptoms (i.e. locking) are not at the fore.

Primary care

Patient presents to primary care with ACJ pain. Primary care team to consider common clinical presentations of AC joint pain.

1. Osteoarthritis
2. Osteolysis (younger patients with clear history of escelating loading in overhead activity and subsequent pain
3. Inflammatory- the ACJ is a potential site of RA, gout, and non-inflammatory arthropathy (i.e psoriatic) symptoms can be unilateral.
4. Dislocation- A clear mechanism of injury of a fall or blow to the apical shoulder is needed to disrupt the AC joint.

Non- pharmacological management strategies:

• Check BMI/ smoking/ exercise status:
  • If lifestyle factors highlighted discuss as risk factors for MSK ill health/OA. Refer to MSK web hub for lifestyle advice.
• If osteolysis suspected clinically advise rest from provocative overhead activities for 6-12 weeks.

Radiology

• X-ray not generally indicated
• Pharmacological management

For osteoarthritis: Optimise medication management as per NICE guidelines. Consider topical NSAIDS, oral NSAIDs plus PPI, Paracetamol. Address any maladaptive beliefs around medication usage in conjunction with MSK web resource

 

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:
For osteoarthritis: To explore education around osteoarthritis, discuss activity management strategies, signpost to medication advice, and provide specific exercise-based interventions.

For suspected non settling AC joint symptoms explore activity modification options and relative rest.

Flair up management:
The MSK service will offer 1 to 1 appointments for patients experiencing a flair up. If corticosteroid injection indicated, consider whether this can be done Landmark or whether USGI is indicated.

 

MSK extended scope practitioner

To support primary care and physiotherapy teams in management 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.

Assurance of optimised conservative management:
To ensure conservative management pathways have been fully optimised for patients with AC joint symptoms including: medication, exercise, pacing, and lifestyle factors AND ensure expectations have been discussed.
 

For cases of none settling osteolysis discuss risks and benefits of proceeding with corticosteroid injection vs watchful waiting.

Ultrasound guided injection:
To provided guided injection into AC joint for symptom management, where this is not possible by landmark guidance.
 

Support decision making regarding orthopaedic intervention e.g. ACJ reconstruction, ACJ excision

Onward referral options (following primary care)

• Bloods may be useful if patients present with spontaneous onset of AC joint swelling and pain.
• Orthopaedic review should be sought via ED in cases of acute traumatic ACJ injury (due to the potential for co-existing fracture)
• Physiotherapy can be useful for osteoarthritis or non-settling osteolysis or for treatment of chronic ACJ instability
• ESP team can offer support on complex case management

 

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 opportunities.
• Complex condition management/Ultrasound guided injection/ orthopaedic options: refer to MSK ESP team in cases of diagnostic uncertainty, or significant disability, or if further intervention needs to be explored.
   

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, make recommendation for that referral to GP.
• Condition management: refer to MSK Physiotherapy team.
• Lifestyle management: Consider local referral options- smoking cessation, weight management, HEAL programme.
• Orthopaedics: direct to list/ outpatient opinion.