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 Anterior knee pain clinically without investigation if a person has:

• Symptoms of pain arising from the anterior compartment of the knee – patella femoral joint and/or associated soft tissues
• Onset could relate to trauma/overuse or insidious
• True mechanical symptoms commonly absent but can see pseudo locking and giving way

Primary care:

Patient presents to primary care with anterior knee 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

Pharmacological management

• Optimise medication management
• Consider topical NSAIDS, oral NSAIDs plus PPI, Paracetamol. Address any maladaptive beliefs around medication useage in conjunction with MSK web resource

Radiology

• X-ray not required prior to referral

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

• education and reassurance
• exercise management with combined programme of knee and hip strengthening.
• maybe supplemented with patellofemoral taping and foot orthoses if appropriate.

Flair up management:
The MSK service will offer 1 to 1 appointments for patients experiencing a flair up. This may include education, reassurance and the above therapeutic interventions.

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
• MRI if mechanical symptoms and ? chondral lesion/patellar tendinopathy after failed conservative treatment

Assurance of optimised conservative management:
To ensure conservative management pathways have been fully optimised for patients with anterior knee pain 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 primary care)

• Understand/manage expectations prior to referral- what are the goals of onward referral?
• Condition management: MSK service- note patient must have engaged with online resources before making a condition management referral to MSK.
• Flair up management: MSK service- can offer 1 to 1 management for flairs of anterior knee pain if initial self management not successful.
• Lifestyle management: Consider local referral options- smoking cessation, weight management, HEAL programme.
• Complex condition management: Refer to MSK ESP team in cases of diagnostic uncertainty
   

Onward referral options (following MSK physiotherapy)

• Medication management: refer to primary care team if medication optimisation required.
• Lifestyle management: Consider local referral options- smoking cessation, weight management, HEAL programme.
• Complex condition management: refer to MSK ESP team in cases of diagnostic uncertainty, or significant disabiltiy, or if surgery needs to be considered.
   

Onward referral options (following MSK extended scope practitioner)

• Medication management: refer to primary care team 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.