HNY Policy and Pathway Repository - York

Symptom of FAI syndrome is motion-related or position-related pain in the hip or groin. Pain may also be felt in the back, buttock or thigh. In addition to pain, patients may also describe clicking, catching, locking, stiffness, restricted range of motion or giving way.

Clinical Signs: Diagnosis of FAI syndrome does not depend on a single clinical sign; Hip impingement tests usually reproduce the patient’s typical pain; the most commonly used test, flexion adduction internal rotation (FADIR), is sensitive but not specific. There is often a limited range of hip motion, typically restricted internal rotation in flexion.

Any non MSK causes fully screened and documented in the referral (i.e. soft CES signs).

 

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.
• Green light to remain active with activity modification as required see MSK website.
• Promotional materials at strategic locations
• Appropriately targeted community initiatives
• SEO of web hub
• Pain not settling after six weeks of selfdirected exercise refer for MSK review.

 

None provided

Primary care

Patient presents to primary care with signs and symptoms of FAI Syndrome.

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:

• Green light to stay active and modify activity as per MSK website.
• 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.
• Refer to MSK web hub long term condition pages.

Pharmacological management

• Optimise medication management as required.

Radiology

• AP pelvic view to aid diagnosis
   

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.

All patients regardless of access point should have a discussion of expectations and functional goals to support planned management pathway.

Referral via GP, ESP, Self Referral

• All patients screened for red flags and default to apptoriate pathway if needed (CES, acute motor loss, Cervical Spine, MSCC)

Physio 1:1

• treatment as per local guidelines. and evidence based practice .

Referral Options:

• 1:1 Treatment.
• Gym based lower limb class for strengtheing and conditioning.
• Community programmes for gym based strengthening and conditrioning.

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 hip/groin presentations.
• (i.e Hip FAI Syndrome, GTPS, Osteitis Pubis, OA Hip patients who have optimised physiotherapy based care, diagnostic uncertainty with no overt medical cause).

Investigations

• X-ray AP pelvis if not already carried out
• discuss MRI/MR Arthrogram with radiologist/orthopaedic

Assurance of optimised conservative management:

• To ensure conservative management pathways have been fully optimised for patients with hip conditions including: medication, exercise, pacing, and lifestyle factors and ensure expectations have been discussed.

Support hip surgery decision making:

• Support patients in their decision making as to whether to proceed with surgery. Refer appropriately to secondary /tertiarycare.

Onward referral options (following primary care):

• Imaging/investigations not required unless suspecting a medical differential. ie CES, acute motor loss, MSCC.
• Screen for red flags CES, other non MSK causes and do not refer to MSK until excluded.
• 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.
• Lifestyle management: Consider local referral options- smoking cessation, weight management, HEAL programme.
• Complex condition management.
   

Onward referral options (following MSK physiotherapy):

• Medication management: refer to primary care team or Physio independent prescriberif medication optimisation required.
• Lifestyle management: Consider local referral options- smoking cessation, weight management, HEAL programme, Move and Lose, water based exercise oppertunities.
• 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 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, Neurosurgical, Rheumatology, General Surgery, Vascular, Neurology, outpatient opinion to secondary care/tertiary centre.