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 in reducing risk of osteoarthritis
• Promotional materials at strategic locations
• Appropriately targeted community initiatives particularly in relation to work related upper limb disorders (WRULD)
• SEO of web hub

None provided

Where active range of motion and passive range of motion is equally limited in a capsular pattern (i.e. lateral rotation is most profoundly affected), the most likely diagnosis is:

• 45-65 Frozen shoulder contracture syndrome
• >65 Osteoarthritis

If the restriction has come on following significant trauma or a fit consider posterior dislocation / fracture as a differential diagnosis

If the patient is under 40 with a stiff shoulder an ESP opinion should be sought.

Where passive movement is normal through lateral rotation but the patient is actively restricted consider a massive rotator cuff tear as a differential diagnosis.

 

Primary care

Patient presents to primary care with stiff shoulder.

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:

• Where shoulder osteoarthritis is suspected:
• Check BMI/ smoking/ exercise status:
• If lifestyle factors highlighted discuss as risk factors for MSK ill health/ and osteoarthritis. Refer to MSK web hub for lifestyle advice.

Pharmacological management

• Where a frozen shoulder is suspected oral analgesics may be of limited benefit. The condition is inflammatory in nature and therefore nsaids can be considered in less severe cases.
• Rapid pain relief is usually gained from an intraarticular corticosteroid injection (NOT subacromial) so should be offered if the clinician is appropriately skilled to provide.
• 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
• IA joint injection may be useful if clinician appropriately skilled to provide.
• Radiology X-ray is only indicated if 1
  • following trauma a fracture/ posterior dislocation is suspected or
  • sudden onset of shoulder stiffness following grand mal seizure (possible posterior dislocation)
• Ultrasound/MRI is unhelpful in the diagnosis of stiff shoulders.
• Refer to the MSK team: where corticosteroid injection is required for frozen shoulder.
• For frozen shoulder physiotherapy exercise is only appropriate once the pain has settled.
• For management for osteoarthritis and management of suspected massive rotator cuff tears. Investigations for potential operative cases to be arranged by the ESP team.

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:

• For frozen shoulder where pain is dominant clinical feature arrange an corticosteroid injection with injection therapist.
• For stage 3 (stiffness dominant frozen shoulder) discuss role of mobility exercises.
• For Osteoarthritis: provide educational package of care including osteoarthritis education, NICE medication recommendations, Activity management strategies. Consider specific exercises.
• For massive rotator cuff tears: utilise torbay deltoid retraining program.

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 limb presentations or advanced disability.
• X ray to differentiate GHJ OA v capsulitis

Assurance of optimised conservative management:
To ensure conservative management pathways have been fully optimised for patients with stiff shoulder presentations: medication, exercise, pacing, and lifestyle factors AND ensure expectations have been discussed.

Extended Scope treatment options:
Consider role of ultrasound guided procedures including intraarrticular corticosteroid injection/ hydrodilatation

Support Surgical decision making:
Osteoarthritis: Support patients in their decision making and ensure patients are informed about the likely outcomes of arthroplasty.

Massive rotator cuff tears: 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 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 options- smoking cessation, weight management, HEAL programme.
• Orthopaedics: direct to list/ outpatient opinion.