Triage GuidelinesExclusion Criteria

• Under 18 years old

•Significant Red Flags

•Non MSK condition – e.g. podiatry referrals for diabetic patients, chiropody, neurological related disorders, falls

•Chronic Fatigue Patients

•Already under secondary care for the same condition

•Maternity and gynae related conditions e.g SPD, pelvic floor or incontinence problems

General Triage Guidelines•GP management and review for 4-6 weeks post onset unless acute or trauma•Suspected inflammatory condition/polyarthralgia – rheumatology referral•Recent surgery for same condition – orthopaedic referral•Thoracic spine pain – community MSK referral•Complex hand symptoms or CTS – community MSK(GPwSI)•Lumps & bumps – community MSK (GPwSI)•Complex PMHx, co morbidity or previous Ca – community MSK (GPwSI) •If GP has provided insufficient clinical information to enable an informed triage decision to take place then reject the referral documenting your reasons

General Triage Guidelines cont’d•If GP has not attached copies of diagnostic reports or relevant documents/letters put outcome as “obtaining information” and send task to admin and then put it on the caseload MSK Triage – awaiting further info

•Acupuncture – unable to accept referrals specifically for acupuncture only but able to offer within package of care of physio

•Dual referrals – unless related conditions, ask admin to upload as 2 referrals and triage each condition separately

General Triage Guidelines cont’d• CHRONIC PAIN REFERRALS (Bedford GP only):-

- triage onto Bedford MSK Chronic Pain Triage waiting listReject referral if:-

-Previous pain clinic input for same condition that failed to respond/deemed inappropriate

• CHRONIC PAIN REFERRALS (outside Bedford):-- end referral and note patient details to picked up by PatientChoice Advisor

•LBP community MSK requests – If referring GP is within Bedford then triage onto MSK ESP caseload and Waiting List for Kay/Lori to see. If outside Bedford then refer to Back Pain Clinic in outcome and end referral. If South Beds GP then triage to spinal ESP in Dunstable

NECK PAIN

GP MANAGEMENT<4-6 weeks onset with local neck pain and stiffness (no suspicion of #)GP to review as necessary

PHYSIO>4-6 weeks onset with local neck symptoms +/- referred pain but no adverse neurologyNo recent physio

COMMUNITY MSK

Ongoing symptoms +/- referred pain and adverse neurology. Failed conservative management

SECONDARY CARE

Ongoing pain with worsening or significant neuro signs and +ve diagnostics correlating to symptoms

LBP/SIJ

GP MANAGEMENT<4-6 weeks onset with mild/mod pain and dysfunction

Stable & mild neurological signs

GP to review as necessary

PHYSIO>4-6 weeks onset

Ongoing moderate pain and dysfunction

No significant or worsening neurological signs

No recent physio

COMMUNITY MSK

Ongoing symptoms Mod/severe pain and dysfunctionAcute pain and onset with inability to WB, poor mobilityProgressive neurologyFailed conservative management

SECONDARY CARE

Ongoing chronic pain and dysfunction

Failed conservative treatments

+ve diagnostics consistent with ongoing symptoms

THORACIC SPINE PAIN

GP MANAGEMENTIsolated thoracic spine pain < 2 weeks onsetNo red flags, trauma or significant & relevant PMHxGP to review regularly

PHYSIO COMMUNITY MSK

>2-4 weeks onset, with non resolving or worsening pain and dysfunction

SECONDARY CARE

Red Flags – ortho/neuro

Possible inflammatory condition - rheumatology

KNEE PAIN (NON OA)

GP MANAGEMENT<4-6 weeks onset with mild/mod pain & dysfunction.

GP to review as necessary

PHYSIO>4-6 weeks onset with ongoing pain and dysfunction

No recent physio

COMMUNITY MSK

>4-6 weeks onset, mod/severe pain and dysfunction?diagnosis from GP(e.g suspected ligament or meniscal damage)Failed conservative management

SECONDARY CARE

Acute trauma or likely ligament or meniscal tear +/-haemarthrosisClear mechanical symptomsOngoing pain and dysfunctionFailed conservative treatments+ve diagnostics consistent with symptoms

OA KNEE

GP MANAGEMENTMild pain & dysfunction.

GP to review as necessary

PHYSIOModerate pain and dysfunction

Minimal night pain

No recent physio

COMMUNITY MSK

Mod/severe pain and dysfunction

+/- night pain

Failed conservative management

SECONDARY CARE

Clear OA – mod/severe changes confirmed on XrayModerate/severe pain and dysfunction and night painFit for surgery and patient willing

OA HIP

GP MANAGEMENTMild pain & dysfunction.

Mild OA on XRay

GP to review as necessary

PHYSIOMild/Moderate pain and dysfunction

Minimal night pain

Mild/mod OA on Xray

No recent physio

COMMUNITY MSK

Mod/severe pain and dysfunction

+/- night pain

Failed conservative management

GP/patient uncertain re surgical options

SECONDARY CARE

Mod/severe OA confirmed on Xray

Moderate/severe pain and dysfunction

Night pain

Fit for surgery and patient willing

HIP PAIN (NON OA)

GP MANAGEMENT<4-6 weeks duration

Mild pain & dysfunction.

GP to review as necessary

PHYSIO>4-6 weeks duration

Moderate pain and dysfunction

No recent physio

COMMUNITY MSK

Mod/severe pain and dysfunction

Failed conservative management

SECONDARY CARE

Ongoing pain and dysfunction despite conservative treatment

Diagnostics suggest ortho referral needed e.g labral tear

Diagnostic doubt

FOOT & ANKLE PAIN

GP MANAGEMENT<4-6 weeks

Mild pain or dysfunction

PHYSIO/POD

>4-6 weeks

Mild/Mod pain & dysfunction

Failed GP management and no treatment to date

COMMUNITY MSK

Diagnostic uncertainty from GP/physio

Mod/severe pain and dysfunction – acute or ongoing despite treatment

SECONDARY CARE

Poss inflamm involvement +/- abnormal bloods – rheum referral

Structural instability of foot/ankle with inability to WB

OA ANKLE

GP MANAGEMENT<4-6 weeks

Mild pain or dysfunction

PHYSIO/POD

>4-6weeks

Ongoing pain and limited function

No conservative treatment to date

COMMUNITY MSK

Failed conservative treatment and ongoing moderate pain and dysfunction

SECONDARY CARE

Failed conservative management

Ongoing moderate/severe pain and dysfunction

Night pain

Gr IV OA seen on XRay

MORTON’S NEUROMA

GP MANAGEMENT

<4-6 weeks mild pain and dysfunction

PODIATRY

Confirmed Morton’s on USS – patient not wanting injection

COMMUNITY MSK

>6 weeks

? Morton’s Neuroma – USS appt

Confirmed Morton’s Neuroma - appt with injecting clinician

SECONDARY CARE

HALLUX VALGUS/RIGIDUS

GP MANAGEMENT<4-6 weeks

Mild pain or dysfunction

PHYSIO/POD

>4-6 weeks

Moderate pain and dysfunction

Failed GP management and no treatment to date

COMMUNITY MSK

Failed conservative treatment and ongoing pain.

SECONDARY CARE

Failed conservative management and injection

Bunion Pain ++

Transfer Metatarsalgia

Significant 2nd toe deformity

Shoe wear probs

SHOULDER

GP MANAGEMENT<4-6 weeks

Mild pain or dysfunction

Non acute or traumatic onset

PHYSIO/POD

>4-6weeks

Mild/moderate pain and limited function

Failed GP management

No conservative treatment to date

COMMUNITY MSK

Ongoing moderate or severe pain and dysfunction

Failed conservative treatment

Acute or traumatic onset

Suspected cuff tear

SECONDARY CARE

ELBOW PAIN

GP MANAGEMENT<4-6 weeks duration

Mild pain & dysfunction.

GP to review as necessary

PHYSIO>4-6 weeks duration

Moderate pain and dysfunction

No recent physio

COMMUNITY MSK

Mod/severe pain and dysfunction

Failed conservative management

Diagnostic uncertainty

SECONDARY CARE

TRIGGER DIGIT

GP MANAGEMENTMild pain & dysfunction

Catch/click

Full mobile finger

GP to review as necessary

OT(splinting)

Mild pain and dysfunction

Patient not wanting injections

COMMUNITY MSK

Moderate pain and dysfunction and triggering

Difficult extension or passive extension neededIncomplete flexionInjecting clinician needed

SECONDARY CARE

Ongoing triggering/pain & dysfunction after 2 x injections

Locked finger

OA HAND/THUMB

GP MANAGEMENT< 4-6 weeks mild pain & dysfunction

GP to review as necessary

OT

>4-6 weeks and moderate pain and dysfunction

COMMUNITY MSK

Mod/severe pain and dysfunction

Failed conservative treatment

+/- OA confirmed on Xray

Injecting clinician needed

SECONDARY CARE

Severe pain and dysfunction

Failed injections

Severe OA seen on Xray

RA/Inflamm disorder – rheum referral

OTHER HAND/WRIST CONDITIONS

GP MANAGEMENTDorsal ganglia

<4-6weeks mild pain and dysfunction

GP to review as necessary

PHYSIO/OT

>4- 6 weeks and moderate pain and dysfunction

Failed GP management

?splint required

COMMUNITY MSK

Volar ganglia with pain and dysfunctionDupuytrens ContractureDiagnostic uncertaintyOngoing moderate pain & dysfunction with failed conservative management

Need GPwSI +/- USS clinic

SECONDARY CARE

CTS

GP MANAGEMENTMild symptoms

Intermittant paraesthesia

Night waking

+/- pain

+ve Tinels/Phalens

PHYSIO/OT

If suspect symptoms referred from cervical spine

Request for splints

COMMUNITY MSK

Mod symptoms

Constant paraesthesia

ADL affected

Reversible numbness

+ve Tinels/Phalens

GPwSI appt

SECONDARY CARE

Severe or worsening symptoms

Reduced sensation

Severe pain

Failed injection

Wasting of muscles

DE QUERVAIN’S TENOSYNOVITIS

GP MANAGEMENT< 4-6 weeks Mild/mod pain and dysfunction

PHYSIO/OT

>6 weeks duration

Failed GP management and activity modification

COMMUNITY MSK

>6 weeks

Mod/severe pain and dysfunction

Failed conservative treatment

Needs appt with injecting clinician

SECONDARY CARE

CHRONIC PAIN

GP MANAGEMENT

PHYSIO

If mechanical or non specific spinal problem with no previous physio input

COMMUNITY MSK –

ESP/GPwSI

If failed physio/GP management

GP not indicating any clear reason for chronic pain input or further assessment needed

CHRONIC PAIN CONSULTANT

(in COMM MSK/2°CARE)

Clear chronic pain diagnosisGP requesting repeat interventions/FU from previous chronic pain inputRequest from another consultant for input