1. Triage Guidelines Exclusion 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

2. 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

3. 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

4. General Triage Guidelines cont’d CHRONIC PAIN REFERRALS (Bedford GP only):- - triage onto Bedford MSK Chronic Pain Triage waiting list Reject 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 Patient Choice 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

5. 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 neurology No 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

6. 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 dysfunction Acute pain and onset with inability to WB, poor mobility Progressive neurology Failed conservative management SECONDARY CARE Ongoing chronic pain and dysfunction Failed conservative treatments +ve diagnostics consistent with ongoing symptoms

7. THORACIC SPINE PAIN GP MANAGEMENT Isolated thoracic spine pain < 2 weeks onset No red flags, trauma or significant & relevant PMHx GP to review regularly PHYSIOCOMMUNITY MSK >2-4 weeks onset, with non resolving or worsening pain and dysfunction SECONDARY CARE Red Flags – ortho/neuro Possible inflammatory condition - rheumatology

8. 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 +/- haemarthrosis Clear mechanical symptoms Ongoing pain and dysfunction Failed conservative treatments +ve diagnostics consistent with symptoms

9. OA KNEE GP MANAGEMENT Mild pain & dysfunction. GP to review as necessary PHYSIO Moderate 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 Xray Moderate/severe pain and dysfunction and night pain Fit for surgery and patient willing

10. OA HIP GP MANAGEMENT Mild pain & dysfunction. Mild OA on XRay GP to review as necessary PHYSIO Mild/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

11. 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

12. 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

13. 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

14. 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

15. 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

16. 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

17. 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

18. TRIGGER DIGIT GP MANAGEMENT Mild 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 needed Incomplete flexion Injecting clinician needed SECONDARY CARE Ongoing triggering/pain & dysfunction after 2 x injections Locked finger

19. 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

20. OTHER HAND/WRIST CONDITIONS GP MANAGEMENT Dorsal 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 dysfunction Dupuytrens Contracture Diagnostic uncertainty Ongoing moderate pain & dysfunction with failed conservative management Need GPwSI +/- USS clinic SECONDARY CARE

21. CTS GP MANAGEMENT Mild 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

22. 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

23. 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 diagnosis GP requesting repeat interventions/FU from previous chronic pain input Request from another consultant for input