Lower limb

Red flag presentations:

Serious pathology as a cause of MSK conditions is considered rare, but needs to be managed either as emergency or urgent referral to relevant secondary care service.

Please make sure all red flag concerns have been managed prior to any MSK Physiotherapy referral

Emergency conditions

Cauda equina symptoms with radiculopathy

Suspected septic arthritis
Suspected unreduced hip, knee or ankle dislocation
Suspected fracture
Signs and symptoms of DVT
Sign and/or symptoms of acute infection of the lower limb

Urgent conditions

Major spinal related neurological deficit/ worsening neurological deficit- suspected
Suspected acute traumatic resulting in an inability to weight-bear, unusual deformity, sudden severe loss of flexion and extension of the hip, knee or ankle
Suspected inflammatory arthritis
Suspected primary and secondary cancers
Suspected age-related conditions: Slipped Capital Femoral Epiphysis (SCFE), Perthes disease, recurrent patella dislocations
Post arthroplasty
Acute foot drop with not obvious cause

Consider serious pathology as a differential diagnosis if person presents with:

Systemically unwell (fever, weight loss)
Night pain that prevents sleep due to escalating pain and/or difficulty lying flat

What not to refer – other:

Plantar fasciitis and foot pain – please refer these conditions to Podiatry

Presence of significant red flags as detailed above
Age <12 consider referral to AHP Physio
Non MSK complaints
Mod/severe hip/knee or ankle joint osteoarthritis in an individual who wishes to consider surgical opinion- refer direct orthopaedics
Loose body with locking in the hip, knee or ankle - refer direct orthopaedics
Chronic lower limb pain with a significant psychological/psychiatric/ drug addiction element.

Who to refer, who not to refer, how to refer

Who to refer

Patients with ongoing pelvic, hip, knee and ankle pain and dysfunction who have not responded with first line management, who do not have the presence of significant red flags or other exclusion criteria highlighted above. Examples include – Achilles tendinopathy, ankle fractures, OA hip and knee. Radicular and pelvic pain. Leg and foot pain with minor to moderate altered power and sensation.

Note: If suspected fracture ensure they have undergone an X-ray. If suspected radiculopathy consider an MRI referral if deemed warranted to help with the management

Who not to refer

Presence of significant red flags as highlighted above
Age <12 – consider referral Paediatric Physio
Non MSK complaints
Chronic pelvic, hip, knee, ankle or foot pain with a significant psychological/ psychiatric/drug addiction element

How to refer

All lower limb referrals should be made through the normal channels i.e. SCI gateway

Please provide as much detail as possible to help with the triage process

Primary care management

Check for the presence of red flags
Provide advice including reassurance, to stay as active as possible, continue with normal daily activities, increase physical activity progressively over a few days to weeks, stay at work if possible or return to work as soon as possible.
Advise most MSK pains in general usually settle within 8-12 weeks so reassure the patient, IF THE PAIN IS MANAGEABLE, to try the advice and resource links below before seeking a referral.
Ensure adequate analgesia has been prescribed especially in cases of referred arm and hand pains with use of neuropathic medication
Symptom control measures: local cold pack (particularly early days – care that skin protected with damp layers and short duration e.g. 5-20 mins with minimum 2 hr break) or heat e.g. 10-20 mins (ensure skin protection e.g. through towelling). Check skin regularly throughout application.
If suspected radiculopathy pain (sciatica type symptoms) advise that nerve root pains may take a few months to settle (consider neuropathic medication for sciatica as one of the first lines of treatment).

Note: the caveats for this are conditions that have research to support early intervention such as suspected:

Moderate to severe collateral ligament sprain or rupture
Locking or sudo locking knee joint
Moderate to severe meniscus tears
Moderate to severe radicular pain presenting as sciatica causing loss of power and/or sensation in the lower limb or foot

Consider psychosocial factors e.g. attitudes and beliefs about pain, behaviour, compensation claims, diagnosis and treatment, emotions, family, relationships, work, sleep, mood, disability etc.
Direct patients to advice / education resources
Direct patient to via NHS Inform Musculoskeletal Helpline for self-management advice and self-referral information https://www.nhsinform.scot/care-support-and-rights/nhs-services/helplines/musculoskeletal-msk-helpline.
Consider directing patients to the App "NHS 24 MSK Help" https://www.nhsinform.scot/care-support-and-rights/tools-and-apps/nhs-24-msk-help-app.

Note: Failure to respond to Primary care management then consider referral to local MSK physiotherapy services via SCI Gateway etc.

RADIOLOGY GUIDELINES

If any doubt about choice of investigation please discuss with radiology department Radiologist.Advice@borders.scot.nhs.uk

Patient self-management guidelines for the lower limb as required

Leg and foot problems and conditions | NHS inform

Exercises for hip problems | NHS inform

Exercises to help with osteoarthritis of the knee | NHS inform

Exercises to help with patellofemoral knee pain | NHS inform

Knee pain | The Chartered Society of Physiotherapy

Managing your knee pain | The Chartered Society of Physiotherapy

Foot pain | The Chartered Society of Physiotherapy

Arthritis | The Chartered Society of Physiotherapy