Upper 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

Suspected septic arthritis
Suspected unreduced shoulder dislocation
Suspected fracture

Urgent conditions

Major spinal related neurological deficit/ worsening neurological deficit- suspected
Suspected acute traumatic rotator cuff tear in the younger individual (<60 yr of age)
Suspected acute reduced dislocations or subluxation of the shoulder joint in teenagers (<20 yr of age)
Suspected inflammatory arthritis
Suspected acute distal biceps rupture
Suspected primary and secondary cancers

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:

Presence of significant red flags as detailed above
Age <12
Non MSK complaints
Mod/severe glenohumeral/ elbow joint osteoarthritis in individual who wishes to consider surgical opinion- refer direct orthopaedics
Loose body with locking in elbow or wrist - refer direct orthopaedics
Chronic upper 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 shoulder, elbow, wrist or hand 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 non-specific shoulder pain, rotator cuff tendinopathy, Tennis elbow, Frozen shoulder, CRPS. This includes radicular arm and finger pain with altered or loss of power and sensation.

Note: If suspected fracture ensure they have undergone an X-ray. If suspected radiculopathy consider an MRI referral

Who not to refer

Presence of significant red flags as highlighted above

Dupytren’s or trigger finger conditions-may benefit from injection
Age <12 consider referral Paediatric Physio
Non MSK complaints

Chronic Shoulder, elbow, wrist or hand pain with a significant psychological/ psychiatric/drug addiction element

How to refer

All upper 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, diagnosis, relevant advice on condition, 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.
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 into the arm and hand advise that nerve root pains may take a few months to settle. 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.
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.
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

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

Self-management guidelines for patients

Arm, shoulder and hand problems and conditions | NHS inform

Patient Information | ShoulderDoc

Shoulder pain - NHS

Elbow and arm pain - NHS

Hand pain - NHS - Hand, wrist & finger management

De Quervain's syndrome | The British Society for Surgery of the Hand – Thumb tendonitis management

https://www.bssh.ac.uk/patients/conditions/24/basal_thumb_arthritis - Thumb OA management

NHS Inform - Shoulder, elbow, wrist, hand. Musculoskeletal Helpline for self-management advice and self-referral information: https://www.nhsinform.scot/care-support-and-rights/nhs-services/helplines/musculoskeletal-msk-helpline.