• Bisset 2006 - Bisset L et al. BMJ 2006;333:939. n=198, 3-arm RCT
• Coombes 2013 - Coombes BK et al. JAMA 2013;309:461-9. n=165, 2x2 factorial RCT

Bisset compared steroid injection vs physio vs wait-and-see for chronic tennis elbow. Steroid superior at 6 weeks; significantly worse than the other arms at 1 year with higher recurrence rates. Coombes added a sham injection control and confirmed: steroid worsens 1-year outcomes and increases recurrence. Adding physio doesn't rescue this.

Counsel patients away from steroid injection. Offer education + load management (isometric → eccentric progression) + wait-and-see for mild cases. Reserve injection only for severe pain limiting essential function with explicit counselling about 1-year harm. PRP and surgery are downstream options for refractory cases.

Steroid injection for tennis elbow is now considered contraindicated by many UK practitioners except as last resort.

• Stasinopoulos 2014 - Stasinopoulos D et al. Br J Sports Med 2014. Review
• Coombes 2013 (extrapolation) - Coombes BK et al. JAMA 2013. RCT (lateral epicondyle but applicable)

Less RCT evidence specifically for medial than lateral epicondylalgia, but the pathology is similar (insertional tendinopathy of common flexor origin) and the management principles map across. Eccentric/isometric loading is the cornerstone; steroid injection should be avoided based on lateral epicondylalgia data.

Apply the tennis elbow framework - education, load management, wait-and-see for mild cases. Steroid injection is not recommended. Reserve PRP/surgery for refractory cases. Address ergonomics and grip strength.

Convergence with tennis elbow pathway; load-management-first.

• Macadam 2008 meta - Macadam SA et al. J Hand Surg Am 2008;33:1314.e1-12. Meta-analysis
• Caliandro 2016 Cochrane - Caliandro P et al. Cochrane 2016. Systematic review

Meta-analysis showed simple in situ decompression has equivalent outcomes to anterior transposition with shorter recovery and lower complication rate. Conservative measures (night splinting, activity modification, ergonomic changes) help mild-moderate cases. Severe disease (intrinsic wasting, persistent paraesthesia) warrants surgical referral.

Stratify by severity. Mild-moderate (intermittent symptoms, no wasting): conservative trial 8-12 weeks. Moderate-severe (constant symptoms, weakness): surgical referral. Don't accept a routine recommendation for anterior transposition over simple decompression - equivalent outcomes, lower morbidity.

In situ decompression as preferred first surgical option.

• Watson 2014 meta - Watson JN et al. JBJS Am 2014;96:2086-90. Systematic review
• AAOS 2016 - AAOS clinical practice guideline 2016. Guideline

Conservative management of complete distal biceps rupture results in 40-50% loss of supination strength and 30% loss of flexion strength. Surgical repair restores function in active patients. Single-incision and two-incision techniques have equivalent outcomes; two-incision has lower risk of radial nerve injury but higher heterotopic ossification risk.

Active patients with complete distal biceps rupture: urgent specialist referral (ideally within 2-4 weeks; late repair more difficult). Older or sedentary patients with low functional demand: conservative reasonable with informed consent about strength loss.

Surgical pathway timely; specialist surgical decision on technique.

• Sayegh 2014 - Sayegh ET, Strauch RJ. J Shoulder Elbow Surg 2014. Systematic review
• Smith 1989 - Smith DL et al. Arch Intern Med 1989. Cohort

Non-septic olecranon bursitis: conservative management (NSAIDs, compression, activity modification) resolves most cases over 4-8 weeks. Aspiration with steroid does not improve outcomes vs aspiration alone and carries skin atrophy, infection, and chronic drainage risks. Septic bursitis: aspirate, gram stain + culture, antibiotics; surgical drainage if abscess.

Differentiate septic from non-septic clinically (fluctuant, erythematous, hot, systemic features = septic). Non-septic: compression sleeve, NSAIDs, education, time. Avoid steroid injection. Septic: aspirate, send fluid, antibiotics, consider admission if systemic.

Conservative-first; reduced use of steroid injection.

• Lubahn 2008 - Lubahn JD et al. J Am Acad Orthop Surg 2008. Review
• Ferdinand 2006 - Ferdinand BD et al. J Hand Surg 2006. Diagnostic study

Radial tunnel syndrome: tender point 4-5cm distal to lateral epicondyle (vs at the epicondyle in tennis elbow), pain worse with resisted supination/middle-finger extension, often nocturnal pain. EMG often normal - diagnosis is clinical. Can coexist with tennis elbow ("double crush").

Examine carefully - palpate along extensor mass distal to the epicondyle. If radial tunnel features predominate or coexist, manage initially as tennis elbow (load, education) but reduce expectations of injection efficacy. Refer for hand surgery opinion if refractory at 6+ months and clinical features supportive.

Better recognition reduces fruitless tennis elbow injections.

• Rohrbough 2002 - Rohrbough JT et al. AJSM 2002. Cohort
• Erickson 2015 - Erickson BJ et al. AJSM 2015. Systematic review

For non-throwers: MCL elbow injuries usually heal with rehab. For high-level throwers (baseball, javelin, tennis): partial tears often heal; complete tears with persistent symptoms benefit from UCL reconstruction ("Tommy John") with ~80-90% return to play at previous level. Recovery 12-18 months.

For typical MSK presentations (fall on outstretched hand, occupational valgus stress), conservative care first. For elite throwing athletes with valgus instability symptoms, refer to sports orthopaedics. Most non-elite cases recover without surgery.

Surgery reserved for selective high-demand athletic cases.

• Pugh 2004 - Pugh DM et al. JBJS Am 2004;86:1122-30. Cohort study (protocol)
• Chen 2014 meta - Chen HW et al. Int Orthop 2014;38:1681-91. Meta-analysis

Terrible triad = elbow dislocation + radial head fracture + coronoid fracture. Pugh standard protocol: fix all components - coronoid (suture or screw), radial head (replace if not reconstructable), LCL repair. Restored stability in 80-90%. Delayed treatment (>2 weeks) has worse outcomes due to chronic instability. Persistent instability after repair: hinged external fixator.

High-suspicion clinical pattern after elbow dislocation. CT essential to characterise fractures. Urgent specialist elbow surgical referral - within 1-2 weeks. Patients waiting weeks for surgery have significantly worse outcomes. Don't wait for "swelling to settle" - refer immediately for surgical planning.

Standardised systematic approach; urgent surgical pathway.

• Chinchalkar 2017 - Chinchalkar SJ et al. J Hand Ther 2017. Cohort + protocol review
• Higgs 2012 meta - Higgs ZC et al. Bone Joint J 2012. Surgical outcomes review

Static progressive splinting (Joint Active Systems, dynamic splints) + aggressive physiotherapy can restore most lost motion in first 6 months post-injury. After 6 months, motion plateaus. Surgical capsular release (open or arthroscopic) for fixed deficits: average 40-50° gain in arc, higher for arthroscopic. NSAIDs and indomethacin reduce heterotopic ossification risk in high-risk patients.

Aggressive early hand therapy + splinting essential in all elbow trauma - don't accept "let it settle". For established stiffness at 6 months: refer to specialist elbow surgery for capsular release. Consider HO prophylaxis (NSAIDs) in high-risk patients (head injury, burns, severe fractures).

Early aggressive rehab + lower threshold for surgical release at 6 months.

• DRAFFT 2014 - Costa ML et al. Lancet 2014;383:1037-44. n=461, UK multicentre RCT
• DRAFFT2 2022 - Costa ML et al. Lancet 2022;399:1359-1368. n=500, UK multicentre RCT

DRAFFT (adults) and DRAFFT2 (≥50 years) both compared K-wire fixation vs volar locking plate for displaced distal radius fractures. Equivalent PRWE scores at 12 months. K-wire significantly cheaper. Reserve plate for complex intra-articular or failed K-wire reduction.

K-wire is the cost-effective first-line surgical option per NICE NG38. Reserve volar locking plate for complex fractures (intra-articular, comminuted, failed K-wire). Don't default to plate.

UK practice shifted toward K-wire as default; volar plate now reserved for specific indications.

• WRIST 2020 - Chung KC et al. JAMA 2020;323:1601-1611. n=304, multicentre RCT (US) ages 60+

Compared cast immobilisation vs volar locking plate vs percutaneous pinning vs external fixation in patients ≥60 with displaced distal radius fractures. All four arms had clinically similar MHQ scores at 12 months. Cast group had slightly more dorsal tilt residual but no functional difference.

Most elderly patients with displaced distal radius fractures do well with cast immobilisation. Reserve surgery for younger high-demand patients or specific indications (open, intra-articular with step-off, failed reduction).

Reduced rate of surgical fixation in elderly distal radius fractures.

• Page 2013 Cochrane - Page MJ et al. Cochrane 2013;CD010003. Systematic review
• Atroshi 2013 - Atroshi I et al. BMJ 2013;347:f7027. n=111, RCT (steroid vs placebo)
• NICE NG201 - NICE 2022. Guideline

Night splinting and steroid injection both give meaningful short-term improvement for mild-moderate CTS. Surgical decompression gives the best sustained outcomes for moderate-severe disease (greater symptom relief at 6-12 months than conservative). Steroid injection delays but does not replace surgery in most refractory cases.

Stratify by severity. Mild: night splint, activity modification, expectant management. Moderate: trial of splint or injection. Severe (constant symptoms, thenar wasting, denervation on NCS): direct surgical referral - don't delay with multiple steroid trials.

Severity-stratified pathway; avoidance of repeated steroid injections for severe CTS.

• Richie & Briner 2003 - Richie CA, Briner WW. J Am Board Fam Pract 2003;16:102-6. Systematic review n=495

Pooled cure rate of single corticosteroid injection in De Quervain's tenosynovitis was 83% (95% CI 75-91%). USS guidance improves accuracy when separate EPB sub-compartment is suspected (20-40% of patients).

Injection should be confidently offered as first-line invasive treatment after activity modification + splinting fails. USS guidance for any failed-first-injection or when EPB sub-compartment is suspected. Reserve surgical release for the small minority who fail.

High confidence in injection as definitive treatment for most De Quervain's cases.

• SWIFFT 2020 - Dias JJ et al. Lancet 2020;396:390-401. n=219, UK multicentre RCT
• Buijze 2010 meta - Buijze GA et al. JBJS Am 2010;92:1534-44. Meta-analysis

SWIFFT compared cast immobilisation vs surgical fixation for undisplaced/minimally displaced scaphoid waist fractures. Similar functional outcomes at 1 year; cast cheaper and avoids surgical risk. Surgery indicated for: displaced fractures (>1mm step), proximal pole fractures (~30% non-union rate), elite athletes wanting faster return.

Cast management is appropriate first-line for undisplaced waist fractures - counsel patient about 6-8 week immobilisation timeline. Surgery referral for: displacement >1mm, proximal pole location, established non-union, elite athletes with informed shared decision.

Cast-first pathway for undisplaced waist fractures, supported by UK RCT.

• Spaans 2015 - Spaans AJ et al. Hand 2015;10:1-9. Systematic review
• Wajon 2015 Cochrane - Wajon A et al. Cochrane 2015. Cochrane review

Steroid injection provides short-term pain relief (6-12 weeks) but no significant 6-month difference vs placebo. Hyaluronic acid: small short-term benefit, no durable effect. Custom splinting + hand therapy: modest pain reduction with good long-term tolerance. Trapeziectomy remains the gold standard for severe refractory disease; LRTI and suspension arthroplasties have similar outcomes.

First-line: hand therapist input for splinting (often soft thumb splint), joint protection education, grip modification. Injection reasonable for short-term flare management - counsel on limited durable benefit. Surgical referral for severe symptomatic disease after conservative trial.

Hand-therapy-first pathway; reduced reliance on repeated injections.

• Skov 2017 - Skov ST et al. Lancet 2017;390:1289-1296. RCT
• BSSH guidance - British Society for Surgery of the Hand 2018. Guideline

Skov compared collagenase vs needle aponeurotomy: similar initial correction but higher recurrence with both vs limited fasciectomy. Open surgery (limited fasciectomy) has longest durability but longest recovery. Collagenase (Xiapex) has been withdrawn from UK market since 2020 for commercial reasons, removing it as a routine option.

Discuss patient priorities - fastest recovery (needle aponeurotomy, but ~50% recurrence at 5 years), best long-term result (open surgery, longer recovery, lower recurrence). Hand surgical referral when MCP contracture >30° or any PIP contracture. Tabletop test guides timing.

Collagenase no longer routinely available in UK; needle aponeurotomy or open surgery main options.

• Henry 2008 - Henry MH. J Am Acad Orthop Surg 2008. Review
• Sammer 2009 - Sammer DM, Rizzo M. J Hand Surg Am 2009. Review

Degenerative TFCC tears (often associated with positive ulnar variance, age >40): conservative management with splinting, activity modification, and progressive load typically effective. Traumatic Palmer 1B tears with mechanical symptoms (clicking, catching, ulnar-sided pain on rotation) may benefit from arthroscopic repair or debridement. Persistent positive ulnar variance with chronic symptoms: ulnar shortening osteotomy.

Differentiate degenerative vs traumatic. Conservative trial 6-12 weeks for most. MRI helpful for surgical decision-making. Refer for hand surgery opinion if mechanical symptoms or failed conservative care. Address ulnar variance if present.

Conservative-first pathway; surgery for selected refractory cases.

• Handoll 2004 Cochrane - Handoll HH, Vaghela MV. Cochrane 2004. Cochrane review
• Lin 2018 - Lin JS, Samora JB. J Hand Surg Am 2018. Systematic review

Cochrane review: continuous DIP extension splinting for 6-8 weeks resolves most closed mallet injuries. Comparable outcomes between stack splint and custom thermoplastic. Surgical intervention required for: large bony mallet (>1/3 articular surface) with volar subluxation, open injuries, failed splint trial.

Splint compliance is everything. Educate patient: DIP must NEVER drop into flexion during the 6-8 weeks - including during splint changes/washing. Refer for hand surgery if: large bony fragment, volar subluxation on lateral X-ray, or 6 weeks compliant splinting has failed.

Conservative-first established as standard.

• Dias 2007 - Dias JJ et al. J Hand Surg Eur 2007. Cohort study
• Head 2015 meta - Head L et al. J Hand Surg Eur 2015. Meta-analysis

Dias: ~58% of untreated wrist ganglia resolved spontaneously at 6 years. Aspiration: ~50% recurrence rate at 6 months. Surgical excision: ~10-20% recurrence, small risk of stiffness/scar tenderness. No intervention often the best option.

Reassure: ganglia are benign, often resolve on their own, and treatment options have meaningful recurrence and complication rates. Refer for surgery only if: significant pain, functional impairment, suspicion of alternative pathology, or cosmetic distress with informed consent about recurrence.

Conservative reassurance now standard for asymptomatic/minimally symptomatic ganglia.

• Peters-Veluthamaningal 2009 - Peters-Veluthamaningal C et al. Ann Fam Med 2009;7:325-33. RCT injection vs placebo
• Wang 2013 meta - Wang J et al. PLoS One 2013. Meta-analysis

Single corticosteroid injection: ~60-70% sustained resolution at 1 year for primary trigger finger. Repeat injection if first partially effective: additional 30-40% respond. Diabetics have lower response rate (~40-50%). Open trigger finger release: ~95% success, low complication rate, definitive treatment.

First-line: corticosteroid injection into A1 pulley region (USS guidance optional but improves accuracy). If first injection fails or symptoms recur within 6 months: consider surgical release. Diabetic patients: lower injection response, earlier surgical referral reasonable. Trigger thumb in children: usually self-resolves.

Injection-first pathway widely adopted; surgical referral for refractory.

• Lutsky 2012 review - Lutsky K, Beredjiklian PK. J Hand Surg Am 2012;37:1942-52. Review
• BSSH guidance - British Society for Surgery of the Hand. Guideline

Lichtman classification (I-IV based on collapse and arthrosis). Stage I-II: immobilisation and observation may halt progression in ~30%. Joint-levelling procedures (radial shortening osteotomy in ulnar-negative variance) for II-IIIA. Vascularised bone grafts for IIIB. Stage IV: salvage (proximal row carpectomy, fusion, arthroplasty). Outcomes worse in older patients.

Refer suspected Kienböck's for hand surgery specialist opinion. Don't delay - early disease has more reconstructive options. MRI for early diagnosis (X-ray often normal). Patient counselling: chronic condition requiring surveillance even if asymptomatic. Discourage heavy manual labour during active treatment.

Stage-directed pathway; earlier specialist referral.

• Daar 2019 meta - Daar DA et al. J Hand Surg Am 2019;44:946-956. Meta-analysis
• Watts 2017 - Watts AC. Hand Clin 2017;33:601-617. Review

Scapholunate Advanced Collapse (SLAC) and Scaphoid Non-union Advanced Collapse (SNAC) follow predictable degenerative patterns. Proximal row carpectomy (PRC): equivalent outcomes to four-corner fusion for stage II, easier rehab. Four-corner fusion better preserves grip strength but more rehab. Stage III (capitolunate involvement): four-corner fusion preferred over PRC. Total wrist fusion: definitive last resort with good pain relief but no motion. Wrist arthroplasty: niche role.

Refer wrist OA with characteristic SLAC/SNAC pattern for hand surgery. Stage with CT/imaging. Stage II without capitolunate involvement: PRC or four-corner fusion equivalent. Stage III: four-corner fusion preferred. Counsel patients about motion-vs-strength trade-offs and likely return to manual work.

Stage-directed reconstruction; PRC increasingly accepted as alternative to fusion.

• SPORT 2006/2008 - Weinstein JN et al. JAMA 2006;296:2441; Spine 2008;33:2789. n=501 RCT + observational cohort, US
• Peul 2007 - Peul WC et al. N Engl J Med 2007;356:2245-56. n=283, Dutch RCT

SPORT and Peul independently showed that microdiscectomy provides faster symptomatic relief (weeks to months) but 1-year and longer outcomes are similar between surgical and conservative groups. Crossover rates were high (~40% of conservative arm eventually had surgery).

Counsel patients honestly: surgery speeds recovery but doesn't change long-term outcome unless there's significant deficit. 6-12 week conservative trial appropriate for most. Surgery indicated for: progressive motor weakness, CES features, intolerable pain despite optimised conservative.

Pathway prioritises 6+ weeks structured conservative care before surgical referral except for specific indications.

• SPORT stenosis 2008 - Weinstein JN et al. NEJM 2008;358:794-810. n=634 RCT + observational
• Försth 2016 (NLSS) - Försth P et al. N Engl J Med 2016;374:1413-23. n=247, Swedish RCT

SPORT: decompression significantly better than conservative for spinal stenosis (sustained to 8 years). Försth NLSS: adding fusion to decompression did NOT improve outcomes for degenerative spondylolisthesis with stenosis. Only fuse if there's clear instability.

Refer symptomatic refractory stenosis for surgical opinion confidently. Push back if surgical plan includes routine fusion in absence of instability - Försth changed UK practice. Patient counselling should be honest: stenosis surgery does work; fusion adds morbidity without clear benefit unless instability is present.

Major reduction in fusion-added-to-decompression in UK practice post-Försth.

• AOSpine guidelines 2017 - Fehlings MG et al. Global Spine J 2017;7(3 Suppl):70S-83S. Systematic review + consensus
• Fehlings 2013 - Fehlings MG et al. J Bone Joint Surg Am 2013;95:1651-8. Prospective cohort n=479

For moderate-severe degenerative cervical myelopathy (mJOA ≤14), surgical decompression yields significant functional improvement sustained at 1-2 years. Delayed surgery in moderate-severe disease is associated with worse outcomes. Mild myelopathy (mJOA 15-17) can be observed cautiously with low threshold for intervention if any deterioration.

Don't delay surgical referral for moderate-severe myelopathy with hand dysfunction or gait instability. Mild disease: cautious observation with serial mJOA assessment, low threshold to escalate. Even subtle progression warrants surgical consideration.

Lower threshold for surgical referral; earlier intervention in symptomatic disease.

• Maas 2015 Cochrane - Maas ET et al. Cochrane 2015;CD008572. Cochrane review
• NICE NG59 - NICE 2016. Guideline

Cochrane meta-analysis: insufficient evidence to support facet joint injections for chronic LBP. NICE NG59 (2016) explicitly recommends against using imaging-guided injections of corticosteroids into the facet joints. Radiofrequency denervation has stronger evidence in carefully selected patients with confirmed facet-mediated pain (positive diagnostic block).

Don't refer for facet joint injections as routine LBP treatment. If patient has been offered/discussed this, explain the evidence. Radiofrequency denervation is a specialist intervention for very specific facet-mediated pain (confirmed by diagnostic block) - not generic LBP.

Reduced rate of facet injections in NHS pain pathways post-NICE NG59.

• Pinto 2012 meta - Pinto RZ et al. Ann Intern Med 2012;157:865-77. Meta-analysis
• NICE NG59 - NICE 2016. Guideline (supports use for radicular pain)

Epidural steroid injection provides modest short-term pain relief (4-8 weeks) for acute radicular pain but no significant effect on long-term function or surgical rate. NICE NG59 supports consideration in acute/severe radicular pain but advises against use for non-radicular LBP. Most benefit in the first 6 weeks of acute radicular pain.

Reasonable referral option for severe acute radicular pain limiting function - frame as a "bridge" not a cure. Counsel patients that it doesn't change long-term outcome. Don't request for non-radicular LBP. Surgical pathway not affected - patients who need surgery still need it.

Specific indication-based use (radicular pain) rather than generic LBP injection.

• Lamb MINT 2013 - Lamb SE et al. Lancet 2013;381:546-56. n=599, UK multicentre RCT
• Quebec Task Force - Spitzer WO et al. Spine 1995;20:1S-73S. Consensus classification

Lamb MINT trial: active management (single education + advice session) gave equivalent outcomes to a full physiotherapy package in most acute whiplash patients. Both far superior to no intervention. Early collar use associated with worse outcomes. Persistent symptoms beyond 3 months: psychosocial factors (catastrophising, fear-avoidance, compensation issues) more predictive than imaging.

First contact: education, reassurance, exercises, advice to stay active. No routine collar. Identify yellow flags early (fear-avoidance, depression, work issues). Most patients recover with simple advice. Refractory cases need a biopsychosocial approach, not more passive treatment.

UK NHS pathway: minimal intervention with selective escalation for refractory cases.

• Buchbinder 2009 - Buchbinder R et al. N Engl J Med 2009;361:557-68. n=78, sham-controlled RCT
• Kallmes 2009 - Kallmes DF et al. N Engl J Med 2009;361:569-79. n=131, sham-controlled RCT
• VERTOS IV 2018 - Firanescu CE et al. BMJ 2018;361:k1551. n=180, sham-controlled

Three sham-controlled RCTs (Buchbinder, Kallmes, VERTOS IV): no significant difference between vertebroplasty and sham procedure for typical osteoporotic vertebral fractures. Earlier non-sham trials had shown apparent benefit, illustrating placebo and natural history effects. Some uncertainty remains for very acute (within days) severe cases.

Don't routinely refer for vertebroplasty in osteoporotic vertebral fractures. Optimise conservative management: analgesia, gradual mobilisation, bone health pathway (FLS), DEXA, fragility fracture prevention. Specialist consideration only for severe intractable pain after conservative trial.

Significant reduction in vertebroplasty rates post-2009 sham trials.

• NICE NG59 - NICE 2016. Guideline
• Wong 2017 meta - Wong JJ et al. Eur J Pain 2017. Meta-analysis

NICE NG59 + Cochrane reviews: education and advice to stay active outperform bed rest. NSAIDs provide modest short-term benefit. Paracetamol no better than placebo. Manual therapy: small short-term benefit. Most acute LBP improves substantially within 6 weeks regardless of intervention. Routine imaging causes harm.

First contact: reassurance + activity advice + STarT Back stratification. NSAIDs short course if no contraindication. Avoid paracetamol monotherapy. Don't image without red flags. Don't prescribe bed rest. Yellow flag screening influences pathway intensity.

Established pathway for acute LBP across UK NHS.

• Owen 2020 meta - Owen PJ et al. Br J Sports Med 2020;54:1279-1287. Network meta-analysis
• Saragiotto 2016 Cochrane - Saragiotto BT et al. Cochrane 2016. Cochrane review

Network meta-analysis of exercise types for chronic LBP: Pilates, motor control, resistance training, yoga, and general aerobic exercise all produced similar modest pain and function improvements. No single exercise type clearly superior. Adherence is the strongest predictor of outcome.

Stop arguing about which exercise is "best" for chronic LBP. Match the prescription to patient preference and resources - what will they actually do? Group classes, swimming, gym, structured rehab all work if the patient sticks with it. Pacing and graded exposure matter more than modality.

Patient-centred exercise prescription standard.

• NICE IPG306 - NICE 2009. IPG guidance
• Jacobs 2013 meta - Jacobs W et al. Cochrane 2013. Cochrane review

Cochrane meta-analysis: lumbar disc replacement and fusion gave similar 2-5 year outcomes for symptomatic discogenic pain. Both with significant complications. NICE IPG306 recommends "special arrangements" for governance and consent - i.e. not routinely recommended. Re-operation rates similar. Adjacent segment disease (theoretical advantage of disc replacement) not clearly demonstrated.

For discogenic LBP being considered for surgery, both fusion and disc replacement are limited options with significant morbidity. Conservative care optimised first. If patient asks specifically about disc replacement: explain that NHS pathway typically defaults to fusion when surgery indicated, and disc replacement is not clearly superior.

Limited UK NHS adoption of disc replacement.

• BrAIST 2013 - Weinstein SL et al. N Engl J Med 2013;369:1512-1521. n=242, RCT

BrAIST randomised adolescents with curves 20-40° to bracing vs observation. Bracing significantly reduced curve progression beyond 50° (the surgical threshold): success rate 72% with bracing vs 48% with observation. Effect dose-dependent - more hours of wear = better outcome. >13 hours/day strongly predicted success.

For adolescents with significant curves (20-40°) still growing, refer to specialist spinal service for bracing assessment. Don't reassure with "they'll grow out of it" - bracing works. Discuss honestly with family about wear-time commitment. Surgical referral for curves >50° or rapidly progressive.

Reaffirmed bracing as evidence-based intervention; reduced "wait and see" approach.

• Hoeritzauer 2020 - Hoeritzauer I et al. J Neurol 2020. Systematic review
• BASS standards - British Association of Spine Surgeons 2018. UK national standards

Decompression within 48 hours significantly improves neurological recovery compared to delayed surgery. BASS UK standards: emergency MRI within 24 hours of suspected CES, decompression within 24 hours of confirmed diagnosis (incomplete CES) or 48 hours (complete CES). Outcomes substantially worse after delay. Bladder dysfunction and saddle anaesthesia are the most reliable predictors.

CES is a true surgical emergency. If clinical suspicion (saddle anaesthesia, bilateral leg symptoms, urinary retention with overflow, faecal incontinence, painless retention): same-day MRI, same-day neurosurgical referral. Don't wait for "definite" features - MRI is the arbiter. Documentation of red flag screening essential medicolegally.

Standardised UK pathways with 24/48-hour targets; reduced delay to surgery.

• SPORT spondylolisthesis - Weinstein JN et al. JBJS Am 2009;91:1295-304. n=601 RCT + cohort
• Försth 2016 - Försth P et al. NEJM 2016;374:1413-23. Fusion question

SPORT spondylolisthesis: surgical decompression ± fusion superior to non-operative for symptomatic degenerative spondylolisthesis with stenosis at 2-4 years. Försth: adding fusion to decompression doesn't improve outcomes in absence of overt instability. Spondylolytic spondylolisthesis (pars defect): conservative for most; surgery for high-grade slip or progressive symptoms.

Conservative trial 3-6 months for symptomatic spondylolisthesis: exercise, education, manage activity. Surgical referral for neurogenic claudication, progressive neurology, refractory pain. Push back on routine fusion-with-decompression unless clear instability - Försth changed practice.

Decompression-only increasingly preferred when feasible.

• Laslett 2005 - Laslett M et al. Man Ther 2005;10:207-18. Diagnostic study
• NICE IPG578 - NICE 2017. IPG guidance on RFA

Diagnosis difficult - single tests poor diagnostic accuracy. Laslett cluster (Distraction, Compression, Thigh thrust, Sacral thrust, Gaenslen): 3+ positive predicts SIJ pain with ~88% sensitivity and 78% specificity when LBP is centralisable excluded. Image-guided intra-articular injection is both diagnostic and therapeutic. RFA of SIJ branches (NICE IPG578): supports use with standard arrangements.

Suspect SIJ pain in unilateral buttock/posterior thigh pain without radicular features, especially post-partum or after fall onto buttocks. Use Laslett cluster + Fortin finger test. Refer for image-guided injection if clinical suspicion. Don't over-diagnose - most LBP isn't SIJ. RFA for refractory cases via specialist pain.

Better diagnostic discipline; specialist pathway for confirmed cases.

• ASAS criteria - Rudwaleit M et al. Ann Rheum Dis 2009;68:777-83. Classification criteria
• NICE NG65 - NICE 2017. Spondyloarthritis guideline

ASAS classification: chronic back pain >3 months in patient <45, plus either: sacroiliitis on imaging + 1 SpA feature, OR HLA-B27 + 2 SpA features. Inflammatory back pain features: insidious onset, age <40, morning stiffness >30 min, improves with exercise not rest, alternating buttock pain, response to NSAIDs. Mean delay to diagnosis: 8-10 years - primary care opportunity to identify earlier.

High index of suspicion in young adults with chronic LBP, especially if morning stiffness, alternating buttock pain, family history. Check HLA-B27, CRP, ESR. MRI sacroiliac joints (not just X-ray - sensitivity for early disease). Rheumatology referral with these features. Don't accept "non-specific LBP" in young patient with these flags.

Earlier identification and rheumatology referral; reduced diagnostic delay.

• FASHIoN 2018 - Griffin DR et al. Lancet 2018;391:2225-35. n=348, UK multicentre RCT
• FIRST 2018 - Mansell NS et al. AJSM 2018;46:1306-14. n=80, US military RCT

FASHIoN compared hip arthroscopy + best practice rehab vs best practice rehab alone for FAI syndrome. Hip arthroscopy significantly superior on iHOT-33 at 12 months, sustained at 3 years (FASHIoN follow-up). FIRST confirmed in independent cohort.

For young adults with confirmed FAI syndrome (clinical + radiographic + failed conservative trial), surgical referral is genuinely evidence-based. Patient counselling should reflect real benefit, not just "consider physio first then maybe surgery". 3+ months structured PT first remains appropriate before referral.

Confident referral pathway for FAI; FAI is one of the better-evidenced hip preservation surgeries.

• LEAP 2018 - Mellor R et al. BMJ 2018;361:k1662. n=204, Australian RCT
• Mellor 2022 follow-up - Mellor R et al. BJSM 2022;56:1297-1304. 5-year follow-up

LEAP compared education + load programme (gluteal strengthening, hip-stability) vs steroid injection vs wait-and-see for gluteal tendinopathy (GTPS). Education + exercise superior at 8 weeks AND 52 weeks. 5-year follow-up: durable benefit. Steroid showed early benefit that wasn't sustained and didn't equal the rehab arm by 8 weeks.

Counsel patients confidently away from steroid injection as first-line for GTPS. Education about load management + structured rehab is the evidence-based pathway. Reserve injection only for severe pain limiting rehab participation, with explicit counselling.

Reduced rate of GTPS steroid injection; pathway emphasises load management.

• NJR (National Joint Registry) - NJR 21st Annual Report 2024. >1.4 million procedures, UK national registry
• NICE TA304 - NICE 2014. Guideline

NJR data: ~95% implant survival at 10 years for cemented and uncemented THR; satisfaction rates among highest in elective surgery. NICE TA304 supports THR for end-stage hip OA when conservative management fails to provide adequate symptom control.

Counsel patients confidently about THR for end-stage hip OA - this is genuinely effective surgery. But: NICE NG226 conservative measures (education, exercise, weight management, simple analgesia) must be optimised first. Don't bypass conservative care because surgery works well; do escalate confidently when conservative has been adequately tried.

Conservative-first pathway with confident escalation when needed.

• Jüni 2015 Cochrane - Jüni P et al. Cochrane 2015. Cochrane review
• NICE NG226 - NICE 2022. OA guideline

Intra-articular steroid provides short-term pain relief (weeks to ~3 months) for hip OA. NICE NG226 supports for short-term flare. Hyaluronic acid: weaker evidence at hip than knee; not recommended routinely. PRP: emerging evidence base, not yet standard. Repeated steroid injections may accelerate joint deterioration and complicate future arthroplasty.

Reserve injection for severe symptomatic flares or as a bridge to surgery. Counsel patient on short duration of benefit. Avoid repeated injections - limit to 1-2 per year max, ideally USS-guided. Address other modifiable factors (weight, activity, strength). HA and PRP not recommended outside specific scenarios.

Injection positioned as bridge therapy, not primary treatment.

• Lieberman 2017 - Lieberman JR et al. AJSM 2017. Cohort study
• Sansone 2016 - Sansone M et al. AJSM 2016;44:75-82. Registry data

Hip arthroscopy outcomes correlate strongly with: age (worse over 50), joint space (worse if <2mm), Tönnis grade of OA (poor if grade 2+). Younger patients without OA: 80-90% good outcomes. Older patients with OA changes: high conversion to THR within 2-5 years.

For FAI symptoms in patient over 50 with any radiographic OA: discuss honestly that arthroscopy outcomes are limited and progression to THR likely. Conservative pathway with eventual THR may be more appropriate. Specialist hip preservation surgeon for case-by-case discussion.

Patient selection for hip preservation surgery has tightened.

• NJR 21st Annual Report 2024 - National Joint Registry. UK national registry
• Smith 2012 - Smith AJ et al. Lancet 2012. Registry analysis

NJR data: hip resurfacing has higher revision rates than THR overall, particularly in women, small head sizes, and certain implants. Metal-on-metal (MoM) concerns about cobalt/chromium ions and pseudotumour. Surviving indication: young (<55) active men, large head size (>50mm), no metal sensitivity. Preserves bone stock for future revision.

Rarely first-line. Young active men with good anatomy may discuss with specialist. All patients with existing MoM implants should be on surveillance (per MHRA - symptoms, blood metal ions, imaging) - primary care often involved in this surveillance.

Resurfacing rates dropped dramatically post-MoM concerns.

• Krych 2013 - Krych AJ et al. Arthroscopy 2013. Cohort comparison
• Ayeni 2014 meta - Ayeni OR et al. Knee Surg Sports Traumatol Arthrosc 2014. Systematic review

Pooled data: labral repair gives better iHOT and HHS scores than debridement at 1-2 years for symptomatic labral tears at hip arthroscopy. Larger effect in patients with better cartilage. Labral reconstruction (using graft) emerging option for irreparable tears in younger patients with good cartilage.

Decision is intra-operative and specialist. Patients asking about hip arthroscopy can be told that current standard is repair where possible. Outcomes depend heavily on cartilage status, age, and patient selection - see hip-arthroscopy-older-patient card.

Shift to labral preservation/repair over debridement.

• Yen 2015 - Yen YM et al. J Am Acad Orthop Surg 2015. Review

External snapping hip (ITB over greater trochanter): often painless, sometimes associated with GTPS. Internal snapping hip (iliopsoas tendon): often painless, sometimes associated with intra-articular pathology. Asymptomatic snapping requires no treatment. Symptomatic: physiotherapy, address contributing factors. Surgical lengthening rarely needed and has variable outcomes.

Reassure patients with painless snapping hip - it's a normal mechanical phenomenon and doesn't indicate damage. If associated with pain, manage the painful pathology (e.g. GTPS, FAI). Reserve surgical referral for refractory symptomatic cases not responsive to physiotherapy.

Strong reassurance pathway; reduced surgical referral for benign snapping.

• Goom 2016 - Goom TS et al. JOSPT 2016;46:483-93. Clinical commentary + protocol
• Lempainen 2009 - Lempainen L et al. AJSM 2009. Cohort study

Structured loading (eccentric and concentric hamstring loading, progressive HSR, gluteal strengthening, posterior chain integration) gives ~70-80% good outcomes over 3-6 months. Steroid injection: short-term benefit only; potential tendon weakening. Complete avulsion or chronic high-grade tear with retraction: surgical refixation.

Refer for structured rehab with sports physiotherapy experience. Long timeline (3-6 months minimum). Address sitting tolerance, hip flexion-dependent activities. Avoid passive treatments alone. Acute complete avulsion (sudden tearing, audible pop, MRI confirms): refer urgently for surgical opinion within 2-4 weeks.

Loading-first pathway; surgical refixation for complete tears.

• Egol 2002 - Egol KA et al. Orthopedics 2002. Cohort + algorithm
• BOAST trauma standards - British Orthopaedic Association. Standards

Compression-side (inferior cortex) stress fracture: NWB + serial imaging; ~85% heal conservatively. Tension-side (superior cortex) stress fracture: urgent fixation - high risk of progression to complete displaced fracture (catastrophic in young patients). MRI is gold standard for early diagnosis. High-risk groups: female athletes (RED-S, low BMD), military recruits, marathon runners.

Suspect in athletes/military recruits with insidious groin/hip pain. MRI urgently if suspected - not X-ray (often normal). Tension-side requires same-day orthopaedic referral. Address contributing factors (energy availability, RED-S, vitamin D, training load) - recurrence high without addressing root cause.

Early MRI; aggressive surgical management of tension-side fractures.

• METEOR 2013 - Katz JN et al. N Engl J Med 2013;368:1675-84. n=351, US RCT
• Sihvonen 2013 - Sihvonen R et al. N Engl J Med 2013;369:2515-24. n=146, Finnish RCT with sham surgery arm
• ESCAPE 2018 - van de Graaf VA et al. JAMA Surgery 2018;320:1328. n=321, Dutch RCT

METEOR, Sihvonen (sham-controlled), and ESCAPE all independently showed arthroscopic partial meniscectomy provides no clinically meaningful benefit over structured physiotherapy for degenerative meniscal tears in patients aged 45-70. Sihvonen specifically excluded any "surgical" effect - sham arthroscopy gave equivalent outcomes.

Counsel patients firmly: imaging showing degenerative tear does NOT mandate surgery. Structured physio is genuinely first-line and equally effective. Surgical referral reserved for: acute traumatic tear in younger patient, mechanical locking, bucket-handle displacement, true mechanical symptoms not explained by OA.

Marked reduction in APM in UK NHS; physio-first pathway entrenched.

• KANON 2010 - Frobell RB et al. N Engl J Med 2010;363:331-42. n=121, Swedish RCT
• KANON 5-year 2013 - Frobell RB et al. BMJ 2013;346:f232. 5-year follow-up

KANON randomised young active patients with acute ACL rupture to early reconstruction vs structured rehab with optional delayed reconstruction. 51% of the rehab arm never crossed over to surgery. At 2 and 5 years: no significant difference in KOOS, IKDC, or activity level between the always-surgery and rehab-first groups.

Offer rehab-first as a genuine option, especially for: older patients, recreational athletes, lower-demand activities, those willing to modify pivoting sports. Discuss "coper" potential. Surgery confident for: high-demand pivoting athletes, persistent functional instability, concurrent meniscal repair, multi-ligament injury.

KANON shifted the conversation from "ACL rupture = reconstruction" to "rehab first, surgery if needed".

• BEAR-MOON 2021 - Murray MM et al. AJSM 2021;49:3699-3713. n=100, US RCT
• BEAR III ongoing - Ongoing trial. Larger replication

BEAR uses a collagen scaffold to bridge a torn ACL allowing biological healing. Non-inferior to standard reconstruction on IKDC and KOOS at 2 years in selected patients (acute proximal tears, presented within 6 weeks). Preserves native ACL and proprioception. Long-term and high-demand-sport data still emerging.

BEAR is emerging not yet routine UK NHS practice. Patients asking about it should be referred to specialist centres offering it. Reserve for: acute presentation (within 6 weeks), proximal tear pattern, younger patients prioritising native tissue preservation.

Specialist option available but not mainstream; watch for BEAR III results.

• Nascimento 2018 meta - Nascimento LR et al. JOSPT 2018;48:19-31. Systematic review + meta-analysis
• Ferber 2015 - Ferber R et al. J Athl Train 2015;50:366-77. RCT n=199

Hip strengthening (abduction, external rotation) combined with quadriceps work produces significantly better outcomes on pain and function than quadriceps strengthening alone. Effect sizes moderate-large; durable at 6-12 months. Adding patellar taping/bracing modest extra benefit; manual therapy alone insufficient.

Make hip strengthening a core component of PFP rehab - don't just give VMO exercises. Address running mechanics if applicable (cadence, hip drop, foot strike). Education about pain neurophysiology and load progression matters.

Standard of care now includes proximal (hip) strengthening for PFP.

• McAlindon 2017 - McAlindon TE et al. JAMA 2017;317:1967-1975. n=140 RCT
• Migliorini 2021 meta - Migliorini F et al. Br Med Bull 2021. Network meta-analysis
• NICE NG226 - NICE 2022. Guideline

McAlindon: quarterly steroid injections over 2 years caused greater cartilage loss vs saline with no significant pain benefit. Network meta-analyses: HA and PRP have small modest benefits; PRP at least equivalent to HA in most studies. NICE NG226 supports steroid for short-term flare; cautious about repeated use.

Reserve steroid injection for severe symptomatic flares - not as standing maintenance. Counsel on possible cartilage effects with repeated use. HA: option but limited durable benefit, not NHS-funded for routine use. PRP: emerging, often private. Address modifiable factors (weight, exercise) as foundation.

More conservative with repeated steroid injections in knee OA.

• NJR (National Joint Registry) - NJR 21st Annual Report 2024. UK national registry
• TOPKAT 2019 - Beard DJ et al. Lancet 2019;394:746-756. n=528, UK RCT

NJR: ~90% implant survival at 15 years for cemented TKR. TOPKAT: partial knee replacement non-inferior to TKR for unicompartmental disease and significantly cheaper. 15-20% of TKR patients report persistent significant pain at 1 year despite radiographically successful surgery - patient expectations matter.

TKR genuinely effective for end-stage OA - counsel patients positively but honestly about ~15-20% persistent pain risk. Optimise pre-surgery (weight, comorbidities, expectations). Partial knee replacement worth discussing for unicompartmental disease. Pathway: conservative measures exhausted, then surgical referral.

Increased use of unicompartmental replacement where appropriate; better pre-operative counselling.

• Moseley 2002 - Moseley JB et al. N Engl J Med 2002;347:81-88. n=180, sham-controlled RCT
• Kirkley 2008 - Kirkley A et al. N Engl J Med 2008;359:1097-1107. n=178 RCT

Moseley sham-controlled RCT: arthroscopic debridement no better than sham surgery for knee OA. Kirkley confirmed: arthroscopy + physio not superior to physio alone. NICE NG226 explicitly recommends against arthroscopy for OA without mechanical symptoms (locking).

Don't refer for arthroscopy in degenerative knee pain. Address conservative measures, refer for arthroplasty when conservative exhausted. Patients arriving with arthroscopy expectations need honest counselling about the evidence.

Major reduction in arthroscopy for OA in NHS practice.

• STABILITY 2020 - Getgood AMJ et al. AJSM 2020;48:285-297. n=624 RCT
• Mohtadi 2016 Cochrane - Mohtadi NG et al. Cochrane 2016. Cochrane review

Cochrane and STABILITY data: BTB has lower re-rupture rate in young pivoting athletes (~4% vs ~8% for hamstring). BTB associated with more anterior knee pain and kneeling discomfort. Hamstring grafts: less donor-site morbidity but higher re-rupture in young athletes. Quadriceps tendon: emerging, similar re-rupture to BTB with less donor-site morbidity.

Specialist surgical decision. Young pivoting athletes: BTB or quad tendon preferred for re-rupture risk. Kneeling-dependent occupations: hamstring or quad tendon preferred. Add lateral extra-articular tenodesis in high-risk patients (STABILITY data). Patient priorities matter.

Patient-centred graft choice; increased use of quad tendon and LET in selected patients.

• Kongsgaard 2009 - Kongsgaard M et al. Scand J Med Sci Sports 2009. RCT
• van Ark 2016 - van Ark M et al. J Sci Med Sport 2016. RCT (isometrics)

Kongsgaard: heavy slow resistance loading (slow tempo, 3 sets, every other day) improved pain and function in patellar tendinopathy at 12 weeks; sustained at 6 months. van Ark: isometric loading provided immediate analgesia and is useful for in-season athletes who can't reduce activity.

Standard prescription: HSR programme (heel-elevated decline squat or leg press, 3 sets x 6-15 reps, slow tempo, every other day) for 12+ weeks minimum. In-season athletes: isometric loading (5 x 45 sec at 70% MVC) as adjunct for pain control. Counsel patiently - significant improvement typically takes 12-24 weeks.

Loading-based protocols established as evidence-based first-line.

• Smith 2015 Cochrane - Smith TO et al. Cochrane 2015. Cochrane review
• Petri 2013 - Petri M et al. Arch Orthop Trauma Surg 2013. Cohort

Cochrane: for primary patellar dislocation, surgical stabilisation does not improve outcomes vs rehab in most patients. Risk of redislocation ~30-50% with rehab alone; surgical stabilisation reduces redislocation but doesn't improve function. Indications for surgery: osteochondral fragment, persistent recurrent instability despite rehab, anatomical abnormalities (trochlear dysplasia, patella alta).

Primary dislocation: rehab pathway with VMO and hip strengthening, gradual return to activity. Image (MRI) to exclude osteochondral fragment. Refer for surgical opinion if osteochondral fragment, recurrent dislocations, or anatomical risk factors. Counsel on redislocation risk.

Rehab-first pathway entrenched for primary dislocation.

• Knutsen 2007 RCT - Knutsen G et al. JBJS Am 2007;89:2105-12. RCT
• NICE TA477 - NICE 2017. TA guidance

Knutsen RCT comparing microfracture vs ACI for chondral defects: similar 5-year outcomes for small defects. Larger defects (>2-4 cm²): ACI/MACI may have superior durability. NICE TA477 supports MACI for symptomatic articular cartilage defects of the knee in defined patients (failed conservative care, defects 2-10cm², no significant OA).

Specialist decision. Patients with persistent knee pain after cartilage injury who fail conservative care may benefit from specialist assessment. Realistic expectations: cartilage restoration techniques work better in younger patients (<40), isolated defects, no kissing lesions, normal alignment.

MACI available on NHS for selected patients post-TA477.

• TOPKAT 2019 - Beard DJ et al. Lancet 2019;394:746-756. n=528 UK RCT
• Brouwer 2014 Cochrane - Brouwer RW et al. Cochrane 2014. Cochrane review

High tibial osteotomy preserves the native joint by realigning load away from the damaged medial compartment - survival ~75-85% at 10 years. UKA (TOPKAT) is non-inferior to TKR with shorter recovery and less morbidity; in many UK centres UKA has replaced HTO for unicompartmental OA. HTO surviving niche: very young (<50), active manual workers wanting to delay arthroplasty.

Specialist surgical decision. Patients with isolated medial OA refractory to conservative care can be told both HTO and UKA are options. HTO preserves bone stock for future arthroplasty; UKA gives faster recovery. Increasing UK trend favours UKA.

UKA gaining ground over HTO; HTO niche but not obsolete.

• Reider 1994 - Reider B et al. AJSM 1994. Cohort
• Encinas-Ullán 2018 review - Encinas-Ullán CA et al. EFORT Open Rev 2018. Review

Isolated MCL injuries heal well with conservative management at all grades. Grade I (microscopic): 2-3 weeks return. Grade II (partial): 4-6 weeks with hinged brace. Grade III (complete): 6-12 weeks with brace, then progressive rehab. Surgical repair: limited indications (concomitant ACL/PCL, multiligamentous injury, distal tibial avulsion that fails to heal, late chronic valgus instability).

Isolated MCL: brace + progressive rehab. Refer for surgical opinion if: combined ligament injury, persistent valgus instability >3 months despite rehab, distal tibial avulsion on MRI. Patient counselling: most heal completely; structured rehab essential to restore proprioception and quadriceps.

Conservative pathway entrenched; surgical role limited to specific indications.

• Fairclough 2007 - Fairclough J et al. J Anat 2007;208:309-16. Anatomical study (revised pathology)
• Beals 2016 - Beals C, Flanigan D. J Orthop 2016. Review

Fairclough revolutionised understanding: ITB doesn't actually slide forwards over the lateral femoral epicondyle (it's firmly attached). Pain comes from compression of the fat pad/Kaplan fibres at the lateral knee. Hip abductor weakness, increased hip adduction during running, narrow step width are risk factors. Hip-strengthening + gait retraining gives best outcomes in runners.

Stop telling patients about ITB "friction" or "rolling out" the ITB (anatomically impossible). Address proximally: hip abductor strength, single-leg control, gait retraining (cadence increase, step width). Foam rolling addresses muscle tone but doesn't stretch the ITB. Steroid injection reserved for severe refractory cases.

Modern biomechanical understanding; proximal-focused rehab.

• Shelbourne 2013 - Shelbourne KD et al. JBJS Am 2013. Long-term cohort
• Pierce 2013 - Pierce CM et al. AJSM 2013. Review

Isolated PCL injuries have better natural history than ACL injuries - many patients function well with intact secondary stabilisers. Grade I-II isolated: conservative with quadriceps-focused rehab. Grade III isolated: often conservative; some advocate reconstruction in young high-demand athletes. Combined PCL + posterolateral corner (PLC) injury: surgical reconstruction of both essential - missed PLC is the commonest cause of failed PCL reconstruction.

Assess for PLC injury in any PCL injury - varus stress, dial test, reverse pivot shift. Isolated PCL: structured rehab focused on quadriceps strength to compensate. Refer for surgical reconstruction: multiligamentous injuries, combined PCL+PLC, persistent functional instability after rehab, bony avulsions.

Conservative-first for isolated; assertive surgical for combined.

• Frush 2007 - Frush TJ, Noyes FR. Sports Health 2007. Review
• Marra 2015 - Marra MD et al. Skeletal Radiol 2015. Imaging-clinical correlation

Baker's cyst (gastrocnemius-semimembranosus bursa) usually secondary to intra-articular pathology - most commonly OA, meniscal tear, RA, gout. Effusion in joint forces fluid into bursa via one-way valve. Treating the underlying joint pathology resolves the cyst in most cases. Direct aspiration: high recurrence (~50-80%) because underlying mechanism persists. Surgical excision: niche role.

Find and address the knee pathology. Knee OA: optimise per NICE NG226. Mechanical symptoms: investigate meniscal pathology. Inflammatory: rheumatology pathway. Aspiration only for very large symptomatic cysts (rare). Watch for ruptured Baker's cyst mimicking DVT - leg pain, swelling, "crescent sign" of bruising at medial malleolus.

Knee-focused management rather than cyst-focused.

• UKSTAR 2020 - Costa ML et al. Lancet 2020;395:441-448. n=540, UK multicentre RCT
• Soroceanu 2012 meta - Soroceanu A et al. JBJS Am 2012;94:2136-43. Systematic review

UKSTAR randomised acute Achilles ruptures to early functional rehabilitation in equinus boot vs surgical repair. No significant difference in Achilles Tendon Rupture Score at 9 months. Re-rupture rates similar (~5-8% conservative, ~3-5% surgical). Surgery has wound and nerve complication risks; conservative has slightly higher re-rupture in some cohorts but not in UKSTAR.

Offer functional bracing as a genuine first-line option for most Achilles ruptures. Same-day orthopaedic referral remains essential for: open injuries, delayed presentation, very high-demand patients wanting to discuss surgery, re-rupture cases. Honest counselling about ~5% re-rupture risk either way.

UK pathway predominantly conservative for primary Achilles ruptures.

• Rathleff 2015 - Rathleff MS et al. Scand J Med Sci Sports 2015;25:e292-300. n=48 RCT

Compared high-load progressive resistance training (heel raises with towel under toes, slow tempo, 3x12, every other day) vs plantar-specific stretching for chronic plantar fasciopathy. Superior pain and function at 3 months in the loading group, with persistent benefit at 6 months. Mechanism: progressive load tolerance + tissue remodelling.

Make loading the centrepiece of plantar fasciopathy rehab. Education + load + footwear modification. Stretching alone insufficient. Reserve injections for severe pain limiting rehab participation, with caution about fat pad atrophy with repeated steroid use.

Loading-focused rehab replacing stretching-only approach.

• Kerkhoffs 2002 Cochrane - Kerkhoffs GM et al. Cochrane 2002. Systematic review
• Doherty 2017 - Doherty C et al. Br J Sports Med 2017;51:113-25. Systematic review

Early functional rehabilitation (early WB, progressive strengthening, balance training) outperforms cast immobilisation across all key outcomes: faster return to sport, lower re-injury rate, less chronic ankle instability. POLICE (Protection, Optimal Loading, Ice, Compression, Elevation) replaced older PRICE/RICE protocols.

Move patients out of immobilisation early. Aircast or stirrup brace for protection but encourage early WB. Progressive proprioception/balance work is essential to reduce CAI (Chronic Ankle Instability) risk. Refer to ankle physio rather than just "rest and elevate".

Standard of care now functional rehab, not immobilisation.

• Beyer 2015 - Beyer R et al. AJSM 2015;43:1704-11. n=58 RCT
• Alfredson 1998 - Alfredson H et al. AJSM 1998;26:360-6. Original eccentric protocol
• Murphy 2018 meta - Murphy M et al. Br J Sports Med 2018. Meta-analysis

Beyer compared heavy slow resistance (HSR: 3 sets x 15 reps, slow tempo, every other day) vs classic Alfredson eccentric (3 sets x 15 reps, twice daily): HSR had equivalent outcomes with much higher adherence and patient preference. Meta-analyses confirm both protocols effective for mid-portion tendinopathy. Insertional disease: avoid below-neutral dorsiflexion.

Offer patients HSR protocol - fewer sessions, better adherence, equivalent outcomes. Pure eccentric for those who prefer or specifically respond. Counsel on 12-week minimum trial. Insertional disease needs floor-level (not below) heel raises.

HSR increasingly the default loading prescription.

• Mahadevan 2016 meta - Mahadevan D et al. Foot Ankle Surg 2016. Systematic review
• BOFAS guidance - British Orthopaedic Foot & Ankle Society. Specialist consensus

Wide footwear, metatarsal pad, and activity modification resolve symptoms in ~30-40% over 6-12 months. Corticosteroid injection (USS-guided): 50-60% short-term success but recurrence common. Surgical excision: 80-85% good outcomes but ~5-10% stump neuroma recurrence and some persistent toe numbness.

First-line: footwear + pad + education. Trial injection if persistent (preferably USS-guided). Surgical referral for refractory cases - counsel on recurrence and toe numbness. Avoid repeated injections (>2-3) - diminishing returns and fat pad atrophy risk.

Conservative-first pathway with surgical referral threshold defined.

• McMillan 2012 meta - McMillan AM et al. BMC Musculoskelet Disord 2012;13:36. Systematic review
• Tatli 2009 - Tatli YZ, Kapasi S. Curr Rev Musculoskelet Med 2009;2:3-9. Review

Steroid injection provides short-term pain relief (4-12 weeks) but no significant benefit at 6 months vs placebo. Risks: fat pad atrophy (~3-10%), plantar fascia rupture (~2-3%). PRP and ESWT have some evidence for refractory cases. Loading (Rathleff protocol) remains first-line.

Don't inject as first-line - loading is the evidence-based starting point. Reserve for severe pain limiting rehab participation, with informed consent about durable limited benefit. Avoid repeated injections. ESWT/PRP for refractory cases via podiatry/orthopaedic input.

Loading-first pathway; injection reserved.

• Bowring 2009 - Bowring B, Chockalingam N. Foot 2009. Review
• Kulig 2009 - Kulig K et al. Phys Ther 2009. RCT

PTTD staged Johnson-Strom I-IV. Stage I-II (flexible deformity, tendinopathy without fixed deformity): orthoses with medial arch support + tibialis posterior strengthening (heel raises with inversion bias, eccentric loading) effective. Stage III (fixed planovalgus deformity): orthoses palliative, surgical reconstruction often needed. Stage IV (ankle involvement): hindfoot fusion may be required.

Stage clinically before treating. Stage I-II: medial-posted orthoses + structured strengthening + activity modification. Refer to podiatry/orthotics. Surgical referral for: rigid deformity, failed conservative care, advanced stages. Don't delay surgery if Stage III - outcomes worse with progression.

Stage-based pathway; surgical referral threshold defined.

• Dean 2017 meta - Dean BJ et al. Foot Ankle Surg 2017. Meta-analysis
• Bigsby 2014 - Bigsby E et al. Foot Ankle Int 2014. Cohort

Jones fracture has higher non-union risk (~20-30%) than other 5th metatarsal fractures due to vascular watershed at the metaphyseal-diaphyseal junction. Surgical fixation (intramedullary screw) reduces non-union and accelerates return to activity. Cast non-WB for 6+ weeks acceptable for low-demand sedentary patients.

Differentiate Jones (zone 2-3 - proximal diaphysis, distal to TMT joint) from avulsion (zone 1 - typically heals well in walking boot). Refer Jones fractures to fracture clinic / orthopaedics: athletes/high-demand for surgical opinion, low-demand for cast management. Don't treat as a simple metatarsal fracture.

Recognition of Jones zone improves outcomes; surgical pathway for active patients.

• Nunley 2002 - Nunley JA, Vertullo CJ. AJSM 2002. Classification
• BOAST 2020 - British Orthopaedic Association. UK standard

Lisfranc (tarsometatarsal) injuries: missed in up to 20% on initial X-ray. Plantar bruising at midfoot is highly suggestive ("plantar ecchymosis sign"). Weight-bearing X-rays unmask diastasis between 1st and 2nd metatarsal bases. Stable injuries (rare): cast immobilisation. Unstable: surgical reduction and fixation, ORIF or primary arthrodesis depending on severity.

Have a high index of suspicion in midfoot injury - plantar bruising, can't weight-bear, tenderness over TMT joint. Refer for weight-bearing X-rays or specialist opinion. Don't reassure as "soft tissue injury" without ruling out. Outcomes much better with prompt diagnosis and fixation.

BOAST standards mandate weight-bearing imaging when Lisfranc suspected.

• NJR 2024 - National Joint Registry. UK national registry
• Daniels 2014 - Daniels TR et al. JBJS Am 2014. Multicentre cohort

NJR + multicentre data: both total ankle replacement (TAR) and arthrodesis effective for end-stage ankle OA. TAR survival ~85-90% at 10 years (improving with newer designs); arthrodesis durable but increased risk of adjacent-joint OA. TAR preserves motion (~20-25° dorsiflexion-plantarflexion). Arthrodesis: bombproof but loses motion.

For end-stage ankle OA failing conservative care, surgical opinion appropriate. Patient priorities matter: motion preservation (TAR), durability (arthrodesis). Specialist decision. Conservative measures (bracing, custom orthoses, activity modification, intra-articular injection) appropriate before surgery.

TAR increasingly available on UK NHS in specialist centres.

• Coughlin 2003 - Coughlin MJ, Shurnas PS. JBJS Am 2003;85:2072-88. Classification + outcomes
• Polzer 2013 meta - Polzer H et al. J Foot Ankle Surg 2013. Meta-analysis

Coughlin-Shurnas classification (grade 0-IV). Cheilectomy (dorsal osteophyte removal) gives good outcomes for grade I-II (limited motion, dorsal osteophytes, preserved joint space). Grade III-IV (cystic changes, joint space loss, sesamoid changes): 1st MTP fusion gives best pain relief and durability. 1st MTP arthroplasty (implant): inferior long-term outcomes - high revision rate.

Conservative first: rocker-sole shoes, stiff carbon insoles, activity modification, simple analgesia. Surgical referral for refractory disease. Counsel patients honestly: cheilectomy good for early disease but progression common; fusion is definitive - no motion but excellent pain relief and walking function preserved.

Fusion as gold standard for advanced disease; arthroplasty less favoured.

• Heyer 2018 - Heyer JH et al. AJSM 2018. Surgical cohort
• Carreira 2016 - Carreira DS et al. Arthroscopy 2016. Review

Posterior impingement classically in ballet dancers, footballers (especially kickers), runners. Conservative management (avoid plantarflexion, NSAIDs, USS-guided steroid injection) successful in 50-60%. Arthroscopic posterior ankle excision of os trigonum / Stieda process: 85-95% return to previous sport level, recovery 3-6 months.

Suspect in athletes with posterior ankle pain on plantarflexion (en pointe, kicking, downhill running). MRI confirms os trigonum + adjacent oedema. Conservative trial 3-6 months. Refer to specialist foot/ankle surgery (preferably sports-oriented) for refractory cases - arthroscopic technique highly effective.

Arthroscopic technique established; high return to sport.

• Torg 1982 (classic) - Torg JS et al. JBJS Am 1982;64:700-12. Classic series
• Mallee 2015 meta - Mallee WH et al. Br J Sports Med 2015. Systematic review

Navicular stress fracture is a high-risk stress fracture site due to vascular watershed. NWB cast 6-8 weeks: ~80% union in incomplete/non-displaced. Weight-bearing or partial weight-bearing has very high non-union rate (~50%). Complete or displaced: surgical fixation. Return to sport: 3-4 months minimum; specific re-imaging to confirm union.

High suspicion in middle-aged runners, jumpers, basketball/track athletes with dorsal mid-foot pain. MRI for diagnosis (X-ray unreliable). True NWB cast - not "as tolerated". Foot/ankle surgical referral for displaced fractures. Address contributing factors (training load, RED-S, vitamin D). Counsel about long recovery and recurrence risk.

Strict NWB protocols; lower surgical threshold for displaced injuries.

• Geneen 2017 Cochrane - Geneen LJ et al. Cochrane 2017;CD011279. Cochrane overview of reviews
• NICE NG193 - NICE 2021 - chronic primary pain. Guideline

Cochrane overview of 21 reviews covering chronic low back pain, OA, fibromyalgia, and chronic widespread pain. Exercise consistently improves pain and function with moderate effect sizes. Type of exercise matters less than adherence. NICE NG193 strongly recommends supervised exercise + acceptance/CBT-based therapies; explicitly recommends against routine paracetamol/NSAIDs/opioids in chronic primary pain.

Exercise should be central to chronic MSK pain management, not an add-on. Pacing and graded exposure rather than rest-based approaches. Pharmacological interventions have limited evidence and risks; non-pharmacological is the genuine evidence-based default.

Major shift in chronic pain management away from medication-first.

• Choosing Wisely - Multiple national initiatives. Guideline-based
• Brinjikji 2015 - Brinjikji W et al. AJNR 2015;36:811-6. Systematic review n=3110

Imaging findings (disc bulges, protrusions, degeneration) are present in 30-80% of asymptomatic adults rising with age. Routine imaging does NOT improve outcomes and can cause harm: increased surgery rates, worse psychological outcomes, anchoring of pain narratives. NICE NG59 explicitly recommends against imaging for non-specific LBP.

Don't image LBP without red flags or planned intervention. Counsel patients about high prevalence of "abnormal" findings in pain-free people. When imaging is needed (red flags, planned injection, surgical consideration), be explicit about the indication.

Pathway emphasises clinical decision-making over imaging.

• Krebs SPACE 2018 - Krebs EE et al. JAMA 2018;319:872-882. n=240 RCT
• NICE NG193 - NICE 2021. Chronic primary pain guideline

Krebs SPACE: opioid therapy not superior to non-opioid therapy for chronic back, hip, or knee pain at 12 months. NICE NG193: do not initiate opioids for chronic primary pain. Faculty of Pain Medicine guidance: doses above 120mg oral morphine equivalent show diminishing returns and increasing harm; deprescribing is appropriate.

Don't recommend opioid escalation for chronic MSK pain. Counsel patients honestly about evidence base. Focus on exercise, psychological approaches, and acceptance-based work for chronic pain. Support GPs in opioid deprescribing where appropriate - taper plans with shared decision.

Major shift in chronic pain prescribing; NHS deprescribing pathways expanded.

• STarT Back 2011 - Hill JC et al. Lancet 2011;378:1560-71. n=851 RCT
• NICE NG59 - NICE 2016. Guideline

STarT Back stratified LBP patients by 9-item screening tool into low/medium/high risk for chronic disability. Stratified care (matching treatment intensity to risk level) significantly improved outcomes and was cost-effective vs usual care. Low-risk: minimal intervention. Medium: physiotherapy. High: psychologically-informed physiotherapy.

Use STarT Back tool (or similar) at first contact. Low-risk patients: education, reassurance, minimal intervention. High-risk patients (catastrophising, distress, fear-avoidance): early psychologically-informed physiotherapy. Don't treat everyone the same.

STarT Back embedded in many NHS LBP pathways.

• CSAW 2018 - Beard DJ et al. Lancet 2018. Subacromial decompression
• Sihvonen 2013 - Sihvonen R et al. NEJM 2013. Partial meniscectomy
• Buchbinder 2009 - Buchbinder R et al. NEJM 2009. Vertebroplasty
• Moseley 2002 - Moseley JB et al. NEJM 2002. Knee arthroscopy for OA

Four major MSK procedures have failed sham-controlled trials: subacromial decompression, arthroscopic partial meniscectomy for degenerative tears, vertebroplasty, and knee arthroscopy for OA. In each case, the surgical group did better than no-treatment but no better than sham surgery - indicating the effect was from expectation/regression, not the procedure.

When discussing surgical options with patients, the gold-standard question is "has this been tested against sham surgery?". If yes and it passed (e.g. THR, TKR), confident referral. If failed (above procedures), counsel honestly. If untested against sham, treat with caution. Patient expectation management is part of effective surgical referral.

Cultural shift toward sham-controlled evaluation; reduced uncritical referral.

• Williams 2020 Cochrane - Williams ACC et al. Cochrane 2020. Cochrane review
• NICE NG193 - NICE 2021. Guideline

Cochrane review of psychological therapies for chronic pain: CBT and ACT have moderate effect sizes for pain, function, and mood. Effects durable to 12 months. Mindfulness-based stress reduction (MBSR): comparable benefit in chronic LBP. NICE NG193 explicitly recommends CBT and ACT for chronic primary pain.

Refer patients with chronic pain + psychosocial drivers to psychologically-informed services. Pain Management Programmes (PMPs) combine CBT, ACT, exercise, and education. Don't frame this as "your pain is psychological" - frame as "your pain is real and there are tools that help you live well with it".

Psychological therapies as mainstream chronic pain management.

• Watson 2019 meta - Watson JA et al. J Pain 2019;20:1140.e1-1140.e22. Meta-analysis
• Louw 2011 - Louw A et al. Arch Phys Med Rehabil 2011. Systematic review

Meta-analyses: pain neuroscience education (PNE) provides moderate improvement in pain and disability when combined with exercise/movement-based rehabilitation. Stand-alone effects smaller. Particular benefit for chronic widespread pain, fibromyalgia, persistent post-injury pain. Patient understanding of pain biology changes pain behaviour and reduces catastrophising.

Embed pain education in chronic pain pathways - not as a separate lecture, but woven through movement-based work. Use plain language: "pain is the brain's alarm system, not a damage meter". Free resources: Explain Pain books (Butler & Moseley), retrainpain.org, painsciences.com. Combine with structured movement.

PNE now standard adjunct in pain management programmes.

• Vickers 2018 - Vickers AJ et al. J Pain 2018;19:455-474. Individual patient meta-analysis
• NICE NG59 (LBP) - NICE 2016. Guideline

Individual patient meta-analysis (Vickers, n>20,000): acupuncture superior to no acupuncture and to sham acupuncture for chronic pain, including LBP, knee OA, tension headache, neck pain. Effect size modest. NICE NG59 (2016) removed acupuncture recommendation for LBP - citing low-quality evidence and effect size below threshold for routine NHS provision.

Acupuncture is a reasonable option for patients seeking complementary approaches who can access it. Not first-line, not NHS-funded for LBP, but evidence-supported for several conditions. Discuss in shared decision context. Patients responding well: continue. Non-responders: don't persist.

Removed from NICE LBP guideline; still funded in some specialist services.

• Coulter 2018 meta - Coulter ID et al. Spine J 2018. Meta-analysis
• Rubinstein 2019 - Rubinstein SM et al. BMJ 2019;364:l689. Cochrane review

Meta-analyses and Cochrane reviews: manual therapy (mobilisation, manipulation) provides modest short-term pain and function benefit for some conditions (chronic LBP, neck pain). Effects typically not superior to active exercise. No clinically meaningful difference between manipulation and mobilisation. Effects fade without active rehab.

Manual therapy is a reasonable adjunct - not a treatment in itself. Pair every manual technique with active exercise and education. Avoid creating dependency ("you need to come back weekly"). Counsel patients that exercise drives long-term outcome.

Manual therapy positioned as adjunct, not primary intervention.

• Johnson 2015 Cochrane - Johnson MI et al. Cochrane 2015. Cochrane review
• Khadilkar 2008 - Khadilkar A et al. Cochrane 2008. Cochrane (LBP)

Cochrane reviews: TENS provides short-term analgesic effect during use for chronic MSK pain. No durable change in pain or function after stopping. Mechanism: gate control + endogenous opioid release. Heterogeneous responses - some patients get substantial benefit, others none. Low cost, low risk.

Reasonable to suggest as self-management tool for patients with chronic pain seeking active strategies. Loan or purchase trial. Set expectation: works during use, not a cure. Combine with active rehab. Avoid as primary modality.

TENS remains a self-management option; no longer routinely prescribed.

• Pincus 2002 - Pincus T et al. Spine 2002. Systematic review
• Linton 2011 - Linton SJ, Shaw WS. Phys Ther 2011. Review

Systematic reviews: psychological yellow flags significantly predict transition from acute to chronic LBP. Strongest predictors: pain catastrophising, fear-avoidance beliefs, depressive symptoms, low expectations of recovery, perceived injustice. Early identification + targeted intervention can reduce chronicity risk.

Screen early using STarT Back or similar tool. Address yellow flags explicitly - not just "stay positive". Reassurance, education about pain biology, graded exposure, and psychological support for high-risk patients. Don't wait for chronicity - intervene early.

Yellow flag screening embedded in UK MSK pathways.

• Finan 2013 review - Finan PH et al. J Pain 2013;14:1539-52. Review
• Tang 2012 - Tang NK et al. Sleep 2012;35:675-87. CBT-I trial

Sleep disturbance is both consequence and driver of chronic pain. Poor sleep amplifies pain via central sensitisation, impaired descending inhibition, and inflammatory pathways. Bidirectional: pain worsens sleep, poor sleep worsens pain. CBT for insomnia (CBT-I) improves both sleep AND pain in chronic MSK populations.

Routinely ask about sleep in chronic pain patients. Address sleep hygiene, screen for OSA (especially in obese patients with chronic LBP/widespread pain). Refer for CBT-I where available - often via IAPT services. Limit hypnotic prescribing - short-term only. Sleep improvement can be a leverage point for chronic pain management.

Sleep integrated into chronic pain assessment and management.

• Mallon 2004 - Mallon WJ et al. JSES 2004;13:129-32. Cuff repair outcomes
• Faryniarz 1996 (classic) - Faryniarz DA et al. AJSM 1996. Healing rates

Smokers have 2-4x higher tendon re-rupture rates (Achilles, cuff), worse rotator cuff repair outcomes, higher fracture non-union rates, and increased surgical site infection. Nicotine-induced vasoconstriction reduces tissue perfusion. Effect is dose-dependent and largely reversible - quitting before surgery improves outcomes. Smoking also worsens chronic pain outcomes via central effects.

Routinely discuss smoking with MSK patients - surgical referrals, tendinopathy, fracture management. Counsel about specific MSK harms (not just generic). Refer to NHS smoking cessation services. Pre-operative cessation can be 4-8 weeks of abstinence - meaningful improvements. Counsel about post-operative healing requirements.

Routine smoking cessation conversation in MSK clinic.

• Wu 2018 meta - Wu Z et al. Pain Phys 2018. Meta-analysis of RCTs
• NICE evidence on vitamin D - NICE recommendation. Guideline

Severe vitamin D deficiency (<25 nmol/L) causes osteomalacia, proximal myopathy, and bone pain. Wu meta-analysis: vitamin D supplementation produces only modest improvements in chronic musculoskeletal pain overall; benefit concentrated in those with documented deficiency. Routine supplementation in non-deficient patients: minimal effect.

Check vitamin D in: chronic widespread pain, proximal weakness, atypical bone pain, high-risk groups (housebound, dark skin, malabsorption, anticonvulsants). Treat documented deficiency (<25 severe, 25-50 insufficient) with appropriate replacement. Don't routinely supplement in normal levels for non-specific MSK pain. NICE: maintenance supplementation for at-risk groups year-round.

Targeted screening and replacement; reduced indiscriminate supplementation.

• Waddell 2006 - Waddell G, Burton AK. TSO 2006. Evidence review for DWP
• Heymans 2005 Cochrane - Heymans MW et al. Cochrane 2005. Cochrane review on back schools

Waddell evidence review: work is generally good for health; prolonged sickness absence harmful. Predictors of failed return: catastrophising, job dissatisfaction, perceived workplace conflict, low perceived ability to influence work (rather than physical job demands per se). Modified/light duties early facilitate return; waiting for "full recovery" prolongs absence. Multi-disciplinary biopsychosocial approach most effective.

Discuss work return early in MSK management. Issue fit notes recommending modified duties, not "unfit". Engage employer dialogue where possible. Refer occupational health for complex cases. Address fear-avoidance about work specifically. Vocational rehabilitation programmes available via DWP for difficult cases.

Active return-to-work approach; reduced sickness certification.

• BSR GCA guideline 2020 - Mackie SL et al. Rheumatology 2020;59:e1-e23. UK national guideline
• Salvarani 2008 - Salvarani C et al. Lancet 2008;372:234-45. Review of epidemiology and outcomes

GCA can cause irreversible visual loss within hours-days. BSR 2020: high-dose prednisolone (40-60mg/day; 60mg if visual symptoms) should be started immediately on clinical suspicion. Temporal artery biopsy/ultrasound within 1 week - sensitivity preserved despite steroid initiation. Tocilizumab (GiACTA trial) NICE-approved as steroid-sparing for refractory disease.

Suspected GCA = same-day rheumatology contact. New headache + age >50 + raised ESR/CRP + jaw claudication or visual symptoms = treat first, investigate immediately after. Don't wait for biopsy result before starting steroid. Counsel about steroid risks but make the urgency clear. Visual symptoms = ophthalmology + rheumatology emergency.

Fast-track GCA pathways (typically 24h rheumatology assessment with same-day USS) widespread in UK NHS.

• BSR PMR guideline 2010 - Dasgupta B et al. Rheumatology 2010;49:186-90. UK guideline
• EULAR/ACR 2015 criteria - Dejaco C et al. Ann Rheum Dis 2015;74:1799-807. Classification + management recommendations

PMR diagnosis: bilateral shoulder pain + age >50 + morning stiffness >45 min + elevated CRP/ESR + classic clinical picture + dramatic response to prednisolone 15mg within 1 week (typical 70%+ symptomatic improvement). Lack of response in 4 weeks should prompt rethink - consider RS3PE, late-onset RA, malignancy, statin myopathy. GCA overlap in ~20% of PMR.

Clinical diagnosis with confirmatory steroid trial. Start prednisolone 15mg, review in 1-2 weeks - significant improvement supports diagnosis. Plan a slow taper over 12-24 months. Always screen for GCA features (headache, visual, jaw). Counsel about diabetes/osteoporosis risk with prolonged steroids - start bone protection.

Structured taper protocols + bone protection from initiation.

• BSR gout guideline 2017 - Hui M et al. Rheumatology 2017;56:e1-e20. UK guideline
• NICE NG219 2022 - NICE 2022. Gout guideline
• CARES 2018 - White WB et al. NEJM 2018;378:1200-10. CV safety febuxostat vs allopurinol

Treating to a urate target <360 (or <300 for tophaceous/erosive disease) prevents flares and dissolves tophi. NICE NG219 (2022) supports early ULT after first attack rather than waiting for recurrence. Allopurinol first-line (titrate gradually from 100mg, typically to 300-600mg, occasionally higher). Febuxostat second-line - CARES trial showed possible CV mortality signal, restricting to those failing allopurinol.

Don't just treat the acute flare and discharge. Discuss ULT after first episode - especially if tophi, erosive disease, CKD, or recurrent attacks. Allopurinol start should include flare prophylaxis (colchicine 500mcg BD or low-dose NSAID for 3-6 months). Don't stop allopurinol during an acute flare. Lifestyle counselling but recognise its limited impact vs urate-lowering therapy.

Earlier ULT initiation; treat-to-target rather than symptom-led.

• NICE NG100 - NICE RA guideline 2018. Guideline
• EULAR 2022 - Smolen JS et al. Ann Rheum Dis 2023;82:3-18. EULAR recommendations

Treatment within 3 months of symptom onset ("window of opportunity") significantly improves long-term outcomes: lower joint damage, higher remission rates, better function. Delayed treatment = irreversible structural damage. NICE NG100 + EULAR recommend treat-to-target with rapid DMARD escalation. Methotrexate is anchor first-line DMARD; biologics for inadequate responders.

Refer urgently when you suspect inflammatory arthritis - synovial swelling >1 joint, >30 min morning stiffness, MCP/MTP/wrist involvement, family history, elevated CRP. Don't "wait and see" with anti-inflammatories. NICE: refer "urgently" (typically <2 weeks) without waiting for blood results. Anti-CCP and RF help but absence does NOT rule out RA.

Faster referral pathways; same-day early-arthritis clinics in many centres.

• BSR septic arthritis 2006 - Coakley G et al. Rheumatology 2006;45:1039-41. UK guideline
• Mathews 2010 review - Mathews CJ et al. Lancet 2010;375:846-55. Review

Septic arthritis: 10-15% mortality, 30-50% irreversible joint damage if treatment delayed. Aspiration mandatory BEFORE antibiotics (microbiology lost otherwise - only 50% yield post-antibiotic). Send: gram stain, culture, white cell count, crystals. WBC >50,000 in synovial fluid highly suggestive but not pathognomonic. Treatment: surgical washout + IV antibiotics 2 weeks, oral 2-4 weeks total.

Acutely hot, swollen joint with restricted movement in adult = SEPTIC ARTHRITIS UNTIL PROVEN OTHERWISE. Same-day orthopaedic/rheumatology referral. Don't start empirical antibiotics in primary care - refer first so aspirate can be done. Risk factors: prosthetic joint, diabetes, immunosuppression, IVDU, recent joint injection. Polyarticular presentation in 20%.

Standardised pathways with same-day aspiration; reduced post-antibiotic culture failure.

• NICE TA445/433 - NICE TA445 secukinumab; TA433 etanercept etc. Multiple NICE TAs
• EULAR PsA 2019 - Gossec L et al. Ann Rheum Dis 2020;79:700-712. EULAR recommendations

EULAR + NICE pathway: methotrexate first-line for peripheral PsA; biologic after methotrexate failure or active enthesitis/dactylitis/axial disease. TNF inhibitors (adalimumab, etanercept, infliximab) historically first-line biologic. IL-17 inhibitors (secukinumab, ixekizumab) - preferred when significant skin involvement or TNF failure. IL-23 (guselkumab) and JAK inhibitors (tofacitinib, upadacitinib) emerging options.

For active PsA with structural joint involvement, refer rheumatology promptly. Methotrexate trial 12-16 weeks at adequate dose. If failing methotrexate or skin-dominant: biologic discussion. Coordinated care with dermatology where significant psoriasis. Screen for cardiovascular risk and uveitis.

Treat-to-target in PsA; IL-17/23 increasingly prominent over TNF for psoriasis-dominant disease.

• EULAR CPPD 2011 - Zhang W et al. Ann Rheum Dis 2011;70:563-70. EULAR recommendations

Acute CPPD often clinically indistinguishable from gout - joint aspiration with polarised microscopy confirms (positively birefringent rhomboid crystals). Knee and wrist most commonly affected; can mimic septic arthritis. Acute management: intra-articular steroid if monoarticular; oral colchicine 0.5mg BD or NSAID if polyarticular. Unlike gout, no effective urate-lowering equivalent - chronic management focuses on flare prophylaxis (low-dose colchicine 500mcg daily for recurrent attacks).

Aspirate any suspected crystal arthropathy presentation - gout vs CPPD vs sepsis distinction matters. Acute large-joint flare: intra-articular steroid often most effective. Consider chronic prophylaxis in patients with recurrent flares. Search for secondary causes (haemochromatosis, hyperparathyroidism, hypomagnesaemia) in patients <55 or with severe polyarticular disease.

Aspirate-first pathway; chronic prophylaxis in recurrent disease.

• NICE NG100 - NICE RA guideline 2018. Guideline
• BSR DMARD safety 2017 - Ledingham J et al. Rheumatology 2017;56:865-868. UK monitoring guideline

Methotrexate has the strongest evidence in RA and underpins many treatment plans. Critical safety counselling: ONCE WEEKLY (daily dosing has caused fatal pancytopenia); folic acid 5mg weekly (different day to MTX); blood monitoring (FBC, U&E, LFT) fortnightly for 6 weeks, then monthly for 3 months, then 3-monthly; pause during significant infection; live vaccines contraindicated; pregnancy contraindicated (washout 3-6 months M+F); alcohol moderation (BSR ≤14 units/week reasonable).

Counsel meticulously - written information essential. Verify weekly understanding ("what day do you take it?"). Check renal function before any dose change. Check for live vaccine plans. Pregnancy plans for both genders. Stop during sepsis, neutropenia, deranged LFTs. Patient handheld booklet for shared care.

Standardised safety counselling and shared-care monitoring.

• FIT 1996 - Black DM et al. Lancet 1996;348:1535-41. n=2027 alendronate RCT
• HORIZON 2007 - Black DM et al. NEJM 2007;356:1809-22. n=7765 zoledronate RCT

FIT trial: alendronate reduced vertebral fractures by 47% and hip fractures by 51% over 3 years in women with prior vertebral fracture. HORIZON: annual IV zoledronate reduced vertebral fractures 70% and hip 41% over 3 years. Effect size depends on baseline risk - best evidence in those with prior fragility fracture or high FRAX.

Bisphosphonates are first-line for most patients meeting treatment threshold. Alendronate 70mg weekly oral first-line - compliance is the issue. Zoledronate annual IV for those unable to take oral, with adherence issues, or post-fracture. Calcium and vitamin D should be replete before initiation. Counsel about ONJ (rare, dental risk) and atypical femoral fracture (rare, prolonged use).

Treat-to-target; lower threshold for treatment after fragility fracture (FLS pathway).

• FLEX 2006 - Black DM et al. JAMA 2006;296:2927-38. Alendronate extension trial
• HORIZON-Recurrent Fracture trial - Black DM et al. NEJM 2007. Zoledronate extension data

FLEX: continuing alendronate beyond 5 years gives further protection against vertebral fractures but no additional benefit for non-vertebral. Stopping at 5 years preserves much of the BMD gain for 2-3 years. "Drug holiday" appropriate when: no fragility fracture during treatment, T-score >-2.5 hip, no other high-risk features. Continue treatment if: prior fragility fracture during treatment, T-score ≤-2.5, on oral glucocorticoids, very high FRAX.

Reassess every patient after 3 years (zoledronate) or 5 years (oral). Repeat DEXA, check fracture history during treatment, calculate FRAX. Stop and reassess in 1-2 years for lower-risk patients. Continue for high-risk patients. Counsel: not "lifelong" but not "5 years and done" - individualised decision.

Structured drug holiday assessment at 3-5 years.

• ARCH 2017 - Saag KG et al. NEJM 2017;377:1417-27. n=4093 vs alendronate
• NICE TA791 - NICE 2022. TA guidance

ARCH trial: romosozumab (1 year) followed by alendronate gave 48% greater reduction in vertebral fractures vs alendronate alone over 24 months. CV signal in trials prompted FDA boxed warning - caution in patients with prior MI/stroke. NICE TA791 (2022): romosozumab approved for postmenopausal women at very high fracture risk (severe osteoporosis with prior fragility fracture). 12 monthly subcutaneous injections, then transition to anti-resorptive.

Reserve for postmenopausal women with severe osteoporosis (very low T-score + prior fracture). Specialist initiation. CV history screening - avoid in recent MI/stroke. Time-limited to 12 months. Critical: must be followed by anti-resorptive (typically bisphosphonate) to maintain BMD gains.

New high-risk pathway via metabolic bone / rheumatology services.

• NOGG 2022 - National Osteoporosis Guideline Group 2022. UK guideline
• NICE NG121 - NICE 2017 osteoporosis assessment. Guideline

FRAX calculator integrates clinical risk factors + DEXA to estimate 10-year fracture risk. UK-specific FRAX (sheffield) gives intervention thresholds via NOGG. Treatment generally recommended if FRAX hip ≥3% or major osteoporotic ≥20%, OR T-score ≤-2.5, OR vertebral fragility fracture (regardless of T-score). "Treat" thresholds higher in elderly - age modifies risk via NOGG charts.

Calculate FRAX for: postmenopausal women, men ≥50 with fragility fracture, glucocorticoid users, anyone with risk factors. Combine with DEXA. Don't just chase numbers - vertebral fragility fracture in older patient = treat regardless of DEXA. Recheck FRAX every 2-3 years or after fracture. UK NOGG and NICE thresholds slightly different - both reasonable.

Risk-based (not BMD-only) treatment decisions widespread.

• NICE NG124 - NICE hip fracture management; FLS guidance. Guideline
• Lindsay 2001 - Lindsay R et al. JAMA 2001;285:320-3. Cohort risk study

Vertebral fragility fracture (VFF) - including incidental on X-ray - confers ~5x increased risk of further vertebral fracture and ~2x hip fracture in next year. FLS (Fracture Liaison Service) pathways assess all fragility fractures and start treatment for those meeting criteria. NHS England national audit: FLS coverage improving but still incomplete.

Don't ignore an incidental VFF on X-ray or CT. Every fragility fracture should trigger FLS referral or equivalent assessment - not just hip fractures. Counsel patient: "This is a marker that bones are weakening; we have treatments that work." If your area lacks FLS coverage, refer to bone health clinic or arrange DEXA + assessment yourself.

FLS pathways expanding; identification of "incidental" VFFs on imaging.

• D-Cal (RECORD) 2005 - Grant AM et al. Lancet 2005;365:1621-8. n=5292 UK RCT
• VITAL 2019 - LeBoff MS et al. NEJM 2022;387:299-309. n=25,871 RCT vitamin D alone

RECORD: calcium+vitamin D combined modestly reduced fragility fractures in elderly. VITAL: vitamin D alone (2000IU/day) did NOT reduce fracture incidence in general adult population. High-dose annual vitamin D (500,000IU) increased fracture risk (Sanders 2010). Sweet spot: replete vitamin D + calcium intake (dietary or supplemented) for at-risk groups.

Don't supplement everyone. DO supplement when: documented deficiency, housebound elderly, dark skin, anticonvulsants, malabsorption. Aim 800-1000 IU/day cholecalciferol + calcium 700-1200mg/day (dietary preferred). Don't use annual high-dose loading - physiological harm. Combine with falls prevention exercise (which has the strongest fracture-prevention evidence in this population).

Targeted supplementation; less indiscriminate use; emphasis on exercise.

• Bolland 2010 - Bolland MJ et al. BMJ 2010;341:c3691. Meta-analysis CV risk
• Reid 2014 meta - Reid IR et al. JAMA Intern Med 2014;174:765-76. Fracture meta-analysis

Bolland meta-analysis suggested calcium supplements (without vitamin D) may increase MI risk by ~30%. Subsequent analyses mixed - combined calcium + vitamin D may have less CV signal. Fracture benefit modest (~10-15% reduction in non-vertebral fractures). NICE/NOGG: dietary calcium preferred; supplement only when dietary intake inadequate (typically <700mg/day) AND on antiresorptive treatment.

Don't routinely prescribe calcium supplements. Assess dietary intake (3 servings of dairy ≈ 750mg). Supplement only if dietary inadequate AND on bone-active treatment. If supplementing, prefer combined calcium + vitamin D (e.g. Adcal D3, Accrete D3) rather than calcium alone. Discuss CV evidence honestly when prescribing.

Dietary calcium emphasis; reduced indiscriminate supplementation.

• BSR GIOP 2017 - BSR glucocorticoid-induced osteoporosis 2017. UK guideline
• NICE TA161/204 - NICE TAs on osteoporosis treatments. TA guidance

Bone loss is rapid with glucocorticoids - significant decline in first 3-6 months. Fracture risk increases at low doses (≥2.5mg/day) and is independent of BMD. BSR 2017 recommends: start bisphosphonate from day 1 in higher-risk patients (age ≥65, prior fracture) anticipated to be on ≥7.5mg/day for ≥3 months. Lower-risk: DEXA-guided. Calcium + vitamin D for everyone on long-term steroids.

For any patient starting prednisolone expected for >3 months: assess fracture risk, start calcium + vitamin D, consider bisphosphonate. High-risk patients (age, prior fracture): bisphosphonate from start regardless of DEXA. Counsel about bone protection at the start, not retrospectively. Steroid-sparing strategies (e.g. methotrexate, biologics in PMR/GCA) reduce duration.

Earlier bone protection initiation; tighter MDT integration.

• Herring 2004 - Herring JA et al. JBJS Am 2004;86:2103-20. Multicentre prospective trial
• BSCOS guidance - British Society Children's Orthopaedic Surgery. Specialist consensus

Herring multicentre study: age at onset is the strongest outcome predictor. Children <6: most do well with observation regardless of containment. Children 6-8: results mixed; containment may help moderate severity. Children >8: surgical containment (varus osteotomy or pelvic shelf procedure) significantly improves outcomes in Catterall/Herring B and C disease.

Suspected Perthes (limp + groin pain in child) → urgent paediatric orthopaedic referral. Don't treat as "growing pain". Pelvic X-ray (AP + frog lateral) - early disease may need MRI. Conservative for younger children with milder disease. Surgical opinion for older children or moderate-severe disease.

Age-stratified pathways; specialist centre treatment.

• Loder 1993 - Loder RT et al. JBJS Am 1993;75:1134-40. Classification + AVN risk
• BSCOS standards - BSCOS. UK specialist standards

SUFE classification: stable (can WB) vs unstable (cannot WB) - unstable carries ~30-50% AVN risk. Stable SUFE: percutaneous pinning. Unstable: urgent surgical fixation, AVN risk increases with delay. Bilateral disease in 20-50% - must image both hips. Risk factors: age 10-15, obesity, endocrine disorders (hypothyroid, GH deficiency).

Adolescent with hip, knee, or thigh pain ± limp = check the hips (frog lateral X-ray). Don't accept "knee pain" without examining the hip. If SUFE diagnosed: same-day paediatric orthopaedic referral, no weight-bearing while transferring, image both hips. Most commonly missed pathology in adolescent MSK - high index of suspicion.

Same-day surgical pathway; routine bilateral hip imaging.

• Kocher 1999 - Kocher MS et al. JBJS Am 1999;81:1662-70. Diagnostic algorithm
• NICE NG143 - NICE 2020 fever in under 5s. Guideline

Kocher criteria for septic hip in child: fever >38.5°C, non-weight-bearing, ESR >40, WBC >12. 0 criteria = <0.2% probability septic; 4 criteria = 99.6% probability. Most acute limps in young children are transient synovitis (resolves 1-2 weeks). Must not miss: septic arthritis, osteomyelitis, SUFE (10-15yo), Perthes (4-10yo), malignancy (leukaemia, bone tumours), NAI.

Age-targeted thinking: toddler (consider NAI, occult fracture, transient synovitis), young child (Perthes, JIA), adolescent (SUFE). Red flags = unwell child, fever, night pain, weight loss, bruising/pallor, refusal to bear weight, single joint hot/swollen. Use Kocher criteria for suspected septic hip. Same-day paediatric referral for any concerning feature. Don't accept "growing pains" if features atypical.

Structured paediatric MSK pathways; better triage of red flag features.

• Vaishya 2016 review - Vaishya R et al. Cureus 2016. Narrative review
• Gholve 2007 - Gholve PA et al. Curr Opin Pediatr 2007. Review

Osgood-Schlatter: self-limiting condition resolving with closure of tibial tubercle apophysis (typically 14-18 in boys, 12-16 in girls). Activity modification (avoid jumping/squatting during flares), ice after activity, NSAIDs short-term. No good evidence that immobilisation, manual therapy, or specific exercises change the timeline. Persistent symptoms into adulthood ~10% (typically from unfused ossicle).

Reassure family - this resolves. Maintain sport participation within tolerance - don't force prolonged rest. Knee pads for sports with knee contact. Quadriceps and hamstring flexibility work reasonable. NSAIDs short-term during flares only. Persistent symptoms after skeletal maturity warrant orthopaedic opinion (ossicle excision occasionally needed).

Conservative reassurance pathway; reduced over-investigation.

• Steppacher 2008 - Steppacher SD et al. CORR 2008;466:1633-44. Long-term cohort
• Lerch 2017 - Lerch TD et al. JBJS Am 2017. Long-term outcomes

Periacetabular osteotomy (PAO) for symptomatic developmental dysplasia of the hip in skeletally mature young adults. Long-term outcomes: ~70-80% survivorship at 20 years in well-selected patients (no significant OA, joint congruence, age <40, BMI <30). Outcomes worse with significant OA at time of surgery - joint preservation window is finite.

Suspect adult dysplasia in young adults with insidious groin/anterior hip pain, female>male, family history. AP pelvis X-ray: lateral centre-edge angle <20° concerning. Refer to specialist hip preservation centre. Don't delay - joint preservation window narrows with OA progression. Conservative measures (activity modification, strengthening) helpful but PAO is the definitive joint-preserving option.

Earlier referral to specialist hip preservation centres.

• James 2016 - James AM et al. Br J Sports Med 2016. RCT footwear
• Wiegerinck 2014 review - Wiegerinck JI et al. JBJS Br 2014. Review

Sever's disease: traction apophysitis of the calcaneal physis, peaking ages 8-14 (boys) and 7-12 (girls). Self-limiting; resolves with apophyseal closure. James RCT: heel cups/silicone heel pads more effective than insoles for symptom relief in short-term. Eccentric calf strengthening + activity modification. Surgery never indicated.

Reassure family. Heel cups during activity for symptom relief. Calf stretching, eccentric loading. Activity modification rather than rest - gradual return as symptoms allow. Counsel about likely 12-18 month resolution timeline. Investigate atypical presentations (unilateral severe pain, swelling, night pain) for stress fracture or osteomyelitis.

Reassurance + simple measures; reduced over-investigation.

• McLauchlan 2002 - McLauchlan GJ et al. J Bone Joint Surg Br 2002. Outcomes review
• BOAST paediatric trauma - BOAST paediatric standards. UK standards

Paediatric bone remodels - younger child, more growth remaining, greater remodelling potential. Acceptable angulation (rough guide): age <10 with >2 years growth: 30° sagittal, 20° coronal often acceptable. >10 or near skeletal maturity: more conservative reduction. Translation: full apposition not required if alignment acceptable. Rotational malalignment does NOT remodel - must correct.

Don't over-treat paediatric distal radius fractures with aggressive reduction in young children. Cast immobilisation 4 weeks generally sufficient. Refer to paediatric orthopaedic for: significant deformity in older child, intra-articular involvement, open fractures, neurovascular concern, displaced physeal injuries (Salter-Harris). Counsel families about bone remodelling - visible "bump" may resolve.

Less aggressive reduction in young children; targeted surgical referral.

• Salter-Harris classification - Salter RB, Harris WR. JBJS Am 1963. Original classification
• Mizuta 1987 - Mizuta T et al. JBJS Am 1987. Outcomes review

SH I (slip): low risk of growth arrest; usually heals well with immobilisation. SH II (most common, ~75%): metaphyseal fragment; usually conservative. SH III (epiphyseal): intra-articular, often needs ORIF for joint congruity. SH IV (transphyseal): both metaphyseal and epiphyseal - highest risk of growth arrest; ORIF for any displacement. SH V (crush): often unrecognised initially; high growth arrest risk.

All physeal injuries need paediatric orthopaedic follow-up to monitor for growth disturbance (annual review 1-2 years minimum). SH III/IV displacement = urgent surgical opinion. Family counselling: most heal well but small risk of growth issues - schedule follow-up. Don't accept "discharge with cast" - these need follow-up to detect early growth arrest.

Standardised follow-up pathways; growth monitoring.

• BOAST 10 - British Orthopaedic Association Standards for Trauma 2014. UK standards
• McQueen 1996 - McQueen MM, Court-Brown CM. JBJS Br 1996;78:99-104. Diagnostic study

Compartment syndrome causes irreversible muscle necrosis within 4-6 hours of established compromise. Classic "5 Ps" are LATE - pulselessness, paralysis, pallor are end-stage. Early signs: severe disproportionate pain, pain on passive stretch, paraesthesia in nerve distribution. McQueen: compartment pressure within 30mmHg of diastolic = surgical decompression indicated. BOAST 10 sets UK national standards for diagnosis and management.

High index of suspicion in: tibial fractures, supracondylar humerus fractures (children), crush injuries, prolonged compression, tight casts. PAIN OUT OF PROPORTION TO INJURY is the key clinical sign. Pain on passive stretch of compartment muscles. Don't wait for pulselessness - that's end-stage. Same-day orthopaedic surgical assessment. Document time and findings carefully - medicolegal implications.

Earlier recognition pathways; BOAST 10 standards widely adopted.

• Todd 2017 - Todd NV. Br J Neurosurg 2017. Diagnostic review
• Hoeritzauer 2020 - Hoeritzauer I et al. J Neurol 2020. Systematic review

Suspected CES symptoms have positive predictive value ~25% for confirmed CES on MRI - most "suspected CES" patients don't have it. Best diagnostic features: saddle anaesthesia (variable definition matters), urinary retention with overflow incontinence, faecal incontinence, bilateral leg neurological symptoms. Single isolated symptoms much less specific. PVR bladder scan >300ml supports diagnosis. MRI is mandatory - cannot exclude clinically.

Use systematic red-flag assessment with documented findings (PR exam, perineal sensation testing, post-void residual). Don't rely on single symptoms. If concern: same-day MRI and neurosurgical referral. Document carefully - medicolegal vulnerability. Negative MRI = relieved patient and you, but follow-up plan if symptoms progress. Patient communication: "We need to rule this out today" not "It might be serious".

Structured red-flag screening with documentation; better diagnostic discipline.

• NASCIS 1990/1997 - Bracken MB et al. NEJM 1990. High-dose methylprednisolone trials
• AANS/CNS guidelines 2013 - Hadley MN et al. Neurosurgery 2013. Updated guidance

High-dose methylprednisolone (NASCIS protocol) for acute SCI - no longer routinely recommended due to lack of clear benefit and significant complications (sepsis, GI bleeding). AANS/CNS 2013 specifically advised against routine use. Modern management: maintenance of mean arterial pressure >85 mmHg for first 7 days improves outcomes. Urgent transfer to spinal injuries centre. Early bladder care, DVT prophylaxis, skin care.

Don't give high-dose steroid to suspected acute SCI without specialist guidance. Maintain BP - aggressive resuscitation. Spinal immobilisation during transfer. Same-day spinal centre referral. Document neurological level carefully. Bladder care from day 1 (intermittent catheterisation typically). Multi-disciplinary input.

Steroids removed from routine protocols; BP-driven management.

• Wong LRINEC 2004 - Wong CH et al. Crit Care Med 2004. Diagnostic score
• Stevens 2014 IDSA - Stevens DL et al. Clin Infect Dis 2014. Treatment guideline

Necrotising fasciitis mortality 25-30% even with prompt treatment. Diagnosis often delayed because early presentation looks like simple cellulitis. Clues: pain out of proportion to skin findings, rapid progression, systemic toxicity, woody/oedematous induration, skin necrosis, crepitus, bullae. LRINEC score (CRP, WBC, Hb, Na, Cr, glucose) supports diagnosis but doesn't exclude - clinical suspicion dominates. CT may help but should not delay surgery.

High suspicion if "cellulitis" is rapidly progressing, has disproportionate pain, or systemic toxicity. Same-hour surgical opinion + IV broad-spectrum antibiotics + resuscitation. Don't wait for definitive imaging if clinical picture is fitting. Early surgical debridement is the only intervention that changes outcome. Cleanse low-suspicion cellulitis from rapidly progressing concerning cases.

Earlier recognition with clinical risk stratification; aggressive surgical pathway.

• NICE NG12 - NICE 2015 cancer recognition. Guideline
• NICE NG87 sarcoma - NICE sarcoma guidance. Specialist guideline

MSK presentation red flags for malignancy: night pain not relieved by position, unintentional weight loss, age <20 or >50 with new bone pain, palpable mass >5cm or deep to fascia or rapidly growing, atypical clinical pattern. Bone tumours commonly missed initially as "growing pain" or sports injury in young patients. Bone metastases common in adults with breast/prostate/lung primaries. NICE NG12: 2-week cancer pathway for suspected sarcoma (mass >5cm, deep, fixed, increasing in size).

Take "atypical" presentations seriously, especially in adolescents and older adults. Plain X-ray for bone pain - fracture or lytic lesion. MRI for suspected soft tissue mass. Direct referral to soft tissue sarcoma MDT (don't biopsy in primary care). Counsel without alarming: "I want to rule some things out - most often these tests come back fine".

Standardised cancer pathways; earlier MRI for atypical presentations.