To include syndromes such as work related upper limb disorder, RSI and cumulative trauma disorder.

Red flags for elbows, wrists & hands

Prior to referral consider / screen to exclude:

Key Clinical Observations of concern

  • Hot / red / swollen joint with raised body temperature
  • Rapidly worsening deformity
  • Neuro-vascular compromise
Urgent elbow / wrist / hand referral

Patients with any of the following suspected should be sent to A&E:

  • Fracture or dislocation
  • Suspected infection
  • Recent tendon or ligament rupture

Urgent appointments can be made in elective Hand Clinics for patients with:

  • Rapidly worsening symptoms
  • Hand pain with confirmed presence of cancer on imaging.
  • Constant unrelenting hand or forearm pain / especially unrelenting night pain in presence of cancer
  • Progressive or significant neurological loss suggestive of acute peripheral nerve compression
GP / Primary Clinician

Exclude red flags: Inflammatory conditions, PMR,SLE, connective tissue disease.

Consider Diagnosis (discuss within peer review).

Diagnoses may include:

  • Tendonitis.
  • Tenosynovitis.
  • CTS.
  • Dystonia.
  • Cerviogenic  symptoms.
  • Fibromyalgia.

Complete psychosocial assessment yellow flags:

  • Distress/Disability.
  • Diagnostic uncertainties.
  • Drug escalation / dependency.


  • Optimal analgesia/ NSAIDS.
  • Consider psychosocial risk factors and advise
  • With low risk patients advise:
    • Activity modification; minimise overuse; reduce exposure to force, vibration and repetitive movement.
    • Advise occupational health assessment if available; often, simple modifications to workplace are sufficient.
    • Weight lossSmoking cessation if applicable.
  • With high risk patients refer to physiotherapy or occupational therapy.


  • Nerve Conduction Studies if indicated.
  • X-ray if suspicious of trauma, infection, tumour or arthritis.
Physiotherapist / Occupational Therapist
  • Consider guidelines in previous section.
  • Assessment / Diagnosis /Detailed advice/ Lifestyle advice/Posture correction/Ergonomic assessment.
  • Exercise; upper limb stretches/ consider acupuncture as part of a package of care.
  • Explain Pain - Pain Tool kit (www.paintoolkit.org) / Pacing activity).
  • Corticosteroid injection if indicated and able to offer within service.

If not responding consider referral to Interface Team.

Interface Team
  • Consider/ review previous assessment, diagnosis and management.
  • Review psychosocial risk factors and management.
  • Challenge unhelpful attitudes and beliefs and give advice and information.
  • If not responding consider  diagnostic corticosteroid injection.
  • Explain pain – Pain Tool kit (www.paintoolkit.org) / Pacing activity).
  • If none of the above effective consider criteria for onward referral to surgeon, pain clinic or psychologist.
  • If patient does not wish to explore surgical option refer back to GP or Pain Consultant for advice regarding analgesia and pain management.


  • Nerve conduction studies if indicated.
  • X-ray if suspicious of trauma, infection, tumour or arthritis.


Pain Medicine Services Criteria

Criteria for referral to Pain Medicine services:

  • Intrusive pain, failed primary treatments and analgesic ladder.
  • High risk of persistent pain e.g. Distressed, Drug escalation, Disabled, Diagnostic uncertainties, Dependency.
  • Strong opiods are being considered.
  • Unlikely to benefit from surgery.
Surgical Criteria
  • Referral is appropriate if surgery is likely or for complext diagnosis.
  • Surgery is unlikely in non-specific pain syndromes.
  • Consider the following:
    • willingness to undergo surgery
    • general health
    • understanding of recovery period post surgery

Dependent on specific condition(s) identified (see identified condition pathways).