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Lower Limb Glos Care Pathway Overview

MSK Specialist Triage commenced in July 2018. All lower limb triage referrals for Orthopaedic review across Gloucestershire are divided between Gloucester Care Services (GCS) and Gloucestershire NHS Foundation Trust (GHNHSFT). GHNHSFT triage patients within the Gloucester and Cheltenham localities, and GCS triage the five other localities. The two organisations work closely together to ensure consistency and standardisation of approach.

Please strongly consider Supported Self-Management

Please click the relevant flowchart box to be taken directly to textual information


Red Flags
Clinical Observations of concern:
  • Hot / red / swollen joint with raised body temperature  (raised inflammatory markers)
  • Septic/Unwell
  • Rapidly worsening deformity
  • Neuro-vascular compromise
  • Weight loss
  • Continuous pain, including at night and when not weight bearing.
  • Unable to walk or move hip/knee
  • Progressive or significant neurological loss suggestive of acute peripheral nerve compression
  • Confirmed presence of cancer on imaging.
If suspected tumour - refer via 2ww
If the patient is still under consultant care post-operatively any issues relating to post-operative recovery should be referred back to the consultant.
Refer to the Trauma Triage Service or A& E for suspected fracture
Differential Diagnosis

Please do not refer to the MSK Specialist Triage Service for the following:


Action to take

Suspected fracture or acute traumatic injury

Refer to A&E or the Trauma Triage Service

Suspected new diagnosis of inflammatory arthritis

Refer to Rheumatology

Patient with significant likelihood or peripheral vascular disease or occlusion 

Refer to Vascular Surgery

Patient with suspected DVT

Follow DVT Pathway

Supported Self-Management

Many patients with lower limb problems can, with advice and guidance, manage their problems without additional support. Please see the individual conditions for specific guidance.

See the Core Physiotherapy Services section for patient self-referral information, printable posters and business cards.

When to do Investigations

  • Recommend X-ray AP Pelvis centred on pubic symphysis for OA diagnosis or where rapid deterioration of symptoms present.
  • X-ray AP Pelvis where suspicious of trauma, infection, tumour, inflammatory arthritis (AVN maybe X-ray negative until established 6-9 months).
  • If the X-ray is negative MRI is the best second line investigation for further evaluation of X-ray negative pain.

  • X-ray only for suspected:
    • trauma
    • instability
    • Osteoarthritis
    • infection
    • tumour
    • inflammatory arthritis
  • Consider weight bearing X-ray AP and lateral views with skyline only if patella involvement implicated
  • Weight bearing X-ray if no improvement in acute on chronic or degenerative knee
  • Consider Standing AP and Lateral if symptoms are not managed with early stage management
  • Consider skyline X-ray if PFJ OA suspected
  • MRI not routinely indicated - rarely adds to diagnosis only indicated as second line investigation
  • US can be of value if confirmation of patella tendinopathy is required
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