MSK Ultrasound - Guidance for Primary Care Diagnostic* referrals

*(injection criteria are not routinely included and can be accessed at Leeds Health Pathways (leedsth.nhs.uk))

Ultrasound = US     Leeds Healthcare Pathways = LHP

  1. Hernia
  2. Soft tissue swelling
  3. Hand & wrist
  4. Elbow
  5. Shoulder
  6. Hip
  7. Knee
  8. Ankle & foot

Joint Ultrasound Overview

  • Ultrasound (US) is not indicated for the majority of patients presenting with non-acute, non-severe pain without red flags - initially should be managed as per local pathways without the need for imaging.  
  • Ultrasound is usually most useful for focal symptoms/diagnoses and not diffuse/generalised clinical features.

1. Hernia

  • US not routinely indicated if:
    • If there are characteristic history and examination findings for a hernia, eg. Reducible palpable lump or cough impulse, then US not routinely required.
    • Irreducible and/or tender lumps suggest incarcerated hernia and require urgent surgical clinical assessment rather than urgent OP imaging.
    • If groin pain is present without any examination evidence of a hernia or swelling, clinical assessment should also consider MSK causes. US for these cases should only be requested by secondary care referrers.
  • US indicated if:
    • Imaging for characteristic clinical features of a hernia should be considered for:
      • All women query femoral hernia
      • Men if c/o increasing pain (-ref EBI21)
    • If there is clinical doubt as to the cause of a swelling, Mass lesion - see section 2.

2. Soft tissue swelling

  • US not routinely indicated if2:
    • Do not scan lesions less than 1cm in size unless causing clinically significant local symptoms, clinical review of cases at 6-8 weeks is advised
    • The majority of soft tissue lumps are benign and if there are classical clinical signs of a benign lump then US is not routinely required for diagnosis.
    • Skin lesions, especially those <3cm, should be directly referred to dermatology or plastics, not for US.
    • Uncomplicated ganglia and small lipomata do not routinely require imaging.
    • <5cm stable, soft, mobile, non-tender lumps do not routinely warrant US.
  • US indicated if 2:
    • Equivocal findings and diagnosis is essential to management.
    • Significant findings (including >5cm, fixed, tender mass, increasing in size, overlying skin changes) should be scanned on an urgent basis as per regional guidance.
  • Where ultrasound is not initially indicated clinical review of cases at 8 weeks is advised.

3. Hand & Wrist

  • US not routinely indicated if:
    • Trauma/arthritis - X-ray.
    • Synovitis/erosions - refer to Rheumatology if inflammatory arthritis suspected. (Rheumatology do for some patients undertake US assessments of small joints for this as part of research protocols).
    • Septic arthritis - urgent referral to Orthopaedics is advised if joint sepsis is felt clinically likely.
    • Pulley/sagittal band injury/ruptures - not indicated for primary care referral, refer to MSK service, GP with MSK interest.
    • Thumb/finger collateral ligament injuries - not indicated for primary care referral, refer to MSK service, GP with MSK interest.
    • Volar plate injury - not indicated for primary care referral, refer to MSK service, GP with MSK interest.
    • Guided Injection - not indicated for primary care referral, refer to MSK service, GP with MSK interest.
  • US indicated if:
    • US is potentially useful for the diagnosis and treatment of tendon and symptomatic mass lesions
    • Nerve compression
    • Mass lesion -see section 2.

4. Elbow

  • US not routinely indicated if:
    • Trauma/arthritis – X-ray.
    • Synovitis/erosions –refer to Rheumatology if inflammatory arthritis suspected. (Rheumatology do for some patients undertake US assessments of small joints for this as part of research protocols).
    • Septic arthritis - urgent referral to Orthopaedics is advised if joint sepsis is felt clinically likely.
    • Guided Injection – not indicated refer to MSK service, GP with MSK interest.
  • US indicated if:
    • Distal biceps tendon tear.
    • Nerve compression.
    • US is potentially useful for the diagnosis and treatment of tendon and symptomatic mass lesions
    • Mass lesion - see section 2.

5. Shoulder

  • US not routinely indicated1:
    • For the majority of patients presenting with shoulder pain without red flags, non acute, non severe shoulder pain -should be managed as per LHP without the need for imaging
    • Trauma/arthritis - X-ray.
    • Adhesive capsulitis/Frozen shoulder - clinical diagnosis with X-Ray to exclude arthropathy.
    • Acromioclavicular OA/instability, Sternoclavicular joint disease - x-rays.
    • Glenohumeral joint instability/Labral pathology - specialist clinical diagnosis.
  • US only indicated where x-ray not helpful and initial management/ therapy is not effective to query1;
    • Site and size of tendon tears.
    • Post op cuff failure.
    • Occult greater tuberosity fracture (if normal xray).
    • Mass lesion - see section 2.
  • US guided subacromial injection:
    • Only refer if patient has already undergone recent (<6months) physiotherapy treatment AND patient has had a recent (<6months) unguided injection in Primary and/or MSK Community care.
    • The use of other guided injections for glenohumeral joint and acromioclavicular joint problems should only be offered under the guidance of a secondary care shoulder service responsible for definitive treatment of these patients.
    • US guided barbotage of calcific tendonitis is not indicated for primary care referral, refer to MSK service, GP with MSK interest.

6. Hip

  • US not routinely indicated:
    • X-ray is usually the first imaging investigation for hip pain
    • Trauma/arthritis - X-ray
    • Lateral/Trochanteric pain – ultrasound not usually helpful, initially manage clinically as per LHP.
  • Ultrasound indicated if:

7. Knee

  • US not routinely indicated:
    • for the majority of patients presenting with knee pain without red flags, non acute, non severe knee pain.
    • Diffuse pain, degeneration - X-ray should be performed if symptoms warrant.
    • Trauma/arthritis - X-ray.

  • US indicated if:
    • Quadriceps/patella tendon - acute severe onset tendinopathy/tears.
    • Not routinely indicated for Chronic tendinopathy but use if initial treatment is ineffective for;
    • Suprapatellar/infrapatellar/pre patellar bursitis
    • Patellar or Quadriceps tendinopathy
    • Baker’s cyst, unless clinical concern for Mass lesion -see section 2.

8. Ankle & Foot

  • US not routinely indicated for;
    • Ankle ligament injury - if persistent symptoms refer to MSK service.
    • Trauma/arthritis - X-ray.
    • Plantar fasciitis - refer to Podiatry service unless seronegative arthropathy, plantar fibroma or plantar fascia rupture is considered clinically.
    • Morton’s neuroma - refer to Podiatry service.
  • US indicated if:
    • acute severe onset tendinopathy/tears.
    • Achilles tendinopathy not responding to conservative management.
    • Retrocalcaneal/pre Achilles bursitis.
    • Mass lesion - see section 2.
    • Not routinely indicated for Chronic ankle tendinopathy but consider if initial treatment is ineffective.

References

  1. EBI 12. https://www.aomrc.org.uk/wpcontent/uploads/2020/12/EBI_list2_guidance_150321.pdf
  2. iRefer - https://www.irefer.org.uk and NICE NG12.

 

 

 

 

 

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