Serious MSK pathology:

History/questionnaire:

Escalating pain and progressively worsening symptoms that do not respond to conservative management or medication as expected?

Systemically unwell (fever, weight loss)?

Night pain that prevents sleep due to escalating pain and/or difficulty lying flat?

Cauda Equina Syndrome/CES (red flag cards)?

History/questionnaire:

Spinal and leg pain with neurological symptoms, saddle sensory disturbance +/- bladder/bowel dysfunction (late sign)?

Paraesthesiae with loss of feeling/pins and needles between thighs/genitals, numbness in/around buttocks/anus, altered feeling when wiping with toilet paper?

Urine symptoms with difficulty when trying to pass urine, difficulty stopping or controlling stream, loss of sensation when passing urine, leaking urine or recent need to use pads, not knowing if bladder full or empty?

Bowel problems with inability to stop bowel movement, loss of sensation when opening bowels?

Sexual function with change in ability to get erection or ejaculate, loss of genital sensation during sex?

Management:

Same day referral

Metastatic spinal cord compression/MSSC?

History/questionnaire:

Breast, lung, prostate and renal cancer?

Referred back pain is multi-segmental or band-like?

Escalating pain which is poorly responsive to treatment (incl medication)?

Different character or site to previous symptoms?

Funny feelings, odd sensations or heavy legs (multi-segmental)?

Lying flat increases back pain?

Agonising pain-causing anguish and despair?

Gait disturbance, unsteadiness, especially on stairs (not just a limp)?

Sleep grossly disturbed due to pain being worse at night?

Management:

Same day referral

Spinal infection (e.g. discitis/osteomyelitis)?

History/questionnaire:

Spinal pain?

Fever?

Worsening neurological symptoms?

Risk factors (eg immunosuppressed, primary source of infection, personal or family history of TB)?

Management:

Same day referral

Septic arthritis:

History/questionnaire:

Hot swollen, painful joint and multi-directional restriction of movement?

Fever (may or may not be present)?

(Note: consider in children who present with painful limp or loss of limb function - they often do not present with typical hot/swollen joint.)

Management:

Same day referral

Giant Cell Arteritis/GCA?

History/questionnaire:

New-onset headache, typically in the temple region?

Associated symptoms include jaw claudication, shoulder or pelvic girdle pain and stiffness?

Visual symptoms?

Raised ESR/CRP?

Management:

Steroids started?

Visual symptoms?

If yes, same day referral to ophthalmology

If no, urgent referral to rheumatology within 3 days

Primary or secondary cancers?

History/questionnaire:

Breast, prostate and lung most likely to metastasise to the spine?

Progressive escalation of pain and night pain?

Management:

Urgent referral

If systemically unwell: same day referral

Insufficiency fracture?

History/questionnaire:

Acute pain, mostly in the thoracic-lumbar region following low impact trauma?

Pain can vary in presentation but is usually localised to the area of fracture?

Risk factors associated with osteoporosis?

More serious cause e.g. malignant fracture/risk of MSCC?

Management:

Urgent referral

Cervical myelopathy:

History/questionnaire:

Cervical spondylosis?

Worsening pain?

Lack of coordination e.g. buttoning a shirt?

Heaviness or weakness in arms/legs?

Pins and needles and pain in arms?

Difficulty walking?

Bladder/bowel dysfunction?

Management:

Urgent referral

Persistent synovitis suggesting acute inflammatory arthritis:

History/questionnaire:

Small joints of hands or feet affected?

Persistent early morning stiffness of >30 minutes?

(Note normal ESR/CRP or rheumatoid factor/anti-CCP antibodies do NOT rule out serious acute inflammatory arthritis e.g. rheumatoid arthritis or psoriatic arthritis)

Management:

If acute inflammatory arthritis: urgent referral

Suspected new-onset autoimmune connective tissue disease or vasculitis:

History/questionnaire:

MSK symptoms?

New inflammatory arthritis?

Extra-articular manifestations?

- Rash

- Raynauds syndrome

- Mouth ulcers +/- sick symptoms (dry mouth and eyes)

Management:

Urgent referral

Reference(s):

Urgent and Emergency MSK conditions Dec 2020 (compiled by BASS, BOA, BSR, RCGP, Ch. Soc. Physio)