Secondary Care Management Changes







  • Urgent and emergency musculoskeletal conditions requiring onward referral

  • USS guided steroid injection service provided by Clinical Imaging

    The RCHT Clinical Imaging Directorate are now able to restart a limited US guided MSK steroid injection service for primary care. There is limited capacity so referrals should be reserved for patients with significant disabling and persistent symptoms.

    As well as the usual clinical details, referrers will be expected to provide the following information 

    To confirm that all other treatment options have been exhausted and that the patient is experiencing high levels of pain and disability.

    To confirm that the theoretical risks of steroid injections during the Covid pandemic have been discussed with the patient including possible increased susceptibility to the virus.

    There is a theoretical possibility that a patient may not mount such a good immune response to the vaccine if it is administered within a short while of a steroid injection. We will not be giving a steroid injection 2 weeks either side of the vaccine dates. For this reason, please state the patient's first and second vaccination dates so that we can adjust the timing of the ultrasound appointment.

    Dr Tom Sulkin, Consultant Radiologist, RCHT 27 April 2021


    Therapeutic Steroid Joint Injections

    The Intercollegiate guidance on use of corticosteroids and therapeutic steroid injections during Covid 19 has been updated in the context of phase 3 of the pandemic, please see here for details. 

    In summary:

    Only give a steroid injection if a patient has significant disease activity and/or intrusive and persisting symptoms and there are no appropriate alternatives where the benefits outweigh the risks.  Only consider a steroid injection if a patient has high levels of pain and disability, has exhausted first line conservative measures and continued symptoms will have a significant negative impact on health and wellbeing.  Consider using the minimum appropriate dose possible.  Patients should be given guidance about activity modification and exercise therapy following an injection. 

    The patient must be counselled on the potential risks of immunosuppression as a result of the injection and subsequent risk of coronavirus and informed consent documented.  There is a potential risk that a steroid injection given to an asymptomatic patient could put them at an increased risk of adverse outcome from the virus, although this is not known at this stage and the level of risk is not known.  This potential risk will be increased in patients who are more clinically vulnerable such as over 70, patients with BAME ethnicity, chronic co-morbidities and also high BMI.  The guidance advises to adhere to local infection control and public health policies.

    All requests for steroid injections including image guided requests such as Mortons require that the patient has been counselled and risk assessment happen prior to referral.  This should be documented including that all other treatment options have been exhausted on the referral letter.

    Intercollegiate Guidelines.  Management Of Patients With Musculoskeletal Conditions Who Are On Corticosteroids, Require Initiation Of Oral/IV Corticosteroids, Require A Corticosteroid Injection.  20 November 2020


    Dr Rebecca Hopkins

    GP, Orthopaedic Guidelines Lead Planned Care Advisory Group and CCG Lead MSK Rightcare

    4th March 2022