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Musculoskeletal conditions

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What is covered

This interactive flowchart covers musculoskeletal conditions, including arthritis, bone and joint conditions, congenital conditions, maxillofacial conditions, soft tissue conditions, and spinal and back conditions. It also includes links to the NICE interactive flowcharts on low back pain and sciatica, osteoarthritis, osteoporosis and rheumatoid arthritis.

Updates

Updates to this interactive flowchart

20 December 2016 The following guidance was added:
  • radiation therapy for early Dupuytren's disease (NICE interventional procedures guidance 573) and extracorporeal shockwave therapy for Achilles tendinopathy (NICE interventional procedures guidance 571) added to soft tissue conditions
  • epiduroscopic lumbar discectomy through the sacral hiatus for sciatica (NICE interventional procedures guidance 570) added to spinal and back conditions.
22 November 2016 Percutaneous insertion of craniocaudal expandable implants for vertebral compression fracture (NICE interventional procedures guidance 568) added to spinal and back conditions.
4 October 2016 Belimumab for treating active autoantibody-positive systemic lupus erythematosus (NICE technology appraisal guidance 397) in systemic lupus erythematosus updated on publication of managed access agreement.
27 September 2016 Secukinumab for active ankylosing spondylitis after treatment with non-steroidal anti-inflammatory drugs or TNF-alpha inhibitors (NICE technology appraisal guidance 407) added to ankylosing spondylitis and non-radiographic axial spondyloarthritis.
19 July 2016 Direct C1 lateral mass screw for cervical spine stabilisation (NICE interventional procedures guidance 146) added to spinal and back conditions.
21 June 2016 Microstructural scaffold (patch) insertion without autologous cell implantation for repairing symptomatic chondral knee defects (NICE interventional procedures guidance 560) added to bone and joint conditions and belimumab for treating active autoantibody-positive systemic lupus erythematosus (NICE technology appraisal guidance 397) added to systemic lupus erythematosus.
24 May 2016 Biodegradable subacromial spacer insertion for rotator cuff tears (NICE interventional procedures guidance 558) added to bone and joint conditions.
26 April 2016 The following guidance was added to spinal and back conditions:
  • percutaneous transforaminal endoscopic lumbar discectomy for sciatica (NICE interventional procedures guidance 556)
  • percutaneous interlaminar endoscopic lumbar discectomy for sciatica (NICE interventional procedures guidance 555).
1 February 2016 TNF-alpha inhibitors for ankylosing spondylitis and non-radiographic axial spondyloarthritis (NICE technology appraisal guidance 383) added to ankylosing spondylitis and non-radiographic axial spondyloarthritis.
The following guidance was added to spinal and back conditions:
  • percutaneous intradiscal radiofrequency treatment of the intervertebral disc nucleus for low back pain (NICE interventional procedures guidance 545)
  • percutaneous electrothermal treatment of the intervertebral disc annulus for low back pain and sciatica (NICE interventional procedures guidance 544)
  • percutaneous coblation of the intervertebral disc for low back pain and sciatica (NICE interventional procedures guidance 543)
  • peripheral nerve-field stimulation for chronic low back pain (NICE interventional procedures guidance 451)
  • percutaneous intradiscal electrothermal therapy for low back pain (NICE interventional procedures guidance 319)
15 December 2015 Apremilast for treating active psoriatic arthritis (NICE technology appraisal guidance 372) added to psoriatic arthritis and abatacept, adalimumab, etanercept and tocilizumab for treating juvenile idiopathic arthritis (NICE technology appraisal guidance 373) added to juvenile idiopathic arthritis.
3 June 2015 Ustekinumab for treating active psoriatic arthritis (NICE technology appraisal guidance 340), golimumab for the treatment of psoriatic arthritis (NICE technology appraisal guidance 220), and etanercept, infliximab and adalimumab for the treatment of psoriatic arthritis (NICE technology appraisal guidance 199) added to psoriatic arthritis, and suture fixation of acute disruption of the distal tibiofibular syndesmosis (NICE interventional procedures guidance 521) added to bone and joint conditions.
27 January 2015 The following guidance was added:
  • open reduction of slipped capital femoral epiphysis (NICE interventional procedures guidance 511) added to bone and joint conditions.
  • thoracoscopic repair of congenital diaphragmatic hernia in neonates (NICE interventional procedures guidance 379) added to congenital conditions.
  • rituximab in combination with glucocorticoids for treating anti-neutrophil cytoplasmic antibody-associated vasculitis (NICE technology appraisal guidance 308) added to vasculitis.
  • combined bony and soft tissue reconstruction for hip joint stabilisation in proximal focal femoral deficiency (PFFD) (NICE interventional procedures guidance 297) added to bone and joint conditions.
25 November 2014 Insertion of an annular disc implant at lumbar discectomy (NICE interventional procedures guidance 506) added to spinal and back conditions.
24 June 2014 Arthroscopic radiofrequency chondroplasty for discrete chondral defects of the knee (NICE interventional procedures guidance 493) added to bone and joint conditions.
17 June 1014 The following guidance was added to spinal and back conditions:
  • The MAGEC system for spinal lengthening in children with scoliosis (NICE medical technologies guidance 18)
  • interspinous distraction procedures for lumbar spinal stenosis causing neurogenic claudication (NICE interventional procedures guidance 365)
  • prosthetic intervertebral disc replacement in the cervical spine (NICE interventional procedures guidance 341)
  • therapeutic percutaneous image-guided aspiration of spinal cysts (NICE interventional procedures guidance 223).

Your responsibility

Guidelines

The recommendations in this interactive flowchart represent the view of NICE, arrived at after careful consideration of the evidence available. When exercising their judgement, professionals are expected to take these recommendations fully into account, alongside the individual needs, preferences and values of their patients or service users. The application of the recommendations in this interactive flowchart is not mandatory and does not override the responsibility of healthcare professionals to make decisions appropriate to the circumstances of the individual patient, in consultation with the patient and/or their carer or guardian.
Local commissioners and/or providers have a responsibility to enable the interactive flowchart to be applied when individual health professionals and their patients or service users wish to use it. They should do so in the context of local and national priorities for funding and developing services, and in light of their duties to have due regard to the need to eliminate unlawful discrimination, to advance equality of opportunity and to reduce health inequalities. Nothing in this interactive flowchart should be interpreted in a way that would be inconsistent with compliance with those duties.
Commissioners and providers have a responsibility to promote an environmentally sustainable health and care system and should assess and reduce the environmental impact of implementing NICE recommendations wherever possible.

Technology appraisals

The recommendations in this interactive flowchart represent the view of NICE, arrived at after careful consideration of the evidence available. When exercising their judgement, health professionals are expected to take these recommendations fully into account, alongside the individual needs, preferences and values of their patients. The application of the recommendations in this interactive flowchart is at the discretion of health professionals and their individual patients and do not override the responsibility of healthcare professionals to make decisions appropriate to the circumstances of the individual patient, in consultation with the patient and/or their carer or guardian.
Commissioners and/or providers have a responsibility to provide the funding required to enable the recommendations to be applied when individual health professionals and their patients wish to use it, in accordance with the NHS Constitution. They should do so in light of their duties to have due regard to the need to eliminate unlawful discrimination, to advance equality of opportunity and to reduce health inequalities.
Commissioners and providers have a responsibility to promote an environmentally sustainable health and care system and should assess and reduce the environmental impact of implementing NICE recommendations wherever possible.

Medical technologies guidance, diagnostics guidance and interventional procedures guidance

The recommendations in this interactive flowchart represent the view of NICE, arrived at after careful consideration of the evidence available. When exercising their judgement, healthcare professionals are expected to take these recommendations fully into account. However, the interactive flowchart does not override the individual responsibility of healthcare professionals to make decisions appropriate to the circumstances of the individual patient, in consultation with the patient and/or guardian or carer.
Commissioners and/or providers have a responsibility to implement the recommendations, in their local context, in light of their duties to have due regard to the need to eliminate unlawful discrimination, advance equality of opportunity, and foster good relations. Nothing in this interactive flowchart should be interpreted in a way that would be inconsistent with compliance with those duties.
Commissioners and providers have a responsibility to promote an environmentally sustainable health and care system and should assess and reduce the environmental impact of implementing NICE recommendations wherever possible.

Person-centred care

People have the right to be involved in discussions and make informed decisions about their care, as described in your care.
Making decisions using NICE guidelines explains how we use words to show the strength (or certainty) of our recommendations, and has information about prescribing medicines (including off label use), professional guidelines, standards and laws (including on consent and mental capacity), and safeguarding.

Short Text

Everything NICE has said on musculoskeletal conditions in an interactive flowchart

What is covered

This interactive flowchart covers musculoskeletal conditions, including arthritis, bone and joint conditions, congenital conditions, maxillofacial conditions, soft tissue conditions, and spinal and back conditions. It also includes links to the NICE interactive flowcharts on low back pain and sciatica, osteoarthritis, osteoporosis and rheumatoid arthritis.

Updates

Updates to this interactive flowchart

20 December 2016 The following guidance was added:
  • radiation therapy for early Dupuytren's disease (NICE interventional procedures guidance 573) and extracorporeal shockwave therapy for Achilles tendinopathy (NICE interventional procedures guidance 571) added to soft tissue conditions
  • epiduroscopic lumbar discectomy through the sacral hiatus for sciatica (NICE interventional procedures guidance 570) added to spinal and back conditions.
22 November 2016 Percutaneous insertion of craniocaudal expandable implants for vertebral compression fracture (NICE interventional procedures guidance 568) added to spinal and back conditions.
4 October 2016 Belimumab for treating active autoantibody-positive systemic lupus erythematosus (NICE technology appraisal guidance 397) in systemic lupus erythematosus updated on publication of managed access agreement.
27 September 2016 Secukinumab for active ankylosing spondylitis after treatment with non-steroidal anti-inflammatory drugs or TNF-alpha inhibitors (NICE technology appraisal guidance 407) added to ankylosing spondylitis and non-radiographic axial spondyloarthritis.
19 July 2016 Direct C1 lateral mass screw for cervical spine stabilisation (NICE interventional procedures guidance 146) added to spinal and back conditions.
21 June 2016 Microstructural scaffold (patch) insertion without autologous cell implantation for repairing symptomatic chondral knee defects (NICE interventional procedures guidance 560) added to bone and joint conditions and belimumab for treating active autoantibody-positive systemic lupus erythematosus (NICE technology appraisal guidance 397) added to systemic lupus erythematosus.
24 May 2016 Biodegradable subacromial spacer insertion for rotator cuff tears (NICE interventional procedures guidance 558) added to bone and joint conditions.
26 April 2016 The following guidance was added to spinal and back conditions:
  • percutaneous transforaminal endoscopic lumbar discectomy for sciatica (NICE interventional procedures guidance 556)
  • percutaneous interlaminar endoscopic lumbar discectomy for sciatica (NICE interventional procedures guidance 555).
1 February 2016 TNF-alpha inhibitors for ankylosing spondylitis and non-radiographic axial spondyloarthritis (NICE technology appraisal guidance 383) added to ankylosing spondylitis and non-radiographic axial spondyloarthritis.
The following guidance was added to spinal and back conditions:
  • percutaneous intradiscal radiofrequency treatment of the intervertebral disc nucleus for low back pain (NICE interventional procedures guidance 545)
  • percutaneous electrothermal treatment of the intervertebral disc annulus for low back pain and sciatica (NICE interventional procedures guidance 544)
  • percutaneous coblation of the intervertebral disc for low back pain and sciatica (NICE interventional procedures guidance 543)
  • peripheral nerve-field stimulation for chronic low back pain (NICE interventional procedures guidance 451)
  • percutaneous intradiscal electrothermal therapy for low back pain (NICE interventional procedures guidance 319)
15 December 2015 Apremilast for treating active psoriatic arthritis (NICE technology appraisal guidance 372) added to psoriatic arthritis and abatacept, adalimumab, etanercept and tocilizumab for treating juvenile idiopathic arthritis (NICE technology appraisal guidance 373) added to juvenile idiopathic arthritis.
3 June 2015 Ustekinumab for treating active psoriatic arthritis (NICE technology appraisal guidance 340), golimumab for the treatment of psoriatic arthritis (NICE technology appraisal guidance 220), and etanercept, infliximab and adalimumab for the treatment of psoriatic arthritis (NICE technology appraisal guidance 199) added to psoriatic arthritis, and suture fixation of acute disruption of the distal tibiofibular syndesmosis (NICE interventional procedures guidance 521) added to bone and joint conditions.
27 January 2015 The following guidance was added:
  • open reduction of slipped capital femoral epiphysis (NICE interventional procedures guidance 511) added to bone and joint conditions.
  • thoracoscopic repair of congenital diaphragmatic hernia in neonates (NICE interventional procedures guidance 379) added to congenital conditions.
  • rituximab in combination with glucocorticoids for treating anti-neutrophil cytoplasmic antibody-associated vasculitis (NICE technology appraisal guidance 308) added to vasculitis.
  • combined bony and soft tissue reconstruction for hip joint stabilisation in proximal focal femoral deficiency (PFFD) (NICE interventional procedures guidance 297) added to bone and joint conditions.
25 November 2014 Insertion of an annular disc implant at lumbar discectomy (NICE interventional procedures guidance 506) added to spinal and back conditions.
24 June 2014 Arthroscopic radiofrequency chondroplasty for discrete chondral defects of the knee (NICE interventional procedures guidance 493) added to bone and joint conditions.
17 June 1014 The following guidance was added to spinal and back conditions:
  • The MAGEC system for spinal lengthening in children with scoliosis (NICE medical technologies guidance 18)
  • interspinous distraction procedures for lumbar spinal stenosis causing neurogenic claudication (NICE interventional procedures guidance 365)
  • prosthetic intervertebral disc replacement in the cervical spine (NICE interventional procedures guidance 341)
  • therapeutic percutaneous image-guided aspiration of spinal cysts (NICE interventional procedures guidance 223).

Sources

NICE guidance and other sources used to create this interactive flowchart.
Pegloticase for treating severe debilitating chronic tophaceous gout (2013) NICE technology appraisal guidance 291
Febuxostat for the management of hyperuricaemia in people with gout (2008) NICE technology appraisal guidance 164
Radiation therapy for early Dupuytren's disease (2016) NICE interventional procedures guidance 573
Extracorporeal shockwave therapy for Achilles tendinopathy (2016) NICE interventional procedures guidance 571
Epiduroscopic lumbar discectomy through the sacral hiatus for sciatica (2016) NICE interventional procedures guidance 570
Biodegradable subacromial spacer insertion for rotator cuff tears (2016) NICE interventional procedures guidance 558
Percutaneous transforaminal endoscopic lumbar discectomy for sciatica (2016) NICE interventional procedures guidance 556
Percutaneous interlaminar endoscopic lumbar discectomy for sciatica (2016) NICE interventional procedures guidance 555
Suture fixation of acute disruption of the distal tibiofibular syndesmosis (2015) NICE interventional procedures guidance 521
Open reduction of slipped capital femoral epiphysis (2015) NICE interventional procedures guidance 511
Insertion of an annular disc implant at lumbar discectomy (2014) NICE interventional procedures guidance 506
Arthroscopic trochleoplasty for patellar instability (2014) NICE interventional procedures guidance 474
Peripheral nerve-field stimulation for chronic low back pain (2013) NICE interventional procedures guidance 451
Autologous blood injection for tendinopathy (2013) NICE interventional procedures guidance 438
Autologous blood injection for plantar fasciitis (2013) NICE interventional procedures guidance 437
Partial replacement of the meniscus of the knee using a biodegradable scaffold (2012) NICE interventional procedures guidance 430
Arthroscopic femoro–acetabular surgery for hip impingement syndrome (2011) NICE interventional procedures guidance 408
Open femoro–acetabular surgery for hip impingement syndrome (2011) NICE interventional procedures guidance 403
Hand allotransplantation (2011) NICE interventional procedures guidance 383
Thoracoscopic repair of congenital diaphragmatic hernia in neonates (2011) NICE interventional procedures guidance 379
Insertion of metal rib reinforcements to stabilise a flail chest wall (2010) NICE interventional procedures guidance 361
Percutaneous intradiscal laser ablation in the lumbar spine (2010) NICE interventional procedures guidance 357
Prosthetic intervertebral disc replacement in the cervical spine (2010) NICE interventional procedures guidance 341
Therapeutic endoscopic division of epidural adhesions (2010) NICE interventional procedures guidance 333
Surgical correction of hallux valgus using minimal access techniques (2010) NICE interventional procedures guidance 332
Extracorporeal shockwave therapy for refractory tennis elbow (2009) NICE interventional procedures guidance 313
Extracorporeal shockwave therapy for refractory plantar fasciitis (2009) NICE interventional procedures guidance 311
Prosthetic intervertebral disc replacement in the lumbar spine (2009) NICE interventional procedures guidance 306
Sinus tarsi implant insertion for mobile flatfoot (2009) NICE interventional procedures guidance 305
Percutaneous endoscopic laser cervical discectomy (2009) NICE interventional procedures guidance 303
Therapeutic percutaneous image-guided aspiration of spinal cysts (2007) NICE interventional procedures guidance 223
Intramedullary distraction for lower limb lengthening (2006) NICE interventional procedures guidance 197
Mosaicplasty for knee cartilage defects (2006) NICE interventional procedures guidance 162
Direct C1 lateral mass screw for cervical spine stabilisation (2005) NICE interventional procedures guidance 146
Automated percutaneous mechanical lumbar discectomy (2005) NICE interventional procedures guidance 141
Percutaneous endoscopic laser thoracic discectomy (2004) NICE interventional procedures guidance 61
Computed tomography-guided thermocoagulation of osteoid osteoma (2005) NICE interventional procedures guidance 53
Needle fasciotomy for Dupuytren's contracture (2004) NICE interventional procedures guidance 43
Endoscopic laser foraminoplasty (2003) NICE interventional procedures guidance 31
The MAGEC system for spinal lengthening in children with scoliosis (2014) NICE medical technologies guidance 18
The EOS 2D/3D imaging system (2011) NICE diagnostics guidance 1
Mobi-C for cervical disc replacement (2016) NICE medtech innovation briefing 70
The PediGuard for placing pedicle screws in spinal surgery (2015) NICE medtech innovation briefing 26
Skin involvement in systemic sclerosis: rituximab (2017) NICE evidence summary ES7
Systemic juvenile idiopathic arthritis: canakinumab (2014) NICE evidence summary ESNM36
Gouty arthritis: canakinumab (2013) NICE evidence summary ESNM23
Digital ulcers: sildenafil (2015) NICE evidence summary ESUOM42
Systemic lupus erythematosus: oral mycophenolate (2014) NICE evidence summary ESUOM36
Scleroderma: oral mycophenolate (2014) NICE evidence summary ESUOM32

Quality standards

Quality statements

Effective interventions library

Effective interventions library

Successful effective interventions library details

Implementation

NICE has produced resources to help implement its guidance on:

Information for the public

NICE produces information for the public that summarises, in plain English, the recommendations that NICE makes to healthcare and other professionals.
NICE has written information for the public explaining its guidance on each of the following topics.

Pathway information

Your responsibility

Guidelines

The recommendations in this interactive flowchart represent the view of NICE, arrived at after careful consideration of the evidence available. When exercising their judgement, professionals are expected to take these recommendations fully into account, alongside the individual needs, preferences and values of their patients or service users. The application of the recommendations in this interactive flowchart is not mandatory and does not override the responsibility of healthcare professionals to make decisions appropriate to the circumstances of the individual patient, in consultation with the patient and/or their carer or guardian.
Local commissioners and/or providers have a responsibility to enable the interactive flowchart to be applied when individual health professionals and their patients or service users wish to use it. They should do so in the context of local and national priorities for funding and developing services, and in light of their duties to have due regard to the need to eliminate unlawful discrimination, to advance equality of opportunity and to reduce health inequalities. Nothing in this interactive flowchart should be interpreted in a way that would be inconsistent with compliance with those duties.
Commissioners and providers have a responsibility to promote an environmentally sustainable health and care system and should assess and reduce the environmental impact of implementing NICE recommendations wherever possible.

Technology appraisals

The recommendations in this interactive flowchart represent the view of NICE, arrived at after careful consideration of the evidence available. When exercising their judgement, health professionals are expected to take these recommendations fully into account, alongside the individual needs, preferences and values of their patients. The application of the recommendations in this interactive flowchart is at the discretion of health professionals and their individual patients and do not override the responsibility of healthcare professionals to make decisions appropriate to the circumstances of the individual patient, in consultation with the patient and/or their carer or guardian.
Commissioners and/or providers have a responsibility to provide the funding required to enable the recommendations to be applied when individual health professionals and their patients wish to use it, in accordance with the NHS Constitution. They should do so in light of their duties to have due regard to the need to eliminate unlawful discrimination, to advance equality of opportunity and to reduce health inequalities.
Commissioners and providers have a responsibility to promote an environmentally sustainable health and care system and should assess and reduce the environmental impact of implementing NICE recommendations wherever possible.

Medical technologies guidance, diagnostics guidance and interventional procedures guidance

The recommendations in this interactive flowchart represent the view of NICE, arrived at after careful consideration of the evidence available. When exercising their judgement, healthcare professionals are expected to take these recommendations fully into account. However, the interactive flowchart does not override the individual responsibility of healthcare professionals to make decisions appropriate to the circumstances of the individual patient, in consultation with the patient and/or guardian or carer.
Commissioners and/or providers have a responsibility to implement the recommendations, in their local context, in light of their duties to have due regard to the need to eliminate unlawful discrimination, advance equality of opportunity, and foster good relations. Nothing in this interactive flowchart should be interpreted in a way that would be inconsistent with compliance with those duties.
Commissioners and providers have a responsibility to promote an environmentally sustainable health and care system and should assess and reduce the environmental impact of implementing NICE recommendations wherever possible.

Person-centred care

People have the right to be involved in discussions and make informed decisions about their care, as described in your care.
Making decisions using NICE guidelines explains how we use words to show the strength (or certainty) of our recommendations, and has information about prescribing medicines (including off label use), professional guidelines, standards and laws (including on consent and mental capacity), and safeguarding.

Supporting information

Glossary

autologous chondrocyte implantation
anti-neutrophil cytoplasmic antibody-associated
Bath Ankylosing Spondylitis Disease Activity Index
disease-modifying anti-rheumatic drugs
juvenile idiopathic arthritis
non-steroidal anti-inflammatory drugs
Psoriasis Area and Severity Index
Psoriatic Arthritis Response Criteria
Safety of Estrogen in Lupus National Assessment – Systemic Lupus Erythematosus Disease Activity Index
tumour necrosis factor
visual analogue scale

Paths in this pathway

Pathway created: December 2013 Last updated: March 2017

© NICE 2017

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