MSK toolkit
Theme 3: Case studies

Service provision for MSK podiatry varies across the country but generally fits into 3 formats. The most common set-up is in a community service, where there are several roles at different competency levels within the team and set pathways for referrals and conditions treated. Separate to this model is an advanced level of practice that sits within an MDT/MCATS service within a hospital discipline. Podiatry services here provide care for complex cases, pre and post-operative care as well as supporting rehabilitation services. Then more recently a third level of service provision is emerging as FCP in primary care networks where podiatry MSK sits in a triage role for patients in GP surgeries.

The following case studies highlight examples of service provision. Additional examples can be seen in Appendix 1. Summary of care levels is presented in Table 4.

First Contact Practitioner, Northants Rural PCN

Based on the MSK FCP physiotherapy model (9) this role has been set up within Northants Rural PCN and provides a triage service of MSK patients at 5 GP surgeries. Graded at Band 8 the podiatrist is employed by the GP and objectives are set by the PCN with salary controlled and negotiated by the group. The service provides appointments for any patient with a lower limb MSK complaint and is supported by GP mentorship as well as team support from practice nursing staff and physiotherapists. Within the PCN, guidance on mapping patients to the service was created to fit with the HEE guidance on FCP and AP in MSK (9). The pathway is set up and designed to appoint urgent red flag conditions the same day with support of the GP team and routine care at the next available appointment.

The podiatrist can provide a range of treatments at first contact, including Nail Surgery, Exercise prescription, preform orthoses provision, general diagnosis and advice. If required patients can then be referred into secondary and tertiary care including surgical provision, imaging, community physiotherapy and community podiatry. Follow up care appointments are provided by telehealth with face-to-face review given if further treatment is required.

Community MSK podiatry, Bradford District

From a team of 53 podiatrists, there are 15 roles that are providing care for MSK patients. Referral into the service is primarily from the GP after an initial 6-week period of self-care directed by the GP with footwear advice and simple exercises. On review, if there is limited progress, the only route of referral is to MSK podiatry. The podiatry team consists of 1 advanced practitioner, (band 8) 3 practitioners at band 7 and 11 band 6 podiatrists.

The average journey for patients starts with an assessment (6 weeks after seeing the GP), which includes a diagnosis and treatment plan, and treatment is provided. This is then followed up between 4-8 weeks and if successful at review, then the patient is discharged. If a persisting problem is identified then this is rectified or the patient is referred into another service for further diagnostic services, surgery or supportive physiotherapy. Assessment includes gait analysis including plantar pressure scanning, biomechanical and pathology diagnosis. Treatments include pre-form orthoses, prescribed bespoke orthoses, extracorporeal shockwave therapy, steroid soft tissue injections, acupuncture, specialist footwear and specialist clinics in rheumatology.

Royal Orthopaedic Hospital Case MSK podiatry

 The Royal Orthopaedic Hospital (ROH) is a tertiary centre in Birmingham where patients are referred primarily by GP’s but also by other hospitals. There are currently 4 advanced podiatric practitioners (B8a), and further development of the team is planned with a trainee APP (B7) new to post next month with workload planned around the HEE 4 pillars of practice. ROH is a teaching hospital and the APP’s are actively involved in the undergraduate medical student placements, delivering lectures and also have them shadowing in clinic.

The Podiatry service is delivered as part of the MSK medicine service (including Advanced physiotherapist practitioners and pain management). The advanced podiatric practitioners (APP) work closely with the orthopaedic foot and ankle consultants in an out patient setting. APP’s workload includes triage, assessment of complex patients, requesting diagnostic imaging (including x-ray, US, MRI, CT, NCS and bloods), injection therapy, listing patients for surgery with the agreement of the consultant, post-op reviews and care.

Shetland Isle MSK triage

As there are no orthopaedic services on the island an MDT triage service has been set up with podiatry and physiotherapy at the forefront. This allows for assessment, diagnosis and surgical triage to be completed with suitable input into Orthopaedic consultants at Glasgow Royal Infirmary. This is facilitated by video conferencing with case discussions and pathways produced within a team environment. By creating this service, the patient is able to receive the most appropriate care, within a suitable time frame whilst also minimising travel and cost.

Clinical stories and career progression

Developing a special interest and career in MSK podiatry does not have a standard route as there are many sub-specialities to be trained in. This leads to a varied career choice with several postgraduate courses and qualifications to be gained [Appendix 4]. Examples of career journeys into different roles can be read in Clinical Stories Appendix 1. These routes to leadership and advanced clinical practice include academic achievements, a desire for research and enquiry and a desire to learn more about the care provided.

Patient experiences from receiving care from an MSK podiatrist are often life changing with reports of people never looking back once their diagnosis and plan have been established and outcomes achieved. Patients often report that seeing a podiatrist first would have helped them most with their complaint. 

Table 4 - Summary of the levels of service provision from first contact, community team and tertiary advanced care.

First Contact Practitioner Triage

Community MSK Team

MDT / Hospital MSK Team

  • Front line service

  • Extended Scope

  • Band 7-8

  • Immediate care
         
  • Aligned referral 
     
  • Right person first time

  • Limited follow-up care

  • Urgent care
  • Self-referral, GP referral / consultant referral

  • Team approach and varied capabilities bands 3, 4, 5, 6, 7 and 8

  • Package of care following care pathways for common MSK foot and ankle conditions.

  • All packages include: Self-management, health promotion, Orthoses provision, Exercise prescription.

  • Some trusts also offer Shockwave, Acupuncture, MSK injections.

  • Scope for advanced care e.g. imaging and contact ultrasound Specialist clinics can include gait analysis with scope for plantar pressure  assessment.

  • Direct referral pathways into tertiary care
  • GP referral / consultant referral

  • Band 7 or 8

  • Complex cases

  • Pain management

  • Advanced practitioner

  • Pre and post-op care

  • Guided injection

  • Non-medical prescribing

  • Referral for non-medical imaging and blood tests

  • Work closely with:

    • Orthopaedics
    • Rheumatology
    • Orthotist
    • Physiotherapy
    • Pain Clinics

 


To provide a fully established provision of MSK podiatry care all 3 service models can work together responding to patients needs and referring between each level of care, (Figure 1). Depending on the demographic of patient, population size and MSK need the variability of service may be tailored to localised requirements.

Notes:

9  Higher Education England – Advanced Clinical Practice Framework 2020 https://www.hee.nhs.uk/our-work/advanced-clinical-practice/multi-professional-framework

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