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Musculoskeletal care pathways for adults with hip and knee pain referred for specialist opinion: a systematic review
  1. Kate Button1,
  2. Fiona Morgan2,
  3. Alison Lesley Weightman3,
  4. Stephen Jones4
  1. 1 School of Healthcare Sciences, Cardiff University, Cardiff, UK
  2. 2 Specialist Unit for Review Evidence (SURE), University Library Service, Cardiff University, Cardiff, UK
  3. 3 Information Services, Cardiff University, Cardiff, UK
  4. 4 Trauma and Orthopaedics, Cardiff and Vale University Health Board, Cardiff, UK
  1. Correspondence to Kate Button; buttonk{at}


Objective Musculoskeletal care pathways are variable and inconsistent. The aim of this systematic review was to evaluate the evidence for the clinical and/or cost effectiveness of current care pathways for adults with hip and/or knee pain referred for specialist opinion.

Design Systematic review.

Data sources Electronic database searches were carried out in MEDLINE, MEDLINE In-Process, Cumulative Index of Nursing and Allied Health Literature, Embase, PEDro, PubMed, Web of Science, Cochrane Central and Health Management Information Consortium without language restriction from 1990 onwards. Websites were reviewed for grey literature.

Eligibility criteria All study designs and documents that considered care pathways for adults with musculoskeletal hip and/or knee pain referred for specialist opinion were screened by two reviewers. Risk of bias was assessed using The Critical Appraisal Skills Programme checklist for randomised controlled trials and the Joanna Briggs Institute checklists.

Data extraction and synthesis Data extraction and quality assessment were performed by one reviewer and checked by a second. Findings are reported narratively.

Results The titles and abstracts of 1248 articles were screened and 140 full-text articles retrieved. 19 papers reporting 17 studies met the study inclusion criteria. Quality was low due to study design and methodological flaws. Most of the outcomes relate to organisational process at the ‘meso’ level of a whole systems approach.

Conclusion It can be concluded that the pathway is not linear, containing variations and activity loops. The available evidence suggests that, from the point of referral for specialist opinion, a model is required that integrates the skills of all the different healthcare professionals and streamlining is required to ensure that individuals are seen by the healthcare professional that best meets their needs. There is very limited evidence of patient experience informing knee and hip care pathways.

PROSPERO registration number CRD42016035510.

  • musculoskeletal
  • hip pain
  • knee pain
  • care pathway
  • service delivery

This is an open access article distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited, appropriate credit is given, any changes made indicated, and the use is non-commercial. See:

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  • Contributors KB is the guarantor. KB, FM, ALW and SJ designed the protocol. ALW conducted the searches. KB and FM selected studies, undertook data extraction and critical appraisal. KB, FM and SJ were responsible for writing this publication. All authors read and approved the final manuscript.

  • Funding This work was funded by Health and Care Research Wales, Research for patient and public benefit, grant number 1114.

  • Competing interests None declared.

  • Provenance and peer review Not commissioned; externally peer reviewed.

  • Data sharing statement The findings of the search strategy are available to any readers if they contact the corresponding author by email.

  • Patient consent for publication Not required.

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