Date published: 20 March, 2026
Date last updated: 20 March, 2026
Armed forces, Commissioning, Specialised commissioning

Clinical commissioning policy – orthopaedic procedures

This document is an NHS England commissioning policy that applies to members of the Armed Forces and their families. For more details, see: NHS commissioning » NHS England Armed Forces health commissioning policies

Bunion (hallux valgus) and stiff big toe (hallux rigidus)

Conservative management

Conservative, nonsurgical measures include footwear modification, use of insoles or toe spacers / pads. Footwear modification involves wearing wider fitting shoes with low heels. In addition, other measures include over-the-counter analgesics, ice to relieve pain and inflammation, physiotherapy and orthotics.

Criteria for commissioning

The policy statement is in accordance with the commissioning guide on painful deformed great toe in adults produced by the British Orthopaedic Foot & Ankle Society, British Orthopaedic Association (BOA), Royal College of Surgeons of England (RCSEng) 2017.

It is expected that most patients with great toe deformity and mild pain will be managed in primary care.

The clinician proposing this intervention is not required to secure prior approval from the Armed Forces Health Commissioning team and can proceed with treatment if the criteria in the relevant policy are met.

NHS England will fund:

Requests for bunionectomy and cheilectomy where the patient meets the following criteria:

  • repeated episodes of ulceration or infection;

OR

  • the patient suffers persistent moderate to severe joint pain (or any pain under the ball of the foot), with significant functional impairment (including inability to wear suitable shoes), which causes a severe impact on their ability to undertake activities of daily living, and will therefore gain significant benefit from the surgery; and
  • conservative management, attempted over a 3-month period, have failed. This includes wearing appropriate shoes and non-surgical treatments such as bunion pads, insoles and shields, splints, simple analgesia and exercises where appropriate; and
  • a shared decision-making process has been followed, and the patient is prepared to undergo surgery, understanding that they will be unable to undertake sedentary work for 2-6 weeks and physical work for 2-3 months and they will be unable to drive for 6-8 weeks (2 weeks if left foot and driving an automatic car).

NHS England will not fund:

  • Surgery when the indication is primarily aesthetic.

Patients should not be referred into secondary care or a community podiatric service for aesthetic or prophylactic reasons.

Minimal access techniques will not be funded. These must only be undertaken as part of a research project or where special arrangements for audit are in place. (NICE IPG 332) https://www.nice.org.uk/guidance/ipg332

Evidence base

Hip conditions

Red flag hip conditions requiring urgent referral should follow the appropriate urgent secondary care pathway:

  • suspicion of septic arthritis, osteonecrosis, malignancy or slipped capital femoral epiphysis
  • fracture cannot be excluded
  • severe soft tissue injury with gross instability
  • neurovascular compromise

Other red flags of concern with respect to the patient presenting with hip and/or groin pain include a history of trauma, fever, unexplained weight loss, burning with urination, night pain, and prolonged corticosteroid use.

Conservative management

Conservative management prior to referral may include the following measures, where appropriate. These should be evidenced with the referral and should be clearly detailed throughout the patient’s primary care record, Musculoskeletal Services’ clinic letters and/or FMed 7: 

  • advice and engagement in activity modification
  • structured physiotherapy and exercise programmes e.g. local pathway, protocol (Protection, Rest, Ice, Compression, Elevation) or Defence Primary Health Care (DPHC) rehabilitation pathways
  • oral analgesics as clinically appropriate
  • advice and engagement in weight loss
  • podiatry/orthotics
  • corticosteroid injections to the affected part of the joint where clinically appropriate 

Diagnostic imaging

Plain radiographs should be used as the first line investigation in primary care.

Note: MRI should not routinely be undertaken in any setting where clinical assessment is indicative of osteoarthritis (OA) and plain radiographs demonstrate typical OA features. See EBI policy MRI scan of the hip for arthritis.

Criteria for commissioning

Flag hip conditions – any hip condition red flags should be referred urgently to secondary care for assessment.

The clinician proposing the following interventions is not required to secure prior approval from the Armed Forces Health Commissioning team and can proceed with treatment if the criteria in the relevant policy are met:

  • Hip impingement – the patient has undergone an appropriate NHS primary care or Defence Primary Health Care pathway which has been clearly detailed throughout the patient’s primary care record, Musculoskeletal Services’ clinic letters and/or FMed 7
  • Hip resurfacing – when undertaken as a clinical decision in accordance with NICE TA304 

NHS England will not fund:

Hip arthroscopy in patients with femoro-acetabular impingement where any of the following criteria apply:

  • patients with advanced osteoarthritic change on preoperative X-ray or severe cartilage injury
  • patients with a joint space on plain radiograph of the pelvis that is less than 2mm wide anywhere along the sourcil
  • patients who meet the criteria for a hip replacement
  • any patient with severe hip dysplasia or with a Crowe grading classification of 4
  • patients with osteogenesis imperfecta

Hip replacement

The clinician proposing this intervention is required to secure prior approval via Blueteq from the Armed Forces Health Commissioning team.

NHS England will fund hip replacement when the following criteria are met:

  • the patient has undergone an appropriate NHS primary care or DPHC rehabilitation pathway which has been clearly detailed throughout the patient’s primary care record, Musculoskeletal Services’ clinic letters and/or FMed 7, and
  • Conservative management has been undertaken for a minimum of 12 weeks where clinically appropriate and may include:
    • advice and engagement in modified behaviour to reduce aggravation of the condition
    • structured physiotherapy and exercise programmes for example local pathway, PRICE protocol or DPHC rehabilitation pathway
    • oral analgesics as clinically appropriate
    • advice and engagement in weight loss
    • use of recommended walking aids, home adaptation
    • corticosteroid injections to the affected part of the joint where clinically appropriate

AND

  • an Oxford Hip Score (OHS) of less than 30 (patient’s pain and disability should be sufficiently severe that it interferes with the patient’s daily life and / or ability to sleep), and
  • the patient has a BMI of below 35 or is of athletic build*, and
  • the patient has been informed of the potential risks and benefits of joint replacement and agrees to be considered for hip replacement surgery and is considered fit for surgery
  • *Where a patient’s BMI is above 35 and of non-athletic build, the referrer will consider joint replacement surgery ONLY if there is evidence the patient has:
    • mobility so compromised that they are in immediate danger of losing their independence and that joint replacement would relieve this threat, or
    • joint destruction of such severity that delaying surgical correction would increase the technical difficulty of the procedure if delayed, and
    • engaged actively with a weight management programme and achieved a 10% reduction in their weight

Evidence base

Knee conditions

Red flag knee conditions requiring urgent referral should follow the appropriate urgent secondary care pathway:

  • suspicion of septic arthritis, osteonecrosis, malignancy or slipped capital femoral epiphysis
  • fracture cannot be excluded
  • severe soft tissue injury with gross instability
  • neurovascular compromise

Conservative management (non-surgical interventions)

The conservative management to be evidenced prior to referral includes the following:

  • activity modification
  • structured physiotherapy and exercise programmes, for example, PRICE protocol or DPHC rehabilitation pathway
  • oral analgesics, including NSAIDs (unless contraindicated)
  • weight management
  • podiatry/orthotics
  • corticosteroid injections to the affected part of the joint where clinically appropriate.

Criteria for commissioning

Any knee condition ‘red flags’ identified during primary, community and intermediate care assessment should be referred urgently to secondary care.

The clinician proposing this intervention is not required to secure prior approval from the Armed Forces Health Commissioning team and can proceed with treatment if the criteria in the relevant policy are met:

Locked knee

knee replacement (clinical decision*) – if this is considered as part of osteoarthritis pathway referrers should follow EBI guidance: Knee arthroscopy for patients with osteoarthritis

*Serving personnel have undergone an appropriate DPHC rehabilitation pathway (evidenced by FMed 7 or clinical letter).

Knee arthroscopy

NHS England will not fund knee arthroscopy:

  • for diagnostic purposes; radiological investigations should be used for this
  • for debridement and lavage
  • for osteoarthritis
  • for symptoms of giving way without true locking

Knee arthroscopy for meniscal tear and ligament sprain or tear:

the clinician proposing this intervention is required to secure prior approval via Blueteq from the Armed Forces Health Commissioning team when the following criteria are met:

  • clear history of a new significant acute knee injury with mechanical symptoms, or
  • knee pain with persistent mechanical symptoms (locking, catching and intermittent sudden pain on movement) that has not responded to 3 months of initial conservative management under the DPHC rehabilitation pathway and (evidenced by FMed 7 or clinical letter); and
  • has a symptomatic meniscal tear

Evidence base

Shoulder conditions

Red flag shoulder conditions requiring urgent referral should follow the appropriate urgent secondary care pathway:

  • a suspected infected joint needs same day emergency referral
  • an unreduced traumatic shoulder dislocation needs same day emergency referral
  • suspected tumour and malignancy will need urgent referral following the 28 day faster diagnosis standard (FDS) cancer referral pathway
  • an acute rotator cuff tear as a result of a traumatic event needs urgent referral
  • shoulder pain in which the symptoms and signs suggest a more systemic inflammatory joint disease or polymyalgia rheumatica, should be considered as a ‘rheumatological red flag’ (following rheumatology referral pathways)
  • new inflammatory oligo or polyarthritis, with symptoms of inflammation in several joints, should be referred urgently (following rheumatology referral pathways)

NHS England does not fund the use of shoulder arthroscopy for diagnostic purposes; radiological investigations should be used for this.

Any shoulder condition ‘red flags’ identified during primary, community and intermediate care assessment should be referred urgently to secondary care. See The British Elbow and Shoulder Society patient care pathways for the shoulder. 

Acute calcific tendinopathy is not a red flag however an early secondary care referral for more interventional treatment is recommended.

Conservative measures (Non-surgical interventions)

The conservative management to be evidenced prior to referral includes the following:

  • activity modification
  • structured physiotherapy and exercise programmes
  • oral analgesics, including NSAIDs (unless contraindicated)
  • corticosteroid injections to the affected part of the joint where clinically appropriate

Criteria for commissioning

Any shoulder condition ‘red flags’ should be referred urgently to secondary care.

Shoulder arthroscopy

This policy covers the use of shoulder arthroscopy to treat a number of different conditions. These include labral tears, rotator cuff repair, adhesive capsulitis and non-traumatic joint instability.

The clinician proposing this intervention is required to secure prior approval via Blueteq from the Armed Forces Health Commissioning team.

NHS England will fund shoulder arthroscopy when one or more of the following criteria are met:

  • full thickness rotator cuff tear as demonstrated by clinical symptoms and radiological imaging; or
  • significant superior labrum anterior posterior (SLAP) tear as demonstrated by clinical symptoms and radiological imaging; or
  • partial thickness rotator cuff tear as demonstrated by clinical symptoms supported by radiological imaging which has not responded to 3 months of conservative management; or
  • minor (type I*) SLAP tear as demonstrated by clinical symptoms supported by radiological imaging which has not responded to 3 months of conservative management; or
  • adhesive capsulitis* demonstrated by clinical symptoms which has not responded to 6 months of conservative management; or
  • adhesive capsulitis* demonstrated by clinical symptoms and in the view of the treating consultant is having an extraordinarily severe impact on quality of life, and which has not responded to conservative management including corticosteroid injection where clinically appropriate, or
  • non-traumatic shoulder joint instability that has not responded to 6 months of conservative management, or
  • traumatic shoulder joint instability which has received conservative management as clinically appropriate. Radiological imaging should be considered if there is a history of trauma; there is little improvement with conservative treatment; symptoms last more than 4 weeks; there is severe pain or restriction of movement; or arthritis is suspected.

*Sydner classification (Synder SJ, Karzel RP, Del Pizzo W, et al. SLAP lesions of the shoulder. Arthroscopy 1990; 6; 274-279) The following procedures are outside the scope of this policy:

Arthroscopic sub-acromial decompression

Referrers must follow the national programme guidance for arthroscopic shoulder decompression for subacromial shoulder pain: Arthroscopic shoulder decompression for subacromial pain – EBI (aomrc.org.uk)

Patients with persistent symptoms as defined in the EBI policy who meet all of the following criteria can be referred for a surgical opinion:

  • patient has continuous symptoms for at least 6 weeks from the start of treatment; and
  • patient has undertaken structured physiotherapy rehabilitation for 6 weeks initially unless physiotherapists identify a reason for earlier referral to secondary care. If there is improvement in the first 6 weeks of physiotherapy, then at least another six weeks physiotherapy is justified; and
  • symptoms have a significant impact which are intrusive and debilitating when undertaking activities of daily living, e.g. waking several times a night, pain when putting on a garment
  • patient has been compliant with conservative intervention (education, rest, NSAIDs, simple analgesia, structured physiotherapy) for at least 6 weeks; and
  • patient has initially responded positively to a corticosteroid injection but symptoms have returned despite compliance with conservative management*; and
  • referral is at least 8 weeks following corticosteroid injection; and
  • a shared decision-making conversation has taken place, and the patient confirms they wish to have surgery

*A second injection is occasionally appropriate after 6 weeks but should only be administered in patients who received good initial benefit from their first injection and who need further pain relief to facilitate their structured physiotherapy treatment.

Diagnostic arthroscopy

NHS England does not fund the use of shoulder arthroscopy for diagnostic purposes; radiological investigations should be used for this.

Rationale

Rationale for shoulder arthroscopy includes adhesive capsulitis, rotator cuff damage and recurrent instability. In these cases, the evidence supports the use of shoulder arthroscopy for treatment purposes. However, the use of arthroscopy for diagnostic purposes is not supported and radiological investigations should be used for this.

In the majority of circumstances, a clinical examination (history and examination) by a competent clinician will give a diagnosis and demonstrate if internal joint derangement is present. If there is diagnostic uncertainty despite competent examination or if there are ‘red flag’ symptoms / signs / conditions then an MRI scan might be indicated.

Evidence base

Spinal conditions

Red flag spinal symptoms requiring urgent referral should follow the appropriate urgent secondary care pathway and include:

  • bowel and bladder dysfunction
  • saddle sensory disturbance
  • widespread or progressive weakness in legs or gait disturbance
  • radiologically proven spinal cord or cauda equina compression

Conservative management

Conservative management prior to referral may include the following measures, where appropriate:

  • advice and engagement in activity modification
  • structured physiotherapy and exercise programmes e.g. NHS primary care MSK or DPHC rehabilitation pathway
  • advice and engagement in weight loss
  • corticosteroid injections to the affected part of the joint where clinically appropriate

These should be clearly detailed throughout the patient’s primary care record, Musculoskeletal Services’ clinic letters and/or FMed 7 evidenced in the referral.

Diagnostic imaging

Imaging should not be routinely offered in a non-specialist setting for people with low back pain with or without radicular pain.

Imaging should be considered in within a MSK pathway at intermediate/secondary care for low back pain with or without radicular pain only if the result is likely to change management.

Criteria for commissioning

The clinician proposing discectomy, fusion surgery or spinal decompression is not required to secure prior approval from the Armed Forces Health Commissioning team and can proceed with treatment if the criteria in the relevant policy are met.

Lumbar discectomy

Lumbar discectomy surgery in adult patients when the EBI criteria are met:

  • the patient has had MRI showing disc herniation (protrusion, extrusion, or sequestered fragment) at a level and side corresponding to the clinical symptoms; and
  • the patient has radicular pain (below the knee for lower lumbar herniation’s, into the anterior thigh for upper lumbar herniation’s) consistent with the level of spinal involvement, or there is evidence of nerve-root irritation with a positive nerve-root tension sign (straight leg raise-positive between 30° and 70° or positive femoral tension sign); and
  • Symptoms persist despite non-operative treatment for at least 3 months (for example analgesia, physical therapy and bed rest) except in severe cases and if analgesia is adequate and there is no imminent risk of neurological deficit.

Fusion surgery

Fusion surgery in adult patients use EBI criteria.

Where the EBI criteria are not met apply the following criteria apply:

  • when there is unequivocal root compression spinal stenosis instability failure of adequate conservative trial of >6 months
  • for people with radicular pain and instability/structural problems

Spinal fusion is not recommended for patients with non-specific, mechanical back pain.

Spinal decompression surgery

Spinal decompression for adult patients with sciatica when the following criteria are met:

  • non-surgical treatment has not improved pain or function (including a single spinal epidural injection where appropriate) over a 3-month period and
  • radiological findings are consistent with sciatic symptoms

Medial branch blocks

The clinician proposing this medial branch block is required to secure prior approval via Blueteq from the Armed Forces Health Commissioning team.

NHS England will fund:

Medial branch blocks for the management of cervical, thoracic and lumbar back pain when the following clinical criteria are met:

  • the patient has undergone a clinically appropriate NHS primary care MSK or DPHC rehabilitation pathway which has been clearly detailed throughout the patient’s primary care record, Musculoskeletal Services’ clinic letters and/or FMed 7; and
  • all conservative management has been undertaken where clinically appropriate and failed; and
  • a diagnostic procedure leading to radiofrequency denervation of the medial branch if the diagnostic block is positive; and
  • the pain has resulted in moderate to significant impact on daily life; or
  • if the initial medial branch block has had a proven therapeutic benefit but the patient is not suitable for radiofrequency denervation or a pain management programme (for example multiple comorbidities, cardiac and respiratory dysfunction, cardiac pacemaker or other nerve stimulator, or frail and elderly)

Radiofrequency denervation

The clinician proposing radiofrequency denervation is required to secure prior approval via Blueteq from the Armed Forces Health Commissioning team.

NHS England will fund radiofrequency denervation of the facet or sacroiliac for patients with severe chronic pain in the cervical, thoracic or lumbar spinal regions when the following clinical criteria are met:

  • the patient has undergone a clinically appropriate NHS primary care MSK or Defence Primary Health Care (DPHC) rehabilitation pathway which has been clearly detailed throughout the patient’s primary care record, Musculoskeletal Services’ clinic letters and/or FMed 7; and
  • all conservative management has been undertaken where clinically appropriate and has failed – physiotherapy, guided exercise programmes, pharmacotherapy including analgesia and neuropathic pain medication; and
  • the patient is experiencing severe pain (assessed by a spinal surgeon or a pain specialist using a visual analogue pain scale) for more than 6 months; and
  • the symptoms are not consistent with identifiable pathology including disc herniation and spinal stenosis; and
  • back or neck pain predominates over leg or arm pain; and
  • the patient has had 1 medial branch or intra–articular nerve block that has provided symptom relief physiologically consistent with medial nerve branch pathology

In the rare circumstance that a patient meets the guidance criteria for radiofrequency denervation, but the procedure is contraindicated (for example presence of pacemaker / ICD / complex spinal anatomy/presence of spinal metal work), and the clinician recommends facet joint injections, a prior approval application should be submitted.

See EBI: Lumbar radiofrequency facet joint denervation

Spinal epidural injections (SEI)

The clinician proposing SEI is required to secure prior approval via Blueteq from the Armed Forces Health Commissioning team.

NHS England will fund a single* SEI of local anaesthetic and steroid when the following criteria are met:

  • for severe, non-controllable radicular pain in prolapsed intervertebral disc early in the clinical course for symptom control
  • for treatment of lumbar radicular pain with the aim of avoiding surgery

*Note: Repeat SEI are not routinely commissioned for patients with neurogenic claudication and who have central spinal canal stenosis

Injections for isolated lower back pain without sciatica

In line with the national EBI programme guidance, injections for isolated lower back pain without sciatica are not routinely commissioned:

Injections for isolated lower back pain without sciatica – EBI  

NHS England will not fund injections for isolated lower back pain without sciatica.

Evidence base

Date published: 20 March, 2026
Date last updated: 20 March, 2026