Knee Pain

Scope

This clinical referral guideline covers referrals for knee pain, including elective knee replacement (TKR) to replace some or all of the components of the knee joint with a synthetic implant, and repair damaged weight bearing surfaces.

Conservative management is the main stay of treatment; rest, analgesia and primary care physiotherapy.

Hip pathology can present with pain in the knee only

Referrals for arthroscopy and washout for global knee pain due to osteoarthritis are considered as a low value procedure through lack of evidence around long term benefits and will be considered to the practice.

Leave the decision to MRI scan to the Extended Scope Physiotherapist (ESP) or Integrated Clinical Assessment and Treatment (ICAT) clinician; GP's are no longer able to order MRI through the Any Qualified Provider (AQP) process.

Please note pre-referral criteria are applicable in this referral and referrals may be returned if this information is not contained within the referral.

Unless red flags are present, all patients referred for consideration of arthroplasty due to knee osteoarthritis will be assessed by a community interface service which provide a holistic assessment of their symptoms and disabilities before being helped to make a decision on the possible treatment options. This assessment will include Oxford knee scoring and patient decision making aids. Treatment options will include lifestyle modifications, physiotherapy, improved general health and well being or surgery.

Please note primary care is requested to follow In Shape for Surgery best practice which can be seen here.

Out of scope

The guideline does not cover arthroscopy recommended by an orthopaedic specialist in those under 18 years of age or in adults following acute injury with suspected internal joint derangement, septic arthritis or suspected malignancy.

Assessment

Signs and Symptoms

Atraumatic:

  • Anterior knee pain – anterior pain; worse on stairs; worse getting up from sitting
  • Degenerative Meniscal Tears – often atraumatic and a natural consequence of degeneration NOT needing surgery
    • Pain and swelling with mechanical instability with actual painful giving way on twisting or turning; painful catching; locking
  • Osteoarthritis - Global knee pain; worse after exertion (Patello-femoral Osteoarthritis may present as anterior knee pain)

Traumatic:

  • Degree of signs/ symptoms depend on severity of injury and mechanism

History

  • Age
  • Exact mechanism of injury or trauma if present
  • Onset of pain or swelling
  • Anatomical location, character and severity of pain
  • Knee laxity (excessive range of movement)
  • Associated catching, clicking, locking or sensation of the knee 'giving way'
  • Whether there was an audible 'pop' at the time of injury
  • Previous episodes, other knee conditions or past knee surgery
  • Other joint problems (in particular the hip and lower back)
  • Other medical and drug history and general systemic health

Assessment following the Ottawa knee rules – see below:

A knee x-ray is only required for knee injury patients with any of these findings:

  • Age 55 or over
  • Isolated tenderness of the patella (no bone tenderness of the knee other than the patella)
  • Tenderness at the head of the fibula
  • Inability to flex to 90 degrees
  • Inability to weight bear both immediately and in ED - (four steps - unable to transfer weight twice onto each lower limb regardless of limping)

The following red flags should be sent through the Fast Track Knee Service:

  • Adults of working age with a totally locked knee
  • Young adult with twisting injury

Red Flags

Atraumatic:

Septic Arthritis – refer to Emergency Department

Tumour - Sarcoma service guidelines and other suspicious swellings - see Southwest Sarcoma guidelines and complete 2WW referral form

Traumatic:

High energy impact

  • Dislocation
  • Acute haemarthosis
  • Any fractures around the knee either new, old or suspected

Clinically

  • Tendon rupture
  • Ruptured/torn anterior cruciate ligament and or acute meniscal lesion in a patient who is likely to benefit from surgery (young, active)
  • Asymmetric laxity to varus/valgus strain indicating collateral ligament rupture any fractures around the knee either new, old or suspected clinically

All to Emergency Department

The following red flags should be sent through the Fast Track Knee Service:

  • Adults of working age with a totally locked knee
  • Young adult with twisting injury

Red Flags which will bypass the Community Interface Service (should be referred urgently to secondary care)

  • Fracture or trauma
  • Suspicion of tumour or evidence of any destructive lesion on radiograph
  • Unexplained, increasing or sudden onset severe pain in a previously replaced joint
  • Any features suspicious of infection, including:
    • Cellulitis over the joint
    • Large effusion and erythema
    • Inflamed scar/wound over a previously replaced joint
  • Inability to walk or weight bear
  • Evidence of new inflammatory arthropathy
  • The following hip conditions:
    • Protrusio acetabula
    • Avascular necrosis of femoral head

Investigations

Consider x-ray if osteoarthritis is suspected following the Ottawa knee rules

Management

Atraumatic

The vast majority of rapid and atraumatic knee pain should be managed with conservative treatment in primary care including rest, analgesia and physiotherapy

If knee is painful and swollen, advice regarding PRICE:

  • Protection
  • Rest
  • Ice
  • Compression
  • Elevation

Consider paracetamol and/or topical NSAIDs as a safe method of mild to moderate pain relief (oral NSAIDs, unless contra-indicated, may be considered if non-responsive)

Early physiotherapy recommended:

  • The vast majority of anterior knee pain patients should be managed with conservative treatment in primary care including rest, analgesia and physiotherapy – refer to ICATS/ ESP after 12 weeks if no resolution
  • The majority of degenerative (atraumatic) cartilage tears without locking will settle within six months, acute pain normally settles in a few weeks – if not improving after 12 weeks may refer to ICATS/ ESP
  • In proven Osteoarthritis - Arthroscopy and washout are not indicated for knee osteoarthritis unless there are true mechanical instability symptoms
    • Trial of conservative management – good evidence for Physiotherapy and exercise in mild to moderate osteoarthritis especially Patello-femoral osteoarthritis
    • Please be aware that injection can cause chondrolysis or infection, and should not be performed if joint replacement is anticipated in the next 6 months

If no response discuss management options - Shared decision making – osteoarthritis of the knee

Arthroplasty should only be considered if:

  • Function restriction resulting from significant or progressive deformity and instability of knee may be most important indication
  • Moderate to severe pain
  • Moderate to severe joint pathology identified by X-ray
  • Failed conservative measures, when appropriate Chapter 10 - Musculoskeletal & joint diseases
  • Patient willing and fit for surgery

Other impaired quality of life factors, e.g. loss of independence, depression (in the case of the latter – have they tried CBT which can help also chronic pain)

For any patient where surgical intervention is being considered then the fitness for surgery needs to be addressed:

  • Lifestyle advice (including weight management and smoking cessation) Much more in the hip CRG
  • Optimum pharmacological treatments (including Analgesia, HbA1c, Hb, BP)

Unless red flags are present all patients referred for consideration of arthroplasty due to knee osteoarthritis will be assessed by a community interface service which provide a holistic assessment of their symptoms and disabilities before being helped to make a decision on the possible treatment options. This assessment will include Oxford knee scoring and patient decision making aids. Treatment options will include lifestyle modifications, physiotherapy, improved general health and well being or surgery.

Contraindications to knee arthroplasty

Absolute:

  • Current infection of knee
  • Other site of infection
  • Muscular dysfunction
  • Severe peripheral vascular disease
  • Presence of functional knee arthrodesis

Relative:

  • History of osteomyelitis
  • Skin conditions around knee
  • Neuropathy of knee joint
  • Obesity
Trauma

Non disabling soft tissue trauma should be managed with conservative treatment in primary care including rest, analgesia and physiotherapy.

Referral

Referral Criteria

Referral to specialist secondary care:

Patients with knee pain will be expected to have had 12 weeks of evidence based non-surgical treatments. This time is to include any manual therapy, including physiotherapy, received in Primary Care. A recent course of physiotherapy will be expected unless this is not clinically appropriate. This clinical decision needs to be stated and if it is not then the referral will be returned.

Unless red flags are present all patients referred for consideration of arthroplasty due to knee osteoarthritis will be assessed by a community interface service which provide a holistic assessment of their symptoms and disabilities before being helped to make a decision on the possible treatment options. This assessment will include Oxford knee scoring and patient decision making aids. Treatment options will include lifestyle modifications, physiotherapy, improved general health and well being or surgery.

All referrals must include:

  • History and duration
  • Presence and time of onset of any swelling
  • Instability symptoms or history of overuse
  • Relevant examination findings
  • Relevant investigations
  • Include any conservative treatment with dates including physiotherapy & analgesia

DRSS will review the referral letter and direct to Orthopaedics if:

  • Under 16 years of age
  • Recent surgery same joint less than six month ago
  • Metal work in situ in the area
  • Previous arthroplasty same joint/joint replacement
  • Inflammatory Arthritis
  • Suspected serious pathology
  • Leaking wound/possible infections
  • Acute or recent locked knee (of note, referral letter should mention locking knee to enable screening)
  • Meniscal cysts

Refer direct to ED/ Orthopaedic on call team – see Red Flags

Atraumatic
  • Anterior knee pain:
    • Early physiotherapy referral is recommended
    • Patients will be expected to have had a recent course of physiotherapy prior to onward referral to ESP/ GPwSI unless evidence can be provided that this is not necessary.
    • ESP/ICAT referral may be appropriate if patient not improving after 12 weeks conservative management or internal derangement suspected
  • Instability knee pain/ degenerative cartilage:
    • All patients will be expected to have had a recent course of physiotherapy prior to onward referral unless evidence can be provided that this is not necessary
  • Osteoarthritis criteria – see management
Trauma

All patients with a non-disabling injury due to trauma

  • Recent course of physiotherapy prior to onward referral unless evidence can be provided that this is not necessary

Please note primary care is requested to follow In Shape for Surgery best practice which can be seen here.

Referral Instructions

Referral to Fast Track Knee service

Referral Forms

DRSS referral form

Supporting Information

GP Information

Southwest Sarcoma guidelines

Referral form for suspected sarcoma

Shared decision making – osteoarthritis of the knee

Patient Information

Patient will have full assessment and receive treatment and advice which may include:

  • Manual therapy
  • Strapping
  • Exercises to improve strength and range of motion
  • Proprioception training to retain protection and stability of the joint

My Health Devon

PALS information leaflet

Patient transport services

Pathway Group

This guideline has been signed off by the Eastern Locality on behalf of NEW Devon CCG.

Publication date: January 2018

 

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