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This clinical referral guideline covers referrals for knee pain, other than pain caused by osteoarthritis (see link to Knee osteoarthritis guideline).
Knee pain caused by confirmed osteoarthritis: (see link to Osteoarthritic Knee Pain).
Conservative management is the main stay of treatment; rest, analgesia and primary care physiotherapy.
Hip pathology can present with pain in the knee only
MRI requests can be made by 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.
The Fast Track Knee service is for young active patients who have sustained recent trauma that may benefit from early surgery. Older patients with no significant injury/trauma are not suitable for the Fast Track Knee service and should be directed to conservative management.
Please note pre-referral criteria (listed below) are applicable to this referral and referrals may be returned if this information is not contained within the referral.
For any patient where surgical intervention is being considered then the fitness for surgery should be addressed: In Shape for Surgery best practice can be seen here.
Atraumatic:
Traumatic:
Assessment of Acute Knee Injury following the Ottawa knee rules - see below:
Red Flags will bypass the Community Assessment Service (should be referred urgently to secondary care/Emergency Department)
The clinical indications for this are:
In addition, an up-to-date X-ray is extremely useful for remote/virtual consultations.
Please consider repeating an X-ray if a significant time has elapsed since the last one, or there has been a significant change/progression in your patient’s symptoms. This will aid in remote/virtual consultations and help to avoid delay in diagnosis of differentials/red flag conditions.
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:
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:
For any patient where surgical intervention is being considered then the fitness for surgery needs to be addressed: In Shape for Surgery best practice can be seen here.
Non disabling soft tissue trauma should be managed with conservative treatment in primary care including rest, analgesia and physiotherapy.
1. Active patients with a recent history of a specific and notable knee injury/trauma that has resulted in one or more of the following:
2. Non-traumatic symptomatic knee
NB: The Fast Track Knee service is for young active patients who have sustained recent trauma that may benefit from early surgery. Older patients with no significant injury/trauma are not suitable for the Fast Track Knee service and should be directed to conservative management.
Please note referrals to FTKS which do not meet the above criteria will be returned to the practice.
For any patient where surgical intervention is being considered then the fitness for surgery needs to be addressed: In Shape for Surgery best practice can be seen here.
Referral to specialist secondary care:
DRSS will review the referral letter and direct to Orthopaedics if:
Consider referral for persistent pain and disability that has not responded to up to 12 weeks of evidence based nonsurgical treatments. This time to include any manual therapy (including physiotherapy) received in primary care (British Association orthopaedics commissioning guide 2016).
All referrals should include:
All referrals must include:
1. Details of persistent pain or disability that has not responded to up to 12 weeks of evidence based nonsurgical treatments. Please include details (including dates) of conservative treatment (e.g. analgesia, steroid joint injection)
2. A recent course of physiotherapy will be expected unless this is not clinically appropriate (within the twelve months prior to referral). This clinical decision needs to be stated and if it is not then the referral will be returned.
3. Knee X-ray (standing AP and lateral) reports must accompany all knee referrals in all those over 55 years of age (independent of suspected aetiology) or younger when OA is suspected.
The clinical indications for this are:
In addition, an up to date X-ray is essential to facilitate remote/virtual consultations
Please consider repeating an X-ray if a significant time has elapsed since the last one, or there has been a significant change/progression in your patient's symptoms. This will aid in remote/virtual consultations and help to avoid delay in diagnosis of differentials/red flag conditions.
Please ensure that the X-ray report is attached to avoid unnecessary delay.
It is the responsibility of the referrer to attach the report.
For any patient where surgical intervention is being considered then the fitness for surgery needs to be addressed: In Shape for Surgery best practice can be seen here.
For Knee select:
Priority: Routine/ Urgent
Specialty: Orthopaedics
Clinic type: Knee
Service: DRSS-Eastern-Orthopaedics-Knee- Devon ICB- 15N
Fast Track Knee Referral Assessment Service select.
Priority: Urgent
Speciality: Orthopaedics
Clinic Type: Knee
Service: Fast Track Knee Referral Assessment Service-Orthopaedic Department-RDE-RH8 7932867
The fast track knee service is for young active patients who have sustained recent trauma that may benefit from early surgery. Older patients with no significant injury/trauma are not suitable for the Fast Track Knee service and should be directed to conservative management.
MyHealth patient information - Knee pain
This guideline has been signed off on behalf of the NHS Devon.
Publication date: July 2020
Updated: December 2023