Knee Pain Osteoarthritis

Scope

This is the commissioned pathway for knee pain due to osteoarthritis,, including elective knee replacement to replace some or all of the components of the knee joint with a synthetic implant, and repair damaged weight bearing surfaces.

Out of Scope

The pathway does not cover arthroscopy recommended by an orthopaedic specialist in those under 18 years of age or in adults with knee pain that is not due to osteoarthritis.

Key messages

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

Hip pathology can present with pain in the knee only

Because of the lack of evidence around long term benefits, arthroscopy and washout for global knee pain due to osteoarthritis is considered a low value procedure and referrals for arthroscopy will be returned.

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.

Assessment

Signs and Symptoms

  • Age
  • Onset of pain or swelling
  • Anatomical location, character and severity of pain
  • 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

Red Flags

Red Flags which will bypass the Community Assessment 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
  • Avascular necrosis/osteonecrosis
  • The following hip condition:
    • Protrusio acetabula

Investigations

  • Knee X-ray should be performed if suspecting knee osteoarthritis and in all those aged 55 and over

Management

  • In proven Osteoarthritis - Arthroscopy and washout are not indicated for knee osteoarthritis unless there are true mechanical instability symptoms
    • 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.

Arthroplasty should only be considered if:

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 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)
    • Mild Symptoms
    • Offer verbal and written information about condition
    • Offer information to support weight loss if people are overweight or obese (BMI greater than 30) as a core treatment
    • Advise on local muscle strengthening and general aerobic exercise as a core treatment
    • Use of shared decision-making tools
    • Suggest oral simple analgesia and anti-inflammatory medication
    • Assess need for aids and devices (refer to occupational therapy or physiotherapy) including instruction in using a walking aid
    • Prescribe supervised and evidence based physical therapies - refer to Local Physiotherapy Service

Moderate Symptoms:

Unless red flags are present all patients referred for consideration of arthroplasty due to knee osteoarthritis will be assessed by a community assessment 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

Referral

Referral Criteria

Referral to specialist secondary care:

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 including x-rays
  • Include any conservative treatment with dates including physiotherapy & analgesia
  • Result of knee XR for all those aged 55 and over

Patients with knee osteoarthritis will be expected to have had up to 12 weeks of evidence based nonsurgical treatments. This time is to include any manual therapy, including physiotherapy, received in Primary Care (British Association orthopaedics commissioning guide 2016).

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.

Where conservative treatment with lifestyle measures and analgesia has failed – patient to be referred via the MSK "Physio First" Single Point of Access Pathway. This applies even when physiotherapy has recently been undertaken (NHS or private) or is not clinically indicated.



  • GPs will either need to provide the patient with the Patient Knows Best website to self-refer

or

  • the physio self-referral number: 0300 456 9987

If no clinical improvement with physiotherapy – physios are able to refer onto Extended Scope Practitioners (ESPs):

Unless red flags are present all patients referred for consideration of arthroplasty due to knee osteoarthritis will be assessed by a community assessment 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.

Any referral made to secondary care that is not for a red flag condition will be re-directed by DRSS to the relevant community physio team and a letter sent to the GP practice informing them of the correct pathway.

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

Referral Instructions

GPs will either need to provide the patient with the Patient Knows Best website to self-refer

or

the physio self-referral number: 0300 456 9987

Any referral made to secondary care that is not for a red flag condition will be re-directed by DRSS to the relevant community physio team and a letter sent to the GP practice informing them of the correct pathway.

For Knee select:

Priority:Urgent

Specialty: Orthopaedics

Clinic type: Knee

Service:DRSS-South Devon & Torbay-Orthopaedics-Knee- Devon CCG - 15N

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

MyHealth patient information - Knee Pain (Osteoarthritis)

PALS information leaflet

Patient transport services

Pathway Group

This guideline has been signed off on behalf of the NHS Devon Clinical Commissioning Group.

Publication date: April 2019

 

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