Knee Pain Other - Western locality

Scope

This clinical referral guideline covers referrals for knee pain, other than pain caused by osteoarthritis (see link to osteoarthritis guideline).

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.

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 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.

The Acute Knee clinic 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 Acute Knee clinic 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.

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

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). see Knee Osteoarthritis guideline

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 of Acute Knee Injury following the Ottawa knee rules - see below:

  • A knee x-ray is only required for acute 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)

Red Flags

The following should be referred to Emergency Department

Atraumatic:

  • Septic Arthritis
  • Avascular necrosis/osteonecrosis

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.

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

Investigations

  • X-ray should be considered in acute knee injury if fracture cannot be excluded by 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 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 ESP

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)
  • Optimum pharmacological treatments
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:

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 ).

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.

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
  • Knee XR for all those aged 55 and over

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 link to osteoarthritis CRG
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
Only the following patients should be sent through the Acute Knee Clinic:

The Acute Knee clinic is for young active patients who have osteoarthritis or who have sustained soft tissue knee trauma or have ligament and cartilage injuries that may benefit from early surgery. Older patients with no significant injury/trauma are not suitable for the Acute Knee clinic and should be directed to conservative management.

Please note referrals to Acute Knee Clinic which do not meet the above criteria will be returned to the practice.

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

Referral Instructions

Referral to Acute Knee Clinic:

Priority: Urgent

Specialty: Orthopaedics

Clinic Type: Knee

Service: DRSS-Western-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

My Health Devon

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 19

 

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