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 Osteoarthritic 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 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 will bypass the Community Assessment Service (should be referred urgently to secondary care/Emergency Department)

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

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

• 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:

• to rule OA in or out as a differential for the patient's symptoms
• to ensure that deterioration in symptoms isn't due to potential Red Flag conditions e.g., avascular necrosis (an indication for expedited referral).
• deterioration in OA can result in more complex and time-consuming operations. If this is known, then the appropriate surgical list time can be allocated, hence avoiding cancellations of procedures later in the list

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.

• If inflammatory diagnosis is suspected please check FBC/CRP/ Rheumatoid factor
• If a reactive cause is considered chlamydia testing should also be added

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: In Shape for Surgery best practice can be seen here.

• 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 Criteria

• Red Flags will bypass the Community Assessment Service (should be referred urgently to secondary care/Emergency Department

Acute Knee Clinic

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 criteria below will be returned to the practice.

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:

• True episodes of locking/locked knee
• Episodes of giving way particularly if unpredictable in nature
• Significant haemarthrosis/knee effusion or suspected osteochondral fracture which may or may not be seen on X-ray
• Ruptured/torn anterior cruciate ligament and or acute meniscal lesion in a patient who is likely to benefit from surgery (young, active)
• Instability on ligament testing in a patient with a history of recent trauma
• Unexplained new lump or bump around the knee.

2. Non-traumatic symptomatic knee

• Previous Meniscal repair with newly acquired non-traumatic / minor trauma resulting in mechanical symptoms

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:

• Under 16 years of age
• Arthroscopy recommended by an orthopaedic specialist in those under 18 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

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:

• History and duration
• Presence and time of onset of any swelling
• Instability symptoms or history of overuse
• Relevant examination findings
• Relevant investigations

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:

1. to rule OA in or out as a differential for the patient's symptoms
2. to ensure that deterioration in symptoms isn't due to potential Red Flag conditions e.g. avascular necrosis (an indication for expedited referral).
3. deterioration in OA can result in more complex and time-consuming operations. If this is known, then the appropriate surgical list time can be allocated, hence avoiding cancellations of procedures later in the list

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.

Where the circumstances of treatment for an individual patient do not meet the criteria described above exceptional funding can be sought. Individual cases will be reviewed by the appropriate panel of the CCG upon receipt of a completed application from the patient's GP, consultant or clinician. Applications cannot be considered from patients personally.

Referral Instructions

Referral to Acute Knee Clinic:

Priority: Urgent

Specialty: Orthopaedics

Clinic Type: Knee

Service: DRSS-Western-Orthopaedics knee-Devon CCG-15N

For Knee select:

Priority: Routine/ Urgent

Specialty: Orthopaedics

Clinic type: Knee

Service: DRSS-Western-Orthopaedics-Knee- Devon CCG- 15N

Referral Forms

DRSS referral form

Patient Information

MyHealth patient information - Knee pain

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: July 2020

Updated: December 2023