Knee problems - East Cornwall

Scope

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

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

Out of scope

Please note that referrals for arthroscopy and washout for global knee pain due to osteoarthritis will no longer be considered. This is now considered a low value procedure as the evidence for long term benefit is limited.

Assessment

Signs and Symptoms

ATRAUMATIC
  1. Anterior knee pain – anterior pain; worse on stairs; worse getting up from sitting
  2. Degenerative Meniscal Tears – often atraumatic and a natural consequence of degeneration NOT needing surgery
    1. Pain and swelling with mechanical instability with actual painful giving way on twisting or turning; painful catching; locking
  3. 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)

Red Flags

ATRAUMATIC:

Septic Arthritis – refer to Emergency Department

Tumour - Sarcoma service guidelines and other suspicious swellings - see Southwest Sarcoma guidelines and complete urgent 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 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 total locked knee
  • Young adult with twisting injury

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) (see section 10.1 Drugs used in rheumatic diseases and gout)

Early physiotherapy recommended.

  1. 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
  2. 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
  3. In proven Osteoarthritis
    1. Trial of conservative management – good evidence for Physiotherapy and exercise in mild to moderate osteoarthritis especially Patello-femoral osteoarthritis
    2. If no response discuss management options - Shared decision making – osteoarthritis of the knee
    3. For any patient where surgical intervention is being considered then the fitness for surgery needs to be addressed and management options organised where appropriate:
      1. Weight management if BMI more than 35
      2. Smoking Cessation
      3. Exercise/ Physiotherapy
      4. Pain management

Joint School (where available at this early stage to discuss the procedures)

All of these may be arranged through the community service (ESP/ GPwSI – "Step forward") where this facility is available

  • 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
  • Only consider arthroplasty 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
    • Patient willing and fit for surgery
    • Other impaired quality of life factors, e.g. loss of independence, depression
  • Arthroscopy and washout are not indicated for knee osteoarthritis unless there are true mechanical instability symptoms
CONTRAINDICATIONS

ABSOLUTE: current infection of knee; other site of infection; muscular dysfunction; severe 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:

Refer where there is persistent pain and disability not responding up to 12 weeks of evidence based non-surgical treatment (British Orthopaedic Association commissioning guide 2013).

All patients with knee pain 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. Unless it is clearly stated in the referral, these may be returned to the referrer.

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

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

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)

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
  1. 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
  2. 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
    • ESP/ ICAT after 12 weeks of conservative management
  3. 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

Referral Instructions

Referral to Orthopaedics via e-Referral Service

  • Priority: Routine/ Urgent
  • Specialty: Orthopaedics
  • Clinic type: Knee
  • Service: DRSS-Western-Orthopaedics knee-Devon CCG-15N

Referral Forms

DRSS

Supporting Information

GP Information

Southwest Sarcoma guidelines

Derriford 2WW 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

PALS information

Patient transport services

Pathway Group

This guideline has been signed off by the East Cornwall Locality on behalf of NHS Devon CCG.

Publication date: 02 April 2015

 

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