Knee Pain Care Pathway

Review in progress

Disclaimer: The guidance contains helpful primary care information for management of referrals and up to date referral criteria. These guidelines are locality specific to best reflect local services. This guidance does not override or replace the individual responsibility of healthcare and social care professionals involved in the delivery of care to make informed professional judgements appropriate to the circumstances of the individual.

Scope

This guidance refers to:

  • The management of all patients presenting with knee conditions

This guidance does not cover:

  • Under 16s

Commissioning Statements:

  • Referrals for Knee Replacement are subject to an eligibility criteria that must be met before a referral is made - please see Commissioning Statement for further information
  • Referrals for Knee Arthroscopy are subject to an eligibility criteria that must be met before a referral is made - please see Commissioning Statement for further information
  • Upright/Open MRI referrals are subject to an eligibility criteria that must be met before a referral is made - Please see Commissioning Statement for further information
  • For those patients who are not eligible for treatment under these policies consideration will be on an individual basis via the CCGs Prior Approval Process in accordance with NHS North Kirklees and NHS Wakefield CCG Commissioning Policy

Assessment

Signs and Symptoms

ACL Rupture

  • Significant mechanism of injury in the history.
  • Usually involves the knee moving into valgus.
  • Usually non-contact, occurring with either acceleration/deceleration or change of direction.
  • Typically report hearing a 'pop' at the time of onset.
  • Immediate swelling (Haemarthrosis: All acute knee injuries with Haemarthrosis are to be managed as an ACL rupture until proven otherwise).
  • Will report that the knee gives way – usually causing a fall to the floor.

PCL Rupture

  • Mechanism of injury includes possible hyperextension or a 'dashboard injury' – this is where there is direct anteroposterior force applied through the tibial tuberosity.
  • Be mindful of possible associated injuries e.g. Posterolateral Corner (Lateral Meniscus/Lateral Collateral Ligament).

Acute Meniscal Pathology

  • Predominantly an associated injury – always consider that the meniscus has been torn if the ACL has been ruptured.
  • Can occur in isolation: Consider a twisting injury in weight-bearing on a semi-flexed knee.
  • Swelling is not immediate but delayed – occurs a few hours later (usually next day upon waking).
  • Report sharp, stabbing pain local to the affected joint line (medial/lateral) with effusion.

MCL Injury

  • Mechanism of Injury: Usually involves the knee moving into valgus.
  • Medial knee pain that is more diffuse than that of meniscal tear +/- local swelling +/- local bruising tracking distally.

LCL Injury

  • Mechanism of Injury: Usually involves the knee moving into varus.
  • More serious injury than MCL due to it often being associated with other injuries – meniscal and cruciate.
  • Often involved in Posterolateral Corner injuries: observe where the knee is effused of thrusts into varus during gait.

Patella Dislocation

  • Can be traumatic or insidious/recurrent.
  • Pain often located to the medial aspect of the patella.
  • May demonstrate atrophy of the quadriceps and reports symptoms suggestive of 'Anterior Knee Pain'.

Tibiofemoral Joint OA

  • Often insidious, gradual progressive onset.
  • May have a previous history of trauma.
  • Symptoms can be diffuse or can be localised to the affected compartment e.g. medial or lateral.
  • Report early morning stiffness < 30minutes and stiffness of the knee after immobility.
  • Are often overweight.
  • Report crepitus.

Degenerate Meniscus

  • Often insidious, gradual progressive onset.
  • May have a previous history of trauma.
  • Symptoms localised to the affected compartment e.g. medial or lateral.
  • Report slight early morning stiffness < 30minutes and slight stiffness of the knee after immobility.
  • Are often overweight.
  • No deformity.

'Anterior Knee Pain' – Patellofemoral Pain

  • Diffuse symptoms primarily in the anterior knee – Often insidious, rarely trauma.
  • Often reported as deep, retro-patella and have the ability to move around.
  • Common in young population, especially females.
  • Often will be low tone, deconditioned with an increased BMI.
  • May be insidious, may report starting after a period of increased or unaccustomed activity.
  • Can report pseudo-giving way – this is where the knee buckles whilst walking and is not true instability.

Patellofemoral Joint OA

  • As for 'Anterior Knee Pain', however occurs in older individual and may report early morning stiffness and more consistent crepitus.
  • PFJ Stiff with crepitus +/- pain upon assessment.
  • There is no clinical value in PFJ compression/Clarke's test.

Patella Tendinopathy

  • Usually atraumatic following unaccustomed activity (usually involves deep knee flexion and jumping e.g. basketball, volleyball, long jump).
  • Can occur with direct trauma.

History and Examination

For additional information on signs and symptoms please click here - Signs and Symptoms

Examinations:

  • Site of pain
  • Presence of an effusion
  • Range of movement in hip and knee.
  • Retro patella tenderness
  • Joint line tenderness
  • Ligament laxity on stress
  • Patella tendon tenderness
  • Consider meniscal tests such as McMurray's and Apley's
  • Consider referred pain ( hip or spine)

Red Flags

Seek immediate or urgent specialist advice/treatment if:

Urgent referral to Orthopaedics

  • Locked knee post injury ( loss of extension)
  • Suspicion of malignancy (2 week rule)
  • Severe persistent night pain
  • Septic arthritis (urgent admission)

Urgent referral to Rheumatology- Suspicion of Inflammatory joint disease

Urgent admission to vascular - Suspicion of Peripheral limb ischaemia)

Investigations

Undertake the following to aid diagnosis, inform management or prior to referral

  • X-ray indicated in OA when considering surgery or if significant trauma
  • MRI is the investigation of choice to identify meniscal tears, ligament injuries and loose bodies, although in most cases diagnosis should not need an MRI scan.
  • Knee pain without trauma, locking or restriction of movement - MRI is useful in patients with persistent undiagnosed pain, to exclude avascular necrosis, sepsis, or tumour (URGENT MRI)

Management

Clinical Management

  • Patient education
  • Analgesia
  • Trauma – "RICE"+ physiotherapy unless full quick recovery
  • OA -Intra-articular steroids for short term relief, only if not considering surgery in the near future

Refer to CONNECT MSK service if:

  • OA where pain or disability not acceptable for patient with primary care management
  • Persistent Patello femoral or patella tendon pain
  • Suspected Meniscal tear with persistent pain ,locking or swelling
  • Ligament injury with persistent pain or dysfunction
  • Management may include groups, individual Physiotherapy, injections
  • Unexplained knee pain in the young for investigation

Referral

Referral Criteria

  • Red Flags
  • North Kirklees (MSK, Trauma and Orthopaedics and Physiotherapy)
    • All MSK referrals (excluding red flags) should be made to Connect Community MSK who will undertake clinical assessment and triage and refer on as appropriate (including to physiotherapy). Choice of provider will be offered following triage
    • Please click here to open the Clinical Decision Making Aid for further guidance on which part of Connect's pathway to refer into i.e. Physioline, Physio or CATs
  • Wakefield – MSK
    • Those not presenting with red flag symptoms or where diagnosis or treatment is unclear should be referred to Connect Community MSK who will undertake clinical assessment and treatment and/or refer on to physiotherapy or secondary care as appropriate. Choice of provider will be offered for onward referrals.
  • Wakefield - Physiotherapy
  • Wakefield – Trauma and Orthopaedics
    • Patients should be offered choice of provider for trauma and orthopaedics.

Referral Requirements

  • For Knee Replacement, Knee Arthroscopy and Upright/open MRI referrals documented evidence is required to demonstrate that the patient meets the commissioning statement criteria
  • For those patients who do not meet the eligibility criteria evidence of prior approval authorisation is required

Commissioning Statements:

  • Referrals for Knee Replacement are subject to an eligibility criteria that must be met before a referral is made - please see Commissioning Statement for further information
  • Referrals for Knee Arthroscopy are subject to an eligibility criteria that must be met before a referral is made - please see Commissioning Statement for further information
  • Upright/Open MRI referrals are subject to an eligibility criteria that must be met before a referral is made - Please see Commissioning Statement for further information
  • For those patients who are not eligible for treatment under these policies consideration will be on an individual basis via the CCGs Prior Approval Process in accordance with NHS North Kirklees and NHS Wakefield CCG Commissioning Policy

Referral Instructions

  • e-Consultation is not currently available for this specialty
  • Referrals should be made via ICG to TRISH (if training has been undertaken) - See user guides (EMIS & S1) for further information.
  • For those Practices who have not received ICG training referrals should be made via eRS
  • Please identify speciality and clinic type

Supporting Information

Shared Decision Making

  • Patients have a right to make decisions about their care and should be fully informed about the options they face. They should be provided with reliable evidence-based information on the likely benefits and harms of interventions or actions, including any uncertainties and risks, eliciting their preferences and supporting implementation. Prior to referral for surgery the patient should understand their options and the benefits and risks and the likelihood of these occurring. If relevant patients should be signposted to decision aids for Knee Osteoarthritis or NHSE Knee Osteoarthritis aid which can be printed off for the patient if required

Patient information/Public Health/Self Care

All diagnoses - lifestyle advice - weight loss, exercise, cushioned footwear

Evidence/additional information

Assurance & Governance

  • This guidance was developed on: 03.2017
  • This guidance was ratified by: The OSCAR Assurance Group
  • Date ratified: 04.2017
  • Publication Date: 05.2017
  • Updated: 06.2018
  • Review Date: 04.2019
  • Ref No: MSK5 - 03.2017
Any feedback or suggestions to improve this guidance should be sent to: oscaradmin@this.nhs.uk
Only the electronic version is maintained, once printed this is no longer a controlled document

 

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