Document type
Clinical pathways
Place
Hertfordshire and West Essex ICB
Output type
Clinical Pathways
Pathway
Focal Knee SwellingKnee PainManagement of Acute Knee Injuries Presenting to A&ENon-traumatic Knee Symptoms

Knee Pain


Pathway Publish Date: March 2024
Pathway Next Review Date: March 2026
PLEASE NOTE FOR MOST MSK PATHWAYS –

  • DO NOT ORDER MSK MRIs FROM PRIMARY CARE.
  • UNLESS THE PATIENT HAS A RED FLAG MOST MSK PATHWAYS REQUIRE A PERIOD OF CONSERVATIVE MANAGEMENT AND REFERRAL ONLY ON NON-RESOLUTION ONTO TO PHYSIO OR MSK TRIAGE SERVICES (SEE DETAIL FOR EACH PATHWAY ATTACHED).
  • PLEASE NOTE MSK TRIAGE SERVICES CAN ORDER MRIs AND OTHER DIAGNOSTICS

ONLY REFER DIRECT TO SECONDARY CARE IF RED FLAGS.

Red Flag - REFER AS EMERGENCY TO A&E/ ORTHOPAEDICS

Acute Knee Pain

Sudden onset of symptoms and

  • Previous surgery or known infection
  • Hot swollen joint:
    • Septic arthritis
  • History of trauma and:
    • Cannot weight bear or
    • Swelling or
    • Cannot bend knee past 90 degrees or
    • Cannot extend knee fully

A specialist opinion is usually required for suspected septic bursitis

MSK Triage

  • Intra-articular steroid (if not available in practice)
  • Conservative treatment hasn’t achieved rehabilitation milestones after 6 months
  • <45 years of age or previous surgery to knee and history of mechanical symptoms
  • Focal knee swelling

Physiotherapy

  • <45 years of age or previous surgery to knee and no history of mechanical symptoms
  • Anterior knee pain for>1 month, and no improvement following self-management for 6 weeks
  • Acute knee pain: Inflammatory disease or gout (still able to flex and extend knee) - no improvement following self-management for 1-2 weeks

Acute knee pain: No significant physical signs or functional impairment - no improvement following self-management for 1-2 weeks

Knee Pain Management

Patient presents with chronic knee pain

Knee pain for > 1 month

Exclude hip/spine pathology (especially in children) and inflammatory arthritis.

If aged > 45 years of age –

If Osteoarthritis of knee confirmed-

Primary Care management/initial self-management

  • Analgesics/NSAIDs,
  • Walking aid
  • Advise to stay active, continue normal activities
  • Weight management - weight loss especially if BMI > 30
  • Physiotherapy referral
  • Intra-articular steroid (refer to MSK if not available in practice)

Advanced/Moderate OA and Oxford Score 0-19

  • Patients who are obese (BMI >30) should be advised to lose weight
  • If BMI >40 or >30 with metabolic syndrome a 10% weight loss is usually required before referral (if exceptional circumstances please describe on prior approval form)
  • Use patient decision aids to discuss OA management and referral decision
  • If patient requests surgery, complete referral cover and send to prior approval

Mild/ Moderate OA, with Oxford Score 20-29

At least 6 months conservative treatment/Management should include:

  • Analgesics/NSAIDs
  • Walking aid
  • Advise to stay active, continue normal activities
  • Weight management - weight loss especially if BMI >30
  • Physiotherapy referral
  • Intra-articular steroid (refer to MSK if not available in practice)

Consider referral if failure to achieve rehabilitation milestones after 6 months or more of conservative treatment including weight loss if applicable (at least 10% weight loss if patients BMI is >30. If BMI >40 or >30 with metabolic syndrome a 10% weight loss is usually required before referral (if exceptional circumstances please describe on prior approval form).

  • Use patient decision aids to discuss OA management and referral decision
  • If patient requests surgery, complete referral cover and send to prior approval

If <45yrs or previous surgery to the knee

Assessment for mechanical symptoms

  • History of previous significant injury (valgus/varus stress or a twist, feeling of pop/snap at injury, rapid swelling, inability to complete activity e.g. sport or game)
  • Episodes of true locking (block to full extension)
  • Episodes of true giving way (associated with effusion)
  • Effusion/swelling
  • Joint line pain/tenderness
  • Associated with existing meniscal tears, ligamentous instability or loose bodies

If no history of mechanical symptoms then physiotherapist referral/treatment. Consider orthopaedic referral if failure to improve after three months.

If mechanical symptoms present then order MRI and refer to Extended Scope Physiotherapist. (ESP)

If you think a patient requires an MRI as there may be a need for surgery, please refer the patients in the first instance to the Herts MSK Triage Service (Phone 01707 781621).  Patients will then be triaged by an Extended Scope Practitioner (ESP) who will be able to request an MRI if required

See also – Acute Knee Pain pathway and Focal Knee Swelling pathway

Anterior Knee Pain

Characteristics of anterior knee pain:

  • It is common
  • Pain is usually at the front of or all over knee
  • Often bilateral
  • Exacerbated by stairs/hills/sitting long time
  • Pseudo-mechanical symptoms (regular, transient)
  • Often no history of injury

Primary care management of anterior knee pain

  • Analgesics/NSAIDs, walking aid, weight management (especially if BMI >30)
  • Advise to stay active, continue low impact activities

Radiology

  • Radiology usually not required
  • No need for MRI
  • Consider plain X-ray if age >45

Consider referral to physiotherapy if no improvement after 6 weeks

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