Knee Pathway

Scope

This guidance refers to patients ≥ 18 years old who present with knee pain, stiffness or instability.

Background

The prevalence of knee pain with disability in primary care is 6%, and the prevalence of moderate or severe knee pain is 12%. It is common for more females than males to present with knee pain and typically, the prevalence of knee pain in primary care increases in the older population. In older people, knee problems are most commonly due to osteoarthritis, with a prevalence in women over 75yrs of 36% and men over 75yrs of 27%. 3% of patients consult their GPs annually for knee pain in primary care.

Risk factors for knee pain include:

- increasing age - overweight and obesity - social deprivation - South Asian ethnicity - previous knee injury - occupation involving high knee loads - participation in sport involving torsion or high levels of contact.

Causes of Knee Pain in Primary Care

- Patellofemoral Pain - Patella Tendinopathy - Patellofemoral Joint OA - Degenerative Meniscus - Tibiofemoral Joint OA - Trauma (Patella dislocation, MCL/LCL/ACL/PCL injury).

Commissioning Statements

Referrals for Knee Arthroscopy - Osteoarthritis 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 Replacement - Osteoarthritis are subject to an eligibility criteria that must be met before a referral is made - please see Commissioning Statement for further information.

The above Commissioning Statements are aligned with the West Yorkshire & Harrogate Integrated Care System Knee Pathway which outlines thresholds for secondary care referral.

For those patients who are not eligible for treatment under these policies consideration will be on an individual basis via the CCGs Prior Approval or IFR Processes in accordance with NHS North Kirklees Commissioning Policy.

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Red Flags

Seek immediate or urgent specialist advice/treatment if:

• Suspicion of Inflammatory joint disease (Rheumatology)

• Suspected Septic Arthritis (urgent admission via A&E)

• Suspected DVT (A&E)

• Suspected critical limb ischaemia (A&E)

• Suspected fracture (A&E)

• Suspected ACL rupture with significant effusion, difficulty WB four steps and traumatic onset; potential tibial plateu fracture (A&E)

• Suspected MCL rupture – less than two weeks (A&E)

• Suspected Patella dislocation – less than two weeks (A&E)

• Locked knee (loss of passive extension) – less than two weeks (A&E)

OTTAWA Knee Rules: Immediate referral to an Emergency Department for an X-ray of the knee following an acute knee injury is recommended if the person (as per NICE guidance):

• Is unable to bear weight (walk four steps) immediately after the injury and when examined.

• Is unable to flex the knee to 90degrees.

• Is tender over the fibula head.

• Has isolated tenderness of the patella (no other bony tenderness).

• Is aged over 55 years.

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Management of the Degenerative Knee

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History

• Predominant symptoms: instability, stiffness, loss of function pain. • Unilateral or bilateral involvement. • Night pain or rest pain. • Trauma? Mechanism of injury. • Duration of symptoms. • Is this a recurrent problem? • Mechanical features: lock, give way, swell (time course) • 24-hour pattern • Response to previous treatment (if applicable). • Extra-articular features (inflammatory bowel disease, psoriasis).

Examination

• Presence of effusion or deformity. • Systemic examination. • Location of symptoms. • ROM in the hip and knee. • Joint line tenderness. • Patella mobility – symptoms, crepitus • Ligament laxity on stress testing. • Consider meniscal tests e.g. Scoop

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Yellow Flags

Psycho-social factors influencing pain which predict tendency towards chronic/persistent pain: • Attitudes - towards the current problem. Does the patient feel enabled and informed to be able to self-manage?

• Beliefs - The most common misguided belief is that the patient feels they have something serious causing their problem-usually cancer. 'Faulty' beliefs can lead to catastrophisation.

• Compensation - Is the patient awaiting payment from any alleged party that may have caused their problem?

• Diagnosis - or more importantly iatrogenesis.

Inappropriate communication can lead to patients misunderstanding what is meant, the most common examples being 'your joints are wearing away’ or 'your nerve is trapped’. Also, poor communication of scan findings that are known to be common in asymptomatic individuals e.g. your joint is bone on bone.

• Emotions - Patients with other emotional difficulties such as ongoing depression and/or anxious states are at a high risk of developing chronic pain.

Investigations

Routine investigation not recommended best practice.

Consider OTTAWA Knee Rules (above) in the present of trauma.

Diagnose osteoarthritis clinically without investigations, if a person:

1. Is aged 45 years or over, and 2. Activity-related joint pains, and 3. Has either no morning joint-related stiffness or morning stiffness that lasts no longer than 30 minutes.

• Functional impairment such as difficulty walking, climbing stairs, dressing or driving.

• Psychosocial impact: may affect self-confidence, self-esteem, sleep quality, relationships and ability to self-care and care for others; may cause anxiety and depression

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Differential Diagnosis

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 • Can report crepitus. • Worse with knee flexion activities e.g. sitting, descending stairs, squatting • Can sometimes co-exist with ‘fat pad impingement’ – U-shape effusion below the patella that is made worse with prolonged standing/extension. • Refer to Physiotherapy.

Patellofemoral Joint OA

• As for ‘Patellofemoral 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. • Refer to Physiotherapy

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. • Pain located to the inferior pole of the patella. • Pain with deep squat, passive knee flexion and upon palpation of the patella tendon at its attachment to the inferior pole. • Refer to Physiotherapy.

Acute Meniscal Injury

• 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). • Report sharp, stabbing pain local to the affected joint line (medial/lateral) with effusion. • Usually lack end range extension and end range flexion. • May report true locking – an inability to full extend the knee. • Test: Tender on palpation of the joint line (usually on the posterior aspect); Positive McMurray’s • Refer to CATS

Degenerative Meniscus

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• 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. • Rarely effused, no signs of synovial thickening/additional bone growth. • Full range of motion, maybe sore on the extremes. • TOP of the affected joint line. • May have a positive McMurray’s test. • Refer to Physiotherapy

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. o Medial Compartment OA: Varus Deformity o Lateral Compartment OA: Valgus Deformity • Maybe effused, can be signs of synovial thickening/additional bone growth. • Lacks range of movement into flexion and extension with end range pain and often crepitus. • Refer to Physiotherapy

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’. • Acute, effused with positive apprehension test: Refer to CATS if > 2-weeks • Settling with negative apprehension test: CATS

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. • Test: Valgus in full extension and Valgus in slight flexion. • Stable: Refer to Physiotherapy • Not stable (Lax): Refer to CATS if > 2-weeks

LCL Injury

• Mechanism of Injury: Usually involves the knee moving into varus. •

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• 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. • LCL Test: Varus in full extension and Varus in slight flexion. • PLC Test: Dial at 30 and 90 degrees. • Stable: Refer to Physiotherapy • Not stable (Lax): Refer to CATS

ACL Injury

• 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). • May report that they felt the knee had dislocated. • Will usually report that the knee is giving way (especially when turning/changing direction) – sometimes described as ‘buckling or not feeling stable’. • Test: Lachman’s • Refer to CATS if > 2-weeks and no suspicion of associated tibial plateau fracture (see Red Flags)

PCL injury

• 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). • Observe for possible ‘Sag Sign’ with patient in crook lying. • Test: Posterior Draw • Stable: Refer to Physiotherapy • Not stable (Lax): Refer to CATS

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Primary Care Management

(Referral from triage, community or hospital services specifically for primary care medical review)

Inclusions

• Assessment and management of multi-morbidity and psychiatric co-morbidity.

• Medication reviews and non-urgent prescriptions.

• Advice regarding achieving and maintaining optimal weight, nutrition, physical activity and healthy lifestyle, including smoking cessation advice. – Links to Social Prescribing

• Discussion about fitness for work and sickness certification.

• Management following discharge from community or secondary care where no further intervention planned.

• Patients referred from community services with known or suspected serious underlying pathology where non-urgent (for re-evaluation and possible referral to secondary care).

Exclusions

• Patients who need emergency or urgent assessment e.g. joint pain associated with systemic symptoms, signs of infection, known primary or suspected malignancy, sudden inability to bear any weight, suspected fracture or dislocation, suspected quadriceps or patella tendon rupture, severe soft tissue injury with gross instability, neurovascular damage following trauma, compartment syndrome, acute (<2 wks) and persistently ‘true’ locked knee (defined as loss of normal extension only).

• Patients seen in community or secondary care settings who need urgent specialist assessment e.g. severe pain unresponsive to analgesia and persistent loss of function.

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When to refer to Physiotherapy (inc. self-referral)

Includes

• Advice about the knee pain to aid shared decision-making, taking account of health literacy and patient beliefs. • Acute or chronic knee pain. • Suspected or known osteoarthritis. • Anterior knee pain, including where suspected arising from the patellofemoral joint. • Soft tissue injuries including suspicion of meniscal tears, ligament injuries or tendinopathies. • History or clinical examination of knee instability. • Advice regarding achieving and maintaining optimal weight, nutrition, physical activity and healthy lifestyle, including smoking cessation advice – Links to Social Prescribing • Assessment and treatment of functional impairment. • Assessment of falls and provision of walking aids. • Assessment of gait and stability, and provision of orthotics and braces. • Advice and assessment about aids and adaptations to assist activities of daily living and promote independence. • Improve general fitness and participation in regular physical activity. • Exercises for enhancing flexibility and muscle strength

Exclusions

• Patients who need emergency or urgent assessment e.g. joint pain associated with systemic symptoms, signs of infection, known primary or suspected malignancy, sudden inability to bear any weight, suspected fracture or dislocation, suspected quadriceps or patella tendon rupture, severe soft tissue injury with gross instability, neurovascular damage following trauma, compartment syndrome, acute (<2 weeks) and persistently ‘true’ locked knee (defined as loss of normal extension only). • Suspected inflammatory arthritis • Patients who need urgent specialist assessment e.g. severe pain unresponsive to analgesia and persistent loss of function. • Presented with same condition within previous 12 months, and there was no substantive improvement with treatment previously. • Patients with frailty and high risk of falls = refer to Falls Service delivered by Locala. • Co-morbidities that significantly impair a patient’s ability to exercise. For example, neurological (e.g. stroke), severe cardiac, renal, liver or respiratory failure, recurrent disabling hypoglycemia or poorly controlled epilepsy.

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When to refer to MSK CATS

Inclusions

• Unsuccessful conservative treatment (exercises, self-management strategies, physiotherapy, analgesia and steroid injection – if available.) • Including suspected meniscal tears, intermittent locking, ligament pathologies, instability, tendinopathies and anterior knee pain • Steroid injection, where clinically indicated (e.g. acute flare of osteoarthritis, non- septic effusion), if GP has not already administered. • Diagnostic uncertainty. • Interface service to ensure onward referral to secondary care is accompanied by any imaging required by the receiving consultant or unit.

Exclusions

• Patients who need emergency or urgent assessment e.g. joint pain associated with systemic symptoms, signs of infection, known primary or suspected malignancy, sudden inability to bear any weight, suspected fracture or dislocation, suspected quadriceps or patella tendon rupture, severe soft tissue injury with gross instability, neurovascular damage following trauma, compartment syndrome, acute (<2 weeks) and persistently ‘true’ locked knee (defined as loss of normal extension only). These patients will be referred to GP for urgent assessment (same day), or to A&E as clinically appropriate. • Suspected inflammatory arthritis – these patients will be triaged to Rheumatology. • Patients who need urgent specialist assessment e.g. severe pain unresponsive to analgesia and persistent loss of function.

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Clinical Decision-Making Aid Please use this grid to inform your selection on the referral form. for patients that presents with For those unable to self-referral to PhysioLine due to communication Knee Pain difficulties, please use the referral form to refer for face-to-face Physio.

Traumatic Knee Injury Knee (PFJ + TFJ) OA Degenerate Patellofemoral Patella Direct Referral to (ACL, PCL, MCL, LCL, Meniscus Pain (PFP) Tendinopathy Secondary Care Meniscus, Patella Dislocation)

Investigations in X-ray in weight bearing X-ray in weight bearing Not indicated Not indicated Not indicated Suspected fracture, Primary Care AP/Lateral and Skyline AP/Lateral and Skyline dislocation or infection Views to rule out Views. = A&E fracture.

Management Consider Analgesia & Consider Analgesia & Consider Analgesia Consider Consider Analgesia Suspected NSAIDs NSAIDs & NSAIDs Analgesia & & NSAIDs inflammatory condition NSAIDs = Rheumatology Rest, Ice, Compression, Consider 1 x Injection Advise not to Elevation if no improvement stretch quadriceps. after 6-weeks of conservative management to facilitate Physiotherapy

Referral Within two weeks = A&E Mild = Refer to Refer to Refer to Refer to History of, or Physiotherapy Physiotherapy Physiotherapy Physiotherapy suspected malignancy Over a week = Refer to refer as appropriate via CATS Moderate/Severe = 2ww Refer to CATS

Education Traumatic Knee PIL OA PIL OA PIL PFP PIL Lower Limb Tendon PIL

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Underpinning evidence and references

This pathway was created via an adaptation of the NWL MSK Pathways with permission - Bernstein I, NW London Health and Care Partnership

NICE (2014) Osteoarthritis: https://www.nice.org.uk/Guidance/CG177

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