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. Identifier & Version No.: XXXXXX 1 Date of version: 23/01/2020 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. Identifier & Version No.: XXXXXX 2 Date of version: 23/01/2020 Management of the Degenerative Knee https://bjsm.bmj.com/content/bjsports/52/5/313/F2.large.jpg Identifier & Version No.: XXXXXX 3 Date of version: 23/01/2020 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 Identifier & Version No.: XXXXXX 4 Date of version: 23/01/2020 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 Identifier & Version No.: XXXXXX 5 Date of version: 23/01/2020 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 Identifier & Version No.: XXXXXX 6 Date of version: 23/01/2020 • 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