Knee Pain- Adult Leeds

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1.  Background Information / Scope of Pathway

Quick info:

These pathways were developed to guide clinicians when managing adults with common musculoskeletal problems. The pathways are not provider specific and so the guidance and forms apply to all providers.

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2.  Information Resources for Patients and Carers

Quick info:
Patient information

MSK TAS Patient Information Leaflet

information leaflet for Joint/Joint Line Pain (Meniscal Tear, Ligament Injury, Cartilage Injury)

Information leaflet Osteoarthritis of Knee

Decision Aid Knee Replacement

patient information leaflet for knee replacement surgery from Arthritis Research UK.

Patient Information Leaflet Surgery BMI over 35

Knee Replacement Patient Information Leaflet

information leaflet for anterior knee pain

information leaflet for patella tendinopathy

patient information leaflet for Baker's Cyst

information leaflet for bursitis of the knee.

information leaflet for patellofemoral pain

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3.  Development & Updates to this Pathway

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Development

The pathway redesign was a clinicaly lead city wide process. It was conducted through the Musculoskeletal Steering Group which had representation from the 3 CCGs, Patients, NHS Leeds, Leeds Teaching Hospitals Trust and the Leeds Musculoskeletal Services.

The individual pathways were authored by the appropriate clinical staff involved in delivering the pathway, but chiefly comprised of GPs, Consultants and Therapists.

The pathways went live on the 2/7/2012

Updates

Referrals Forms Updated October 2012. Major Review and Update June 2013

This involved reformating of the pathway and referral forms.

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4.  Referral Forms

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Referral Forms

Mail Merged
The forms below are provided as a repository. They can be downloaded to your computer and be imported to your clinical system. This is so all practices have access to the most up to date forms.

EMIS - merged
MSK4 Knee Form V3
MSK5 Knee Replacement Triage Form V3
MSK 6 Acute Severe Knee Injury Form V3
MSK14 Problem not on Pathway Form V3

SystmOne - merged
MSK4 Knee Form V3
MSK5 Knee Replacement Triage Form V3
MSK 6 Acute Severe Knee Injury Form V3
MSK14 Problem not on Pathway Form V3

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6.  Red flags

Quick info:
GP information
Before following the Knee Pathway, it is important to exclude features that may suggest diagnoses including:

  • rheumatological problems
  • neoplasms
  • infections
  • referred pain

Features that may alert the clinician to such causes include, but are not limited, to the following:

  • Multi-joint involvement with marked early morning stiffness – could this be an inflammatory arthropathy requiring rheumatological assessment?
  • Hot, red, swollen joint +/- systemic malaise – could this be gout, or a septic joint requiring urgent admission?
  • Severe, deep bone pain +/- nocturnal pain +/- systemic malaise – could this be a bone neoplasm requiring appropriate urgent assessment?
  • Are features present suggesting referred pain, perhaps from the hip or lumbar spine?

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7.  Suspected Osteoarthritis - GP to assess Pain/Function

Quick info:
Guidance will be provided as part of the IT practice software supporting the referral management process, including scoring criteria for pain/functional impairment.

GP Information
Knee osteoarthritis is common and may affect anyone. The knee cartilage becomes thin and rough, with the underlying bone growing thicker and broader. Osteophytes are formed, and an effusion may develop from the inflammatory response to the changes with the joint (synovitis).

Those at increased risk include:

  • older age-groups
  • female
  • family history
  • overweight
  • previous joint surgery/injury, eg meniscectomy
  • other joint condition, eg rheumatoid disease, gout, etc
  • certain occupations, eg elite sport

The patient with knee osteoarthritis may report:

  • pain (typically worse at the end of the day, or with activity)
  • stiffness with rest that improves within minutes of activity
  • cracking, crunching, grinding etc of the knee with movement
  • swelling
  • knee giving way
  • loss of movement of the knee

On examination, findings may include:

  • joint line tenderness
  • crepitus with patella movement
  • quadriceps muscle bulk wasting
  • flexion, varus or valgus deformity

When osteoarthritis is suspected, an assessment of severity should be made on the basis of the signs and symptoms. The following factors should be taken into account:

  • Pain:
    • What analgesia has the patient tried so far? (see 'Home management' node for advice on pain management)
    • Is the patient on maximum tolerated analgesia?
    • Is the patient kept awake at night with pain?
  • Function:
    • Is the patient able to perform activities of daily living?
    • How far can the patient walk?
    • Are walking aid required?
    • Does the knee persistently give way?
  • Examination:
    • Is there significant loss of quadriceps muscle bulk?
    • Is there a fixed flexion/ varus / valgus deformity?

If there is only mild intermittent pain (settling with analgesia), with no functional disruption and a relatively normal examination there is no need to obtain radiographs at this stage. It would be appropriate to follow the ‘Not severe’ pathway and provide the advice on the ‘Home management’ node.

If symptoms are deemed severe (significant pain, disruption of function, positive examination findings), a weight bearing X-ray AP and Lateral should be obtained to assess for the presence and severity of Tibiofemoral osteoarthritis (see ‘Assess Tibiofemoral Osteoarthritis Severity’ node for further information).

It is worth mentioning here that NICE CG59 states ‘Intra-articular corticosteroid injections should be considered as an adjunct to core treatment for the relief of moderate to severe pain in people with osteoarthritis’. This may be provided in-house if expertise exists and may be useful for those patients who decline or are unsuitable for surgery but report significant pain.

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8.  Injury that is Traumatic in Origin

Quick info:
GP information
The Acute Knee injury:

Suspect significant intra-articular pathology in patients less than 40 years of age with a history of any or all of the following:

  • twisting injury
  • hearing or feeling a pop/crack at the time of injury (suspect ACL tear)
  • significant joint effusion
  • true locking/unlocking
  • inability to fully weight-bear
  • bruising around knee

The history should give a clue to the diagnosis in most circumstances. Check knee extension by standing at the foot end of the bed and lifting the heel off the bed and comparing with the opposite side. Assess tenderness on medial collateral ligament as this is a common injury and is usually treated non-operatively.

Acute knee haemarthrosis:

  • think ACL rupture
  • other causes are:
    • peripheral meniscus tears
    • osteochondral fractures
    • patella dislocations
    • PCL injury

Acute locked knee following injury:

  • meniscus tear
  • ACL rupture
  • loose body knee/osteochondral fracture

Indications for X-rays:

  • There are guidelines like Ottawa rules for indications for X-rays, but most patients who cannot comfortably weight-bear, have bony tenderness and have significant joint swelling require X-rays.
  • If a fracture is suspected then immediate referral to Accident and Emergency is advised. If not, then a referral to the Acute Knee Injury clinic is advised for acute and severe knee injuries. Please arrange for the patient to have an urgent Knee X-ray whilst waiting for this appointment.

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9.  Anterior Knee Pain

Quick info:
GP Information
Anterior Knee Pain is a relatively common presentation and careful history and examination will often reveal the likely diagnosis. See information leaflet for assessment of anterior knee pain.

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10. Joint/Joint Line Pain (Meniscal Tear, Ligament Injury, Cartilage Injury)

Quick info:
GP information
An acute meniscal tear commonly occurs following a sports-related twisting incident with the foot of the affected limb anchored to the ground. The medial meniscus is more commonly injured.

Small tears may cause no immediate symptoms, with discomfort +/- swelling developing over 24 hours.

More severe tears (eg the longitudinal, ‘bucket-handle’ tear) produce more severe symptoms with immediate pain and restricted range of movement. Clicking, catching or locking may be reported. Locking (inability to fully extend the knee) may occur. The torn meniscus impinges on articular surfaces.

Degenerative meniscal tears occur in older populations. There may be a trivial or indeed no inciting event.

Examination findings include:

  • joint-line tenderness (most commonly postero-medial)
  • joint effusion (varies)
  • restricted range of movement (loss of full extension)
  • quadriceps muscle atrophy
  • discomfort on squatting
  • positive McMurray’s test:
    • knee flexion/external rotation pain suggests medical meniscus
    • flexion/internal rotation suggests lateral meniscus

Management:

  • The ‘Injury that is traumatic in origin’ pathway is appropriate for active individuals, perhaps following sporting injuries, presenting with a twisting knee injury, significant pain/loss of function, effusion, +/- locking, in whom a severe meniscal tear is suspected.
  • Commonly an insidious-onset of symptoms (+/- inciting event) would be appropriately managed conservatively without immediate referral. Guidance on referral criteria accompanies the next node on the pathway.
  • The patient information leaflet attached to the 'Conservative management' node contains information on immediate management (PRICE), and subsequent maintenance of muscle strength around the knee.

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11. Focal Swelling

Quick info:
GP information
Meniscal Cysts:

  • These benign swellings arise more commonly from the lateral  than the medial joint line. They may be soft or hard and will fluctuate in size with knee flexion and extension.
  • They are usually associated with an underlying horizontal cleavage tear in the meniscus.
  • Ultrasound can confirm diagnosis if there is diagnostic uncertainty.

Baker’s Cyst:

  • The most common cause of swelling in the popliteal fossa.
  • Baker's cyst may be asymptomatic and are usually associated with underlying intra-articular pathology, eg osteoarthritis. Treatment should be directed at knee pathology, excision rarely indicated. If diagnosis in doubt, obtain ultrasound.

Pre-patellar Bursitis:

  • This is the most common bursal swelling around the knee.
  • May be the result of acute or chronic trauma but can be a result of crystal deposition or infection.

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12. Knee Pain Diagnosis Unclear

Quick info:
Pathway information
The aim of the diagnosis uncertain pathway is to gain quick access to a diagnosis in patients where it is hard to fit them in to other parts of the knee pain pathway, or where diagnostic difficulty remains.

GP Information
Sometimes a patient may present with knee pain and the diagnosis is unclear. Some pointers to a diagnosis for patients with chronic knee pain are listed below.

Diagnosing chronic knee pain:

Meniscus tears

  • patients may have no history of injury in some degenerate tears
  • classical presentation is often with twisting injury not necessarily with sports but could be something like getting up from deep squat
  • diagnosis is achieved by a composite of symptoms and signs   the presence of 3 or more clinical signs gives a meniscus tear suspicion rate of at least 75%. Weight bearing X-rays are necessary to assess chondral damage and MRI scans are indicated in only less classical presentations.
  • the composite of signs to look for are:
    • history of locking
    • pain on full extension
    • pain on deep flexion
    • joint line tenderness
    • presence of positive meniscal stress test, eg McMurray’s test

Knee articular cartilage damage

  • localised articular cartilage damage is very commonly found during knee arthroscopies and can be a cause of knee pain
  • this is not established osteoarthritis
  • patients often present with:
  • clinical history of past injury or repetitive loading with sports or with work
  • refractory knee pain not settling with physiotherapy or other conservative measures
  • X-rays may show osteochondritis dessicans or localised chondral defect
  • examination may reveal effusion and joint line tenderness
  • patello-femoral joint also commonly involved

Ligament injuries

  • chronic ligament injuries usually present with instability and pain
  • there is usually a classical history of twisting injury that has been treated non-operatively
  • remember that patellofemoral wear often gives feeling of instability and locking but the symptoms are present more commonly on doing stairs, getting up from a chair or whilst driving

When the diagnosis is unclear and the patient has significant and/or persistent symptoms a referral to the MSK-MDT is indicated. The rationale here is for the patient to have a full assessment with access to appropriate diagnostic aids, and enabling onward referral where appropriate, eg to Tier 1 physiotherapy, rheumatology or a knee surgeon.

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13. Problem Not on Pathway

Quick info:
There are 2 broad groups of patients who fall into this category:

Those who have a clear problem but there is no Leeds pathway and so you are ensure of where to refer the patient.

Those with a clear problem and course of action but you are unable to make the referral because of referral restrictions caused by some pathways still not allowing GPs to directly refer to the appropriate surgeon. Pathways where these restrictions still occur are the Shoulder / Elbow, Spine, Knee and Foot / Ankle.

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14. Refer to MSK-MDT Form (MSK4)

Quick info:
Referral Form:
MSK4 Knee Form V3

Choose & Book
You can find this clinic on Choose & Book under:
Speciality: Orthopaedics
Clinic Type: Knee

Provider information
The only provider of the MSK-MDT clinic in the city is the Leeds Musculoskeletal Service. This is a multiprofessional clinic including senior physiotherapists and musculoskeletal physicians.

This clinic provides diagnosis, investigation, treatment and onward referral if needed.

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15. Refer to MSK-TAS (Telephone Assessment Service) Form (MSK14)

Quick info:
MSK TAS Patient Information Leaflet

Referral Form:
MSK14 Problem not on Pathway Form V3

The MSK Telephone Assessment Service (MSK-TAS) is offered as a way of ensuring patients get into the right clinic when it is not clear from the pathways what the right course of action is.

This is distinct from the Diagnosis Unclear Pathway which is there to offer quick access to diagnostic assessment when patients present with symptoms that don't immediately fall into a diagnostic group.

Patients who are appropriate for the MSK-TAS fall into two categories:

Those who have a clear problem but there is no Leeds pathway and so you are ensure of where to refer the patient.

Those with a clear problem and course of action but you are unable to make the referral because of referral restrictions caused by some pathways still not allowing GPs to directly refer to the appropriate surgeon. Pathways where these restrictions still occur are the Shoulder / Elbow, Spine, Knee and Foot / Ankle.

When you book the patient into the MSK-TAS via Choose & Book you are booking them a telephone appointment.

Once the referral form has been completed and sent a senior Physiotherapist will review the referral form within 48 hours. They will then decide the appropriate course of action and the patient will be contacted by phone at the allotted time in order to make the necessary arrangements for onward referral.

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16. Conservative Management

Quick info:
GP information
An information leaflet is provided for patients providing guidance on home-management (PRICE and basic muscle (quadriceps) strengthening exercises).

When there is clinical suspicion of meniscal injury (which does not fit criteria for the Knee Injury Clinic, see ‘Injury that is traumatic in origin’ pathway), a period of conservative management is reasonable before referral. Some injuries will settle down and cause little or no further problems.

If symptoms do not settle within 3-4 weeks, or if clinically the injury is likely to require MSK-MDT intervention, the referral is indicated. The patient can be advised the MSK-MDT intervention will comprise assessment and formal conservative treatment/physiotherapy +/- imaging and if indicated, referral onward to orthopaedics for a surgical opinion to consider knee arthroscopy.

Please note GP's should not refer for knee MRI scans. Only a small selected group of patients would benefit from a scan for a fairly limited number of indications. Given the high cost of these scans, the MSK Steering Group strongly believe specialists are much better placed to make imaging decisions.

Factors to consider when assessing meniscal injury severity:

  • How severe was the initial injury?
    • If acute severe twisting injury, rapid development of effusion or locking, the patient needs to attend the Knee Injury Clinic via the ‘Injury that is traumatic in origin’ pathway.
    • If minor or no identifiable precipitating cause with little or no effusion a trial of conservative treatment is reasonable.
  • What are the clinical symptoms and signs?
    • Loss of function/pain with activities of daily living / significantly restricted range of movement / significant effusion / positive
      McMurray’s testing with minimal knee flexion indicate a more considerable injury and referral will most likely be indicated.
    • Absence of these features suggests an injury more likely to settle with conservative treatment.
  • Has conservative treatment been discussed and trialled with the patient?
    • Failure of conservative treatment is an indication for referral.

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19. Refer to MSK-MDT Form (MSK4)

Quick info:
Referral Form:
MSK4 Knee Form V3

Provider information
The only provider of the MSK-MDT clinic in the city is the Leeds Musculoskeletal Service. This is a multiprofessional clinic including senior physiotherapists and musculoskeletal physicians.

This clinic provides diagnosis, investigation, treatment and onward referral if needed.

All referrals to be sent through the national e referral system (ERS).

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25. Refer to Acute Knee Injury Clinic Form (MSK6)

Quick info:
Referral Form:
MSK 6 Acute Severe Knee Injury Form V3

Provider information
LTHT is the only provider of the Acute Knee Injury Clinic

This service was initially set up for access via A&E only but it has been extended to primary care as a result of the redesign process. There is limited capicity of this service currently and so tight inclusion and exclusion criteria have been set, in order to maintain capacity for the severe injuries. We will be closely monitoring this issue and work to match demand and capacity, in the mean time please only refer the severe injuries.

Key Dates
Published: 09-0ct-2015, by Leeds
Valid until: 17-Jun-2016

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