Focal Knee Swelling- Adult Leeds

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1.  Information Resources for Patients and Carers

Quick info:
Patient information

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

Information leaflet Osteoarthritis of Knee

Decision Aid Knee Replacement (http://sdm.rightcare.nhs.uk/pda/osteoarthritis-of-the-knee/ )

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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2. 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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3.  Focal Knee Swelling

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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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4.  Medial or Lateral Focal Swelling

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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.

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5.  Baker's Cyst

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Patient information
See attached patient information leaflet on Baker's Cyst.

GP information
A Baker’s Cyst (Popliteal Cyst) presents as a swelling behind the knee which may be associated with:

  • generalised knee swelling
  • some loss of knee flexion
  • knee ache; and
  • symptoms of any associated knee disorder

Primary Baker’s cysts:

  • occur in otherwise healthy knee joints
  • occur generally in children and younger people
  • are thought to be a communication between the knee joint and the popliteal bursa through which synovial fluid can pass thus forming the cyst

Secondary Baker’s cysts:

  • are more common
  • occur in knees with underlying problems (commonly knee OA) where the problem in the knee results in production of extra synovial fluid stretching the joint capsule generating a bulge of synovial fluid behind the knee

If a Baker’s cyst ruptures then swelling / redness of the calf may develop. The differential diagnosis may include DVT which must be excluded.

If a Baker’s cyst is clinically diagnosed, the pathway suggests obtaining a weight-bearing AP/lateral knee X-Ray. If knee OA is confirmed then the 'Knee Pain - Suspected OA' pathway should be followed. If the X-Ray is normal, an ultrasound scan of the swelling should be obtained to clarify the diagnosis.

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6.  Bursitis

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Patient information

See information leaflet on bursitis of the knee.

GP information
Prepatellar Bursitis:

A bursa is a small sac of fibrous tissue with a thin synovial lining that is filled with fluid. Numerous bursae are found in the body, around joints and in places where ligaments and tendons pass over bones. Bursitis is inflammation within a bursa. The inflammation leads to an increase in synovial fluid production and causes the bursa to swell.

There are 4 bursa located around the knee joint (see image of the knee joint). They are all susceptible to bursitis but the prepatellar bursa is most commonly affected. Less frequently, the infrapatellar and deep patellar can become inflamed.

Aetiology:
Prepatellar bursitis may occur due to:

  • acute trauma
  • recurrent minor injury -  occurs after long periods of time spent kneeling forwards and putting pressure on the patella. Historically, this was typical of housemaids who spent long periods of time scrubbing floors on their knees.
  • infection -  pyogenic prepatellar bursitis is common in children. It may be mistaken for septic arthritis of the knee. Staphylococcus aureus is the usual causal agent. There is usually a history of a break in the skin prior to its onset.
  • a coexisting inflammatory disease, eg synovitis related to rheumatoid arthritis
  • a crystal depositing condition   prepatellar bursitis is more common in people with gout or pseudogout

Presentation:

  • tenderness and swelling superficial to the patella
  • erythema and localised warmth of the skin over the patella
  • reduced knee movement
  • fever, tachycardia or signs of systemic upset may indicate septic bursitis

Key points to elicit in the history:

  • occupation -  does this involve excessive kneeling?
  • history of fall or acute knee injury?
  • history of any repetitive motion involving the knee?
  • recent steroid treatment?
  • is the patient immunocompromised?
  • is there a history of crystal arthropathy or inflammatory disease?

Differential diagnosis:

  • septic arthritis of the knee -  clinical judgement should be used to distinguish between prepatellar bursitis and septic arthritis. The swelling in bursitis is usually distinguishable as being prepatellar but, if very large, the whole knee can appear swollen. If uncertain, refer for a specialist opinion.
  • cellulitis
  • knee joint effusion secondary to trauma

Investigations:

  • aspiration of the prepatellar bursa may be required to differentiate septic and non-septic bursitis

Management:

  • management of prepatellar bursitis depends on its aetiology
  • when considering management, separate into septic and non-septic bursitis. According to one study, patients with septic bursitis usually presented earlier and had more pain, erythema, warmth and tenderness and some had mild fever (37.5°C maximum recorded). Clinical features alone could not identify all the septic cases. Have a low threshold for performing, or referring for, aspiration.

Non-septic bursitis:

  • conservative treatment:
    • rest
    • ice
    • patient education about the condition and its aetiology
    • a thick foam cushion, or knee pads, to kneel on can help prevent recurrence. Occupational therapy referral may be helpful.
    • physiotherapy referral may be helpful if there is reduced range of movement in the knee joint. A stick or cane may be needed to aid walking.
  • medical treatment:
    • aspiration of the prepatellar bursa and injection of a corticosteroid   infection must be excluded prior to this. Complications should be discussed with the patient, including infection, subcutaneous atrophy, bleeding and patellar tendon rupture. Hydrocortisone may be used.
    • non-steroidal anti-inflammatory drugs (NSAIDs), eg ibuprofen   these can be used for mild-to-moderate pain and to reduce inflammation

Septic bursitis:

A specialist opinion is usually required:

  • aspiration -  this should be performed to confirm septic bursitis as detailed in the investigations above
  • antibiotic therapy -  if septic bursitis is suspected and whilst waiting for confirmatory culture results, start antibiotics. Intravenous antibiotics should be used if the patient is systemically unwell. Cephalosporins or penicillinase resistant penicillins (eg Augmentin), or a combination of penicillin V and flucloxacillin may be prescribed.
  • incision and drainage -  if symptoms of septic bursitis have not improved significantly within 36-48 hours of antibiotic treatment, incision and drainage is usually performed.

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7.  Conservative/Self- management

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GP information
Please see the previous 'Bursitis' node for details on conservative/self-management of bursitis.

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10. Ganglion or Meniscal Cyst

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GP information
Management of Meniscal Cysts:

Meniscal cysts are benign lesions that are almost invariably associated with an underlying horizontal cleavage tear in the underlying meniscus, this is likely to be a degenerative tear. The vast majority can be treated conservatively, with an explanation and reassurance. If there is significant pain and/or interference with knee function then referral for arthroscopic assessment is indicated. If there is diagnostic uncertainty then an ultrasound should be arranged.

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13. Refer to MSK-MDT Form (MSK4)

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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.

This service is directly bookable via Choose and Book. Please complete the appropriate form and send via Choose and Book.

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

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