Chronic Knee Pain with Osteoarthritis
This guideline applies to adults over 18 years.
Introduction
Osteoarthritis can be diagnosed clinically in patients aged 45 years of older with activity related joint pain without significant joint stiffness in the absence of trauma and red flags. Out of patients presenting to primary care with chronic osteoarthritis hip pain each year, 25% will improve within 3 months and 35% at 12 months.1
Osteoarthritis symptoms progress in 15% of patients within 3 years and 28% within 6 years1
Red flags
Emergency conditions
High impact trauma
First time traumatic patellar dislocation suspected
Significant haemarthrosis, known bleeding disorder or taking anticoagulants
Quadriceps / patella tendon rupture
Unable to weight bear
Sepsis with NEW or SUDDEN CHANGE in knee pain
Systemically unwell with NEW or SUDDEN CHANGE in knee pain
Unremitting or unexplained pain
Rapid onset of a large, tense effusion within 6 hours
Evidence of neurovascular damage or compartment syndrome
Acutely locked knee
Suspected complete posterior cruciate ligament injury
New and significant knee instability after trauma, especially significant joint opening with medial stress in extension
Malignancy
New malignancy
Common metastases to bone: Prostate, breast, renal, lung, thyroid
Sarcoma
Myeloma
Inflammatory causes
Key Features Of Assessment
Exclusion of trauma and red flags
Nature and location of pain
Absence of significant morning joint stiffness
How the symptoms interfere with activities of daily living, exercise, work, social activities
Presence of risk factors such as raised BMI, previous trauma or surgery to the same joint, high dose steroid use, obesity, lupus, sickle cell, high smoking and alcohol usage
Frailty and other co-morbidities
Systems review to exclude red flags, referred pain and alternative conditions
Conservative measures tried, including exercise
Optimisation factors for MSK health and referral to surgery when needed
The following reduce the risk of post operative joint infection by 2-3 times
BMI less than 40
BP control less than 160/90 mmHg
Diabetes HbA1c less than 69 mmol/mol
Smoking – stop smoking, minimum 8 weeks before any planned surgery
Investigations
Xray within 6 months
MRI is not required prior to referral
Management
For Osteoarthritis
Adopt a shared decision making approach with the patient.
Patient Information
Osteoarthritis (OA) of the knee | Knee pain | Versus Arthritis
Osteoarthritis | Symptoms, Diagnosis and Treatment | Patient
Exercise
OVERVIEW / ESCAPE-pain Online Free NHS programme online 2 sessions/week for 6 weeks3
Let's Move with Leon | Versus Arthritis Free online 30 min videos for 12 weeks4
Move More - (icareimove.com)5 GP/FCP Referral via form, contact info@icareimove.com Online 25 week programme for patients who are at risk of falls, must be medically stable especially no unstable cardiac/respiratory symptoms under investigation. Need to be able to stand up independently from a chair. Some laptops available to loan for Move More programme.
Better Health - NHS (www.nhs.uk)9
Contact us - Healthy Cornwall Patient self referral for exercise advice10.
Weight Loss
NHS Digital Weight Management GP Referral for patients BMI > 30 (or BMI > 27.5 from Black, Asian and ethnic minority backgrounds) with Hypertension or Diabetes
Patient leaflet digital-weight-management-patient-leaflet-a4-folded.pdf (england.nhs.uk)
Better Health - NHS (www.nhs.uk)9
Contact us - Healthy Cornwall Patient self referral10
Analgesia
Analgesia at the lowest effective dose for the shortest duration of time in combination with exercise and weight loss, depending upon patient preference, co-morbidities, individual risk factors, tolerability, and contraindications:
Topical NSAIDs
Oral NSAIDs if no contraindications, consider concomitant proton pump inhibitor therapy where appropriate
Oral paracetamol or weak opioids if they are used infrequently for short term pain relief and NSAIDs are contraindicated, not tolerated or ineffective
Do not treat with glucosamine or strong opioids
Smoking Cessation
Patients are advised to stop smoking for a minimum of 8 weeks prior to surgery and ideally long term
Contact us - Healthy Cornwall Patient self referral
Correct anaemia if possible
Early investigation into cause and correctable deficiencies treated
Please follow RMS Anaemia Guideline
Treat to achieve Hb 130g/L
If maximal treatment in Primary Care and Hb < 130 then refer to Blood Management Service
Additional Devices
TENS machines, appropriate footwear, foot insoles, bracing, mobility aids and assistive household devices are recommended2
Glucosamine, Chondroitin and acupuncture are not recommended2
Advice and Guidance
No formal service currently available.
Referral
Emergency conditions,requiring Emergency Department or discussionwith Orthopaedic SHO on call
High impact trauma
First time traumatic patellar dislocation suspected
Significant haemarthrosis, known bleeding disorder or taking anticoagulants
Quadriceps / patella tendon rupture
Unable to weight bear
Sepsis with NEW or SUDDEN CHANGE in knee pain
Systemically unwell with NEW or SUDDEN CHANGE in knee pain
Unremitting or unexplained pain
Rapid onset of a large, tense effusion within 6 hours
Evidence of neurovascular damage or compartment syndrome
Acutely locked knee
Suspected complete posterior cruciate ligament injury
New and significant knee instability after trauma, especially significant joint opening with medial stress in extension
Malignancy
New malignancy
Common metastases to bone: Prostate, breast, renal, lung, thyroid
X ray suggests the possibility of Sarcoma
Refer to appropriate specialty suspected cancer (2WW) if known primary or non site specific suspected cancer pathway (2WW NSS) if unknown primary
Myeloma work up
http://rms.kernowccg.nhs.uk/primary_care_clinical_referral_criteria/rms/primary_care_clinical_referral_criteria/haematology/mgusmyeloma
Inflammatory causes
New symptoms of inflammation suggesting systemic inflammatory joint disease, workup and refer rheumatology
Urgent Orthopaedic Referral Criteria
Evidence of Avascular Necrosis or bone collapse on X ray
Newly strong opioid (morphine and morphine equivalent opiates) dependent pain in the joint requiring specialist opinion
Significant and evidenced functional impairment such as severely restricted mobility such as house or bed bound or recurrent falls due to the joint requiring specialist opinion
If the diagnosis is unclear, the patient requires further optimisation, medically unfit or declining surgery but requires onward management, refer to MSK Interface
MSK Interface Referral Criteria
Patients with shoulder, hip, knee problems including sports medicine problems of these joints whereby:
Conservative measures have failed including a course of tailored physiotherapy
Diagnostic uncertainty (including if not sure whether surgery is indicated)
Patient is medically unfit or declining surgery
Exclusion Criteria
· Red flag pathology
· Severe symptoms with functional limitations and willingness for surgery
· Previous joint replacement or significant major surgery to the same joint
· Patients under 16 years
· Hand and foot problems
· Spinal problems (see Spinal Interface)
· Multiple/inflammatory arthropathy
· Lumps, bumps, ganglia
Routine Orthopaedic Referral Criteria
Adults with persistent knee pain with:
Severe pain and/or persistent functional limitation of activities of daily living, work and/or leisure not responsive to at least 3 months conservative measures including consistent exercise. Please note for Osteoarthritis, physiotherapy is no longer a pre-requisite for referral
OR
Progressive varus/valgus deformity of the knee with pain and functional disability
Routine Referral Checklist
Meets referral criteria
Specified conservative measures tried including exercise
Have up to date X Ray within 6 months
BMI less than 40 desirable or actively engaging with weight loss
BP controlled less than 160/90mmHg desirable or at maximal tolerated therapy
Up to date HbA1c less than 69 mmol/mol desirable or at maximal tolerated therapy
Smoking cessation, or planning to stop smoking 8 weeks prior to surgery desirable
If the patient declines or is on maximum tolerated therapy please specify on the referral.
Please note an up to date X ray within 6 months is required for all referrals.
No other imaging including MRI is required prior to referral
Supporting Information
For professionals:
Overview | Osteoarthritis in over 16s: diagnosis and management | Guidance | NICE
For patients:
OVERVIEW / ESCAPE-pain Online Free NHS programme online 2 sessions/week for 6 weeks3
Let's Move with Leon | Versus Arthritis Free online 30 min videos for 12 weeks4
Better Health - NHS (www.nhs.uk)9
https://www.nhs.uk/conditions/knee-replacement/
References
1. Painful Osteoarthritis Of The Knee. British Orthopaedic Association, British Hip Society and Royal College of Surgeons Commissioning Guide, 2017.
2. Osteoarthritis In Over 16s: Diagnosis and Management. National Institute Of Clinical Excellence, 2022
3. Orthopaedic Research UK. Escape Pain Online, 15 August 2021 OVERVIEW / ESCAPE-pain Online]
4. Versus Arthritis. Let’s Move With Leon, 2021 Let's Move with Leon | Versus Arthritis
5. iCareiMove. Move More Programme, Move More - (icareimove.com)
6. Lengeurran E et al. Risk Factors Associated With Revision For Prosthetic Joint Infection Following Knee Replacement: An Observational Cohort Study From England And Wales. The Lancet 01 2019 Jun; 19, 6, 589-600
7. Alamanda VK, Springer BD. The Prevention Of Infection: 12 Modifiable Risk Factors. Bone Joint J 2019 Jan; 101-B1 (1 Supple A):3-9
8. NHS England. NHS Digital Weight Management Programme, 2021. NHS England » The NHS Digital Weight Management Programme
9. NHS. Better Health Better Health - NHS (www.nhs.uk)
10. Cornwall Council. Health Cornwall, 2019 Contact us - Healthy Cornwall
11. Joint British Diabetes Societies For Inpatient Care. Management Of Adults With Diabetes Undergoing Surgery And Elective Procedures. Improving Standards; March 2016.
12. Munoz M et al. International Consensus Statement On The Peri-operative Management Of Anaemia And Iron Deficiency. Anaesthesia; 2017, 72, 233-247
13. Centre For Peri-Operative Care. Impact Of Peri-operative Care On Healthcare Resource Use; June 2020
14. Royal Cornwall Hospitals NHS Trust. Pre Assessment Clinical Guidelines v6.0; Nov 2018.
Page Review Information
Review date |
15 March 2024 |
Next review date |
15 March 2026 |
Clinical editor |
Dr Rebecca Hopkins |
Contributors |
Dr Rebecca Hopkins, General Practitioner and Kernow Referral Management Service Orthopaedics Guidelines Lead Dr Gary Matthews, Consultant Anaesthetist, Royal Cornwall Hospitals Trust Mr Tim Powell, Extended Scope Physiotherapist, Royal Cornwall Hospitals Trust |