HNY Policy and Pathway Repository - Humber

If the clinical presentation is outside the normal spectrum then the orthopaedic department are happy to see any adult patient who is causing significant concern

Click here to view the red flag symptoms

• History, age and full examination
• Exercise and weight loss to achieve ideal weight
• Physiotherapy focusing on knee pain
• Simple analgesia, non-steroidal anti inflammatories (oral or topical) and steroid injections (preferably no more than every 4-6 months).
• Cases with a clear history of mechanical locking and a loose body evident on X-ray will require arthroscopy or MRI.
• If suspicion of a meniscus lesion, initial management is conservative with later consideration of MRI if this fails or if there is clear internal derangement
• Pain of less than 4 weeks is likely to be soft tissue related and will not show on a radiograph

Laboratory tests

• Suspected alternative pathology, when clinically indicated
• CRP or ESR (not both) to exclude inflammation or infection elsewhere
• Uric acid
• Rheumatoid factor and antinuclear antibodies (anti- cyclic citrullinated peptied - anit ccp)
• Diagnostic aspiration

Adolescents and Younger Adults

• Joint hyper mobility syndrome
• Osgood-Schlatter's disease and Sinding–Larsen-Johansson
• Osteochondritis dissecans
• Plica syndrome
• Patellar instability
• Fat pad (Hoffa’s) syndrome
• Referred pain (hip and spine)
• Psychological problems

Under 50’s

• History and examination vital

Over 50’s

• Osteoarthrosis extremely common
• Patients over 50 almost invariably have signal changes in the posterior horn of the medial meniscus that can be described as a tear. Only if the symptoms and signs fit a posterior horn tear of the medial meniscus does the diagnosis stand.
• Conservative management is the best treatment for patients with mild to moderate degenerative change who are not disabled enough to need a knee replacement.

Do Not Refer

• Giving way – the most common cause of giving way is muscular weakness, Unless there has been a significant injury in a patient <50 which could indicate a ligament rupture, physiotherapy is the treatment.
• Loose body on xray – these are very common and only need referral if the patient has mechanical locking as above
• Meniscal cyst – only need referring if the patient is symptomatic
• Bakers/ Popliteal  cyst – very rarely need treatment in isolation, the underlying cause (arthritis or meniscal tear) may need treatment
• Anterior knee pain – very common especially in young women, unless the patient has episodes of kneecap dislocation or severe arthritis then physiotherapy is the treatment
• Osteochondral defects – the majority of these reported on MRI scans are in patients >40 and represent degenerative change. In a young patient with a an otherwise normal knee these may need treatment and should be referred.

If referring for MRI please be aware of the absolute and relative contraindications.

Referrals

Any MRI request for patients aged 50+ should only be with prior approval of the local Radiology service - for further advice please use NHS E-Referrals advice and guidance.

• The Clinician should already have the results of the plain knee X-Rays
• For further advice please email NHS E-Referrals advice and guidance.

• Healthshare - Knee Pain guidance
• NICE Osteoarthritis pathway
• NICE IPG230 Guidance - Arthoscopic Knee Osteoarthritis
• BMJ - Article: Arthoscopic surgery for degenerative knee
• Hypermobility
• Knee Pain Guidance
• Knee Pain Pathway