• Diagnosing Knee Problems
  • Overall Principles
  • Essential Features of The Knee Pathway
  • GROUP A: OSTEOARTHRITIS.
  • GROUP B: ANTERIOR KNEE PAIN
  • GROUP C: MECHANICAL SYMPTOMS OR RECENT INJURY
  • GROUP D: INFLAMMATORY ARTHRITIS
  • GROUP E: “DON’T KNOW” GROUP
  • OTHER ASPECTS OF KNEE PATHWAY

Diagnosing Knee Problems

This knee pathway is part of work undertaken with Consultants, General Practitioners and Allied Health Professionals from UHCW NHS Trust, George Eliot Hospital, South Warwickshire Hospital, and Coventry and Warwickshire PCT’s.

The aim of the pathway is to establish an appropriate and clinically relevant pathway to improve care for patients presenting to their general practitioner with a knee problem. The pathway directs patients into appropriate categories guiding specific early investigations and early treatment.


Important Statements


Before reading this document and before using the described pathway it is important to note the following points.

  • There are many different types of knee problems and many options for management and treatment. It is impossible to cover every permutation. The pathway is designed to cover the majority of scenarios and management alternatives.
  • The starting point is from the patient attending the General Practitioner with a knee problem and it is accepted that over time there may be other ways to enter the pathway.
  • The end point of the pathway is treatment by a healthcare professional up to the point of assessment in secondary care.
  • Getting the level of information correct for all practitioners is difficult and this pathway is intended for those with a specific interest in musculoskeletal problems and those that are specialists in other areas. There is understandably a broad spectrum of knowledge in the community relating to knee problems and the pathway allows for detailed investigation or early referral to the musculo-skeletal triage system

Overall Principles

The pathway includes the following general overall principles.

  • It is accepted that not all patients with a knee problem require to be seen in secondary care to determine management. With appropriate specified indications some patients can be directed to initial treatment with options such as podiatry, physiotherapy and orthotics.
  • At any time the pathway can be bypassed and a patient referred directly to secondary care either for criteria specified in the pathway or for any other reason.
  • A system for providing early assessment and treatment has been established in the region devised to provide focussed initial assessment and screening in addition to access to specialist physiotherapists outside of secondary care. In this document this is referenced as the MSCAT system. The pathway allows for patients to be referred direct to these areas or to have initial investigations and primary treatment outside of that system.

Knee problems have been divided into five simple overall groups:

Osteoarthritis
Anterior knee pain
Recent injury or mechanical symptoms
Inflammatory arthritis
None of the above or don’t know.

For each type of problem 3 categories are allocated.

Category 1 is the basic category with relatively minor symptoms that should be suitable for treatment with local core physiotherapy.
Category 2 symptoms or problems require treatment with the MSCAT assessment and treatment team whereas
Category 3 patients require referral through to secondary care.

The pathway allows for patients to be referred directly to MSCAT or secondary care, or progressed through the categories depending on the response to a trial of treatment.

This document summarises the treatment for each diagnostic group and categories.

GROUP A: OSTEOARTHRITIS.

Description and scenario

Patient presenting with non-mechanical pain, intermittent or permanent swelling in the knee, possible deformity and symptoms related to activity.

Investigations


Main appropriate investigation is plain x-ray with 3 views:

• PA 30º weight bearing view
• Lateral at 30 – 45º flexion
• Skyline view single knee at 30 – 45º flexion

Category and Action


Category I: conservative options


This group is patients with controllable pain, no deformity and minimal loss of joint space seen on x-ray.

Treatment options include referral for physiotherapy, education and advice, simple analgesia and anti-inflammatories, other non operative interventions including advice on weight loss and activity modification etc.

Category II: referral to MSCAT treatment


This category is for patients with moderate symptoms who are not down to bare bone on x-ray, tablets are helping, symptoms are not too bad or intrusive, they are no longer mild and have failed category I level treatment.

Treatment options include specialised assessment and physiotherapy, injections or orthotics.

Category III: severe symptoms for referral to secondary care


This category is for those patients with severe pain or symptoms affecting quality of life, complete loss of joint space seen on x-ray, symptoms bad enough that they may accept surgery and patients who have failed category I & II treatment conservative options.

These patients are more likely to need consideration for unloading braces or surgery including arthroplasty, osteotomy, and arthroscopic treatment.

GROUP B: ANTERIOR KNEE PAIN

Description and Diagnosis

Patients complain of pain over the front of their knee with symptoms worse on sitting or standing, they are generally young and do not have clear osteoarthritis. There may be a history of patella dislocation.

There are multiple causes generally grouped into three diagnoses:

• Objected patella instability: history of true dislocation or ability to dislocate patella.
• Potential patella instability: maltracking of the patella with instability leading to overload of part of the joint.
• Anterior knee pain syndrome: covering a multitude of issues such as excessive lateral pressure syndrome, neuromas, patella tendinopathy, quadriceps tendinitis, medial plica syndrome etc.

The key to assessment for investigation of anterior knee pain is detecting the presence of mal-alignment – either limb mal-alignment (varus/valgus) or patella maltracking by examining tracking of the patella as the knee bends and extends against gravity.

Category and Action

Category I: conservative options

This is the group of patients who have no mal-alignment or patella maltracking, symptoms are not intrusive and they may well have general features of anterior knee pain syndrome.

Treatment option is physiotherapy at core physio level.

Category II: referral to MSCAT treatment

This group of patients has mal-alignment or may have failed core physio/level 1 treatment.

Treatment options include referral to MSCAT assessment and treatment with specialist physiotherapy including consideration for orthotics, podiatry or more specific physical evaluation.

Category III: significant symptoms requiring referral to secondary care


This category is for patients who have failed physiotherapy at category I or category II. They may have severe pain or have had multiple episodes of patella dislocation.

Treatment options include referral to secondary care for consideration for patella stabilisation surgery, management advice or specific knee braces.

GROUP C: MECHANICAL SYMPTOMS OR RECENT INJURY

Description and Diagnosis

In this group patients may complain of a recent injury or mechanical symptoms resulting in descriptions of giving way, clicking, catching or locking. There is usually a history of a recent soft tissue injury. There is usually no obvious osteoarthritis. They may have swelling associated with injury or have a history of acute severe swelling of the knee.

The usual causes include meniscal tear, cruciate ligament injury (anterior or posterior cruciate), chondral joint surface injury, osteochondritis dissecans causing loose bodies or patella instability etc.

There are various specific diagnostic patterns that indicate specific diagnoses:

A history of a twist and pop and sensation of distrust in the knee = anterior cruciate ligament until proved otherwise and should lead to direct referral to secondary care.

Medial joint line tenderness with history of joint swelling and twisting trauma = meniscal tear

Category and Action

Category I: Conservative options

This group includes patients with no history of giving way or locking. They may have mild pain but not intrusive. Additionally it includes patients who are within six weeks from injury but do not fit into moderate or severe groups (category II or III).

Treatment for these patients includes physiotherapy and clinical review. Patients less than six weeks from injury may settle with conservative treatment and do not need immediate referral unless in other categories.

Category II: Referral for MRI Scan or MSCAT Physiotherapy.


This category includes patients with joint line tenderness or effusion and symptoms persistent for six weeks or more. It also includes patients who have failed core basic physiotherapy.

Treatment options are referral for MRI scan and referral to MSCAT physiotherapy and assessment. Depending on the result of MRI they then may be candidates for referral to secondary care.

Category III: Symptoms Requiring Referral to Secondary Care.


This category is patients with specific scenarios including: a history of twist or pop and distrusting the knee (indicating ACL deficiency), true locking of the knee, MRI proven meniscal tear and greater than six weeks of joint line tenderness, effusion or failed physiotherapy. In addition this category includes patients who have failed conservative treatment with a normal MRI or anyone with another specific diagnosis on MRI.

Treatment options are referral to secondary care. Patients where ACL are suspected on the above history and patients with true locking of the knee should be referred via MRI scan. Referral for MRI should be made at the same time as MRI scan booked.

GROUP D: INFLAMMATORY ARTHRITIS

Diagnosis

Patients complain of swollen and inflamed joints with no obvious trauma. There may be single or multiple joint involvements with or without system symptoms. There may be a history of flare-ups.

There are multiple causes for inflammatory knee arthritis and management will depend on the diagnosis, usually initiated by blood test investigations including CRP, ESR and FBC.

Category and Action

Category I: Conservative Options


This group is patients with single joint involvement with negative diagnostic blood tests.

Treatment options: referral to physiotherapy.

Category II: Referral for Secondary Care:


This group is for patients who have failed early physiotherapy with or without diagnostic tests.

Category III: Referral to Secondary Care:


This category is patients, who have multiple joint involvements or single joint involvements with system symptoms, for example psoriatic arthropathy, bowel disease or reactive arthritis. This group also includes patients with abnormal diagnostics.

Treatment options are then determined by rheumatology.

GROUP E: “DON’T KNOW” GROUP

This group is patients where the categorisation is not clear or where the referring doctor wishes to consider early referral to MSCAT without dwelling on specific investigations or assessment.

There are many additional causes of knee problems that may not fit into the above categories. These include the following:

  • Problem joint replacement patients: need trial of physiotherapy, x-ray and refer accordingly.
  • Children less than age 16: require paediatric orthopaedic assessment.
  • Problems following recent surgery: need management on a case by case basis.
  • Patients with cancer.
  • Acute injuries: separate trauma management protocol.
  • Bursae, lumps and bumps: require individual assessment and treatment.

OTHER ASPECTS OF KNEE PATHWAY

Indications for MRI Scanning

MRI scans are indicated for patients with meniscal tears, patients with difficulty diagnosing ACL or ligamentous injury of the knee and for patients with traumatic chondral injuries. MRI is also indicated for patients with unexplained pain that do not fit any diagnostic categories.

MRI scans should be restricted to patients with recent injury, aged under 60 (scanning over 60 is rarely helpful). Patients with problems more than six weeks after injury and for patients with suspected key diagnosis that needs confirming.

Knee Radiographic Views


The following three key views are expected for all patients undergoing knee imaging investigation.

  • Weight bearing PA 30º view.
  • Lateral at 30 – 45º with condyles overlapping.
  • Skyline x-rays single knee at 30 – 45º flexion.


Post op TKR views

  • Supine AP and Lateral


Post op ACL reconstruction views (Series of four x-rays).:

  • AP standing,
  • lateral at 30º,
  • lateral in hyperextension (heel supported and knee unsupported),
  • skyline at 30º.



What the Consultant wants

For each of the group categories the Orthopaedic Consultant wants to see the following key features in order to help reduce the “oven ready” scenario that will help patients achieve early appropriate treatment.

A. Osteoarthritic Knee

  • X-rays showing loss of joint space.
  • Significantly severe symptoms.
  • Previous trial of physiotherapy.
  • Failed full conservative package including attempted weight loss, analgesia, exercise programme etc.


B. Anterior Knee Pain


  • Painful Mechanical crepitus that has failed full conservative physiotherapy treatment.
  • Mal-alignment failed conservative treatment.
  • Patients with multiple dislocations.
  • Mechanical/recent injury.
  • Patients with meniscal tear, ACL deficiency ligament injury or chondral defects diagnosed on MRI.
  • Diagnosing Knee Problems
  • Overall Principles
  • Essential Features of The Knee Pathway
  • GROUP A: OSTEOARTHRITIS.
  • GROUP B: ANTERIOR KNEE PAIN
  • GROUP C: MECHANICAL SYMPTOMS OR RECENT INJURY
  • GROUP D: INFLAMMATORY ARTHRITIS
  • GROUP E: “DON’T KNOW” GROUP
  • OTHER ASPECTS OF KNEE PATHWAY

Diagnosing Knee Problems

This knee pathway is part of work undertaken with Consultants, General Practitioners and Allied Health Professionals from UHCW NHS Trust, George Eliot Hospital, South Warwickshire Hospital, and Coventry and Warwickshire PCT’s.

The aim of the pathway is to establish an appropriate and clinically relevant pathway to improve care for patients presenting to their general practitioner with a knee problem. The pathway directs patients into appropriate categories guiding specific early investigations and early treatment.

Important Statements

Before reading this document and before using the described pathway it is important to note the following points.

  • There are many different types of knee problems and many options for management and treatment. It is impossible to cover every permutation. The pathway is designed to cover the majority of scenarios and management alternatives.
  • The starting point is from the patient attending the General Practitioner with a knee problem and it is accepted that over time there may be other ways to enter the pathway.
  • The end point of the pathway is treatment by a healthcare professional up to the point of assessment in secondary care.
  • Getting the level of information correct for all practitioners is difficult and this pathway is intended for those with a specific interest in musculoskeletal problems and those that are specialists in other areas. There is understandably a broad spectrum of knowledge in the community relating to knee problems and the pathway allows for detailed investigation or early referral to the musculo-skeletal triage system

The pathway includes the following general overall principles.

  • It is accepted that not all patients with a knee problem require to be seen in secondary care to determine management. With appropriate specified indications some patients can be directed to initial treatment with options such as podiatry, physiotherapy and orthotics.
  • At any time the pathway can be bypassed and a patient referred directly to secondary care either for criteria specified in the pathway or for any other reason.
  • A system for providing early assessment and treatment has been established in the region devised to provide focussed initial assessment and screening in addition to access to specialist physiotherapists outside of secondary care. In this document this is referenced as the MSCAT system. The pathway allows for patients to be referred direct to these areas or to have initial investigations and primary treatment outside of that system.

Knee problems have been divided into five simple overall groups:

Osteoarthritis
Anterior knee pain
Recent injury or mechanical symptoms
Inflammatory arthritis
None of the above or don’t know.

For each type of problem 3 categories are allocated.

Category 1 is the basic category with relatively minor symptoms that should be suitable for treatment with local core physiotherapy.
Category 2 symptoms or problems require treatment with the MSCAT assessment and treatment team whereas
Category 3 patients require referral through to secondary care.

The pathway allows for patients to be referred directly to MSCAT or secondary care, or progressed through the categories depending on the response to a trial of treatment.

This document summarises the treatment for each diagnostic group and categories.

GROUP A: OSTEOARTHRITIS.

Description and scenario

Patient presenting with non-mechanical pain, intermittent or permanent swelling in the knee, possible deformity and symptoms related to activity.

Investigations

Main appropriate investigation is plain x-ray with 3 views:

• PA 30º weight bearing view
• Lateral at 30 – 45º flexion
• Skyline view single knee at 30 – 45º flexion

Category and Action


Category I: conservative options

This group is patients with controllable pain, no deformity and minimal loss of joint space seen on x-ray.

Treatment options include referral for physiotherapy, education and advice, simple analgesia and anti-inflammatories, other non operative interventions including advice on weight loss and activity modification etc.

Category II: referral to MSCAT treatment

This category is for patients with moderate symptoms who are not down to bare bone on x-ray, tablets are helping, symptoms are not too bad or intrusive, they are no longer mild and have failed category I level treatment.

Treatment options include specialised assessment and physiotherapy, injections or orthotics.

Category III: severe symptoms for referral to secondary care

This category is for those patients with severe pain or symptoms affecting quality of life, complete loss of joint space seen on x-ray, symptoms bad enough that they may accept surgery and patients who have failed category I & II treatment conservative options.

These patients are more likely to need consideration for unloading braces or surgery including arthroplasty, osteotomy, and arthroscopic treatment.

GROUP B: ANTERIOR KNEE PAIN

Description and Diagnosis

Patients complain of pain over the front of their knee with symptoms worse on sitting or standing, they are generally young and do not have clear osteoarthritis. There may be a history of patella dislocation.

There are multiple causes generally grouped into three diagnoses:

• Objected patella instability: history of true dislocation or ability to dislocate patella.
• Potential patella instability: maltracking of the patella with instability leading to overload of part of the joint.
• Anterior knee pain syndrome: covering a multitude of issues such as excessive lateral pressure syndrome, neuromas, patella tendinopathy, quadriceps tendinitis, medial plica syndrome etc.

The key to assessment for investigation of anterior knee pain is detecting the presence of mal-alignment – either limb mal-alignment (varus/valgus) or patella maltracking by examining tracking of the patella as the knee bends and extends against gravity.

Category and Action

Category I: conservative options

This is the group of patients who have no mal-alignment or patella maltracking, symptoms are not intrusive and they may well have general features of anterior knee pain syndrome.

Treatment option is physiotherapy at core physio level.

Category II: referral to MSCAT treatment

This group of patients has mal-alignment or may have failed core physio/level 1 treatment.

Treatment options include referral to MSCAT assessment and treatment with specialist physiotherapy including consideration for orthotics, podiatry or more specific physical evaluation.

Category III: significant symptoms requiring referral to secondary care

This category is for patients who have failed physiotherapy at category I or category II. They may have severe pain or have had multiple episodes of patella dislocation.

Treatment options include referral to secondary care for consideration for patella stabilisation surgery, management advice or specific knee braces.

GROUP C: MECHANICAL SYMPTOMS OR RECENT INJURY

Description and Diagnosis

In this group patients may complain of a recent injury or mechanical symptoms resulting in descriptions of giving way, clicking, catching or locking. There is usually a history of a recent soft tissue injury. There is usually no obvious osteoarthritis. They may have swelling associated with injury or have a history of acute severe swelling of the knee.

The usual causes include meniscal tear, cruciate ligament injury (anterior or posterior cruciate), chondral joint surface injury, osteochondritis dissecans causing loose bodies or patella instability etc.

There are various specific diagnostic patterns that indicate specific diagnoses:

A history of a twist and pop and sensation of distrust in the knee = anterior cruciate ligament until proved otherwise and should lead to direct referral to secondary care.

Medial joint line tenderness with history of joint swelling and twisting trauma = meniscal tear

Category and Action

Category I: Conservative options

This group includes patients with no history of giving way or locking. They may have mild pain but not intrusive. Additionally it includes patients who are within six weeks from injury but do not fit into moderate or severe groups (category II or III).

Treatment for these patients includes physiotherapy and clinical review. Patients less than six weeks from injury may settle with conservative treatment and do not need immediate referral unless in other categories.

Category II: Referral for MRI Scan or MSCAT Physiotherapy.

This category includes patients with joint line tenderness or effusion and symptoms persistent for six weeks or more. It also includes patients who have failed core basic physiotherapy.

Treatment options are referral for MRI scan and referral to MSCAT physiotherapy and assessment. Depending on the result of MRI they then may be candidates for referral to secondary care.

Category III: Symptoms Requiring Referral to Secondary Care.

This category is patients with specific scenarios including: a history of twist or pop and distrusting the knee (indicating ACL deficiency), true locking of the knee, MRI proven meniscal tear and greater than six weeks of joint line tenderness, effusion or failed physiotherapy. In addition this category includes patients who have failed conservative treatment with a normal MRI or anyone with another specific diagnosis on MRI.

Treatment options are referral to secondary care. Patients where ACL are suspected on the above history and patients with true locking of the knee should be referred via MRI scan. Referral for MRI should be made at the same time as MRI scan booked.

GROUP D: INFLAMMATORY ARTHRITIS

Diagnosis

Patients complain of swollen and inflamed joints with no obvious trauma. There may be single or multiple joint involvements with or without system symptoms. There may be a history of flare-ups.

There are multiple causes for inflammatory knee arthritis and management will depend on the diagnosis, usually initiated by blood test investigations including CRP, ESR and FBC.

Category and Action

Category I: Conservative Options

This group is patients with single joint involvement with negative diagnostic blood tests.

Treatment options: referral to physiotherapy.

Category II: Referral for Secondary Care:

This group is for patients who have failed early physiotherapy with or without diagnostic tests.

Category III: Referral to Secondary Care:

This category is patients, who have multiple joint involvements or single joint involvements with system symptoms, for example psoriatic arthropathy, bowel disease or reactive arthritis. This group also includes patients with abnormal diagnostics.

Treatment options are then determined by rheumatology.

GROUP E: “DON’T KNOW” GROUP

This group is patients where the categorisation is not clear or where the referring doctor wishes to consider early referral to MSCAT without dwelling on specific investigations or assessment.

There are many additional causes of knee problems that may not fit into the above categories. These include the following:

  • Problem joint replacement patients: need trial of physiotherapy, x-ray and refer accordingly.
  • Children less than age 16: require paediatric orthopaedic assessment.
  • Problems following recent surgery: need management on a case by case basis.
  • Patients with cancer.
  • Acute injuries: separate trauma management protocol.
  • Bursae, lumps and bumps: require individual assessment and treatment.

OTHER ASPECTS OF KNEE PATHWAY

Indications for MRI Scanning

MRI scans are indicated for patients with meniscal tears, patients with difficulty diagnosing ACL or ligamentous injury of the knee and for patients with traumatic chondral injuries. MRI is also indicated for patients with unexplained pain that do not fit any diagnostic categories.

MRI scans should be restricted to patients with recent injury, aged under 60 (scanning over 60 is rarely helpful). Patients with problems more than six weeks after injury and for patients with suspected key diagnosis that needs confirming.

Knee Radiographic Views

The following three key views are expected for all patients undergoing knee imaging investigation.

  • Weight bearing PA 30º view.
  • Lateral at 30 – 45º with condyles overlapping.
  • Skyline x-rays single knee at 30 – 45º flexion.

Post op TKR views

  • Supine AP and Lateral

Post op ACL reconstruction views (Series of four x-rays).:

  • AP standing,
  • lateral at 30º,
  • lateral in hyperextension (heel supported and knee unsupported),
  • skyline at 30º.

What the Consultant wants

For each of the group categories the Orthopaedic Consultant wants to see the following key features in order to help reduce the “oven ready” scenario that will help patients achieve early appropriate treatment.

A. Osteoarthritic Knee

  • X-rays showing loss of joint space.
  • Significantly severe symptoms.
  • Previous trial of physiotherapy.
  • Failed full conservative package including attempted weight loss, analgesia, exercise programme etc.


B. Anterior Knee Pain

  • Painful Mechanical crepitus that has failed full conservative physiotherapy treatment.
  • Mal-alignment failed conservative treatment.
  • Patients with multiple dislocations.
  • Mechanical/recent injury.
  • Patients with meniscal tear, ACL deficiency ligament injury or chondral defects diagnosed on MRI.