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)⁵GP/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

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

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

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

Move More - (icareimove.com)⁵

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