Reviewed on : 4 Feb 2026

Reviewed by : Gateway Assistant Editor & David Collins Advanced Clinical Practitioner

Expires : 4 Feb 2028

Imaging in Knee Pain

Please note for most knee pain:

• Do not routinely request MRIs from a primary care setting in non-traumatic knee pain
• Unless presence of red flags (see red flag sections of pathways)
• Most red flags will require referral to A&E or urgent orthopaedic referral therefore requesting imaging from primary care may not be appropriate (see pathways)
• Unless the patient has a red flag, most knee pain pathways require a period of conservative management and referral only on non-resolution onto physio or MSK triage services (see detail for each pathway attached)

Common findings on knee MRIs in asymptomatic population (median age 44 years):

• Meniscal tears (30%)
• Cartilage and bone marrow abnormalities of patellofemoral joint (48-57%)
• Moderate and severe cartilage lesions (19-31%)
• Moderate and severe bone marrow oedema (19-31%)

UHCW knee MRI retrospective evaluation (follow link)

• 4466 knee MRIs performed in 1 year period – 71% requested from primary care
• 55% diagnosed with OA
• 43% diagnosed with meniscal tear
• < 50% were reviewed in secondary care
• 15% underwent surgery at UHCW

Key findings

• Most patients can be managed successfully without the need for operative intervention, highlighting the impact of non-operative interventions
• 2/3rds of patients reviewed in primary care did not have an outpatients appointment in secondary care, highlighting that the majority of patients with knee pain can be managed successfully in primary care
• OA was the most common diagnosis, however only 38% of these patients had an X-ray before the MRI scan. This implies thousands of MRI scans could have been avoided per year if an X-ray was performed

Referral for Primary Hip Replacement (Prior Approval)

Referral for Primary Hip Replacement

Prior Approval from the Integrated Care Board (ICB) will be required before any treatment proceeds in secondary care unless an alternative contract arrangement has been agreed with the ICB that does not necessitate the requirement of prior approval before treatment

Background

This policy applies only to elective primary hip or knee replacement for osteoarthritis

The majority of patients with osteoarthritis (OA) of the hip or knee can initially be managed adequately in primary and intermediate care by following the NICE Clinical Guideline 226 (2022) and Quality Standard 87 (2015) for care and management of OA

Indication

The most common indication for elective primary total knee replacement (TKR) is degenerative arthritis (osteoarthritis) of the joint

Other indications include rheumatoid arthritis, osteonecrosis and other types of inflammatory arthritis

Adults aged 45 or over can be diagnosed with OA clinically, without investigations if they have activity-related joint pain and any morning joint stiffness lasts no longer than 30 minutes. Primary or intermediate care x-ray may not be necessary as part of routine investigations

TKR with resurfaced patella

The ICB has reviewed NICE (NG157) guideline and wider literature via PubMed of the evidence for clinical and cost effectiveness of patellar resurfacing as part of primary TKR

The ICB has concluded that there is an overall financial benefit to patellar resurfacing, with patients more likely to need revisions, and seek more primary and secondary care appointments, where resurfacing has not taken place

On this basis, the decision as to whether Patellar resurfacing as part of primary TKR should take place is to be made during the primary TKR operation by the treating clinical team

Eligibility Criteria

Referral for specialist assessment can be considered for patients who meet all the following criteria 1-6:

1. Patient experiences joint symptoms (pain, stiffness and reduced function) that have a substantial impact on their quality of life defined as interfering with their activities of daily living or their ability to sleep

2. Patient has been offered at least the core (non-surgical) treatment options recommended by NICE NG226;

Advise people with osteoarthritis where they can find further information on:

• Osteoarthritis and how it develops (including flares and progression over time), and information that challenges common misconceptions about the condition
• Activity and therapeutic exercise tailored to their needs appropriate to age, comorbidity, pain severity or disability. Exercise should include local muscle strengthening and general aerobic fitness
• Managing their symptoms
• How to access additional sources of information and support after consultations, such as peer-to-peer support and support groups
• Benefits and limitations of treatment

Referral to a recognised weight management programme for patients who are overweight or obese to improve outcomes

Evidence shows that lower BMIs have better surgical outcomes and therefore, patients who are overweight and obese must be offered support and interventions to lose weight and those who are obese must be offered a recognised weight management programme. This should be documented

All overweight and obese patients will be reviewed pre-operatively by the surgeon to ascertain medical fitness for surgery

Patient specific factors (including age, sex, smoking, obesity and co-morbidities) should not be barriers for surgery, however patients who smoke should be advised to attempt to stop smoking at least 4 weeks before surgery to reduce the risk of surgical and post-surgery complications

3. Joint symptoms are refractory to non-surgical treatments listed below including where appropriate; analgesia, steroid injections, local heat and cold therapy

4. Patients have a right to be fully informed about this procedure

As part of this process, clinicians should engage the patients (or their carers) in shared decision making about alternative management and the risks and benefits of surgery

5. Patient has confirmed they wish to have surgery

6. Any underlying medical conditions have been investigated and the patient’s condition has been optimised

Further advice and support

Currently some of this information is available on national websites, such as Arthritis UK (Osteoarthritis | Arthritis UK) however it has not been standardised in any way

Each hospital should have its own locally written information to distribute to patients in clinic. This local information may differ between centres, reflecting local practice, but there is no national standard for this information

The ICB expectation is that the information provided to patients includes the following as a minimum:

• Agree individualised self-management strategies with the person with osteoarthritis
• Manual therapy (such as manipulation, mobilisation or soft tissue techniques) should only be considered for people with hip or knee osteoarthritis and alongside therapeutic exercise
• If discussing manual therapy, explain to people with osteoarthritis that there is not enough evidence to support its use alone for managing osteoarthritis
• Devices – Consider walking aids (such as walking sticks) for people with lower limb osteoarthritis. Do not routinely offer insoles, braces, tape, splints or supports to people with osteoarthritis unless:

▪ there is joint instability or abnormal biomechanical loading and

▪ therapeutic exercise is ineffective or unsuitable without the addition of an aid or device and

▪ the addition of an aid or device is likely to improve movement and function

Pharmacological management

If pharmacological treatments are needed to manage osteoarthritis, use them alongside non-pharmacological treatments and to support therapeutic exercise and at the lowest effective dose for the shortest possible time

Offer a topical non-steroidal anti-inflammatory drug (NSAID) to people with knee osteoarthritis

Consider a topical NSAID for people with osteoarthritis that affects other joints

If topical medicines are ineffective or unsuitable, consider an oral NSAID for people with osteoarthritis and take account of:

potential gastrointestinal, renal, liver and cardiovascular toxicity

any risk factors the person may have, including age, pregnancy, current medication and comorbidities

Offer a gastroprotective treatment (such as a proton pump inhibitor) for people with osteoarthritis while they are taking an NSAID

Do not routinely offer paracetamol or weak opioids unless they are only used infrequently for short-term pain relief and all other pharmacological treatments are contraindicated, not tolerated or ineffective

Explain to people with osteoarthritis that there is no strong evidence of benefit for paracetamol

For more information about opioids, see NICE’s guideline on medicines associated with dependence or withdrawal symptoms

Do not offer glucosamine or strong opioids to people to manage osteoarthritis.

If the person with osteoarthritis asks about glucosamine or strong opioids, explain that there is no strong evidence of benefit for glucosamine and the risks of strong opioids outweigh the benefits

Review with the person whether to continue treatment. Base the frequency of reviews on clinical need

Intra-articular injections: Do not offer intra-articular hyaluronan injections to manage osteoarthritis. Consider intra-articular corticosteroid injections when other pharmacological treatments are ineffective or unsuitable, or to support therapeutic exercise. Explain to the person that these only provide short-term relief (2 to 10 weeks)

Patients who smoke should be advised to attempt to stop smoking at least 4 weeks before surgery to reduce the risk of surgical and post-surgery complications

For patients who DO NOT meet the eligibility criteria, the ICB will only consider funding the treatment if an Individual Funding Request (IFR) detailing the patient’s clinical presentation is submitted to the ICB

6. Guidance/References

https://www.nice.org.uk/guidance/ng157/resources/joint-replacement-primary-hip-knee-and-shoulder-pdf-66141845322181

https://www.nice.org.uk/guidance/ng226/resources/osteoarthritis-in-over-16s-diagnosis-andmanagement-pdf-66143839026373

https://www.nice.org.uk/guidance/qs87/resources/osteoarthritis-in-over-16s-pdf-2098913613253

https://www.nice.org.uk/guidance/ng226/evidence/e-clinical-and-cost-effectiveness-of-manual-therapy-for-the-management-of-osteoarthritis-pdf-11250452850

https://www.nice.org.uk/guidance/mtg76/resources/aposhealth-for-knee-osteoarthritis-pdf-64372240535749

Osteoarthritis | Arthritis UK