COVID-19 Adjusted Treatment Pathways
Community Physiotherapy are accepting referrals for joint injection but only injecting those that are low risk (see exclusions below).
The service is also still accepting non-invasive referrals for musculoskeletal conditions.
Exclusions for steroid injection :
> 70 yrs old
Diabetics and patients with underlying heart and chest conditions.
Steroid joint injections are not currently being performed at UHCW in Musculo-Skeletal / Orthopaedics / Radiology. Please do not currently refer to UHCW for this purpose.
Please note, GP Gateway has separate pages on
GP management and self-management
For adult knee pain where likely diagnosis is osteoarthritis
- Regular analgesia (paracetamol, oral NSAIDs if no contra-indications, topical NSAIDs if unable to take orally, topical capsaicin cream as recommended by NICE)
- Intra-articular steroid injection/s (moderate to severe pain) – most suitable for acute flare-up of pain + swelling
- Strengthening exercises to include gluteal, quads, hamstring + calf muscle strengthening
- Weight loss
- Education re self-management
- Activity modification
- Simple knee support eg Neoprene sleeve or Tubigrip
Chronic knee pain – suspecting diagnosis of Osteoarthritis
- OA series (otherwise MSK physio service will decide on whether imaging is appropriate)
- Note OA series x-rays include a weight bearing PA view on a slightly flexed knee + lateral + patello-femoral skyline views – this is the most sensitive x-ray to show a reduction in joint space
- If patello-femoral OA suspected – skyline view to show patello-femoral joint is vital
- If patella-femoral and tibiofemoral OA suspected – OA series
- If patient <40 with recent history of fever – consider FBC, ESR, CRP and urgent synovial fluid analysis
Acutely inflamed knee
- FBC, ESR, CRP, RA screen, anti CCP & uric acid. (X-ray may not be helpful but request OA views if over 50 years and can tolerate).
- MRI scan if suspected meniscus / anterior cruciate ligament /chondral injury after six weeks therapy, if persistent pain or joint-line tenderness.
Note MR is not appropriate as first line investigation for patients with possible significant OA – please ask for X-ray OA views.
Referral to Adult Physiotherapy Service – Coventry
If patients have ongoing musculoskeletal knee pain and have not improved with relative rest or analgesic advice, refer to the Adult Physiotherapy Service – Coventry. Here they will be assessed and treated with the following:
- Advice and education
- Specific Exercises
- Classes – for Patello-Femoral Pain and Osteoarthritis of the knee
- Manual therapy/ soft tissue technique
- Provision of walking aids
- Injection – Blind or Ultrasound Guided – Intra-articular only. No soft tissue injections
Referral to secondary care
Where joint replacement is strongly indicated Prior Approval for treatment via RSS (using the appropriate referral forms) will be required from the Clinical Commissioning Group.
Please note: The policy for Primary Knee Replacement Surgery contains specific criteria regarding the management and referral of patients with a BMI of 35 or over.
Refer to Secondary Care if any of the following are present:
- Under the care of a consultant for the same condition
- Patient amenable for surgical intervention where relevant
- Physiotherapy options already exhausted
- Suspicion of fracture
- Known cancer / suspicion of tumour (Two Week Wait)
- Bone disease or infection
- Meniscal tear with true locking / giving way etc causing functional impairment for > 6 weeks
- Patients requiring review of existing knee replacement
- Inflammatory – multiple joints or systemic features
- Rheumatology if positive inflammatory markers
- Confirmed compromise to joint stability from physical examination or imaging
- Confirmed ACL rupture
- Recurrent patella instability
Acute Knee Clinic
If your patient is not suitable for extended scope physio, as described above, then consider the Acute Knee Clinic, held every Thursday morning at UHCW. These referrals will need to be sent through the NHS eReferral system, using the dedicated service (ACUTE- Trauma and Orthopaedics RAS- (S houlder, Elbow, Hand, Wrist, Knee) UHCW- RKB).
Referrals will be reviewed by a Clinician and an appointment will be allocated to the patient or in some circumstances the referral may be redirected to a more suitable service.
Please note this service is not for degenerative knee conditions.
Smoking is the biggest cause of post-operative complications. Please encourage smokers to stop, at least eight weeks before their operation.