COVID-19 Adjusted Treatment Pathways
Community Physiotherapy are now injecting all patients, both high and low risk with the only caveat is that we will leave 2 weeks prior or after vaccination to inject (June 2021)
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:
Knee Pain Pathway November 2021
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 (Total Knee Replacement TKR)
Primary Knee Replacement is considered a Low Priority Procedure (LPP).
Where joint replacement is strongly indicated Prior Approval for treatment via RSS (using the appropriate referral form – see right) will be required from the Clinical Commissioning Group.
Patients shall be eligible for surgery if the following criteria is met in either Section A B or C:
Section A All boxes in section A need to be ticked to meet the criteria for referral
Patients shall be eligible for surgery if ALL of the following criteria are met:
- The patient has been referred to and managed by a musculoskeletal (MSK) service AND
- The patient has a BMI below 35 AND
- Please confirm that the patient is supported by a primary care and/or community service referral AND
- Please confirm that conservative means (e.g. Analgesics, NSAIDS, physiotherapy, advice on walking aids, home adaptations, curtailment of inappropriate activities and general counselling as regards to the potential benefits of joint replacement) have been exhausted and failed to alleviate the patient’s pain and disability AND
- Please confirm that the patient’s pain and disability is sufficiently significant to interfere with the patients’ daily life and or ability to sleep AND
- Please confirm that the patient accepts and wants surgery
Patient has a BMI of 35 or over but mobility is so compromised that they are in immediate danger of losing their independence and that joint replacement would relieve this threat
Loss of Independence – Unable to maintain activities of daily living. Activities of daily living- 4 out of 6 needed to require assistance
- Transferring from Chair
- Climbing Stairs
Patient has a BMI of 35 or over but the destruction of their joint is of such severity that delaying surgical correction would increase technical difficulty of the procedure (Recent x-ray report required)
If the patient does not meet any of the above criteria and has a BMI of 35 or over:
If the patient does not meet any of the above criteria and has a BMI of 35 or over they will be referred by their GP to weight management services and will be expected to engage with the services to achieve the required BMI.
Should the patient’s BMI fall below 35 then the patient would be eligible for surgery in line with the policy criteria.
If this weight loss cannot be achieved the patient will be eligible for referral for surgery from two years after the documented date of the GP referral to weight management services for the purpose of weight loss prior to surgery.
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.
Post Operative Joint Replacement Management
See link right for full leaflet
Antibiotics may mask the joint infection temporarily but they are unlikely to cure it.
They will also compromise the success of any further treatments.
Therefore, if you have any queries or concerns please leave a voice mail message on the number below for advice.
We will organise the necessary investigations and arrange an appointment if required.
Contact: 024 7696 8333