GP / Primary Clinician

Exclude red flags.

  • Consider Diagnosis
  • Pain usually gradual onset but can be sudden.
  • Joint may be stiff and swollen.
  • Pain and swelling often worse in morning or after period of activity. May also be increased by stair climbing, kneeling etc.
  • Examine the hip to exclude hip referred pain to the knee.
  • Undertake Oxford PROM to ascertain pre treatment score - will calculate out score.
  • A wide range of options exist; the treatment should be tailored to each patient. The choice should be a shared decision.
  • Refer directly to surgeon via Interface Team if patient has gone throughcomprehensive conservative management and fits the criteria.
  • Refer for Falls Assessment if appropriate.


Early stages:

  • Explanation/fully inform (NICE guidelines).
  • Discuss weight management and smoking cessation if appropriate.
  • Aerobic exercise  / Consider Health Trainers.
  • Exercise to increase local muscle strength and possibly range of movement.
  • Optimal analgesia/ NSAIDS.
  • Modify activities.
  • Ice/Heat/ Topical capsaicin/TENS.
  • Advice on walking stick (held in opposite hand from affected joint) / and appropriate footwear.
  • Consider self referral or referral to Physiotherapy.
  • Corticosteroid can be injected into the joint to relieve pain BUT there is concern that the potential for long term damage to the cartilage/joint. I-2 injections can be given in conjunction with a package of exercise. Repeated injection should only be considered for those who do not require surgical option. Injections should not be given within 6 months of surgery.

Later Stages:


  • Not initially indicated but if symptoms are not managed with early stage management consider Standing AP and Lateral.
  • Consider skyline X-ray if PFJ OA suspected.
  • X-ray prior to surgical referral.
Red flags for knee conditions

Prior to referral consider / screen to exclude:

Key Clinical Observations of concern:

  • Hot / red / swollen joint with raised body temperature  (raised inflammatory markers)
  • Septic/Unwell
  • Rapidly worsening deformity
  • Neuro-vascular compromise
  • Weight Loss
  • Continuous pain, including at night and when not weight bearing
  • Unable to walk or move knee
Urgent knee referral

Patients with any of the following suspected should be sent to A&E:

  • Fracture, or  knee dislocation
  • Quadriceps/Patella Tendon Rupture
  • Suspected Infection


Urgent appointments can be made for patients at Fracture/ Trauma Clinic for:

  • On- going infection
  • Locked knee
  • Recent ligament rupture
  • Large effusion/haemathrosis
  • Trauma suspected soft tissue damage
  • Traumatic patella dislocation


Urgent appointments can be made in elective Orthopaedic/ Rheumatology/Pain Clinics for patients with:

  • Rapidly worsening symptoms
  • Confirmed Cancer i.e not previously documented metastases
  • Confirmed presence of cancer on imaging
  • Constant unrelenting pain / especially unrelenting night pain in presence of cancer
  • Progressive or significant neurological loss suggestive of acute peripheral nerve compression
  • Consider guidelines in previous section.
  • Assessment / Diagnosis/ Combinations of appropriate multi-modal package of care per NICE guidelines.
  • Core treatments include:
    • appropriate advice and information
    • aerobic exercise
    • specific exercise to improve muscle strength
    • possibly exercises to improve joint mobility
  • Consider walking aids as adjuncts to the core treatment where problems with ADL.
  • Consider provision of ‘unloader’ brace from orthotic dept.
  • Consider steroid injection (if able to offer in service) if pain is moderate to severe and symptoms are preventing adherence to exercise (see GP section above).

If not responding consider referral to Interface Team.

Surgical Criteria

No referrals should be made to secondary care unless the following criteria are met:

  • Patient has intrusive pain affecting lifestyle that is not improving despite 6 months of comprehensive conservative management and lifestyle changes in line with NICE Guidance


  • Patient has shown a commitment to weight reduction through active participation in a weight management programme if BMI >30.


  • If total knee replacement is not considered to be the most likely outcome steroid injection should be considered and undertaken (if appropriate) if pain is moderate to severe and symptoms are preventing adherence to exercise. Note that injections might not routinely be carried out if a total knee replacement is the most likely outcome.


  • X-ray undertaken prior to referral


  • Health Care Professional has discussed surgery with the patient who has confirmed they want explore surgery


  • General Health including fitness for anaesthesia has been considered and believed adequate to proceed to potential surgical intervention and it is believed that the patient is likely to derive quality of life benefits from surgery



Individual Funding Requests

Certain knee procedures are listed on Gloucestershire CCG's Effective Clinical Commissioning Policy.  Please the links below for details of access criteria and funding arrangements:

  • Knee Arthroscopy to remove bony spurs or damaged cartilage that is causing significant pain. Day case surgery. Drive when able to undertake an emergency stop. Improvement can be expected for 2-6 months.
  • Total or unicondylar Knee replacement- time to drive 6-12 weeks, time to recovery up to 18 months.
  • Osteotomy- time to drive 6-12 weeks, time to recovery up to 18 months.
  • Patients may need to check with insurance company regarding specific policy driving requirements post surgery.