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 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
GP / Primary Clinician
Exclude red flags.

Consider diagnosis (discuss within peer review)

1. Acute knee injury:

  • Patients physiologically aged below 30 years.
  • Pinpoint joint line tenderness.
  • Acute history/sudden onset.

2. Acute injury to degenerative knee.

3. Delayed presentation of acute knee injury.

4. OA Knee. (see OA Knee Pathway).


Specific Management

1. Acute knee injury:

  • If knee locked send straight to acute knee clinic or fracture clinic.
  • If no locking refer  to physiotherapy but review in 2 weeks from injury. If no improvement, refer to acute knee clinic or fracture clinic.  (If a meniscal tear is present there is only a 6-8 week timeline to repair surgically.)

2. Acute injury to degenerative knee - consider self referral or referral to physiotherapy.

3. Delayed presentation of acute knee injury - consider self referral or referral to physiotherapy.

4. OA knee (Follow OA knee pathway).


Weight bearing X-ray if no improvement in acute on chronic or degenerative knee.

  • Consider guidelines in previous section.
  • Assessment / Diagnosis/ Detailed advice.
  • Acute injury management as appropriate.
  • Combinations of appropriate multi-modal package of care e.g. stretching and strengthening exercises and manual therapy as part of functional restoration.

If not responding consider guidelines above and appropriate referral to acute knee clinic or fracture clinic or Interface Team.

Interface Team
  • Review previous assessment, diagnosis and management.
  • If not responding consider investigation (if diagnosis unclear).
  • No role for corticosteroid injection.
  • Consider referral to Surgeon if fits criteria.

Refer back to GP for advice re. analgesia.


  • Weight bearing X-ray if no improvement in acute on chronic or degenerative knee.
  • MRI scan may be indicated as a second line investigation.
Surgical Criteria

No referrals to secondary care unless:

  • X-ray shows no signs of OA/mild OA


  • MRI shows clear evidence of an internal joint derangement (meniscal tear)


  • The patient has symptoms of true locking


  • Symptoms persist despite 3-6 months of comprehensive conservative management


  • 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:

  • Arthroscopic repair - NWB 6-8 weeks, full recovery 3 months.
  • Arthroscopic menisectomy- to drive 2-4 weeks; full recovery 3 months.