NICE has published Referral Advice – A guide to appropriate referral from general to specialist services, which deals with 11 common complaints. Last month we covered osteoarthritis of the hip. In this issue we reproduce the advice on osteoarthritis of the knee.

The referral advice is set out in consensus statements based on the best available evidence. It is designed to help clinicians determine how urgently particular patients need to be referred. For a summary of the consensus statements click here.

Osteoarthritis of the knee

Osteoarthritis of the knee presents with joint pain, deformity, stiffness, a reduced range of movement and sometimes giving way.

The pain may be sharp and brought on by particular movements (flexing, extending or turning on the knee), or may present as a dull ache occurring at rest especially after periods of activity or during the night.

Stiffness tends to be worse after being immobile, and usually improves for a while with use.

Examination may reveal fixed deformity, swelling, tenderness and loss of normal range of movement. Osteoarthritis is not associated with systemic illness.

Osteoarthritis is common and its prevalence increases with age. In most patients with radiological changes, symptoms are not sufficiently troublesome to prompt a general practice consultation. In some patients symptoms may be intermittent but in others they may be relentless and debilitating.

The underlying joint changes of osteoarthritis are generally irreversible and management aims to relieve symptoms and reduce disability.

In the NHS in England and Wales, around 31000 primary knee replacement operations were undertaken in 1999/2000.

Primary care

Initial management strategies for patients with osteoarthritis of the knee include reassurance and patient education, weight reduction in patients who are obese, walking aids, help with patient-specific exercise programmes, and assessment and advice on cushion-soled footwear.

Drug treatment typically includes courses of simple analgesics and nonsteroidal anti-inflammatory drugs. Aspiration and intra-articular steroid injections are undertaken by some GPs.

If the patient has had a knee X-ray, a copy of the report should be enclosed with any subsequent referral letter.

Specialist services

These are in a position to:

  • confirm or establish the diagnosis
  • provide management advice coupled with physical therapies
  • assess the need for, and undertake, joint surgery and rehabilitation
  • undertake intra-articular injections of drugs.
Referral Advice
The majority of the management of patients with osteoarthritis of the knee is undertaken in primary care. However, referral to a specialist service is advised if:
there is evidence of infection in the joint
there is evidence of acute inflammation caused by, for example, haemarthrosis, gout or pseudo-gout
giving way is a problem despite therapy
symptoms rapidly deteriorate and are causing severe disability
the symptoms impair quality of life. Referral should be based on an explicit scoring system that should be developed locally in a partnership involving patients together with healthcare professionals in primary and secondary care. Referral criteria should take into account the extent to which the condition is causing pain, disability, sleeplessness, loss of independence, inability to undertake normal activities, reduced functional capacity or psychiatric illness
The starring system developed by NICE to identify referral priorities
Arrangements should be made so that the patient:
is seen immediately1
is seen urgently2
is seen soon2
has a routine appointment2
is seen within an appropriate time depending on his or her clinical circumstances (discretionary)

1 within a day
2 health authorities, trusts and primary care organisations should work to local definitions of maximum waiting times in each of these categories. The multidisciplinary advisory groups considered a maximum waiting time of 2 weeks to be appropriate for the urgent category.

Reproduced with kind permission from: Referral Advice – A Guide to Appropriate Referral from General to Specialist Services. London: NICE, December 2001.

The complete document can be downloaded from the NICE website

Guidelines in Practice, June 2002, Volume 5(6)
© 2002 MGP Ltd
further information | subscribe