Knee osteoarthritis: a clinical reference pageKnee osteoarthritis at first contact: what to start today, and when to refer
Start the strength programme and weight advice on the day, refer to physiotherapy at the same visit, and request weight-bearing X-rays to plan treatment. Before any referral to a surgeon, ask one question: would the patient consider an operation? Refer now when the pain is severe and the answer is yes; otherwise after at least 12 weeks of the programme, if the knee is still limiting them.
Written for the clinician seeing the patient first
This page is written for first contact practitioners, advanced practice physiotherapists, MSK physiotherapists and GPs. It is not advice for patients, and it does not replace local pathways or the clinician’s own judgement. Where a statement is Dr Imbuldeniya’s own clinical position rather than published guidance, it says so.
Clinical, with weight-bearing X-rays for every suspected case
NICE diagnoses osteoarthritis clinically, without imaging, in people aged 45 or over with activity-related joint pain and morning stiffness of 30 minutes or less. The commonest patient at first contact has medial compartment osteoarthritis, or medial overload with a degenerate meniscal tear. An MRI is not the first test; weight-bearing X-rays are requested to plan treatment, as set out in when knee pain needs an X-ray, and which views, and the patient is seen again to go through them.
Orwyn asks for weight-bearing X-rays for every suspected case of knee osteoarthritis. This is a deliberate departure from NICE NG226, owned by Dr Imbuldeniya: ‘Patients reaching MSK triage have already seen their GP and not settled. A weight-bearing X-ray confirms the diagnosis, shows how severe the wear is and rules out other causes. It is then ready if surgery is considered later, as the GIRFT knee replacement pathway expects. Treatment starts straight away, and the X-ray is reviewed at follow-up to confirm the diagnosis.’ (GIRFT is the Getting It Right First Time programme.)
Offload and strengthen
Tell the patient on the day what to do and where, and refer to physiotherapy at the same visit so they start now. NICE puts therapeutic exercise at the centre of treatment, and weight loss for people living with overweight.
Dr Imbuldeniya’s strength programme aims for bigger leg muscles, not only “strengthening”: hip thrust, hip abduction and adduction, leg press, calf raise, leg extension, hamstring curl and Romanian deadlift, on machines where possible and with bands where there is no gym; 3 sets of 6 repetitions, about 60 to 70 minutes, once a week, kept up as a lifelong habit. His pain rule: if the joint is not injured, exercise will not wear it out, and discomfort of 3 or 4 out of 10 during exercise is acceptable, no higher. Walking, cycling, yoga and Pilates are fine, but it is resistance training that reduces joint pain. “Properly tried” means at least 12 weeks, every week.
An offloading brace can be considered where there is malalignment, within the NICE conditions for braces. A walking aid can help.
Gel first, tablets with care
NICE recommends a topical anti-inflammatory for knee osteoarthritis first; an oral anti-inflammatory can be considered if that is ineffective or unsuitable, with a stomach-protecting medicine, at the lowest dose for the shortest time; paracetamol is not routinely offered. A first contact clinician cannot usually prescribe, so this goes through the GP, and the letter’s box for the GP says what, if anything, they are asked to do.
A steroid injection into the knee gives short-term relief, which NICE puts at 2 to 10 weeks. Orwyn suggests it only for a patient who is not being referred for joint replacement, and warns against it for a patient who is. NICE advises against hyaluronan injections.
Ask first, then refer on severity and wishes
Nobody is referred for an operation they do not want. “Would you consider surgery?” is asked before any referral to the orthopaedic knee clinic, and a no means no referral, with the patient free to ask for a surgical opinion at any time. Severity and the patient’s wishes decide, not age.
- Severe, and would consider surgery: refer now, and start the strength programme the same day; there is no 12-week wait. Severe means the pain picture: it wakes the patient at night, stops daily activities, is getting worse and is making them miserable, supported by an obvious bow-legged or knock-kneed deformity, or a significant loss of bending or straightening.
- Mild or moderate, or unsure about surgery: at least 12 weeks of the programme first, then review. The referral says how many weeks were completed.
- Does not want surgery: manage well without it: exercise, weight, a brace and a walking aid, and consider a cortisone injection.
Every referral carries a surgical risk history: blood thinners, diabetes, the circulation in that leg, the skin over the knee, serious lung disease, heart disease with poor exercise tolerance, and kidney failure. Where the risk is high, say so plainly and ask whether the patient still wants to see the surgeon; if they do, refer.
How Orwyn handles this
Orwyn gives the plan in one line, “X-rays, and start the offload and strengthen programme today”, with the next step under it: see the patient again to go through the X-rays, and after at least 12 weeks of the programme refer to the orthopaedic knee clinic if the knee is still limiting and the patient would consider surgery. For a severe knee and a patient who wants surgery, it writes the referral now, with the X-rays and the surgical risk history.
The patient’s letter and page explain the programme, the pain rule and pain relief in plain words, with a section from the knee surgeon who wrote the guidance.
Where this came from
- Osteoarthritis in over 16s: diagnosis and management, NG226. National Institute for Health and Care Excellence, 2022. Read it here.
- Knee MRI when symptoms are suggestive of osteoarthritis. Evidence-Based Interventions, Academy of Medical Royal Colleges. Read it here.
Surgeon-governed decision support for first-contact MSK clinicians.