Knee pain (chronic)

ADULT

Emergency

If any of the following are present or suspected, please refer the patient to the emergency department (via ambulance if necessary) or follow local emergency care protocols or seek emergent medical advice if in a remote region.

The list below includes common traumatic injuries that require referral to emergency and should not be referred for elective / fracture clinic categorisation

Adult

Shoulder and elbow conditions

Clinically indicated e.g. suspected septic arthritis
- Evidence of acute inflammation e.g: haemarthrosis, tense effusion

Wrist and hand

Uncontrolled sepsis including hand infections
Upper limb radiculopathy in the presence of suspected cervical spine infection
Acute development of peripheral nerve compression symptoms following trauma or acute event

Hip and knee

Suspected septic arthritis
Knee extensor mechanism rupture
Suspected fracture
Evidence of acute inflammation for example
- haemarthrosis
- tense effusion
Suspected infection or sudden pain in arthroplasty
- if joint infection is suspected refer immediately to emergency or contact the orthopaedic registrar on call. Do not commence antibiotics unless delay to specialist review is likely

Foot and ankle

Suspected septic arthritis
Acute achilles tendon rupture

Spine

Actual or threatened cauda equina syndrome
- Unilateral or bilateral radicular pain
  - And/or dermatomal reduced sensation
  - And/or myotomal weakness
  - Reduced saddle sensation (subjective or objective pin prick)
  - unexplained or unexpected loss or change of bladder or bowel function
  - Sexual disturbance
  - perineal anaesthesia
Presentations that increase the probability of acute threatened Cauda Equina:
- Back Pain with:
  - Presence of new saddle anaesthesia, bladder or bowel disturbance.
  - Age < 50
  - Unilateral onset progressing to bilateral leg pain
  - Alternating leg pain
  - Presence of new motor weakness
Spinal tumour with significant pain and/or neurological deficit
Lumbar Spine Stenosis (LSS) presenting with clinical symptoms of the following:
- Recurring and insidiously but increasing back pain with gradual onset of unilateral or bilateral lower limb sensory disturbance and/or motor weakness
- Incomplete bladder emptying, urinary hesitancy, incontinence, nocturia or urinary tract infections. Bladder and/or bowel dysfunction may progress gradually over time.
Clinical signs of spinal nerve root compression or spinal cord compression with rapidly progressive neurological signs/symptoms
Spinal fractures demonstrated on imaging
Clinical suspicion spinal infections
High risk of irreversible deficit if not assessed urgently

Trauma and fractures

Acute cervical myelopathy
Acute back or neck pain secondary to neoplastic disease or infection
Spinal injuries
Suspected open fracture
Fracture requiring manipulation or operation
Suspected acute bone or joint infection
Acute high energy fracture with/without neurological abnormality
Injury associated with vascular compromise
Clavicle fracture
Osteoporotic / pathological fracture new abnormal neurology
Joint dislocations
Open injuries with possible tendon or joint involved
Nail bed injuries or retained foreign body
Knee extensor mechanism rupture
Acute peripheral nerve injury
Suspected acute compartment syndrome

Hand trauma

Acute ligament injury
Tendon rupture
Compound ‘tooth knuckle’ injury

Upper and lower limb trauma

Open, unstable or suspected fractures

Timing of first review appointments at orthopaedic outpatient’s/fracture clinic

if there is documentation indicating adequate alignment and satisfactory initial treatment of fracture – to be seen within 14 days of referral
all other fracture cases, delayed presentation of tendon and nerve injuries - to be seen within 7 days of referral

Paediatric

Limping child/reluctant to weight bear

Limping child with signs of:
- Being unwell, flushed, lethargic, fever, flat, anorexic and/or
- Irritable and stiff joint and/or
- Not improving
Systemically unwell, febrile or suspicion of septic arthritis
Concern of infection or trauma
Suspicion or concern of non-accidental injury

NB See Slipped upper femoral epiphysis (SUFE) CPC

Slipped upper femoral epiphysis (SUFE)

All suspected or confirmed SUFE should be referred to the ED or local orthopaedic on call registrar service no matter the chronicity

Scoliosis / Kyphosis

Systemically unwell
Abnormal neurological reason

Back pain

Systemically unwell

Tumour – bone and soft tissue

Suspected malignancy

Other useful information for referring practitioners Not an exhaustive list

Refer to HealthPathways or local guidelines
Consider pre‐operative optimisation of patient with diagnosed and undiagnosed diabetes, prior to referral
Consider pre-operative optimisation of anaemia, as defined by a haemoglobin of < 13.0g/dL in men and 12.0g/dL in women, prior to referral
Smoking is a contraindication to hip and knee arthroplasty surgery
Better health self-management program
Obesity is associated with an increase in complications associated with surgery – consider dietitian & weight reduction monitoring if BMI >35. Mandatory for BMI >40.
Chronic disease requires to be optimised prior to referral or the patients may not proceed to surgery

Clinical resources

Patient resources

Hip and knee questionnaire (patient to complete)

Minimum Referral Criteria

Category 1
(appointment within 30 calendar days)
- Suspected malignancy
- New pain in previously well-functioning arthroplasty
Category 2
(appointment within 90 calendar days)
- Symptoms rapidly deteriorating and causing severe disability
Category 3
(appointment within 365 calendar days)
- Some functional impairment and/or pain persists despite maximal management

1. Reason for request Indicate on the referral

To establish a diagnosis
For treatment or intervention
For advice and management
For specialist to take over management
Reassurance for GP/second opinion
For a specified test/investigation the GP can't order, or the patient can't afford or access
Reassurance for the patient/family
For other reason (e.g. rapidly accelerating disease progression)
Clinical judgement indicates a referral for specialist review is necessary

2. Essential referral information Referral will be returned without this

General referral information
History of symptoms: pain, true locking, instability, swelling, recurring infections
Injury details (if any): date, mechanism, severity, recurrence and evolution of injury
Smoking status
HbA1C (diabetic patient referral only)
FBC, ESR, CRP, iron studies results (if indicated by medical history)
Previous joint surgery
Results of clinical ligament and meniscus tests if completed
Height, weight and BMI
XR results - knee, weight bearing AP, lateral and skyline of both knees

3. Additional referral information Useful for processing the referral

Management to date
Investigations for inflammatory arthropathy
Has non-operative management been completed?
Hip and knee questionnaire (patient to complete)

4. Request

Patient's Demographic Details

Full name (including aliases)
Date of birth
Residential and postal address
Telephone contact number/s – home, mobile and alternative
Medicare number (where eligible)
Name of the parent or caregiver (if appropriate)
Preferred language and interpreter requirements
Identifies as Aboriginal and/or Torres Strait Islander

Referring Practitioner Details

Relevant clinical information about the condition

Presenting symptoms (evolution and duration)
Physical findings
Details of previous treatment (including systemic and topical medications prescribed) including the course and outcome of the treatment
Body mass index (BMI)
Details of any associated medical conditions which may affect the condition or its treatment (e.g. diabetes), noting these must be stable and controlled prior to referral
Current medications and dosages
Drug allergies
Alcohol, tobacco and other drugs use

Reason for request

To establish a diagnosis
For treatment or intervention
For advice and management
For specialist to take over management
Reassurance for GP/second opinion
For a specified test/investigation the GP can't order, or the patient can't afford or access
Reassurance for the patient/family
For other reason (e.g. rapidly accelerating disease progression)
Clinical judgement indicates a referral for specialist review is necessary

Clinical modifiers

Impact on employment
Impact on education
Impact on home
Impact on activities of daily living
Impact on ability to care for others
Impact on personal frailty or safety
Identifies as Aboriginal and/or Torres Strait Islander

Other relevant information

Willingness to have surgery (where surgery is a likely intervention)
Choice to be treated as a public or private patient
Compensable status (e.g. DVA, Work Cover, Motor Vehicle Insurance, etc.)

Notes

Please note that where appropriate and available, the referral may be streamed to an associated public allied health and/or nursing service. This may include initial assessment and management by associated public allied health and/or nursing, which may either expedite or negate the need to see the public medical specialist.
A change in patient circumstance (such as condition deteriorating, or becoming pregnant) may affect the urgency categorisation and should be communicated as soon as possible.
Please indicate in the referral if the patient is unable to access mandatory tests or investigations as they incur a cost or are unavailable locally.

Version: 24
Last updated: 11 June 2021

Except as permitted under the Copyright Act 1968, no part of this work may be reproduced, communicated or adapted without permission from Queensland Health. To request permission email ip_officer@health.qld.gov.au.

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