Most knee pain in adults over 45 is osteoarthritis and it is diagnosed without a scan. Exercise is the treatment with the strongest evidence and the one most often skipped. A 30 minute consultation is £150 and an ultrasound guided platelet injection is £650.
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Any of these needs to be seen the same day. If you are severely unwell, go to your nearest emergency department or call 999.
Osteoarthritis is the commonest cause of knee pain over 45. It is a condition of the whole joint rather than simple wear, and it is diagnosed clinically in someone over 45 with activity related pain and morning stiffness lasting no more than 30 minutes.NICE NG226, 2022
In younger adults the usual causes are the kneecap tracking badly, tendon overload and meniscal or ligament injury. Those are separated by what you were doing when it started and by the examination.New England Journal of Medicine Sihvonen, 2013
Pain on stairs, after sitting still, and at the start of activity that eases as you warm up, is the pattern of osteoarthritis. Locking, giving way and a knee that swells hours after a twist point at the meniscus or a ligament.NICE NG226, 2022
Weight is the modifiable factor with the largest effect. Each kilogram lost reduces the load through the knee several times over during walking, which is why weight and activity are addressed together rather than separately.European Heart Journal ESC guideline, 2021
Send us what you are seeing and we will tell you what it is likely to be.
Over 45 with typical pain and short lived morning stiffness, osteoarthritis is diagnosed without imaging. An X ray does not change the treatment and the severity on the film correlates poorly with the pain someone has.NICE NG226, 2022
The examination looks at gait, alignment, swelling, the joint line, the ligaments and the muscle bulk above the knee. Ultrasound in clinic answers whether there is fluid and whether an injection can be placed accurately.NICE NG226, 2022
A hot swollen knee with a fever is treated as an infected joint until proven otherwise, which is an emergency rather than an appointment.NICE NG12, 2015
Exercise, which is the first line
A review of 54 trials found land based exercise reduced pain and improved function in knee osteoarthritis, with benefit sustained for at least 2 to 6 months after supervised sessions stopped. It is free and it is the most skipped part of the plan.Cochrane Database of Systematic Reviews Fransen, 2015
Weight loss where there is weight to lose
Works alongside exercise rather than instead of it, and it is the intervention with the largest effect on load through the joint.NICE NG226, 2022
Pain relief
Topical anti inflammatories first for the knee, oral ones at the lowest effective dose for the shortest time. Paracetamol alone has limited effect in osteoarthritis.NICE NG226, 2022
A steroid injection
Gives short term relief measured in weeks. Repeated injections into the same joint carry cartilage and tendon risks, which is why they are spaced and counted rather than repeated on request.BMC Musculoskeletal Disorders Brinks, 2011
Ultrasound guided platelet rich plasma
Used for mild to moderate knee osteoarthritis and tendon problems, typically one to three sessions. The evidence is mixed and the trials are smaller than those behind exercise, and it is offered as an addition rather than a replacement.NICE NG226, 2022
Referral for a surgical opinion
For a locked knee, for ligament injury in an active person, and for osteoarthritis where pain and function have not responded to a proper programme. What a replacement can and cannot give back is set out before you are referred for one.General Medical Council GMC guidance, 2020
A structured exercise programme is judged at 12 weeks. Benefit builds slowly and continues for months after supervised sessions end, which is why stopping at 4 weeks reads as a failure when the programme had not finished working.Cochrane Database of Systematic Reviews Fransen, 2015
The inconvenient half. In a randomised trial comparing keyhole surgery for a degenerative meniscal tear with sham surgery, the two groups had similar outcomes at 12 months. A tear on a scan in a middle aged knee is often not the thing to operate on.New England Journal of Medicine Sihvonen, 2013
Steroid injections relieve pain for weeks rather than months, and repeated injections into the same joint carry risks to cartilage and tendon. That is why they are counted rather than repeated whenever the pain returns.BMC Musculoskeletal Disorders Brinks, 2011
Test the muscle that matters. Sit in a chair and stand up without using your hands, 5 times, timed. Over 12 seconds points at weakness in the thigh muscle, which is the single most treatable finding in knee osteoarthritis and the one exercise targets.Cochrane Database of Systematic Reviews Fransen, 2015
Start straight leg raises and sit to stands now, twice a day, for 2 weeks before the appointment. The programme works and it takes 12 weeks, so beginning it before you arrive brings the review forward rather than delaying it.Cochrane Database of Systematic Reviews Fransen, 2015
Note three things about the pain. Whether it is worse going up or down stairs, whether it locks, and whether it swelled within an hour of an injury or the next day. Those three answers separate most of the causes before anyone touches the knee.NICE NG226, 2022
Do not buy an MRI for a middle aged knee with typical osteoarthritis. It usually shows a degenerative meniscal tear, and a trial comparing surgery for exactly that with sham surgery found the same outcome at 12 months. The scan leads to an operation that does not help.New England Journal of Medicine Sihvonen, 2013
Do not buy glucosamine or chondroitin. National guidance recommends against them for osteoarthritis, and the shelf space they occupy is larger than the evidence behind them.NICE NG226, 2022
Do not buy a course of platelet injections before you have done 12 weeks of the exercise programme. The evidence behind exercise is stronger, and this is a £650 session we are asking you to postpone.Cochrane Database of Systematic Reviews Fransen, 2015
Step 1
Gait, alignment, the joint line, the ligaments and the muscle above the knee, with ultrasound in clinic where fluid or an injection is the question.
Step 2
Specific exercises, the pain relief that works for knees, and a weight target where there is one. Judged at 12 weeks rather than abandoned at 4.
Step 3
An ultrasound guided injection where it is the right answer, or a surgical opinion arranged and booked where it is not.
Ask before you book if you are not sure this is the right appointment.
Usually not. Over 45, with activity related pain and morning stiffness lasting under 30 minutes, osteoarthritis is diagnosed clinically. An X ray does not change treatment, and the severity on a film matches the pain someone has poorly.
Exercise. A review of 54 trials found land based exercise reduced pain and improved function, with benefit lasting for months after supervised sessions ended. It is free, it is first line, and it is the part of the plan most often skipped.
They relieve pain for weeks rather than months. Repeated injections into the same joint carry risks to cartilage and tendon, so they are spaced and counted rather than repeated whenever the pain comes back.
It is used for mild to moderate osteoarthritis and tendon problems, typically over one to three sessions at £650 each. The evidence is mixed and weaker than the evidence for exercise, so it is offered as an addition to the programme rather than instead of it.
In a middle aged knee with a degenerative tear, usually not. A randomised trial compared that operation with sham surgery and found similar outcomes at 12 months. A locked knee, or a tear in a younger athlete, is a different situation.
A 30 minute appointment with a full examination is £150. An ultrasound guided platelet injection is £650. A same day urgent slot after an injury is £220. The review at 12 weeks by telephone is £59.
National guidance recommends against them for osteoarthritis. The evidence does not support them, and the shelf they sit on is much larger than the case for them. The same money spent on a supervised exercise programme buys a result the trials actually show.
This page is general information about a condition and it is not a diagnosis. Treatment depends on what a doctor finds when they examine you, and no outcome is guaranteed. If you are severely unwell, or if any of the warnings at the top of this page apply to you, go to your nearest emergency department or call 999.
BMC Musculoskeletal Disorders
Adverse effects of extra articular corticosteroid injections, a systematic reviewBrinks, 2011
Cochrane Database of Systematic Reviews
Exercise for osteoarthritis of the kneeFransen, 2015
European Heart Journal, European Society of Cardiology
Guidelines on cardiovascular disease prevention in clinical practiceESC guideline, 2021
General Medical Council
Decision making and consentGMC guidance, 2020
New England Journal of Medicine
Arthroscopic partial meniscectomy versus sham surgery for a degenerative meniscal tearSihvonen, 2013
NICE
NICE
Osteoarthritis in over 16s, diagnosis and managementNG226, 2022
Written by the clinical team at The Wellness. Awaiting clinical sign off.
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