Knee MRI for suspected meniscal tears
Best Practice Guidance
Summary
Patients who have knee pain with persistent mechanical symptoms (locking, catching and intermittent sudden pain on movement) that has not responded to three months of initial non-operative care may have a symptomatic meniscal tear. These patients are referred to intermediate or secondary care and in these circumstances an MRI scan is the best investigation to determine the cause of symptoms.
Patients who have a clear history of a significant acute knee injury and mechanical symptoms or who have a locked knee require referral to intermediate or secondary care and should undergo MRI investigation.
The majority of patients who present to primary care with knee pain do not require initial investigation with an MRI scan once red flag symptoms and signs have been excluded.
This guidance applies to adults aged 19 years and over.
Recommendation
Patients with a clear history of a significant acute knee injury and mechanical symptoms or who have a locked knee may have a repairable meniscal tear and should undergo referral to intermediate or secondary care and have MRI investigation.
The majority of patients who initially present in primary care with knee symptoms, no red flags and no history of acute knee injury or a locked knee do not need an MRI investigation and can be treated with non-operative supportive measures. Patients with persistent mechanical knee symptoms should be referred to secondary care and should have an MRI scan of the knee to investigate for a meniscal tear and/or other pathology.
Rationale for recommendation
Degenerate meniscal tears and OA are extremely common in the general population. MRI is not recommended for a suspected degenerative meniscal tear unless there are mechanical symptoms (e.g. locking) or lack of improvement with conservative treatment (e.g. exercise/therapy, weight loss, bracing, topical or oral analgesia). Acute knee injury can result in meniscal pathology that may require surgical intervention such as meniscal repair and an MRI scan is the investigation of choice in these cases. A locked knee requires urgent assessment and an MRI scan is the investigation of choice to define the cause.
Patient information
There is no specific EBI patient guidance for this intervention.
However, we recommend using the BRAN principles (Benfits, Risks, Alternatives and do Nothing) when speaking with patients about this.
Further information on patient involvement in EBI can be found on the EBI for patients section.
Coding
Code Script
Coding and count merged for T Knee MRI when symptoms are suggestive of osteoarthritis and U Knee MRI for suspected meniscal tears, producing a
single metric.
Outpatient
WHEN LEFT(opa.Der_Procedure_All,4) in ('U133','U211’)
AND (opa.Der_Procedure_All like '%Z846%’
OR opa.Der_Procedure_All like '%O132%’)
AND (not ( opa.der_diagnosis_all like '%M00[01289]%’
OR opa.der_diagnosis_all like '%M01[01234568]%’
OR opa.der_diagnosis_all like '%M0[25][012389]%’
OR opa.der_diagnosis_all like '%M03[0126]%’
OR opa.der_diagnosis_all like '%M0[68][0123489]%’
OR opa.der_diagnosis_all like '%M07[0-6]%’
OR opa.der_diagnosis_all like '%M09[0128]%’
OR opa.der_diagnosis_all like '%M10[012349]%’
OR opa.der_diagnosis_all like '%M11[01289]%’
OR opa.der_diagnosis_all like '%M12[0123458]%’
OR opa.der_diagnosis_all like '%M13[0189]%’
OR opa.der_diagnosis_all like '%M14[01234568]%’
OR opa.der_diagnosis_all like '%M15[12348]%’
OR opa.der_diagnosis_all like '%M16[012345679]%’
OR opa.der_diagnosis_all like '%M17[2345]%’
OR opa.der_diagnosis_all like '%M238%’
OR opa.der_diagnosis_all like '%C40[289]%’
OR opa.der_diagnosis_all like '%C7[69]5%’
OR opa.der_diagnosis_all like '%D162%’)
OR opa.der_diagnosis_all IS NULL)
AND ISNULL(opa.Age_at_Start_of_Episode_SUS,opa.Der_Age_at_CDS_Activity_Date) between 19 AND 120
THEN 'C_knee_arth'
Code Definitions
Procedure codes (OPCS)
U133 Magnetic resonance imaging of bone
U211 Magnetic resonance imaging NEC
Z846 Knee joint (secondary to U code)
O132 Knee NEC (secondary to U code)
Diagnosis codes (ICD)
Inclusion
M150 Primary generalized (osteo)arthrosis
M159 Polyarthrosis, unspecified
M170 Primary gonarthrosis, bilateral
M171 Other primary gonarthrosis
M179 Gonarthrosis, unspecified
M232 Derangement of meniscus due to old tear or injury
S832 Tear of meniscus, current
Exclusion
M000 Staphylococcal arthritis and polyarthritis
M001 Pneumococcal arthritis and polyarthritis
M002 Other streptococcal arthritis and polyarthritis
M008 Arthritis and polyarthritis due to other specified bacterial agents
M009 Pyogenic arthritis, unspecified
M010 Meningococcal arthritis
M011 Tuberculous arthritis
M012 Arthritis in Lyme disease
M013 Arthritis in other bacterial diseases classified elsewhere
M014 Rubella arthritis
M015 Arthritis in other viral diseases classified elsewhere
M016 Arthritis in mycoses
M018 Arthritis in other infectious and parasitic diseases classified elsewhere
M020 Arthropathy following intestinal bypass
M021 Postdysenteric arthropathy
M022 Postimmunization arthropathy
M023 Reiter disease
M028 Other reactive arthropathies
M029 Reactive arthropathy, unspecified
M030 Postmeningococcal arthritis
M031 Postinfective arthropathy in syphilis
M032 Other postinfectious arthropathies in diseases classified elsewhere
M036 Reactive arthropathy in other diseases classified elsewher
M050 Felty syndrome
M051 Rheumatoid lung disease
M052 Rheumatoid vasculitis
M053 Rheumatoid arthritis with involvement of other organs and systems
M058 Other seropositive rheumatoid arthritis
M059 Seropositive rheumatoid arthritis, unspecified
M060 Seronegative rheumatoid arthritis
M061 Adult-onset Still disease
M062 Rheumatoid bursitis
M063 Rheumatoid nodule
M064 Inflammatory polyarthropathy
M068 Other specified rheumatoid arthritis
M069 Rheumatoid arthritis, unspecified
M070 Distal interphalangeal psoriatic arthropathy
M071 Arthritis mutilans
M072 Psoriatic spondylitis
M073 Other psoriatic arthropathies
M074 Arthropathy in Crohn disease [regional enteritis]
M075 Arthropathy in ulcerative colitis
M076 Other enteropathic arthropathies
M080 Juvenile rheumatoid arthritis
M081 Juvenile ankylosing spondylitis
M082 Juvenile arthritis with systemic onset
M083 Juvenile polyarthritis (seronegative)
M084 Pauciarticular juvenile arthritis
M088 Other juvenile arthritis
M089 Juvenile arthritis, unspecified
M090 Juvenile arthritis in psoriasis
M091 Juvenile arthritis in Crohn disease [regional enteritis]
M092 Juvenile arthritis in ulcerative colitis
M098 Juvenile arthritis in other diseases classified elsewhere
M100 Idiopathic gout
M101 Lead-induced gout
M102 Drug-induced gout
M103 Gout due to impairment of renal function
M104 Other secondary gout
M109 Gout, unspecified
M110 Hydroxyapatite deposition disease
M111 Familial chondrocalcinosis
M112 Other chondrocalcinosis
M118 Other specified crystal arthropathies
M119 Crystal arthropathy, unspecified
M120 Chronic postrheumatic arthropathy [Jaccoud]
M121 Kaschin-Beck disease
M122 Villonodular synovitis (pigmented)
M123 Palindromic rheumatism
M124 Intermittent hydrarthrosis
M125 Traumatic arthropathy
M128 Other specific arthropathies, not elsewhere classified
M130 Polyarthritis, unspecified
M131 Monoarthritis, not elsewhere classified
M138 Other specified arthritis
M139 Arthritis, unspecified
M140 Gouty arthropathy due to enzyme defects and other inherited disorders
M141 Crystal arthropathy in other metabolic disorders
M142 Diabetic arthropathy
M143 Lipoid dermatoarthritis
M144 Arthropathy in amyloidosis
M145 Arthropathies in other endocrine, nutritional and metabolic disorders
M146 Neuropathic arthropathy
M148 Arthropathies in other specified diseases classified elsewhere
M151 Heberden nodes (with arthropathy)
M152 Bouchard nodes (with arthropathy)
M153 Secondary multiple arthrosis
M154 Erosive (osteo)arthrosis
M158 Other polyarthrosis
M160 Primary coxarthrosis, bilateral
M161 Other primary coxarthrosis
M162 Coxarthrosis resulting from dysplasia, bilateral
M163 Other dysplastic coxarthrosis
M164 Post-traumatic coxarthrosis, bilateral
M165 Other post-traumatic coxarthrosis
M166 Other secondary coxarthrosis, bilateral
M167 Other secondary coxarthrosis
M169 Coxarthrosis, unspecified
M172 Post-traumatic gonarthrosis, bilateral
M173 Other post-traumatic gonarthrosis
M174 Other secondary gonarthrosis, bilateral
M175 Other secondary gonarthrosis
M238 Other internal derangements of knee (code for knee locking but not specific to this)
C402 Malignant neoplasm: Long bones of lower limb
C408 Malignant neoplasm: Overlapping lesion of bone and articular cartilage of limbs
C409 Malignant neoplasm: Bone and articular cartilage of limb, unspecified
C765 Malignant neoplasm of other and ill-defined sites: Lower limb
C795 Secondary malignant neoplasm of bone and bone marrow
D162 Benign neoplasm: Long bones of lower limb
Additional Exclusions
apcs.der_diagnosis_all not like '%C[0-9][0-9]%' and apcs.der_diagnosis_all not like '%D0%' and apcs.der_diagnosis_all not like '%D3[789]%' and apcs.der_diagnosis_all not like '%D4[012345678]%’
This code captures code in the ranges C00-C99, D00-D09 and D37-D48.
Age range: the codes use the following age ranges 0-18 for children and 19-120
for adults.
— Private Appointment Exclusion
AND apcs.Administrative_Category<>’02’
References
- Choosing Wisely Canada (2015) sport and Exercise Medicine
- Arthritis Alliance of Canada. The Impact of Arthritis in Canada: Today and Over the Next 30 Years [Internet]. 2011 [cited 2017 May 5].
- Buchbinder R, et al. Management of degenerative meniscal tears and the role of surgery. BMJ. 2015;350:h2212. PMID: 26044448.
- Englund M. The role of the meniscus in osteoarthritis genesis. Rheum Dis Clin North Am. 2008;34:573-9. PMID: 18687273.
- Englund M. Meniscal tear — a common finding with often troublesome consequences. J Rheumatol. 2009;36:1362-4. PMID: 19567632.
- Englund M, et al. Incidental meniscal findings on knee MRI in middle-aged and elderly persons. N Engl J Med. 2008;359:1108-15. PMID: 18784100.
- Strobel MJ. Manual of Arthroscopic Surgery. Springer: Verlag Berlin Heidelberg; 2002;1:99-200. US Department of Veteran Affairs. VA/DoD Clinical Practice Guidelines: The Non-Surgical Management of Hip & Knee Osteoarthritis (OA) [Internet]. 2014 [cited 2017 May 5].
- G.F. Abram, D. J. Beard, A. J. Price, BASK Meniscal Working Group. Bone Joint J 2019;101-B:652–659. Arthroscopic meniscal surgery a national society treatment guideline and consensus statement. The Bone & Joint JournalVol. 101-B, No. 6, 2019. DOI: https://doi.org/10.1302/0301-620X.101B6.BJJ-2019-0126.R1.
How up to date is this information?
Last revised December 2023
Changes
December 2023 - Coding updated
