Skip to main content
Knee MRI when symptoms are suggestive of osteoarthritis

Knee MRI when symptoms are suggestive of osteoarthritis

Best Practice Guidance

How up to date is this information?

Published January 2020 | Last reviewed September 2024

Using this guidance

The guidance set out here was reviewed extensively in the Autumn of 2024. There are no plans for any further reviews.

Medicine is constantly evolving and over time it is inevitable that the evidence base will change. Please use your own judgement and/or other sources of clinical guidance alongside the information set out here.

Please note this guidance is a recommendation and it should be used in the context of the overall care pathway and when all alternative interventions that may be available locally have been undertaken.

Summary

Osteoarthritis (OA), the most common form of arthritis, is characterised by joint pain accompanied by a varying degree of functional limitation and reduced quality of life. The most commonly affected joints are the knees, hips and small hand joints with a poor link between changes visible on a radiograph and symptoms of osteoarthritis.

An initial diagnosis of OA can be made when clinical assessment is suggestive of this pathology. If imaging is required to confirm the diagnosis, then weight bearing radiographs are the first-line of investigation. Magnetic resonance imaging (MRI) for knees is not usually needed.

 

This guidance applies to adults aged 19 years and over.

Recommendation

In primary care, where clinical assessment is suggestive of knee OA, imaging is not usually necessary. If imaging is required then weight bearing radiographs are the first-line of investigation. Patients with persistent symptoms should, after three to four months, be referred to secondary care and should have imaging of the knee to investigate for OA and/or other pathology.

Where imaging is necessary, in secondary care the first-line investigation of potential knee OA is weight bearing plain radiography. If the patient has a pattern of disease that allows surgical treatment to be adequately planned with plain radiographs, then MRI is not required.

However, there are a number of situations where MRI of the osteoarthritic knee can be useful:

  • Patients who have severe symptoms but relatively mild OA on standard X-rays. In this situation the MRI offers more detail and can show much more advanced OA or Osteonecrosis within the knee
  • In working up a patient for possible HTO or partial knee replacement an MRI can be a very useful investigation focusing on the state of the anterior cruciate ligament and state of the retained compartments.

In summary an MRI scan can be a useful investigation in the contemporary surgical management of osteoarthritis, giving critical information on the pattern of disease and state of the soft tissues. However, requesting an MRI scan when it is not indicated potentially prolongs further waiting times for patients, can cause unnecessary anxiety while waiting for specialist consultation and can delay MRI scans for appropriate patients.

 

Rationale for recommendation

The diagnosis of knee OA can be effectively made in primary care based upon the patient’s history and physical examination. In particular, NICE recommends diagnosing osteoarthritis clinically, and without investigations, in patients who:

  • Are 45 or over AND
  • Have activity-related joint pain AND
  • Has either no morning joint-related stiffness or morning stiffness that lasts no longer than 30 minutes.

It is important to exclude other diagnoses in some cases where there may be atypical features which may indicate alternative or additional diagnoses such as:

  • A history of trauma
  • History of cancer or corresponding risk factors
  • Prolonged morning joint-related stiffness
  • Rapid worsening of symptoms
  • The presence of a hot swollen joint.

Important differential diagnoses include gout, other inflammatory arthritides (for example, rheumatoid arthritis), septic arthritis and malignancy (bone pain).

In secondary care when surgical intervention for OA is being considered an MRI scan can offer valuable information about the pattern of disease within the knee. This includes planning for osteotomy around the knee for OA and for partial knee replacement, where in both cases information about the state of the preserved compartments and the anterior cruciate ligament are critical to the surgical plan.

A meta-analysis published in 2017 assessing the role of MRI in OA assessed 16 studies, which included 1220 patients. It found that MRI can detect OA with an overall high specificity and moderate sensitivity so better used to exclude OA than to confirm it. The study recommended that standard clinical algorithm for OA diagnosis, aided by radiographs is the most effective method for diagnosing OA.

The European League Against Rheumatism (EULAR) conducted a systematic review including 390 studies leading to seven recommendations concerning the use of imaging in peripheral joint OA as below:

  • Imaging is not required to make the diagnosis in patients with typical presentation of OA. Level of evidence: III–IV. LOA (95% CI) 8.7 (7.9 to 9.4)
  • In atypical presentations, imaging is recommended to help confirm the diagnosis of OA and/or make alternative or additional diagnoses. Level of evidence: IV. LOA (95% CI) 9.6 (9.1 to 10)
  • Routine imaging in OA follow-up is not recommended. However, imaging is recommended if there is unexpected rapid progression of symptoms or change in clinical characteristics to determine if this relates to OA severity or an additional diagnosis. Level of evidence: III–IV. LOA (mean, 95% CI) 8.8 (7.9 to 9.7)

If imaging is needed, conventional (plain) radiography should be used before other modalities. To make additional diagnoses, soft tissues are best imaged by US or MRI and bone by CT or MRI. Level of evidence: III–IV. LOA (95% CI) 8.7 (7.9 to 9.6).

  • Consideration of radiographic views is important for optimising detection of OA features; in particular for the knee, weightbearing and patellofemoral views are recommended. Level of evidence: III. LOA (95% CI) 9.4 (8.7 to 9.9)
  • According to current evidence, imaging features do not predict nonsurgical treatment response and imaging cannot be recommended for this purpose. Level of evidence: II–III. LOA (95% CI) 8.7 (7.5 to 9.7)
  • The accuracy of intra-articular injection depends on the joint and on the skills of the practitioner and imaging may improve accuracy. Imaging is particularly recommended for joints that are difficult to access due to factors including site (e.g., hip), degree of deformity and obesity. Level of evidence: III–IV. LOA (95% CI) 9.4 (8.9 to 9.9).

 

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.

Make the most of your appointment using BRAN

2020

Coding

Outpatient
WHEN ( Any_Appointment_Procedure LIKE '%U133%'
OR Any_Appointment_Procedure LIKE '%U211%')
AND ( Any_Appointment_Procedure LIKE '%Z846%' 
OR Any_Appointment_Procedure LIKE '%O132%')
AND (not ( Any_Appointment_Diagnosis LIKE '%M00[01289]%'
OR Any_Appointment_Diagnosis LIKE '%M01[01234568]%'
OR Any_Appointment_Diagnosis LIKE '%M0[25][012389]%'
OR Any_Appointment_Diagnosis LIKE '%M03[0126]%'
OR Any_Appointment_Diagnosis LIKE '%M0[68][0123489]%'
OR Any_Appointment_Diagnosis LIKE '%M07[0-6]%'
OR Any_Appointment_Diagnosis LIKE '%M09[0128]%'
OR Any_Appointment_Diagnosis LIKE '%M10[012349]%'
OR Any_Appointment_Diagnosis LIKE '%M11[01289]%'
OR Any_Appointment_Diagnosis LIKE '%M12[0123458]%'
OR Any_Appointment_Diagnosis LIKE '%M13[0189]%'
OR Any_Appointment_Diagnosis LIKE '%M14[01234568]%'
OR Any_Appointment_Diagnosis LIKE '%M15[12348]%'
OR Any_Appointment_Diagnosis LIKE '%M16[012345679]%'
OR Any_Appointment_Diagnosis LIKE '%M17[2345]%'
OR Any_Appointment_Diagnosis LIKE '%M238%'
OR Any_Appointment_Diagnosis LIKE '%C40[289]%'
OR Any_Appointment_Diagnosis LIKE '%C7[69]5%'
OR Any_Appointment_Diagnosis LIKE '%D162%')
OR Any_Appointment_Diagnosis IS NULL)
-- Age Between 19 and 120
AND ISNULL(OPA.Age_at_Start_of_Episode_SUS,OPA.Der_Age_at_CDS_Activity_Date) between 19 AND 120 
THEN '2T_knee_MRI'
Exclusions
WHERE 1=1
-- Patient Has Attended Appointment
AND Attendance_Status  IN (5,6)
-- Cancer Diagnosis Exclusion Codes
AND (( Any_Appointment_Diagnosis not like '%C[0-9][0-9]%' 
  AND Any_Appointment_Diagnosis not like '%D0%' 
  AND Any_Appointment_Diagnosis not like '%D3[789]%' 
  AND Any_Appointment_Diagnosis not like '%D4[012345678]%') 
  OR Any_Appointment_Diagnosis IS NULL)

-- Private Appointment Exclusion
AND opa.Administrative_Category<>'02'

                        

                        
                

              

                          

                
                
References

                

                  
                                          
    

  1. NICE clinical guideline (2014) Osteoarthritis: care and management [CG177]
    2. 

  2. Menashe L, et al. The diagnostic performance of MRI in osteoarthritis: a systematic review and meta-analysis. Osteoarthritis Cartilage. 2012 Jan;20(1):13-21. PMID: 22044841.
    3. 

  3. Sakellariou G, et al. EULAR recommendations for the use of imaging in the clinical management of peripheral joint osteoarthritis. Ann Rheum Dis. 2017 Sep;76(9):1484-1494. PMID: 28389554.
    4. 


                        
                

              

            
          

        

        

          

  

    

      

        
Also in this section

        
      

          

  


        

      

    


  






  

          

                            
              

          

                            
              

          

                            
              

          

                            
              

          

                            
              

          

                            
              

          

                            
              

          

                            
              

          

                            
              

          

                            
              

          

                            
              

          

                            
              

          

                            
              

          

                            
              

          

                            
              

      
  

  

    

      Back to top