A Retrospective Audit of the Timescales Involved in the Diagnosis and Management of Soft Tissue Knee Injuries at a Single National Health Service Trust: A Quality Service Improvement and Redesign Project

TL;DR

This study found long delays in diagnosing and treating knee injuries in the NHS, leading to high costs and poor patient outcomes.

Contribution

The paper introduces a proposed physiotherapy-first triage model to reduce delays and costs in knee injury management.

Findings

Median diagnostic delay was 60 days, with MRI access and review as main bottlenecks.

77.7% of patients underwent MRI, but only 40.1% showed ligament/meniscal injuries.

Annual pathway costs were estimated at ~£451,000 for 1,300 referrals.

Abstract

Objective

Acute soft tissue injuries are one of the most common presentations to the emergency department. There are many soft tissue knee injuries that might need surgery; therefore, prompt diagnosis of this injury ensures optimal management decisions at a minimal cost to the UK National Health Service (NHS). Despite this, regional and national variations in diagnosis and management exist, with anecdotal evidence of inefficiencies in the local patient pathway, which is not well established. This results in delays in diagnosis and treatment and inefficient use of imaging and knee clinics, affecting patient outcomes and causing unnecessary financial burden on the trust. To explore these factors further, a retrospective departmental audit of timescales from presentation to MRI diagnosis and definitive treatment decision was undertaken.

Methods

A retrospective audit at a single NHS trust was conducted, analysing all the referrals to the knee clinic over five months, from January 2023 to May 2023. This was done by collecting electronic and written patient records, and information on timescales involved in the diagnosis and management of each was compiled. Descriptive statistics were used to map each step of the pathway and timescales involved.

Results

A total of 346 patients were included; 77.7% (269/346) underwent MRI. Median waits were seven days from presentation to knee clinic, 33 days from MRI referral to scan, and 22 days from scan to review. The median diagnostic delay was 60 days (mean 56.6) from presentation to confirmed diagnosis, identifying MRI access and review as principal bottlenecks. Over half of the cohort (58.0%) waited longer than four weeks for an MRI, and only 10.3% had results reviewed within seven days. Among MRI scans, 42.8% showed normal/degenerative findings and 40.1% ligament/meniscal injury, highlighting a high utilisation of MRI with a relatively low yield. Surgery was required in 11.0% (median 128 days from presentation to operation), while 89.0% were managed conservatively, with physiotherapy initiated after a median delay of 70.5 days. Annualised observed costs were approximately £287,921 (consultations £182,688; MRI £105,233); scaled to an assumed 1,300 annual referrals, the pathway would cost ~£451,000 per year.

Conclusions

The current pathway demonstrates prolonged diagnostic delays (median 60 days), high MRI utilisation (77.7%) with low-yield imaging, and late rehabilitation initiation, all contributing to suboptimal patient outcomes and substantial cost. Introducing a physiotherapy-first triage model with criteria-based MRI referral and streamlined scan-to-review turnaround could significantly reduce diagnostic delays, improve functional recovery, and lower service expenditure across the NHS.

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