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Introduction: Acute rehabilitation on our acute older persons' ward was often hampered by musculoskeletal pain. The physiotherapists in particular found stiff and painful knees made many movement strategies difficult.

Method: An initial audit to translate anecdote into number was carried out. Over a 4 month period, 227 patients were assessed for knee pain. After presentation this audit, the department decided to institute a policy of aggressive pain relief escalation for painful knees. When paracetamol and topical NSAIDS were ineffective (as per NICE guidance for OA knee ), intra-articular steroid and local anaesthetic were used. Timed up and Go (TUAG) scores were recorded by the attending physiotherapists. Pain scores were recorded using a standard visual analogue scale. Intra-articular injection was with triamcinolone 80mg and lidocaine 1% 5mls.

Results: First audit cycle: Significant pain was identified in 14 (6%), with a mean visual analogue pain score of 7.0 and a timed up and go of 82 seconds.

Re-audit of knee pain with aggressive strategy showed 34 painful knees in 384 patients seen over 5 months. The mean pain score (visual analogue scale) pre injection was 7.0 and mean score post injection was 2.2. The timed get up and go fell from 84 seconds to 36 seconds. No acute complications were observed. Laboratory analysis of knee aspirates in 34 patients showed gout in 3 (9%) of aspirates and pseudo-gout in 6 (18%) of patients. These knees were painful but clinically not suspected of crystal arthropathy, demonstrating that these conditions are more common than often thought.

Conclusions: The more aggressive approach was valued by patients and therapists. Crystal Arthopathy is commoner than clinically suspected.

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