When to refer a patient to orthopedics (ortho) for knee pain?

When to Refer a Patient to Orthopedics for Knee Pain

Patients with knee pain should be referred for orthopedic consultation when they have joint symptoms (pain, stiffness, and reduced function) that substantially affect their quality of life and are refractory to non-surgical treatment, before there is prolonged and established functional limitation and severe pain. 1

Step-by-Step Management Algorithm Before Orthopedic Referral

1. Initial Conservative Management (Core Treatments)

• Self-management education
• Regular exercise (strengthening and aerobic)
• Weight loss if BMI >25 kg/m²
• Topical NSAIDs for knee pain
• Acetaminophen and/or oral NSAIDs (with appropriate risk assessment)
• Bracing if indicated (especially for knee OA)

2. Second-Line Interventions

• Physical therapy referral if not improving with initial management
• Intra-articular corticosteroid injections for moderate to severe pain
• Duloxetine for persistent pain not responding to other treatments

3. Specific Indications for Orthopedic Referral

Definite Indications for Referral:

• Mechanical locking of the knee (true locking, not stiffness or "giving way") 1
• Substantial impact on quality of life despite appropriate conservative management 1
• Refractory pain and functional limitation despite comprehensive non-surgical treatment 1
• Radiographic evidence of advanced joint disease with corresponding symptoms 1

Timing of Referral:

• Referral should occur before prolonged and established functional limitation and severe pain develop 1
• Obtain weight-bearing plain radiographs before orthopedic referral 1

Important Considerations

Conservative Management Requirements

Before orthopedic referral, ensure the patient has received:

• Core treatments (exercise, weight management, education) 1
• Appropriate pharmacological management 1
• Physical therapy if indicated 1

Patient Factors

• Age, sex, smoking, obesity, and comorbidities should not be barriers to referral for joint replacement surgery 1
• Patient's willingness to consider surgical intervention should be confirmed 2

Inappropriate Reasons for Referral

• Gelling (stiffness and pain with prolonged immobility) alone 1
• "Giving way" without true mechanical locking 1
• X-ray evidence of loose bodies without mechanical symptoms 1
• Failure to try appropriate conservative management first 3

Avoiding Common Pitfalls

1. Premature referral: Ensure core conservative treatments have been adequately tried. Research shows 33% of patients referred to orthopedics had not previously engaged in any core non-pharmacological management strategies 3.

2. Delayed referral: Don't wait until severe functional limitation and pain are established before referring 1.

3. Inadequate imaging: Obtain weight-bearing plain radiographs before orthopedic referral 1.

4. Inappropriate expectations: Arthroscopic lavage and debridement should not be expected for osteoarthritis without true mechanical locking 1.

5. Inadequate patient education: Only 20% of patients referred to orthopedics report being sufficiently educated about their diagnosis, treatment options, and prognosis 3.

Special Considerations

For knee osteoarthritis, which affects approximately 654 million people worldwide and is the most common cause of knee pain in patients over 45 years 4, a systematic approach to management is essential before orthopedic referral.

For patellofemoral pain (common in those under 40 years), hip and knee strengthening exercises combined with foot orthoses or patellar taping are recommended, with generally no indication for surgery 4.

For meniscal tears, conservative management with exercise therapy for 4-6 weeks is appropriate for most cases. Only severe traumatic tears (e.g., bucket-handle) typically require surgical referral 4.

By following this structured approach to knee pain management and orthopedic referral, primary care providers can ensure appropriate use of specialist services while optimizing patient outcomes.