What specialty should a patient with osteoarthritis (OA) of the knee consult for pain management?

Specialty Referrals for Knee Osteoarthritis Pain Management

Patients with knee osteoarthritis should initially be referred to a primary care physician, rheumatologist, or orthopedic specialist for comprehensive pain management, with subsequent referrals to physical therapy for exercise programs and manual therapy which have strong evidence for improving pain and function. 1

Initial Management Pathway

Primary Care Approach

• Patient education programs are strongly recommended as first-line intervention for improving pain in knee osteoarthritis patients 1
• Exercise regimens, particularly those focusing on quadriceps strengthening, are strongly recommended and should be prescribed early in the treatment course 1
• Weight loss interventions for overweight or obese patients have moderate evidence for improving pain and function 1, 2

Pharmacological Management

• Oral acetaminophen is recommended as the first-line oral analgesic for pain management 1
• Oral NSAIDs should be considered when acetaminophen is ineffective, provided there are no contraindications 1, 2
• Topical NSAIDs may be considered for patients with comorbidities to minimize systemic effects 2

Specialty Referrals Based on Disease Progression

Physical Therapy Referral

• Physical therapy is strongly indicated for supervised exercise programs focusing on quadriceps strengthening and preserving knee mobility 1
• Manual therapy in addition to exercise programs may improve pain and function (limited evidence) 1
• Neuromuscular training programs (balance, agility, coordination) combined with exercise have moderate evidence for improving function 1

Rheumatology Referral

• Appropriate for patients with inflammatory components of osteoarthritis or when multiple joints are affected 2
• Can provide comprehensive management of pharmacological interventions including intra-articular injections 2
• Beneficial for patients with comorbidities requiring careful medication management 2

Pain Management Specialist Referral

• Consider for patients with refractory pain despite conventional treatments 2
• May provide interventional options such as genicular nerve blocks for patients who have failed conservative management 2
• Can manage more complex analgesic regimens when needed 3

Orthopedic Surgery Referral

• Indicated for patients with refractory pain associated with disability and radiological deterioration 1
• Should evaluate patients for potential surgical interventions including high tibial osteotomy or joint replacement 1
• Total knee arthroplasty should be considered when conservative management fails to provide adequate pain relief and function 2, 4

Treatment Modalities by Specialty

Physical Therapy Interventions

• Land-based and aquatic exercise programs 2
• Manual therapy techniques 1
• Transcutaneous electrical nerve stimulation (TENS) has limited evidence for pain relief 1

Rheumatology/Pain Management Interventions

• Intra-articular corticosteroid injections for acute pain flares, especially with effusion 2
• Management of oral and topical analgesics 2
• Consideration of adjunctive medications like duloxetine for chronic pain 5

Orthopedic Interventions

• Joint replacement for severe cases unresponsive to conservative management 1
• High tibial osteotomy for properly indicated patients with unicompartmental knee osteoarthritis 1

Common Pitfalls to Avoid

• Delaying physical therapy referral - early exercise intervention is crucial for maintaining function 1
• Over-reliance on oral narcotics which have been shown to increase adverse events without effectively improving pain or function 1
• Referring directly to orthopedics before attempting comprehensive conservative management 4
• Failing to address weight management in overweight or obese patients 1, 2
• Neglecting patient education which has strong evidence for improving outcomes 1