Does an 80-year-old with osteoarthritis (OA) need to see an orthopedic (ortho) specialist?

Does an 80-Year-Old Need an Orthopedic Specialist for Osteoarthritis?

No, an 80-year-old with osteoarthritis does not routinely need to see an orthopedic specialist initially—comprehensive management should begin with primary care using core non-pharmacological treatments (exercise, education, weight management if appropriate), with orthopedic referral reserved only for patients with severe, refractory symptoms despite optimal conservative management or when joint replacement surgery is being considered. 1

Initial Management in Primary Care

The foundation of OA care at any age, including 80 years old, should be delivered in primary care settings and consists of:

Core Non-Pharmacological Treatments (First-Line for All Patients)

• Patient education about joint protection, disease course, and self-management strategies 1
• Strengthening exercises, particularly targeting muscles supporting affected joints (e.g., quadriceps for knee OA) 1
• Low-impact aerobic exercise such as walking, swimming, or aquatic exercise 1
• Weight loss if BMI ≥25 kg/m²—this is critical as obesity is a modifiable risk factor that significantly impacts symptoms 1

Exercise Prescription Specifics for 80-Year-Olds

The American Geriatrics Society provides detailed guidance for older adults:

• Start with isometric strengthening when joints are acutely inflamed or unstable, beginning at 30% of maximal voluntary contraction 1
• Progress gradually to 75% maximal voluntary contraction as tolerated 1
• Monitor for overexertion: joint pain lasting >1 hour after exercise or joint swelling indicates excessive activity 1
• Include three phases: 5-10 minute warm-up, training period, and 5-minute cool-down with stretching 1

Pharmacological Management (Adjunctive, Not Primary)

When non-pharmacological measures are insufficient:

• Oral or topical NSAIDs are recommended for moderate-to-severe pain, but use with extreme caution in 80-year-olds 1
• Tramadol may be considered 1
• Intra-articular corticosteroid injections for moderate-to-severe pain 1

Critical caveat for the elderly: NSAIDs carry significantly increased cardiovascular, renal, and gastrointestinal risks in patients over 75-80 years 2, 3. If used, employ the lowest effective dose for the shortest duration 3, 4.

When to Refer to Orthopedics

Orthopedic referral is indicated only when:

Surgical Consideration Criteria

• Joint symptoms substantially affect quality of life AND are refractory to non-surgical treatment (meaning the patient has tried at least the core treatments above) 1
• Referral should occur before prolonged functional limitation and severe pain become established 1
• Age alone (80 years) should NOT be a barrier to referral for joint replacement surgery 1

Specific Mechanical Issues

• Clear history of mechanical locking in knee OA (not "giving way" or gelling/stiffness, which are inappropriate reasons for arthroscopic referral) 1

What NOT to Refer For

• Arthroscopic lavage and debridement should NOT be routinely offered for OA 1
• Do not refer based solely on radiographic findings without corresponding functional impairment and failed conservative management 1

Common Pitfalls to Avoid

• Over-reliance on imaging: Radiographic OA severity often does not correlate with symptoms, especially in patients over 70 5, 6
• Premature surgical referral: Ensure the patient has genuinely tried comprehensive conservative management for adequate duration 1
• NSAID overuse in the elderly: The 80-year-old population has dramatically increased susceptibility to NSAID complications 2, 3
• Neglecting exercise: Despite being first-line treatment, exercise is often underutilized while medications are overprescribed 1

Practical Algorithm for the 80-Year-Old

1. Assess current functional status and pain severity 1
2. Initiate core treatments immediately: education, exercise program (starting with isometric if joints inflamed), weight management if BMI ≥25 1
3. Re-evaluate at 4 weeks for pain reduction and improved function 1
4. Add pharmacological adjuncts cautiously if inadequate response (topical NSAIDs preferred over oral in elderly) 1
5. Refer to orthopedics only if symptoms remain disabling despite 3-6 months of optimal conservative management OR mechanical locking present 1

The evidence consistently shows that at 80 years old, OA affects 44-85% of individuals, making it extremely common 1. However, this high prevalence does not necessitate orthopedic involvement—most patients can and should be managed effectively in primary care with the structured approach outlined above.