What should be included in a referral to an orthopedic specialist for a patient with right knee pain due to osteoarthritis (OA)?

Essential Components for Orthopedic Referral in Right Knee Osteoarthritis

Before referring to orthopedics, document that the patient has failed core non-surgical treatments including exercise, weight management (if applicable), and pharmacotherapy, as referral should occur when symptoms substantially affect quality of life and are refractory to conservative management. 1

Pre-Referral Requirements

Documentation of Conservative Treatment Trials

• Document completion of core treatments including patient education programs, regular self-directed exercise (particularly quadriceps strengthening), and appropriate pharmacotherapy (topical NSAIDs, acetaminophen, or oral NSAIDs) 1, 2
• Physical therapy trial with supervised exercise programs focusing on strengthening, aerobic fitness, and neuromuscular training should be documented 1
• Weight management efforts if patient is overweight or obese, as this has moderate evidence for improving pain and function 1
• Duration and response to treatments should be clearly stated, demonstrating inadequate pain relief or functional improvement 1

Required Imaging

• Obtain weight-bearing plain radiographs of the right knee before surgical consultation 1
• Include anteroposterior, lateral, and merchant views to assess all compartments 3
• Document radiographic severity using standardized grading (e.g., Kellgren-Lawrence classification) 3, 4

Critical Clinical Information to Include

Symptom Characterization

• Pain severity and pattern: Specify intensity, duration, timing (rest vs. activity), and impact on daily activities 1
• Functional limitations: Document specific activities that are impaired (walking distance, stair climbing, ability to work) and how substantially they affect quality of life 1
• Mechanical symptoms: Note any true mechanical locking (not gelling or "giving way"), as this may indicate need for arthroscopic intervention 1
• Presence of effusions: Document if recurrent or persistent, as this may influence treatment approach 1

Physical Examination Findings

• Range of motion limitations with specific degrees of flexion/extension deficit 3
• Joint line tenderness and compartment involvement (medial, lateral, patellofemoral) 3
• Alignment abnormalities: Varus or valgus deformity 3
• Crepitus and stability testing results 3
• Muscle atrophy, particularly quadriceps wasting 5

Failed Treatment Documentation

• Pharmacologic interventions tried: List specific agents, doses, duration, and response
  • Topical NSAIDs (strongly recommended first-line for knee OA) 1
  • Acetaminophen and/or oral NSAIDs with documented inadequate response 1
  • Intra-articular corticosteroid injections if attempted 1
• Non-pharmacologic interventions completed:
  • Physical therapy duration and specific exercises performed 1, 2
  • Patient education programs 1, 2
  • Assistive devices tried (cane, knee braces, orthotics) 1

Comorbidities and Risk Factors

• Age, BMI, and weight management efforts 1
• Cardiovascular, renal, or gastrointestinal conditions that may affect surgical candidacy 1
• Smoking status 1
• Other medical comorbidities that could impact surgical outcomes 1

Timing Considerations

Refer before prolonged and established functional limitation and severe pain develop, as delayed referral can worsen outcomes 1. The referral is appropriate when:

• Joint symptoms substantially affect quality of life despite conservative management 1
• Patient has completed at least core treatment options 1
• Progressive functional decline is documented 1

Common Pitfalls to Avoid

• Do not refer for arthroscopic lavage/debridement unless there is clear history of true mechanical locking, as this is not indicated for typical OA symptoms like gelling, "giving way," or radiographic loose bodies 1
• Do not delay referral based solely on patient age, sex, obesity, or comorbidities, as these should not be barriers to surgical consultation 1
• Do not refer without documenting conservative treatment trials, as orthopedic surgeons will expect evidence of failed non-surgical management 1
• Do not use prioritization scoring tools to determine referral thresholds; instead, base decisions on patient-clinician discussions about quality of life impact 1