When to Refer Right Knee Pain to Orthopedics
Refer to orthopedics when knee symptoms substantially affect quality of life despite completing core conservative treatments (patient education, exercise programs, physical therapy, and appropriate pharmacotherapy), particularly when the patient desires specialist evaluation and has documented treatment failures. 1
Pre-Referral Workup Required
Initial Imaging
- Obtain plain radiographs of the knee first (anteroposterior, lateral, and tangential patellar views) before considering referral 2, 3
- If radiographs show abnormalities (OCD, loose bodies, degenerative changes, prior osseous injury) or are normal but pain persists, obtain MRI without contrast to evaluate menisci, cartilage, ligaments, and bone marrow lesions 2
Conservative Treatment Documentation
Before referring, document completion of:
- Patient education programs and self-management strategies 1, 4
- Supervised physical therapy trial with strengthening, aerobic fitness, and neuromuscular training exercises 1, 4
- Weight management efforts if BMI is elevated 1
- Pharmacologic interventions including specific agents (NSAIDs, acetaminophen), doses, duration, and response 1, 5
- Intra-articular corticosteroid injections if appropriate 5
Common pitfall: Avoid referring without documenting adequate conservative treatment trials, as this leads to misdirected referrals and delays appropriate care 6
Clinical Indicators for Referral
Strong Indications
- Severe symptoms (pain intensity, functional limitation) with patient preference for referral 7
- Mechanical symptoms such as true mechanical locking suggesting displaced meniscal tissue (bucket-handle tears) 4
- End-stage osteoarthritis (minimal/no joint space on radiographs) with inability to cope with pain after exhausting conservative options 4
- Radiographic findings showing OCD, loose bodies, or history of cartilage/meniscal repair 2
Moderate Indications
- Moderate symptoms with strong patient preference for specialist evaluation 7
- Persistent effusion on imaging despite conservative management 2
- Chronic patellar instability (recurrent subluxation/dislocation) with medial patellar osseous fragments 2
When NOT to Refer
- Mild symptoms with patient preference against referral 7
- Degenerative meniscal tears without mechanical locking—these respond to exercise therapy, not surgery 4
- Inadequate conservative treatment trial (less than 4-6 weeks of appropriate exercise therapy) 4
Critical Information to Include in Referral
Clinical Details
- Pain characteristics: intensity, duration, timing, and impact on specific daily activities 1
- Functional limitations: which activities are impaired and how substantially they affect quality of life 1
- Mechanical symptoms: presence of true locking, catching, or giving way 1, 4
Treatment History
- Duration and response to each pharmacologic agent tried 1
- Physical therapy specifics: duration, exercises performed, and functional outcomes 1
- Injection history: type, number, and response to intra-articular treatments 1
Risk Factors
- BMI and weight management efforts 1
- Smoking status (affects surgical outcomes) 1
- Comorbidities: cardiovascular, renal, gastrointestinal conditions affecting surgical candidacy 1
- Age (relevant for treatment planning) 1
Timing Considerations
Refer before prolonged functional limitation and severe pain become established, as delayed referral worsens outcomes 1. However, ensure core treatments are completed first to avoid inefficient resource utilization 7.
The decision should be strongly influenced by symptom severity and patient preference, with less weight given to age, BMI, or comorbidities alone 7. Patients with severe symptoms who want referral should be referred; those with mild-to-moderate symptoms who prefer conservative management should continue non-surgical treatment 7.