What is the appropriate course of action for a patient with right knee pain that has not responded to physical therapy (PT) or pain medication, warranting an orthopedic (ortho) specialist referral?

Writing an Orthopedic Referral for Refractory Right Knee Pain

Obtain weight-bearing plain radiographs of the right knee before making the orthopedic referral, as this is the critical next step for patients who have failed conservative management with physical therapy and pain medications. 1

Pre-Referral Requirements

Before writing the orthopedic referral, you must:

• Order weight-bearing plain radiographs (AP, lateral, and sunrise views) of the right knee to document structural damage and severity of osteoarthritis 1
• Document failed conservative treatments including specific physical therapy duration/exercises attempted and pain medications trialed with dosages 1
• Assess for presence of effusion or signs of inflammation that might warrant intra-articular corticosteroid injection as a bridge therapy 1

What to Include in the Referral

Your orthopedic referral should contain:

• Chief complaint: Right knee pain refractory to conservative management
• Failed treatments: Specify duration and type of physical therapy (e.g., "completed 8 weeks of supervised PT with quadriceps strengthening"), list all pain medications tried with dosages (acetaminophen, NSAIDs, topical agents) 1
• Functional limitations: Document specific disabilities (e.g., "unable to climb stairs," "difficulty with activities of daily living") 1
• Pain severity: Current pain level and impact on quality of life 1
• Imaging results: Attach or reference the weight-bearing radiographs showing degree of joint space narrowing and structural damage 1
• Reason for referral: "Evaluation for surgical consultation including consideration of joint replacement" for end-stage disease, or "evaluation for joint-preserving procedures" if earlier stage 1, 2

Additional Considerations Before Referral

Consider these interventions that may delay or avoid surgery:

• Intra-articular corticosteroid injection for persistent pain with effusion—this can provide temporary relief while awaiting orthopedic consultation 1
• Duloxetine 30-60 mg daily as adjunctive therapy if not yet tried, particularly effective for OA pain 1
• Weight loss counseling if patient is overweight, as this reduces surgical risk and may improve outcomes 1

Common Pitfalls to Avoid

• Do not refer without imaging: Orthopedic surgeons require radiographic documentation to determine surgical candidacy 1
• Do not use opioids (including tramadol) as a bridge therapy—these are specifically recommended against for knee OA due to limited efficacy and significant adverse effects 1, 3
• Do not delay referral if radiographs show end-stage disease (minimal/no joint space) and patient has refractory pain despite appropriate conservative management 1, 2