Referrals - Orthopedics or Rheumatology? Save

“Orthopedics or rheumatology, who should I see?"

A question, often asked with urgency, posed by those who genuinely don’t know who to see for a musculoskeletal (MSK) complaint.  Inquiring patients, family, or other physicians may be one forum for such a request. Another occurs in the hospital and clinic when referrals for MSK issues can go in either direction.  How would you guide such requests?  And what would your answers be based on?

As a rheumatologist, I manage patients with a variety of musculoskeletal (MSK) problems and will often refer to orthopedists, as they often refer to me.

While this is a patient centric question, it is also an issue of delivering optimal care, without bias or self-serving rationale.

The American College of Rheumatology (ACR), defines a rheumatologist as an “internist or pediatrician who has received further specialized training in the diagnosis and treatment of musculoskeletal diseases and systemic autoimmune conditions, commonly referred to as rheumatic diseases.”

The American Academy of Orthopedic Surgeons (AAOS) defines an orthopedist (or orthopedic surgeon) as a “medical doctor dedicated to the prevention, diagnosis, and treatment of disorders of the bones, joints, ligaments, tendons, and muscles.”

Not much help there…

Many reduce the Ortho vs. Rheum question to unidimensional, simple terms – it’s either surgical or medical, acute or chronic, traumatic or not; inherited or not.  All would acknowledge there’s significant proficiency overlap between rheumatologists and orthopedists.  Hence both are quite capable in managing musculoskeletal pain, arthritis especially when degenerative, and performing simple procedures.

The few (generalist) articles on this issue provide polarizing differences between the providers and services with orthopedics focused on sprains, strains, fractures and rheumatology on autoimmune disease and immunosuppression.  Such a separation is arcane and often useless.

We do know that primary care referrals for MSK complaints are mostly (50-60%) for spinal complaints, followed by knee and shoulder issues. A 2005 UK analysis of 1087 MSK referrals (63% without a diagnosis) found 682 for Ortho and 393 for Rheum.

• Ortho referrals – 58% were “appropriate”; 27% should’ve gone to Rheum; and 15% could’ve been seen by either.
• Rheum referrals – 94% were “appropriate”; 2% were not; and 4% could’ve seen either.

The patient’s perspective differs on this differs from a referring physician. The patient usually wants to know “what do I have” and “what can be done for it”. The patient doesn't start out pursuing surgery or an expensive immunosuppressive drug.  Appropriate, time and cost-effective diagnostic services AND relief are the patients’ goals.

If the goal is to help refer the patient and best serve their needs, first then here are my rules for referral to either discipline.  These “rule of thumb” are based on 40 years of practice and are offered without influence or guidance from those smarter, richer or more skillful than me.  Referral Rules

1. Musculoskeletal ailments resulting from a fall, trauma, especially if acute, should be seen by the orthopedist or by an emergency medicine specialist, where the first assessment is a clinical one followed by imaging to define the problem (that may lead to the next best referral - Ortho or rheumatology).
2. If the musculoskeletal problem is a chronic, nagging one that has never been evaluated by a medical professional, the first step should be to seek help from a primary care doctor (or advanced practice provider). These individuals are well able to diagnose the most common MSK ailments and presentations, and they can also refer appropriately to the next best specialist.
3. If the problem involves the large joints (shoulders, hips, or knees) then it's a toss-up between the rheumatologist and orthopedist.  I would only favor the orthopedist if the joint was deformed or didn't look right compared to the unaffected contralateral joint or normal joint. Any large joint that is subluxed, deformed, abnormally bent or abnormally larger is best addressed by an orthopedist.
4. Small joint MSK complaints (hands, fingers, wrists, elbows, ankle, feet, and toes) should be referred to the rheumatologist, especially if there is swelling or inflammation or if there is no history of trauma preceding the complaint.
5. Neck, spine and low back complaints may require imaging, followed by an evaluation by a spine specialist, rheumatologist, orthopedist and that's my order of preference.

These recommendations are based on who is more likely to make an expedient diagnosis and manage the problem going forward.

Many orthopedists are capable of diagnosing and managing arthritis, but are less keen on managing autoimmune and systemic rheumatic problems like rheumatoid lupus, PMR, gout, ankylosing spondylitis etc. 

Many rheumatologists are good at diagnosing and managing athletic injuries and orthopedic problems, that they can refer or manage  conservatively. Rheumatologists don't do surgery. 

I invite my rheumatology colleagues to weigh in on how they prefer to guide patients to either orthopedics or rheumatology. I believe that both patients and non-MSK clinicians (eg PCPs) would benefit from cogent and efficient guidelines. Until then we are left with opinions such as this.

Full disclosure, I am a rheumatologist, and I approve this message.