Referrals for musculoskeletal disorders: Patterns, predictors, and outcomes

Objective. To examine factors associated with musculoskeletal referral and determine whether referral influences clinical outcomes. Methods. Patients included in the study presented with knee or shoulder pai n to primary care physicians affiliated with an academic teaching hospital. The primary clinical outcome was change in pain or function measured up to 12 months after initial presentation. Covariates included baseline pain an d function. duration of complaint, initial diagnosis, insurance status. and several demographic factors. Results. Forty-one percent (65 of 160 patients) were referred for knee or s houlder conditions, 47 (29%) patients were referred only to an orthopedic s urgeon, and 12 (8%) only to a rheumatologist. 6 (4%) patients saw both spec ialists. For patients with knee pain, the only variable correlated with ref erral was an initial diagnosis of internal derangement (p = 0.02). No varia ble was significantly associated with referral for shoulder pain. Baseline pain, baseline function. duration of complaint, age, and insurance status w ere not associated with referral for either knee or shoulder pain (all p va lues > 0.05). The variables most associated with improvement in pain and fu nction were more severe pain and function at baseline (all p values < 0.000 1). In multivariate analyses controlling for clinical and demographic facto rs among patients with shoulder complaints, referral was associated with si gnificantly less improvement in clinical outcomes than non-referral (p = 0. 02). Referral was not associated with clinical outcomes for patients with k nee pain. Conclusions. Referral was common for patients with knee or shoulder conditi ons. The only baseline variable correlated with referral was a diagnosis of knee internal derangement. Referral was not associated with improvement in pain or function and may actually be correlated with worse outcomes among patients with shoulder pain, although this is likely due to unmeasured fact ors contributing to the referral decision.