How can I effectively assess the need for referral to orthopaedics in patients with knee pain, particularly in cases of suspected ligament injuries?

To effectively assess the need for referral to orthopaedics in patients presenting with knee pain, particularly with suspected ligament injuries, start with a thorough clinical evaluation focusing on history and examination findings suggestive of significant injury.

Immediate referral to orthopaedics is indicated if:

• There is suspicion of severe soft tissue injury with gross instability.
• First-time traumatic patellar dislocation or recurrent dislocation with moderate or severe swelling occurs.
• There is evidence of neurovascular damage following trauma (e.g., loss of sensation, weakness, absent or asymmetric pedal pulses, or compartment syndrome).
• Quadriceps or patellar tendon rupture is suspected.
• Fracture cannot be excluded.
• Septic arthritis is suspected or cannot be excluded.

These cases require urgent specialist assessment, often within 2 weeks or immediately depending on severity ¹.

For suspected ligament injuries without immediate red flags:

• Consider conservative management initially, including functional bracing and physiotherapy focusing on therapeutic exercises and neuromuscular training.
• Arrange MRI if symptoms persist or worsen after conservative treatment to identify high-grade ligament injuries, osteochondral defects, or occult fractures, as MRI is the gold standard for ligament and intra-articular knee assessment.
• Refer to orthopaedics if symptoms persist beyond six weeks, or if there is suspicion of degenerative meniscal tear, recurrent patellar dislocation, or other complex knee pathologies.
• In professional athletes or cases with chronic instability after lateral ligament sprain, surgical referral may be considered earlier to facilitate quicker return to activity.

Referral pathways may vary locally, and if uncertain, seek specialist advice or refer to integrated musculoskeletal services for further assessment ¹,².