What are the guidelines for referring patients with sports-related injuries to specialist services?

For patients with sports-related injuries, referral to specialist services is guided by the nature and severity of the injury, as well as the presence of specific red flags or diagnostic uncertainty ¹,²,⁴,⁶.

General Referral Considerations:

• If the diagnosis is uncertain, consider referring to an appropriate specialist such as a rheumatologist, orthopaedic surgeon, sports physician, or other musculoskeletal specialist ¹.
• For sprains and strains, after initial primary care management, ensure referral to physiotherapy has been arranged if external support (bracing or taping) is needed ³.
• Physiotherapy and home exercises may provide some short-term improvement for conditions like shoulder pain ².
• Local services and guidelines for referral can vary significantly, with physiotherapy often accessed through an integrated musculoskeletal (MSK) service ¹.
• Intermediate care services, which may include physiotherapists, GPs with a special interest in musculoskeletal problems, and clinical nurse practitioners, provide rapid assessment, diagnosis, and treatment for musculoskeletal problems and aim to reduce hospital referrals ².

Urgent and Immediate Referrals:

Knee Injuries:

• Refer for immediate specialist assessment if septic arthritis, slipped capital femoral epiphysis, fracture (if cannot be excluded), or quadriceps or patellar tendon rupture is suspected ¹.
• Immediate assessment is also required if there is any evidence of neurovascular damage following trauma, such as loss of sensation or weakness, absence or asymmetry of pedal pulses, or compartment syndrome ¹.
• If a first-time traumatic patellar dislocation is suspected, or a recurrent dislocation is associated with moderate or severe swelling, immediate assessment is recommended ¹.
• Severe soft tissue injury with gross instability also warrants immediate specialist assessment ¹.
• Depending on local arrangements, refer to an accident and emergency department, fracture clinic, or acute knee clinic if a significant soft tissue injury is suspected following trauma, indicated by a sensation of a 'pop' or 'snap', effusion, rapid or gradual onset of swelling, inability to complete the activity, instability, locking, giving way, or difficulty weight bearing ¹.
• Refer urgently (to be seen within 2 weeks) if a tumour or persistent synovitis (inflammatory polyarthritis) is suspected ¹.
• Urgent referral to an orthopaedic surgeon is also recommended if osteonecrosis is suspected ¹.
• If unsure of the appropriate referral pathway, seek specialist advice ¹.

Shoulder Injuries:

• Refer a person urgently to secondary care for same-day assessment following acute trauma, depending on clinical judgement ².
• Discuss a suspected neurological lesion with neurology, neurosurgery, or orthopaedics, depending on clinical judgement ².

Head Injuries:

• Refer people who have sustained a head injury to a hospital emergency department if there are risk factors such as any loss of consciousness, amnesia, a persistent headache, any vomiting episodes, any previous brain surgery, a history of bleeding or clotting disorders, current anticoagulant or antiplatelet treatment (except aspirin monotherapy), current drug or alcohol intoxication, or any safeguarding concerns ⁴.
• Other risk factors for emergency department referral include a Glasgow Coma Scale (GCS) score of less than 15, any focal neurological deficit, any suspicion of a complex skull fracture or penetrating head injury, or any seizure since the injury ⁴.

Spinal Injuries:

• For people in a trauma unit or major trauma centre who have a spinal cord injury, the trauma team leader should immediately contact the specialist neurosurgical or spinal surgeon on call ⁶.
• The specialist neurosurgical or spinal surgeon at the major trauma centre or trauma unit should contact the linked spinal cord injury centre consultant within 4 hours of diagnosis to establish a partnership of care ⁶.
• All people with a spinal cord injury should have a lifetime of personalised care guided by a spinal cord injury centre ⁶.
• Imaging (X-rays, CT, MRI) may be indicated for suspected spinal column injury, with specific criteria for referral to specialist imaging and subsequent management ⁶.

Other Traumatic Injuries:

• For adults with a fragility fracture, assess bone health and refer as necessary, for example, to a specialist bone health clinic or outpatient service ⁵.
• If a traumatic injury has been caused by a fall, ask about previous falls and consider a falls risk assessment and referral to a community falls service ⁵.