What criteria should I use to decide whether to refer a patient with persistent tendinopathy to a specialist?

When determining whether to refer a patient with persistent tendinopathy to a specialist, consider the following criteria:

• Lack of Improvement with Conservative Management: Refer to orthopaedics or a sports physician if symptoms are chronic or do not improve with conservative treatment ¹. For tennis elbow, this specifically means if there is no response to treatment 6–12 months after initial presentation or despite 6–12 months of optimal management in primary care ³.
• Refractory Pain or Severe Functional Impairment: Consider referral if the patient experiences refractory pain or severe functional impairment ³.
• Uncertain Diagnosis: If the diagnosis of tendinopathy is uncertain, consider referring to an appropriate specialist such as a rheumatologist, orthopaedic surgeon, sports physician, or other musculoskeletal specialist ²,³. Imaging techniques like ultrasonography or MRI may be used to confirm the diagnosis ³.
• Suspected Inflammatory Conditions: If the tendinopathy is suspected to be part of a broader inflammatory condition, such as spondyloarthritis or rheumatoid arthritis, specific referral criteria apply:
  • Enthesitis: Refer to a rheumatologist for a spondyloarthritis assessment if enthesitis (tendon/ligament inflammation at bone attachment) without apparent mechanical cause is persistent, in multiple sites, or accompanied by other features such as back pain without mechanical cause, current or past uveitis, psoriasis, gastrointestinal or genitourinary infection, inflammatory bowel disease, or a first-degree relative with spondyloarthritis or psoriasis ⁴.
  • Persistent Synovitis: Refer urgently to a rheumatologist for specialist opinion if suspected persistent synovitis of undetermined cause, especially if small joints of the hands or feet are affected, more than one joint is affected, or there has been a delay of 3 months or longer between symptom onset and seeking medical advice ²,⁵.
• Suspected Red Flags: Refer urgently if a tumour or osteonecrosis is suspected ².