When should I consider referring a patient with musculoskeletal pain t

Guideline-aligned answer with reasoning, red flags and references. Clinically reviewed by Dr Kola Tytler MBBS CertHE MBA MRCGP.

Consider referring a patient with musculoskeletal pain to a specialist if:

They have low back pain starting before age 45 that has lasted longer than 3 months, plus 4 or more of the following: onset before 35 years, waking at night due to symptoms, buttock pain, improvement with movement, improvement within 48 hours of NSAIDs, first-degree relative with spondyloarthritis, current or past arthritis, enthesitis, or psoriasis. This suggests possible spondyloarthritis and warrants rheumatology referral .
If exactly 3 of these criteria are present, perform an HLA-B27 test and refer if positive .
Urgently refer patients with suspected new-onset inflammatory arthritis (excluding suspected rheumatoid arthritis, gout, or acute CPP arthritis) to rheumatology .
Refer patients with dactylitis or persistent/multisite enthesitis without mechanical cause, especially if accompanied by back pain, uveitis, psoriasis, gastrointestinal/genitourinary infection, inflammatory bowel disease, or family history of spondyloarthritis or psoriasis .
Refer immediately adults with severe low back pain radiating to the leg plus new bladder, bowel, sexual dysfunction, or perineal numbness for assessment of cauda equina syndrome .
Consider referral for neurological assessment if musculoskeletal pain is accompanied by neurological signs such as rapidly progressive limb weakness or other neurological symptoms .

When should I consider referring a patient with musculoskeletal pain to a specialist?