You’ve treated the same patient for three sessions. The pain pattern doesn’t fit, progress is slow, and something about their story makes you uneasy. They’re not deteriorating — but not improving either. Do you keep going or suggest a review?

This is where the art of physiotherapy meets the ethics of healthcare: deciding when to refer.

Beyond the obvious: what makes referral decisions complex

Physiotherapists are trained to spot red flags — the signs that point clearly to systemic or serious disease. But many real-world situations are less black and white. Patients present with overlapping symptoms, complex psychosocial contexts, and varied access to other providers.

The question often isn’t whether you should refer — it’s how soon, to whom, and how to frame it so that both the patient and the next clinician understand your reasoning.

When red flags hide in plain sight

Some indicators are textbook red flags, but others surface gradually.
A few worth keeping front of mind:

• Persistent or worsening pain that defies expected recovery timelines.
• Unexplained fatigue, weight loss, or fever.
• Neurological changes such as numbness, weakness, or altered sensation.
• Night pain unrelieved by rest or position.
• Cardiorespiratory symptoms that occur during physical activity.
• Sudden changes in function without clear cause.

It’s not about memorising the list — it’s about recognising patterns and knowing when something doesn’t belong to the musculoskeletal story.

Case example 1: The patient who “just doesn’t get better”

Jason, a 44-year-old carpenter, presents with mid-back pain after lifting at work. You expect steady improvement, but after several sessions, he reports constant night pain and new tingling in his legs. He brushes it off — “just a pinched nerve.”

You explain your concern, document findings, and contact his GP with consent. Imaging later reveals a spinal tumour.

Takeaway: Experienced clinicians know the danger of normalising persistent symptoms. Acting early — and communicating clearly — can be life-changing.

Grey zones: when the decision isn’t clear

Sometimes, there are no textbook signs. The uncertainty lives in tone, timing, or behaviour.

Perhaps a patient becomes unusually anxious about pain, or you sense a mismatch between symptoms and test results. Maybe they’re not recovering as others would, or you suspect underlying psychosocial contributors.

These are the moments that test clinical reasoning.

When uncertainty creeps in, take a step back and analyse what’s driving it.

• Does the pattern still align with a musculoskeletal explanation?
• Is the patient’s progress consistent with your expectations?
• Would involving another professional add safety, speed, or clarity to their care?

If you can’t confidently answer “yes” to all three, it’s time to discuss a referral.

Navigating the conversation

Referrals can be delicate. Some patients resist seeing another practitioner, worrying it means their problem is “serious” or that you’ve “given up.”

Communication is key.

• Be transparent: explain that referral is a normal part of best-practice care, not an alarm.
• Use collaborative language: “I’d like to get another opinion to make sure we’re not missing anything.”
• Emphasise safety and teamwork: “It’s important we have your GP involved so we can manage this together.”

Good communication preserves trust and encourages follow-through. Clarity in language is as important as timing — what you write can shape how your referral is received.

Who to refer to — and how to decide

Referral pathways depend on the clinical picture:

• GPs for undiagnosed systemic signs, prescription needs, or imaging.
• Specialists for confirmed conditions requiring advanced medical management.
• Allied health colleagues (psychologists, dietitians, exercise physiologists) for contributing factors like pain behaviours, nutrition, or activity modification.
• Emergency services if you suspect acute neurological, cardiac, or respiratory compromise.

The Physiotherapy Board of Australia’s Code of Conduct emphasises coordination and referral as part of collaborative care. It reminds practitioners that their duty of care continues when the limits of their own practice are reached — by ensuring the patient is directed to appropriate care promptly.

Case example 2: The blurred line

Marina, a 36-year-old recreational runner, presents with knee pain. You suspect overuse, but she also mentions persistent fatigue and occasional night sweats. There’s no obvious swelling or redness, and her presentation doesn’t fit a straightforward mechanical pattern.

You document your reasoning and refer her to her GP for review. Blood tests confirm early rheumatoid arthritis.

Takeaway: Some red flags don’t announce themselves dramatically. Subtle systemic symptoms — especially when the story doesn’t match the mechanics — should always prompt a medical review.

Documentation: clarity that counts

A good referral doesn’t end with “referred to GP.” It tells a concise story of what led you there. Effective documentation captures why you were concerned, how you communicated it, and what follow-up you planned.

When writing notes or a referral letter, keep your language objective — describe findings, not theories. For example,

“Patient reports night pain and unrelieved fatigue; advised GP review for systemic assessment,”
is far stronger (and safer) than
“Possible inflammatory condition — referred to GP.”

This kind of phrasing shows sound reasoning without stepping into diagnosis.

The APA’s Writing Clinical Notes Guidelines offer practical examples of clear, compliant record-keeping that support both continuity of care and professional accountability.

Case example 3: Ethical clarity in uncertainty

An older patient, Frank, attends after minor back strain. You notice mild confusion and unsteadiness during exercises — new symptoms since his last visit. You ask a few orientation questions; his answers are vague. His spouse looks worried.

You gently recommend an urgent GP review and offer to call ahead. Frank is later admitted with early-stage stroke.

Takeaway: Sometimes, ethical clarity means acting before proof. The patient’s wellbeing outweighs any hesitation about “overreacting.”

The professional mindset

Referral isn’t about relinquishing care — it’s about exercising professional humility and teamwork. The most effective clinicians are those who balance confidence with curiosity, always willing to question whether they’re the best person for the next step.

When in doubt, communicate, document, and collaborate.
Because in physiotherapy, knowing when not to act alone is just as vital as knowing what to do next — it’s what safeguards your patients, your profession, and your integrity.