Educational draft · awaiting clinical reviewThe full textbook explains uncertainty but does not replace live national or local guidance, specialist advice, or current prescribing information.
Recognise persistent synovitis and spondyloarthritis signals in first-contact care, exclude immediate infection, and secure the correct specialist route without waiting for serology, inflammatory markers or radiographic damage.
The referral decision is driven by objective inflammation and phenotype, not diagnostic certainty. Confirm synovitis through soft joint-line swelling, warmth, effusion or painful restriction. Map every joint and examine tendons, entheses, digits, skin, nails and eyes. Record duration and function. Early disease may be intermittent, asymmetric or seronegative; photographs and review during a flare can support an evolving pattern without justifying unsafe delay when swelling is present.
Refer every adult with suspected persistent synovitis of undetermined cause for specialist opinion. Mark the referral urgent, even with normal inflammatory markers or negative serology, when small hand or foot joints are involved, more than one joint is affected, or at least three months elapsed before medical advice was sought. Offer RF when examination confirms synovitis and, if RF is negative, consider anti-CCP; run testing in parallel and never wait for results before referring. Use HLA-B27 only within a compatible spondyloarthritis assessment.
Referral quality affects triage. Include onset, joints swollen, stiffness, extra-articular features, infection and drug history, function, examination, blood results, imaging and treatments already given. Highlight pregnancy, immunosuppression, work impact and rapid progression. A generic 'joint pains, rule out RA' referral without objective findings may delay the correct clinic or obscure an emergency.
Rheumatoid, psoriatic and undifferentiated inflammatory arthritis often begins before antibodies, radiographic change or the complete disease pattern becomes visible.
Inflammation may centre on entheses, whole digits, sacroiliac joints or asymmetric lower-limb joints and associate with psoriasis, uveitis or bowel disease.
Septic, viral, reactive and crystal arthritis can resemble early immune disease and need exposure history, aspiration and targeted testing.
Objective swelling may arise from autoimmune synovitis, enthesis-centred spondyloarthritis, crystal-triggered innate inflammation or joint infection; distribution, tempo and associated features determine the pathway.
Persistent inflammatory synovium, enthesitis or infection can damage cartilage, bone, tendon and function, so appropriate referral or acute treatment should not await a fully evolved label.
Undifferentiated arthritis can resolve, persist or acquire defining rheumatoid, psoriatic or systemic features, making longitudinal review part of diagnosis.
Soft swelling of MCP, PIP, wrist or MTP joints lasting weeks with prolonged morning stiffness warrants urgent specialist assessment despite normal screening tests.
Dactylitis, enthesitis, asymmetric lower-limb arthritis, psoriasis, nail disease, uveitis or inflammatory bowel disease should be made explicit in the referral.
Back pain beginning before age forty-five, night waking, buttock pain and improvement with movement supports axial assessment even when radiographs are normal.
Acute severe monoarthritis with fever, immunosuppression, skin infection or a prosthesis requires urgent acute-team sampling and specialty management instead of routine referral.
Proteinuria, haematuria, hypoxia, neuropathy, visual symptoms, cytopenia or myocarditis redirects toward urgent systemic-rheumatic and organ-specialty review.
Persistent symmetrical small-joint swelling and prolonged stiffness supports rheumatoid arthritis even with normal markers and negative antibodies.
Dactylitis, enthesitis, psoriasis, nail change, uveitis, bowel disease or asymmetric lower-limb arthritis indicates a spondyloarthritis referral pathway.
Abrupt monoarthritis, marked warmth, fever, immunosuppression or a prosthesis requires synovial culture and crystal analysis before routine referral assumptions.
Bony enlargement, load-related symptoms and absence of objective swelling support osteoarthritis or periarticular disease, with review if the pattern changes.
Waiting for serology or erosions can postpone disease-modifying treatment while active synovitis causes preventable structural damage and functional loss.
Routing an acutely infected joint to routine rheumatology can allow rapid cartilage destruction, bacteraemia, sepsis and prosthetic failure.
Failure to identify uveitis, psoriasis, inflammatory bowel disease or pulmonary–renal and neurological features can delay organ-specific treatment and misroute urgent care.
Early-arthritis services exist to resolve uncertain inflammatory phenotypes before damage, not only to accept already proven rheumatoid arthritis.
Normal markers, antibodies and radiographs have incomplete sensitivity and must not override persistent objective synovitis.
Exact swollen joints, entheses and associated features allow safer triage than a long symptom list without examination.
Septic arthritis requires immediate sampling and source control; a routine inflammatory clinic cannot safely absorb that delay.
Submitting a referral without confirming receipt or providing a deterioration route leaves a preventable gap in care.
Waiting for a positive RF, anti-CCP or HLA-B27 before referral.
Failing to state which joints are objectively swollen.
Sending a septic-joint presentation to a routine clinic.
Using repeated corticosteroid courses to bridge an administrative delay without review.
Assuming a normal radiograph excludes early inflammatory disease.
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A 29-year-old with psoriasis has eight weeks of heel enthesitis and a newly swollen whole toe. CRP is normal, with no fever or acutely hot joint. What is the best next action?
National guidance is shown before implementation-dependent detail. Apply principles in context and verify current guidance when a decision affects care. Source check completed 27 Aug 2026; clinical approval remains outstanding.
Editorial contact: Doctor’s Passport editorial team. Source-check date is separate from clinical approval. Report a content problem · Content changes
While awaiting review, use safe analgesia, maintain activity within tolerance and address smoking and vaccination when appropriate. If a short glucocorticoid intervention is necessary, document the indication, infection assessment, dose, duration and response. Confirm receipt of the referral and provide a route back when symptoms progress; the administrative handoff is part of clinical safety.