Synopsis
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.
- Refer suspected persistent synovitis affecting more than 1 joint or the small joints of the hands or feet to rheumatology within 3 working days of primary-care presentation; refer every persistent synovitis of uncertain cause without waiting for normal inflammatory markers, negative serology or normal early radiographs.
- Refer rheumatoid-pattern synovitis even when CRP, ESR, RF and anti-CCP are normal and early radiographs show no erosion.
- For suspected axial or peripheral spondyloarthritis, use age at onset, inflammatory back pain, enthesitis, dactylitis, psoriasis, uveitis, bowel disease and family history rather than HLA-B27 alone.
- Examine and document objective swelling; 'joint pain' without anatomy does not allow safe triage.
- Before routine referral, identify a septic-joint phenotype and arrange aspiration, cultures and acute orthopaedic or medical assessment.
- Do not use empirical long courses of oral corticosteroid as a substitute for referral because they mask infection, change the baseline and create cumulative harm.
- Baseline FBC, renal and liver tests, CRP or ESR and targeted serology help later treatment but must run in parallel with the referral.
- Give the patient a clear explanation, expected timeframe and return instructions for fever, one rapidly hotter joint, eye pain, breathlessness, weakness or reduced urine output.
Key red flags
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.
Investigation priorities
Provide the core evidence for inflammatory-arthritis triage and a baseline for specialist review.
Management branches
Persistent synovitis exists without current sepsis or organ-threatening features.
- Map swollen joints, function and extra-articular findings; offer RF and, after a negative result, consider anti-CCP for a rheumatoid phenotype while obtaining baseline bloods.
- Send the referral without awaiting tests. For suspected persistent synovitis affecting more than 1 joint or the small joints of the hands or feet, refer within 3 working days of primary-care presentation; also mark it urgent under NG100 when symptoms began at least 3 months before medical advice was sought.
- Confirm receipt, manage symptoms with a reviewed plan and arrange reassessment if the appointment is delayed or disease progresses.