What are the recommended referral criteria for a patient with joint pain who has not responded to first-line treatment?

For a patient with joint pain who has not responded to first-line treatment, the recommended referral criteria include:

• Referral to a local musculoskeletal multidisciplinary team or physiotherapist for individualized management such as therapeutic exercise, manual therapy (if hip or knee osteoarthritis), provision of joint supports, and intra-articular corticosteroid injections if drug treatments are ineffective or unsuitable.
• Referral to an occupational therapist for advice on assistive aids and devices to support daily activities and reduce symptom flares.
• Referral to a podiatrist for biomechanical assessment and advice on orthotic devices if clinically appropriate.
• Referral to an orthopaedic surgeon if non-surgical management is ineffective or unsuitable after approximately 3 months, especially if symptoms such as pain, stiffness, reduced function, or progressive joint deformity substantially impact quality of life, or if there is diagnostic uncertainty or atypical features (e.g., sudden worsening, hot swollen joint).
• Referral to a pain management service if pain remains uncontrolled despite optimal non-surgical and/or surgical management or if a chronic pain syndrome is suspected.
• Referral to psychology or specialist mental health services if co-morbid anxiety or depression is not responding to primary care management.
• Referral to a rheumatologist or other specialist if the diagnosis is uncertain, or if inflammatory arthritis, persistent synovitis, or other specific conditions (e.g., spondyloarthritis, psoriatic arthritis) are suspected.

Urgent referral is indicated if there are red flags such as suspected tumour, osteonecrosis, or persistent synovitis suggestive of inflammatory polyarthritis.

Referral decisions should be based on clinical assessment rather than age, sex, BMI, or comorbidities, and scoring tools are not recommended for referral decisions.

These recommendations align with NICE guidelines on osteoarthritis, rheumatoid arthritis, spondyloarthritis, and knee pain assessment.

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