When should I consider referring a patient with arthritis to a rheumatologist for further evaluation?

Consider referring a patient with arthritis to a rheumatologist for further evaluation if they present with suspected persistent synovitis of undetermined cause, especially when small joints of the hands or feet are affected, more than one joint is involved, or symptoms have persisted for 3 months or longer without diagnosis. This referral should be urgent even if initial blood tests such as rheumatoid factor or anti-CCP antibodies are negative or acute-phase response is normal.

Additional indications for referral include:

• New-onset inflammatory arthritis suspected to be spondyloarthritis, particularly if low back pain started before age 45 and has lasted over 3 months with associated features such as improvement with movement or NSAIDs, family history, or psoriasis.
• Presence of dactylitis or enthesitis without mechanical cause, especially if persistent, in multiple sites, or accompanied by other spondyloarthritis features.
• Signs of progressive joint damage, worsening function, deformity, or persistent localized synovitis despite optimal non-surgical management.
• Complications such as imminent tendon rupture, nerve compression, stress fractures, or suspected septic arthritis.
• Symptoms suggestive of cervical myelopathy (e.g., paraesthesia, weakness, unsteadiness) warrant urgent MRI and specialist surgical opinion.

For osteoarthritis, referral to rheumatology is generally not required unless joint symptoms substantially impact quality of life and non-surgical management is ineffective or unsuitable, at which point referral for joint replacement assessment may be appropriate.

Investigations such as rheumatoid factor, anti-CCP antibodies, and X-rays of hands and feet can be performed in primary care but should not delay referral if clinical suspicion is high.

This approach aligns with UK NICE guidelines emphasizing early specialist assessment to enable timely diagnosis and initiation of treat-to-target strategies, improving long-term outcomes in inflammatory arthritis ¹,²,³. The German Society of Rheumatology also supports referral for joint swelling of unclear cause to ensure appropriate specialist management (Keitel et al., 2000).