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From First Presentation to Referral:
Stratified Decision-Making in Joint Pain Care

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Joint pain is one of the most common presentations in primary care1 ranging from transient discomfort to early osteoarthritis or inflammatory disease. A structured, stratified approach shared across primary care clinicians supports earlier pathway selection, optimised outcomes and reduced unnecessary investigations.

Common Presentations in Primary Care

Patients typically present with pain in the knee, hip, shoulder or small hand joints, often accompanied by stiffness, reduced movement, crepitus, swelling or functional decline. Many cases reflect mechanical overload or early degenerative change,2 but metabolic health, low-grade inflammation and previous injury can also influence presentation. Recognising these patterns allows GPs and pharmacists to tailor management appropriately.

Recognising Red Flags

Although most joint pain is benign, clinicians should identify features requiring urgent investigation or referral, including:3

  • Acute hot, swollen joint (possible septic arthritis or crystal disease)
  • Significant trauma with inability to weight-bear
  • Systemic symptoms such as fever, weight loss or night sweats
  • Persistent night pain or unexplained severe pain
  • Progressive neurological deficit
  • Suspected inflammatory arthritis with prolonged morning stiffness

These presentations warrant timely imaging, laboratory testing or referral to rheumatology or orthopaedics.

Pharmacists should prompt urgent GP review when red flags are present, while GPs should arrange investigation and referral as needed.

When Imaging is Useful and When it Isn’t

Imaging should not be performed routinely.3 X-ray or MRI is most useful when:

  • Red-flag features are present
  • Symptoms persist despite conservative care
  • Surgery or interventional management is being considered
  • Diagnosis is unclear and will change the management plan

Conversely, early osteoarthritis can often be diagnosed clinically without imaging. Imaging should be reserved for situations in which it changes management. Routine X-ray or MRI may reveal age-related changes unrelated to symptoms, which can increase anxiety without improving outcomes.

While imaging decisions sit with GPs, pharmacists play an important role in reinforcing when imaging is and isn’t appropriate.

Risk Factor Stratification

Risk factors help determine management intensity and follow-up frequency.4 Key considerations include:

  • Age: Increases structural vulnerability
  • Obesity: Increases mechanical load and systemic inflammation
  • Previous injury: Accelerates degenerative change
  • Metabolic health: Influences inflammatory activity and disease progression

 

Patients with multiple risk factors may benefit from earlier intervention and closer monitoring due to higher progression risk. Pharmacists can identify risk factors during consultations and signpost patients to the GP when needed.

A stepwise pathway supports self-management and prevents unnecessary escalation:5

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Guideline Alignment

Most musculoskeletal (MSK) care guidelines emphasise early identification, education, exercise therapy, weight management and conservative treatment before imaging or surgical referral.6 A stepped model aligns with NICE, primary-care MSK pathways and multidisciplinary practice.

 

Practical Tools for Clinicians

Useful tools include:

  • Outcome measures: Instruments such as Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC), Oxford Knee/Hip Scores, Health Assessment Questionnaire (HAQ) and pain scales help quantify baseline status and monitor response to treatment over time, supporting objective decision-making
  • Patient education resources: Materials from the GOPO® HCP Portal, decision aids and joint-health education tools help clinicians deliver consistent, evidence-based messages, improving patient understanding and engagement in care
  • Self-management plans: Structured plans outlining activity targets, pacing strategies and flare-management guidance empower patients to take an active role in their condition, supporting adherence and better long-term outcomes

A carefully stratified approach supports timely diagnosis, effective early intervention, and more personalised care for patients living with joint pain.

 

1Aboulenain S, Saber AY. (2022) Primary Osteoarthritis. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing.
 

2 Right Decisions (2024). Osteoarthritis - prevalence, risk factors, and non-radiographic diagnosis approach. NHS Scotland MSK-pathway.
 

3 NICE Guidelines (2022). Osteoarthritis in over-16s: Diagnosis and management. NG226 NICE guidelines. 
 

4 Dong Y, Yan Y, Zhou J et al. (2023). Evidence on risk factors for knee osteoarthritis in middle-older aged: a systematic review and meta analysis. J Orthop Surg Res. 29;18(1):634.
 

5 Arslan IG, van Berkel AC, Damen J et al. (2024). Patterns of knee osteoarthritis management in general practice: a retrospective cohort study using electronic health records. BMC Prim. Care 25, 2.
 

6 NICE Clinical Knowledge Summaries (2024). Osteoarthritis. National Institute for Health and Care Excellence.