What are the symptoms of rheumatoid arthritis (RA)?

Symptoms of Rheumatoid Arthritis

The primary symptoms of rheumatoid arthritis include symmetric joint swelling, tenderness, and morning stiffness lasting at least 1 hour, typically affecting small joints of the hands and feet, along with systemic manifestations such as fatigue and malaise. 1

Key Joint Symptoms

• Joint involvement pattern:

  • Symmetric polyarthritis (hallmark feature)
  • Preferential involvement of:
    • Metacarpophalangeal joints (knuckles)
    • Proximal interphalangeal joints (middle finger joints)
    • Wrists
    • Metatarsophalangeal joints (toe joints)
    • Knees, elbows, ankles, and shoulders 1, 2
  • Distal interphalangeal joints, sacroiliac joints, and lumbar spine are rarely involved 2

• Joint manifestations:

  • Swelling (visible and palpable)
  • Tenderness to touch
  • Warmth over affected joints
  • Reduced range of motion
  • Joint stiffness, particularly pronounced in the morning or after inactivity 2

Morning Stiffness

• Duration of at least 1 hour before maximal improvement 1, 2
• Distinguished from pain (patients should understand this difference)
• Duration correlates with disease activity 2

Early Disease Presentation

The clinical presentation can vary, with several patterns:

• Insidious onset with symmetric small joint involvement (most common)
• Acute or subacute onset (25% of patients)
• Palindromic onset (recurrent episodes of oligoarthritis)
• Monoarticular presentation
• Extra-articular synovitis (tenosynovitis, bursitis)
• Polymyalgic-like onset (resembling polymyalgia rheumatica in elderly)
• General systemic symptoms 2

Systemic Symptoms

• Fatigue
• Low-grade fever
• Weight loss
• Malaise 1, 2

Extra-articular Manifestations

• Rheumatoid nodules (subcutaneous)
• Vasculitis
• Hematologic abnormalities
• Interstitial lung disease
• Inflammatory eye disease
• Sjögren's syndrome (dry eyes and mouth) 1, 2, 3

Laboratory Findings

While not symptoms per se, these findings often accompany symptomatic disease:

• Elevated inflammatory markers:
  • Erythrocyte sedimentation rate (ESR)
  • C-reactive protein (CRP)
• Positive rheumatoid factor (RF)
• Positive anti-citrullinated protein antibodies (ACPA) 1, 2

Disease Progression

Without treatment, RA typically follows a pattern of:

1. Early: Soft tissue swelling and mild periarticular osteoporosis
2. Intermediate: Development of erosions at joint margins
3. Advanced: Joint deformities, subluxations, and loss of function 3

Common Pitfalls in Symptom Recognition

• Confusing osteoarthritis with RA (osteoarthritis typically lacks prolonged morning stiffness and systemic symptoms)
• Missing RA with atypical presentations (monoarticular or polymyalgic onset)
• Overlooking early disease when radiographic changes are absent
• Failing to distinguish between inflammatory and mechanical joint pain (improvement with NSAIDs but not with opioids suggests inflammatory arthritis) 1

Early recognition of these symptoms is crucial as timely intervention can significantly reduce disease progression, joint destruction, and disability, ultimately improving quality of life and survival 1.