What are the typical physical findings in patients with rheumatoid arthritis (RA)?

Physical Findings in Rheumatoid Arthritis

The most characteristic physical findings in rheumatoid arthritis include symmetric polyarthritis with joint swelling, especially of the hands and feet, morning stiffness lasting 1 hour or longer, and subcutaneous nodules. 1

Joint Involvement

• Symmetric polyarthritis affecting multiple joints is the hallmark presentation 1
• Metacarpophalangeal (MCP), proximal interphalangeal (PIP), and wrist joints are most commonly affected, showing swelling, tenderness, and limited range of motion 1, 2
• Metatarsophalangeal joints of the feet are also frequently involved 2, 3
• Joint swelling is due to synovitis, which causes a characteristic tender swelling on palpation 2
• Early severe motion impairment in affected joints is common, even before radiographic evidence of bone damage 2

Timing and Pattern of Symptoms

• Morning stiffness lasting 1 hour or longer is a cardinal symptom that helps differentiate RA from osteoarthritis (where stiffness typically lasts <30 minutes) 1, 4, 5
• Prolonged morning stiffness (>60 minutes) reflects significant inflammatory processes that occur during periods of inactivity 4, 5
• Improvement of symptoms with NSAIDs or corticosteroids, but not with opioids, may suggest inflammatory arthritis 1

Distribution of Joint Involvement

• Symmetrical joint involvement is characteristic of RA 2, 3
• Small joints of hands and feet are typically affected early in the disease 1, 2
• Large joints (knees, ankles, elbows, shoulders) may also be involved 1, 2
• Distal interphalangeal joints, sacroiliac joints, and lumbar spine are rarely affected 2

Extra-articular Manifestations

• Subcutaneous rheumatoid nodules are characteristic, particularly in patients with more severe disease 1
• Other extra-articular manifestations include interstitial lung disease, vasculitis, and inflammatory eye disease 1
• Systemic symptoms such as fatigue, low-grade fever, weight loss, and malaise may be present 2

Tendon and Bursal Involvement

• Tenosynovitis (inflammation of tendon sheaths) is frequent and often clinically dominant in early disease 2
• Flexor tenosynovitis has been described as a predictor of early RA 1
• Bursitis may also be present 2, 3

Physical Examination Techniques

• Joint examination should focus on the number and pattern of tender and swollen joints 1
• The 28-joint count (which includes PIPs, MCPs, wrists, elbows, shoulders, and knees) is commonly used for assessment 1
• Careful assessment of functional status is important as disability begins early in the disease course 1

Imaging Findings on Physical Examination

• Ultrasound and MRI are superior to clinical examination for detecting joint inflammation and should be considered for more accurate assessment 1
• Ultrasound can detect synovial thickening even within finger joints that may not be clinically apparent 2
• X-rays of hands and feet should be used as the initial imaging technique to detect damage, though they may be normal in early disease 1

Common Pitfalls in Physical Examination

• Early RA may present with only a few affected joints, making diagnosis challenging 1
• Differentiating RA from other forms of inflammatory arthritis requires careful attention to the pattern of joint involvement and extra-articular features 1, 2
• Patients may confuse pain and stiffness; careful questioning about morning stiffness duration is essential 2
• Relying solely on clinical examination may underestimate the extent of joint involvement; imaging studies may reveal subclinical inflammation 1

Early recognition of these physical findings is crucial as timely intervention can reduce disease progression, improve functional outcomes, and enhance survival 1.