What are the signs and symptoms of rheumatoid arthritis?

Signs and Symptoms of Rheumatoid Arthritis

Rheumatoid arthritis presents with symmetric polyarthritis affecting small joints of the hands and feet, accompanied by morning stiffness lasting 1 hour or longer, which is the cardinal feature distinguishing it from other joint diseases. 1, 2

Joint Involvement Pattern

The hallmark presentation is symmetric swelling and tenderness of multiple joints, particularly:

• Metacarpophalangeal (MCP) and proximal interphalangeal (PIP) joints of the hands are the most characteristic early sites, showing tender swelling with severe motion impairment 1, 3
• Wrist joints are commonly affected early in disease 1, 3
• Metatarsophalangeal (MTP) joints of the feet, particularly the second through fifth MTP joints 4, 3
• Large joints including knees, ankles, elbows, and shoulders may also be involved 4, 1

Notably, distal interphalangeal (DIP) joints are characteristically spared, which helps differentiate RA from osteoarthritis and psoriatic arthritis 3, 5

Morning Stiffness: The Defining Symptom

Morning stiffness lasting ≥1 hour is pathognomonic for RA and reflects the significant inflammatory process occurring during inactivity 4, 1, 2:

• This prolonged stiffness (>60 minutes) is a cardinal symptom that differentiates RA from osteoarthritis, where stiffness typically lasts <30 minutes 2, 6
• The duration of morning stiffness correlates directly with disease activity 3
• Stiffness improves with activity and worsens with rest 4

Physical Examination Findings

On examination, look for these specific signs:

• Soft tissue swelling is the most important sign of inflammation, appearing as fusiform swelling around affected joints 7, 5
• Joints are tender and warm but often not hot or red, distinguishing RA from septic arthritis 7
• Symmetric involvement is the hallmark—if one MCP joint is affected, the corresponding joint on the opposite hand is typically involved 3, 5
• Limited range of motion with early severe motion impairment in involved joints 1, 3

Extra-Articular Manifestations (Markers of Severe Disease)

The presence of extra-articular features indicates more severe disease with worse prognosis 4:

• Subcutaneous rheumatoid nodules are characteristic findings, particularly in seropositive patients 4, 1
• Interstitial lung disease 4, 1
• Vasculitis 4, 1
• Inflammatory eye disease (scleritis, episcleritis) 4

Systemic Symptoms

Constitutional symptoms are frequent and include:

• Fatigue and malaise 3
• Low-grade fever 3
• Unintentional weight loss 3

Laboratory and Inflammatory Markers

While not physical signs, these support the clinical diagnosis:

• Elevated C-reactive protein (CRP) is the most clinically useful biomarker 4
• Elevated erythrocyte sedimentation rate (ESR) 4, 3
• Rheumatoid factor positive in approximately 75% of patients 7
• Anti-citrullinated protein antibodies (ACPA) with 90% specificity 4

Critical Clinical Pitfalls to Avoid

Early RA may present atypically, making diagnosis challenging:

• Early disease may involve only a few joints rather than the classic polyarticular pattern, so don't dismiss oligoarticular presentations 1
• Clinical examination alone underestimates joint involvement—ultrasound and MRI reveal subclinical inflammation not apparent on physical exam 1
• Radiographs may be normal in early disease despite active synovitis, so negative x-rays don't exclude RA 1
• Don't confuse pain with stiffness—patients must be carefully questioned about the difference, as morning stiffness is a subjective symptom 3

Timing and Urgency

Patients presenting with these signs require urgent rheumatology referral:

• Refer within 6 weeks of symptom onset to prevent irreversible joint damage 6
• Joint destruction begins early, with 70% of seropositive patients developing erosions within 2 years if untreated 5
• Early aggressive treatment can alter disease progression and prevent disability 3