What is the diagnosis and treatment for a 30-year-old female experiencing significant hand and foot pain, stiffness, and swelling, especially worse overnight and early morning?

Diagnosis: Early Inflammatory Arthritis (Likely Rheumatoid Arthritis)

This 30-year-old female with significant hand and foot pain, stiffness, and swelling worse overnight and early morning most likely has early inflammatory arthritis, and she requires urgent rheumatology referral within 6 weeks of symptom onset. 1, 2, 3

Why This is Inflammatory Arthritis, Not Osteoarthritis

The clinical presentation strongly indicates inflammatory arthritis rather than osteoarthritis based on several key features:

• Morning stiffness lasting ≥60 minutes indicates inflammatory arthritis, reflecting significant inflammatory processes during inactivity 2
• Morning stiffness <30 minutes would suggest osteoarthritis, which is brief and mechanical in nature 2
• The patient's age of 30 years makes osteoarthritis extremely unlikely, as hand osteoarthritis typically occurs in adults over age 40 1
• Osteoarthritis causes only mild morning stiffness affecting one or a few joints intermittently, not the severe bilateral hand and foot involvement described here 1

Critical Diagnostic Features Present

Joint swelling with pain and stiffness in multiple joints (hands and feet) meeting the threshold for urgent rheumatology referral 1:

• Arthritis of more than one joint with swelling associated with pain or stiffness 1
• Morning stiffness >30 minutes is a validated predictor of persistent inflammatory arthritis 1, 3
• Small joint involvement (hands and feet) is an independent predictor of persistent inflammatory arthritis 3
• Involvement of metacarpophalangeal and/or metatarsophalangeal joints is characteristic of early inflammatory arthritis 1

Immediate Clinical Actions Required

1. Confirm Synovitis on Physical Examination

• Perform the "squeeze test": lateral compression of metacarpophalangeal and metatarsophalangeal joints eliciting pain confirms inflammatory arthritis 1, 2
• Palpate for visible and palpable joint swelling (synovitis), not just pain alone 2
• The presence of actual joint swelling is essential for diagnosing inflammatory arthritis 2

Common pitfall to avoid: Morning stiffness without objective joint swelling may represent osteoarthritis with secondary inflammation or other non-inflammatory conditions 2

2. Order Initial Laboratory Tests

First-line investigations 3, 4:

• ESR and CRP to assess inflammation 3, 4
• Rheumatoid factor (RF) and anti-CCP antibodies (ACPA) - these are predictive of RA diagnosis and prognosis (Level 1a evidence) 3
• Complete blood count 1
• Urinalysis 1
• Transaminases 1
• Antinuclear antibodies (ANA) to exclude other connective tissue diseases 1, 4

3. Obtain Baseline Imaging

• Plain radiographs of hands and feet at baseline - presence of erosions predicts development of RA and persistence of disease (Level 1a evidence) 3
• Consider ultrasound with power Doppler or MRI if clinical findings are equivocal, as these detect synovitis 2.18-2.20 fold more frequently than clinical examination alone 4
• Ultrasound is particularly useful when patients don't meet 2010 ACR/EULAR criteria but inflammatory arthritis is suspected 3

4. Urgent Rheumatology Referral

Refer to rheumatology ideally within 6 weeks of symptom onset 1, 2, 3:

• Multiple studies show better outcomes when treatment starts earlier 1
• There is a critical "window of opportunity" within which DMARD therapy should be commenced to arrest progressive disease and joint destruction 3
• Patients at risk of developing persistent or erosive arthritis should be started with DMARDs as early as possible, even if they don't yet fulfill established classification criteria 3

Predictors of Persistent Inflammatory Arthritis to Document

The following features predict persistent disease and support urgent treatment initiation 1:

• Disease duration ≥6 weeks 1
• Morning stiffness >30 minutes 1
• Small joint involvement (hands and feet) 1
• Involvement of ≥3 joints 1
• Positive RF and/or ACPA 1
• Functional impairment 1
• Presence of radiographic erosion 1

Differential Diagnosis to Consider

While early rheumatoid arthritis is most likely, the rheumatologist will need to exclude 1:

• Psoriatic arthritis - ask about psoriasis history, nail changes, dactylitis ("sausage digits") 1
• Other connective tissue diseases - hence the need for ANA testing 1
• Viral arthritis - typically self-limited 1

Key distinguishing feature: Psoriatic arthritis may present with recurrent early morning stiffness lasting longer than 30 minutes, but typically has asymmetric joint involvement and associated skin/nail findings 2

Why Delay is Harmful

• Evaluation of treatment delay impact shows worse outcomes with later treatment initiation 1
• Disease duration exceeding 6 weeks is an independent predictor of persistent inflammatory arthritis (Level 1b evidence) 3
• Early DMARD therapy prevents irreversible joint damage and disability 3