Symptoms of Rheumatoid Arthritis
Rheumatoid arthritis presents with symmetric joint pain, swelling, and prolonged morning stiffness lasting 1 hour or longer, most commonly affecting the small joints of the hands and feet. 1, 2, 3
Cardinal Joint Symptoms
Joint involvement is the hallmark of RA and follows a characteristic pattern:
- Symmetric polyarthritis affecting multiple joints simultaneously, particularly the metacarpophalangeal (MCP), proximal interphalangeal (PIP), wrist, and metatarsophalangeal joints 4, 5
- Joint swelling and tenderness on palpation, with limited range of motion in affected joints 4, 5
- Large joints including shoulders, elbows, hips, knees, and ankles may also be involved 1, 4
- The distal interphalangeal joints are characteristically spared in RA, which helps distinguish it from other arthritides 1
Morning Stiffness: A Distinguishing Feature
Morning stiffness lasting ≥1 hour is a cardinal symptom that differentiates RA from other joint conditions:
- According to the American College of Rheumatology, morning stiffness in RA typically lasts 1 hour or longer, reflecting significant inflammatory processes during periods of inactivity 2, 3
- This prolonged stiffness contrasts sharply with osteoarthritis, where stiffness is typically mild and lasts less than 30 minutes 2, 3
- The duration of morning stiffness correlates with disease activity and is considered a key diagnostic feature 5
- Stiffness improves with activity throughout the day 5
Constitutional Symptoms
Systemic manifestations frequently accompany joint symptoms:
- Fatigue, malaise, and generalized weakness 5, 6
- Low-grade fever 5
- Unintentional weight loss 5
- These constitutional symptoms reflect the systemic inflammatory nature of RA 7, 8
Extra-Articular Manifestations
Extra-articular features indicate more severe disease:
- Subcutaneous rheumatoid nodules, particularly in patients with severe disease 1, 4
- Interstitial lung disease 1, 4
- Vasculitis 1, 4
- Various forms of inflammatory eye disease 1
- Hematologic abnormalities and Felty's syndrome 5
Clinical Presentation Patterns
Onset patterns vary but follow recognizable trajectories:
- Insidious onset (most common): Gradual development of symmetric small joint swelling over weeks to months 5
- Acute or subacute onset: Occurs in approximately 25% of patients 5
- Palindromic onset: Recurrent episodes of oligoarthritis without residual damage 5
- Monoarticular presentation: Single joint involvement initially, which can delay diagnosis 5
Common Pitfalls in Recognition
Early RA may be subtle and easily missed:
- Early disease may present with only a few affected joints rather than the classic polyarticular pattern 4
- Tendon and bursal involvement (tenosynovitis, bursitis) may be clinically dominant in early disease and mistaken for other conditions 5
- Some patients present with polymyalgia-like symptoms, particularly elderly patients, making differentiation from polymyalgia rheumatica challenging 5
- Clinical examination alone may underestimate disease extent; imaging studies often reveal subclinical inflammation 4