What are the symptoms of inflammatory arthritis?

Symptoms Indicating Inflammatory Arthritis

The hallmark symptom of inflammatory arthritis is joint pain accompanied by visible joint swelling (synovitis), combined with morning stiffness lasting more than 30 minutes to 1 hour that improves with activity. 1, 2

Cardinal Clinical Features

Joint Swelling (Synovitis)

• Visible and palpable joint swelling is essential for diagnosis - pain alone without objective swelling is insufficient to diagnose inflammatory arthritis 1, 2, 3
• Swelling typically affects multiple joints in a symmetric pattern, particularly metacarpophalangeal, proximal interphalangeal, wrist, and metatarsophalangeal joints 2, 4
• A positive "squeeze test" (pain on lateral compression of metacarpophalangeal or metatarsophalangeal joints) strongly suggests inflammatory arthritis 3

Morning Stiffness Pattern

• Stiffness lasting ≥60 minutes indicates inflammatory arthritis, reflecting significant inflammatory processes during periods of inactivity 3
• Stiffness occurs after any period of inactivity, not just mornings 1
• Improvement with movement and activity is pathognomonic for inflammatory conditions 3
• In contrast, stiffness lasting <30 minutes suggests osteoarthritis rather than inflammatory disease 3

Response to Medications

• Improvement with NSAIDs or corticosteroids, but NOT with opioids or other pain medications, is highly suggestive of inflammatory arthritis 1
• This differential response helps distinguish inflammatory from mechanical or degenerative joint disease 1

Associated Inflammatory Signs

Local Joint Findings

• Erythema (redness) over affected joints 1
• Warmth on palpation of involved joints 1
• Tenderness to palpation 2
• Limited range of motion in affected joints 2, 4

Systemic Symptoms

• Fatigue and malaise are common, often not correlating with disease activity 1, 4
• Low-grade fever may be present 4
• Weight loss can occur in active disease 4

Distribution Patterns to Recognize

Polyarticular Pattern

• Symmetric involvement of small joints (hands and feet) is the most frequent presentation 5, 4
• More than five joints affected, particularly upper extremity joints, suggests type 2 arthropathy 1

Oligoarticular Pattern

• Asymmetric involvement of fewer than five joints, often large weight-bearing joints (knees, ankles) 1
• May be associated with features of reactive arthritis including conjunctivitis or urethritis 1

Axial Involvement

• Chronic back pain (≥3 months) with insidious onset before age 45 years 3
• Pain worse in the latter part of the night that awakens the patient 1, 3
• Pain that improves with exercise but not rest 1, 3

Critical Timing for Referral

Patients with joint swelling plus pain or stiffness affecting more than one joint should be referred to rheumatology within 6 weeks of symptom onset, as early diagnosis and treatment significantly impacts long-term outcomes and prevents erosive joint damage 1, 2, 3

Early referral is also indicated for:

• Persistent arthralgia symptoms lasting >4 weeks even without obvious swelling 1
• Any patient with confirmed synovitis on examination 1, 2

Common Diagnostic Pitfalls

• Do not diagnose inflammatory arthritis based on arthralgia alone - objective joint swelling must be present 2, 3
• Morning stiffness without swelling may represent osteoarthritis with secondary inflammation 3
• Symptoms in primary care populations are common (42% report persistent joint pain, 36% stiffness, 18% swelling) even among non-musculoskeletal consulters, making clinical judgment essential 6
• Distal interphalangeal joints are rarely involved in rheumatoid arthritis, so their involvement suggests alternative diagnoses 4