What are the symptoms of rheumatoid arthritis, particularly in middle-aged women with a family history of the disease?

Symptoms of Rheumatoid Arthritis

Rheumatoid arthritis characteristically presents with symmetric joint pain, swelling, and morning stiffness lasting ≥1 hour, predominantly affecting the small joints of the hands and feet, particularly the metacarpophalangeal (MCP), proximal interphalangeal (PIP), and metatarsophalangeal (MTP) joints. 1, 2, 3

Cardinal Joint Symptoms

• Morning stiffness lasting ≥1 hour is the hallmark symptom, reflecting significant inflammatory burden during periods of inactivity 2, 4, 3
• Joint pain and swelling with symmetric distribution, most commonly affecting MCPs, PIPs, wrists, and MTPs 1, 3
• Joint tenderness on palpation, especially of small joints, which is associated with disease progression 5, 3
• Severe motion impairment in involved joints, even in early disease without radiologic damage 3

Pattern of Joint Involvement

• Small joint predominance: The hands, wrists, and feet are typically affected first, with MCPs, PIPs, thumb interphalangeal joints, and 2nd-5th MTPs being characteristic targets 1
• Symmetric polyarthritis is the most common pattern, though monoarticular presentation can occur in approximately 25% of patients 3
• Large joints including knees, ankles, elbows, and shoulders may also be involved 5, 3
• Spared joints: Distal interphalangeal joints, sacroiliac joints, and lumbar spine are rarely affected, which helps differentiate RA from other arthritides 3

Periarticular Manifestations

• Tenosynovitis (tendon sheath inflammation) is frequently present and may be clinically dominant in early disease 5, 3
• Bursitis can occur and contribute to periarticular symptoms 3
• Joint swelling with characteristic tender swelling on palpation 3

Systemic Symptoms

• Fatigue is a prominent feature that can be disproportionate to objective disease activity 5, 3
• Malaise and general unwellness commonly accompany active disease 3
• Weight loss may occur during periods of high disease activity 3
• Low-grade fever can be present, though high-spiking fevers are not typical of RA (this would suggest alternative diagnoses like Adult-Onset Still's Disease) 5

Extra-Articular Manifestations

• Rheumatoid nodules develop in some patients, particularly those who are seropositive 3, 6
• Cutaneous manifestations including vasculitis, neutrophilic dermatoses, and vasculopathy may occur 6
• Hematologic abnormalities such as anemia of chronic disease are common 5

Clinical Presentation Patterns

The disease can present in several distinct patterns 3:

• Insidious onset (most common): Gradual development of symmetric small joint pain and swelling
• Acute/subacute onset (approximately 25%): Rapid development of symptoms over days to weeks
• Palindromic onset: Recurrent episodes of oligoarthritis without residual damage between episodes
• Polymyalgic-like onset: Particularly in elderly patients, may mimic polymyalgia rheumatica

Important Clinical Pitfalls

Discordance between patient-reported symptoms and objective findings can occur, particularly when central pain amplification or fibromyalgia coexists with RA 5. In such cases, high tender joint counts and patient global assessments may not correlate with swollen joint counts or inflammatory markers. This requires careful clinical judgment rather than reflexive treatment escalation 5.

Prolonged morning stiffness (>60 minutes) in at-risk individuals (such as those who are ACPA-positive with musculoskeletal symptoms) is a cardinal symptom predicting progression to clinical arthritis and warrants urgent rheumatology referral 5, 1.