Signs and Symptoms
Rheumatoid arthritis (RA) is a heterogeneous systemic inflammatory disorder that mainly affects the diarthroidal joint (See Fig.3305). In approximately two-thirds of patients, disease onset is insidious, with fatigue, anorexia, generalized weakness, and vague musculoskeletal symptoms appearing as typical sequelae, with the appearance of synovial inflammation following soon afterwards.7189 This prodrome stage of the condition can occur for several weeks to months. Typically, the joints of the hands, wrists, knees, and feet, become affected in a symmetric, gradual fashion. Some patients present with initial symptoms of RA associated with the joints of the feet, so it is important to include the feet in clinical evaluations.10084
Figure 3305 – Diagrammatic Representation of Synovial Joint
Reprinted with permission, from the Annual Review of Immunology, Volume 14 © 1996 by Annual Reviews www.annualreviews.org
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In 8%-15% of patients, the onset is more acute with a rapid development of polyarthritis in conjunction with fever, lymphadenopathy, and splenomegaly. About 15% - 20% of patients experience intermediate onset of symptoms, which appear over the course of days to weeks.6815 In addition, RA can present as a monoarthritis of either acute or subacute onset. In RA, radiographs Imaging in Rheumatoid Arthritis of the joints of the feet show damage more often and earlier than the joints of the hand.10084
Articular Features of Rheumatoid Arthritis - Signs and Symptoms of Articular Disease
Classic symptoms of rheumatoid arthritis (RA) are pain, stiffness, and swelling of the peripheral joints. Soft Tissue Swelling and Juxta-Articular Osteoporosis Signs and Symptoms Pain in affected joints, aggravated by movement, is the most common manifestation of established RA. Pain does not always correlate with the degree of apparent inflammation. Clinical Manifestations of Rheumatoid Arthritis Radiographic evidence ( Radiographic Assessment of Rheumatoid Arthritis, Evaluating the Development of Erosions) of retardation of disease progression in RA was first reported in the 1970s.10873 A disconnect between signs and symptoms and radiographic damage has been observed, both in patients (more typically managed with traditional disease-modifying antirheumatic drugs [DMARDs]) who are well controlled for signs and symptoms, but who still progress radiographically,4554 and an opposite disconnect in patients (more typically on biologic therapy) whose signs and symptoms of RA are poorly controlled, but who do not progress radiographically.4556 Molenaar, et al., also found a disconnect between signs and symptoms and radiographic progression in 187 patients who had been treated with traditional DMARDs. These researchers observed that new erosions developed in previously unaffected joints in 15% of patients judged to be in persistent clinical remission of their RA using a modification of the American College of Rheumatology criteria (“fatigue” was omitted). These patients were allowed to take DMARDs and nonsteroidal anti-inflammatory drugs. The authors suggested that the absence of ongoing structural joint damage be added to the criteria to define clinical remission.10858
Articular Disease and Pain: Joints with rapidly evolving effusions, as seen in early disease, or swollen joints with an applied load, may be extremely painful. This is due, in part, to excessive stresses on the extensively innervated, periarticular supporting structures.10731 Warmth is typically palpable on large joints, particularly during the early course of the disease.
Early in the disease process, there is an influx of inflammatory cells into the synovial membrane and this inflammatory process is accompanied or mediated by angiogenesis, infiltration of chronic inflammatory cells, proliferation of synovial cells, marked histological changes, and ultimately macroscopic synovial hyperproliferation.10731 Joint edema, Fig.2987 detectable by magnetic resonance imaging, Magnetic Resonance Imaging results from accumulation of synovial fluid, hypertrophy of the synovium, and thickening of the joint capsule.7189 A doughy texture may be apparent on examination of the proximal interphalangeal (PIP), metacarpophalangeal (MCP) ( Fig.2688), elbow, ankle, and metatarsophalangeal (MTP) joints in the presence of marked synovial proliferation.
Patients may complain of puffy hands secondary to increased blood flow to inflamed areas, tenosynovitis, and edema. Without the use of imaging technology ( Imaging in Rheumatoid Arthritis), detection of hip and shoulder edema may be difficult unless it is severe in nature.
Figure 2987 – Bone Edema Evident on MRI
Boninger ML, Towers JD, Cooper RA, Dicianno BE, Munin MC. Shoulder imaging abnormalities in individuals with paraplegia. J Rehabil Res Dev. 2001;38(4):401-408.
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Joint stiffness is a major symptom of RA, and is often accompanied by significant stiffness throughout the day that may, at times, in itself, be disabling.10731 Edema of the synovium and periarticular structures contributes to the stiffness in RA by mechanically interfering with the usual motion of the joint. Although stiffness is usually most prominent around clinically involved joints, generalized morning stiffness, a feeling that all muscles have “gelled” or thickened, is also characteristic of RA. Initially, the joints most frequently involved in RA are the MCP joints ( Fig.2688), PIP joints, MTP joints, and the wrists.
Figure 2688 – Metacarpophalangeal (MCP) Joint
Metacarpophalangeal joint.http://en.wikipedia.org/wiki/File:Gray338.png. Accessed July 14, 2009.
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The joints most commonly affected are those with the highest ratio of synovium to articular cartilage. Large-joint synovitis appears to occur following small joint inflammation. Guerne, et al., evaluated the distribution of joints involved in RA flares in 227 patients.6815 Fig.1015 lists the joints and frequency of flare during attacks.6815
Figure 1015 – Distribution of Joints Involved in Attacks Based Upon a Cumulative Experience
Table 66.2, Page 1047 in Harris ED, et al, eds., Kelley’s Textbook of Rheumatology, Vol. II, 7th ed., Philadelphia, PA, WB Saunders. Clinical Features of Rheumatoid Arthritis II; 2004:1043-1054 is used with permission of Elsevier Inc. All rights reserved.
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Ulnar Deviation Deformity
Ulnar deviation, also known as ulnar drift, is a hand deformity that is more commonly a characteristic of patients with rheumatoid arthritis (RA) rather than osteoarthritis. Fig.1016 The swelling Soft Tissue Swelling and Juxta-Articular Osteoporosis of the metacarpophalangeal joints (the big knuckles at the base of the fingers) and poorly controlled inflammatory activity in RA leads to bone erosions and destruction of the joint surface, which impairs the range of motion of the joint and leads to joint disarticulation and deformity. Shortening of the intrinsic muscles of the hand due to inflammation is part of the etiology of this deformity. The term ulnar deviation comes from the displacement of the fingers toward the ulna (as opposed to radial deviation, in which fingers are displaced toward the radius).6815, 10731
Figure 1016 – Ulnar Deviation Deformity, an Artist’s Depiction
MP Ulnar Deviation. 3-Point Products website. http://www.3pointproducts.com/uploads/UlnarDeviationlabel.jpg. Accessed March 7, 2007.
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Boutonniere Deformity
Boutonniere deformity refers to a finger that has hyperflexion at the proximal interphalangeal joint with hyperextension at the distal interphalangeal joint (the finger is toward the palm at the joint nearest the knuckles and bent back away from the palm at the joint furthest from the knuckles). This deformity occurs subsequent to inflammatory activity in poorly controlled rheumatoid arthritis.6815, 10731
Swan Neck Deformity
Swan neck deformity is characterized by hyperextension at the proximal interphalangeal joint and hyperflexion at the distal interphalangeal joint. The most common cause is rheumatoid arthritis.6815, 10731
Z-Thumb Deformity
The Z deformity, also known as "gamekeeper’s thumb," is seen at the thumb and consists of hyperextension of the interphalangeal joint of the thumb, and fixed flexion and subluxation of the metacarpophalangeal joint. It is a characteristic of poorly controlled inflammation in patients with rheumatoid arthritis. Fig.1019.7173
Figure 1019 – Z-Thumb Deformity With Superimposed X-ray
van Vugt RM, Derksen RH, Kater L, Bijlsma JW. Deforming arthropathy or lupus and rhupus hands in systemic lupus erythematosus. Ann Rheum Dis 1998;57(9):540-544, Reproduced with permission from the BMJ Publishing Group. http://group.bmj.com/products/journal.
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Deformity
Joint deformities develop over time as articular and supporting structures are damaged by the inflammatory process.10731 Joint effusions can lead to stretching of tendons and ligaments, resulting in deformity. Cartilage degradation due to enzymatic and mechanical injury, coupled with stretching and atrophy of the periarticular ligaments and associated structures, allows forces acting across joints to deform them. When this cartilage degradation progresses unabated, the supporting structure of the joints becomes so compromised that the joint can become subluxed leading to irreversible deformity. A study of 100 RA patients with a mean disease duration of approximately 1 year found that 33% of patients developed at least 1 hand deformity after 20 months of disease.10185 The majority of deformities reported include ulnar deviation (13%) ( Ulnar Deviation Deformity), boutonniere or button-hook (16%) ( Boutonniere Deformity), and swan neck (8%) deformities ( Swan Neck Deformity). Patients with deformities had significantly greater disease activity and radiographic scores compared with controls.
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