Rheumatoid arthritis (RA) is a chronic autoimmune and inflammatory condition that primarily targets the joints, causing joint stiffness, swelling, and pain. An autoimmune disorder, RA occurs when your immune system — which typically protects your body by fending off infections such as viruses, bacteria, or helping you heal after injuries — mistakenly launches an attack on your joints. This immune attack causes damage to the joints, making them painful, swollen, and stiff.
While many joints can be affected by RA, the joints of the hands, wrists, feet as well as the elbows, shoulders, hips and knees often bear the biggest brunt of rheumatoid arthritis. However, while it can happen, it is unusual for RA to affect the spine.
Interestingly, RA is often ‘symmetric’ which means that the joints on both sides of the body are attacked equally on both sides of the body. This means if one wrist or elbow is affected, the other wrist or elbow will most likely be affected as well. It’s this ‘symmetry’ that helps clinicians initially tell RA from other forms of arthritis that can often occur such as gout which typically only affects 1 or 2 joints at at time, or other forms of arthritis such as ankylosing spondylitis, psoriatic arthritis (PsA), and osteoarthritis (OA) which also can commonly involve the spine.
While the joints are the most common parts of the body affected, because RA is a systemic condition (the term for a disease that affects the whole body), it also impacts the:
- Blood (e.g. anemia)
- Bones (e.g. osteoporosis)
- Skin (e.g. nodules)
- Respiratory system (e.g. lung disease)
- Cardiovascular system (e.g. atherosclerosis)
How common is RA?
Even though it’s not the most common form of arthritis, RA isn’t considered a rare disorder. According to the Arthritis Foundation, around 1.5 million Americans currently have physician-diagnosed rheumatoid arthritis, which translates to nearly 0.5 percent of the US population. 41 out of every 100,000 people in the U.S. are diagnosed with RA annually.
Women are three times more likely to develop RA than men, with a lifetime risk of 3.6 percent, according to a 2011 study. In women, the onset of the disease is usually between the ages of 30 and 60, whereas in men it can start developing a little later in life.
Because the damage to the joints can be irreversible, the key is to get diagnosed early when it can still be treated much more effectively.
Keep reading to learn everything you need to know about rheumatoid arthritis.
Signs and symptoms of RA
Early stages of RA
At the onset of RA, a person may experience mild symptoms like pain, warmth, or swelling at the joints. In some individuals this can come on gradually, and slowly build over time first in one joint, then another until multiple joints are affected. In others, it may be explosive with multiple joints becoming affected over a few days. In others, the joint symptoms may come and go, with days or weeks of feeling ‘normal’ in between ‘flares’ due to triggers like stress, activity, or stopping medication.
Early diagnosis is the key to preventing or minimizing joint damage over the long haul.
Inflamed joints will gradually become stiff, making them difficult to move and to use. For example, if your hand joints are affected, you may not be able to make a tight grip; or, if your elbow joints are affected, you may not be able to completely fold, bend, or flex your arms. Stiffness normally starts in smaller joints, particularly in your hands, before advancing elsewhere. As discussed below, often in RA joint stiffness is worse after periods of activity, such as in the morning after a night’s sleep, or after prolonged sitting.
One of the hallmarks of RA is joint stiffness that is typically much worse after a lengthy period of inactivity, which is mostly in the morning or after naps. This is often referred to as morning stiffness if it occurs after sleep, and ‘gelling’ if it occurs during the day after inactivity. Morning stiffness is one of the earliest signs of any autoimmune or inflammatory arthritis. That’s why it is very common in people who have RA. Although it is a shared symptom across all forms of arthritis, morning joint stiffness often lasts longer in RA. In the early days of RA, however, it can last for a few minutes but worsens over time - and in some individuals can last for hours a day. In comparison, in osteoarthritis, it usually takes no more than 30 minutes for joints to become flexible and feel loose again in the morning. However, even in RA, movement can help improve the morning stiffness.
The joint inflammation in RA can cause swelling of the joint lining, or cause the generation of too much joint fluid. This can make your joints look and feel larger than usual. This can be subtle, especially in the early days of RA, and something you feel more than see. However, over time it can develop into swelling that is noticeable to the eye. While swelling can happen all by itself, it is usually accompanied by tenderness, warmth, redness, and pain at the affected joints.
Mild to severe joint pain is the primary symptom of all forms of arthritis, and it is also prominent in RA. Inflammation inside or around the joints makes them painful whether you are engaging them or resting. Frequently, this follows joint stiffness and occurs alongside tenderness and redness. The type of pain linked to RA is often an aching and throbbing pain that’s typically more severe in the mornings, after naps, and following a spell of inactivity.
Unsurprisingly, your wrists and fingers are the most common spots of pain in the early stages of rheumatoid arthritis. However, you may also feel pain in the joints of your shoulders, ankles, feet, and knees.
As discussed above, joint pain associated with RA is symmetrical (sometimes called bilateral), which means it equally affects the same joints or limbs on both sides of your body. For example, if you experience joint pain in one of your wrists, the other wrist will probably be painful, too.
Depending on the individual, joint pain, stiffness or swelling may be the ‘first’ thing they notice when they first get RA; however, for most individuals pain and/or stiffness are the earliest symptoms.
Joint warmth and redness
Inflammation generates a significant amount of heat and puffiness. As a result, inflamed joints usually become warm (or even hot) to the touch and will change in color. In many cases, the joints develop redness around the site of inflammation. Joint redness and warmth typically happen alongside swelling and pain.
Did you know that fatigue is one of the earliest signs of RA? You may start to feel unusually fatigued several weeks if not months before additional symptoms appear. As such, while there are certainly many causes of fatigue, if you feel abnormally tired and weak, these could be early signs of RA. In addition, in RA, a feeling of tiredness or exhaustion can come alongside depression, anxiety, stress, and other signs that indicate you are unwell. But, even if you don’t have any joint symptoms, as a rule of thumb, you should never ignore any fatigue that lasts unusually long. Keep in mind that there are many other potential causes of fatigue, including anemia, thyroid problems, depression, and chronic infection.
Reduced range of motion
Reduced range of motion is directly related to joint stiffness, pain, swelling, and inflammation. This can occur in early RA and improve with treatment. However, if joint damage occurs, the reduced range of motion may be permanent.
In the early stages of the disease, you may experience symptoms in other parts of your body. Like the point about fatigue mentioned above, you may feel overall weak, fatigued, or generally ill, without any other cause. Your mouth may feel dry, and the eyes may become itchy, dry, and inflamed. In some cases, the eyes of a person with RA may produce excess discharge. In the early days, you may lose appetite and later have more severe weight loss. Chest pain/discomfort when breathing, difficult in falling asleep, and bumpy skin are other early signs of RA.
In some cases, inflammation in the wrist can pinch the nerves to the hand and cause carpal tunnel syndrome that can feel like numbness, tingling or pain in your fingers. Very rarely individuals with RA may feel feverish; however, that is rare in RA and therefore any fever should be investigated carefully to make sure that there is no infection or other condition.
It’s important to see a physician right away if you suspect you have symptoms of RA, especially persistent pain and swelling in your joints. Diagnosing RA quickly is crucial because early treatment can help reduce the risk of further joint damage, deformity, and disability, as well as prevent symptoms from getting worse.
If rheumatoid arthritis is left undiagnosed or uncontrolled
If left undiagnosed or uncontrolled, RA can have far-reaching health consequences - even beyond joint function and damage. That is why you should get tested and treated as soon as possible to avoid further damage to joints, cartilage, and other dangers of untreated RA. Remember, this is an autoimmune condition that can strike at any age, regardless of your race, gender, or ethnicity.
Unfortunately, many people with RA are undiagnosed and therefore untreated because they don’t know they have the disease. Others downplay their symptoms. But if you think an RA diagnosis should wait, think again. While joint damage and loss of function is the major problem with undiagnosed or uncontrolled RA, it can also develop into several long-term complications such as:
- Heart problems including premature heart attacks
- Lung problems
- Eye problems
- Skin problems
- Even early mortality
Causes and risk factors of rheumatoid arthritis
What causes the immune system to become abnormal in RA patients still puzzles the medical community. However, what scientists know is that there must be a trigger. Extensive scientific research and clinical trials have been conducted to establish some of these triggers.
Even though more research is still needed, scientists believe that there are some specific factors that trigger or play a role in the development of RA:
While most individuals who develop RA do not have a family history of RA, there’s a growing body of research and clinical evidence that family history and genetic predisposition may play a significant role. Even though the risk of inheriting the condition is minimal, rheumatoid arthritis tends to run in families, which shows genes are responsible to some extent. In particular, several studies suggest some familial and/or genetic effects:
In one study involving sets of twins, British investigators noted that rheumatoid arthritis occurred in 15 percent of the sets of identical twins, as opposed to 4 percent of non-identical sets of twins. These results are nearly identical to another 2013 Danish twins study.
As of this date, scientists have discovered more than 100 genetic alterations that happen more prominently in people with rheumatoid arthritis. For instance, in a 2011 study, researchers have found that people with gene variants called ‘HLA-DRB1’ are five times more likely to develop RA than the general population. However, not all patients with RA have known genes. And the opposite is also true – not everyone with these genes eventually gets rheumatoid arthritis. Because of this, at this time, genetic testing is not usually done to diagnose RA.
Traditionally, women are at a two to three times greater risk of developing RA than men. About 1-3% of all women may get RA in their lifetime! This has led scientists to believe that factors associated with female biologic sex may play a role in risk for RA. While not known exactly, these factors may include hormones, the number of births, or breast feeding. The research findings, however, are conflicting; and more needs to be learned before we know what exactly about being female is related to RA.
While nothing is proven yet, scientists hypothesize that certain infections like viruses or bacteria may increase the chances of getting RA. This is an area of interest because if a certain microbe was identified in RA, treating it could lead to improved treatments - or even prevention. However, much more needs to be learned.
Even though rheumatoid arthritis can start at any age, the onset is most common between the ages of 40 and 60. Because of this, there may be factors related to aging that contribute to the risk of getting RA.
Having significant extra weight has been found to increase the chance of developing RA, especially in women under the age of 55.
Smoking has been shown in multiple studies to be one of the strongest risk factors for getting rheumatoid arthritis. In addition, if someone smokes with rheumatoid arthritis, they are at risk for more severe joint damage as well as things such as heart and lung disease. As such, it is strongly recommended that anyone with RA stop smoking - and for general health, anyone who is smoking should stop!
Exercise and healthy eating
Several studies suggest that lack of exercise may be a risk for getting RA. In addition, some studies suggest diets such as the Mediterranean diet that is rich in whole grains, fruits and vegetables, and low in animal products may protect against getting RA. While not yet well-proven to protect against getting RA, since exercise and healthy diet may be of broad benefit for other conditions such as heart disease and cancer, people at risk for RA may consider adopting exercise and a healthy diet!
Getting tested for RA
Diagnosing RA can be quite challenging, and it’s easy to understand why. Many symptoms of RA, especially in early disease, are non-specific and often vary from person to person. In addition, there is no single test for diagnosing RA.
Even still, you shouldn’t ignore symptoms. If you suspect that you have any of the above symptoms, get in touch with your physician quickly so you can get started with diagnosis. Because no single symptom, test or othe finding alone is enough to diagnose RA, your doctor will likely ask you a number of questions, do a thorough physical examination and request a battery of lab tests.
Medical history and physical examination
During your initial visit, your doctor will most likely ask you a series of questions about your joint symptoms including location (e.g. what joints, and if on both sides of the body), severity, and type of symptoms (e.g. pain, stiffness or swelling). They will also perform a physical examination, making sure to check for obvious signs of rheumatoid arthritis. They may touch your joints for signs of tenderness or warmth, swelling and normal range of motion.
Your health-care provider will also ask a series of questions particularly about your family history, personal clinical history, and other risk factors. You will also need to have blood tests or imaging tests done to confirm a suspected diagnosis.
Joint scans and imaging tests
Your health-care provider will probably order a series of images tests, especially those that will scan your joints for damage, and inflammation. Though image scans may not conclusively diagnose RA, they can help your doctor differentiate RA from other forms of arthritis. It can also help your doctor track the progress of the disease. The most common image tests that can aid your physician in gauging the severity of the disease, and monitor the progress over time include:
- X-ray exam – An X-ray test will help show (if any) deformities, erosion, and damage in your joints. X-rays might be normal in early arthritis, but can be useful to see if the disease is progressing.
- MRI scan – This test helps provide a clearer picture of the affected joints especially if the physical examination and plain x-rays do not show any clear problems.
- Ultrasound test – Like an MRI scan, an ultrasound test can help the doctor detect the condition early, and see the severity of the disease.
If the joint damage is not visible via imaging tests, it may not rule-out RA. It could mean that the disease is in its early stages.
Blood tests for rheumatoid arthritis
In addition to the history and physical examination and imaging, the work-up for RA nearly always includes blood tests. Common blood tests include antibody blood testing. As the name suggests, these are blood tests that screen for the presence of antibodies linked to rheumatoid arthritis such as:
- Rheumatoid factor (RF) test
- Anti-CCP test
- Antinuclear antibody test (ANA)
- Erythrocyte sedimentation rate
- C-reactive protein test
- Complete Blood Count
Learn more about these tests in our guide to RA testing.
Rheumatoid arthritis treatment options
There’s no known cure for RA; however, there are numerous treatment options that can help you manage the condition better, and live a fuller and happier life.
As such, the aims of most RA treatments are:
- Relieve symptoms of rheumatoid arthritis, such as pain, swelling, redness, fatigue, etc.
- Prevent further damage to joints and harm to organs or parts of the body
- Improve overall health, well-being, and quality of life
- Reduce disability and other long-term complications
There are many medications geared towards rheumatoid arthritis. Some of them help reduce inflammation, while others slow down or prevent joint damage.
Medications that relieve the symptoms
Acetaminophen, and nonsteroidal anti-inflammatory drugs (NSAIDs) are the most available OTC (over-the-counter) meds for relieving symptoms such as inflammation and pain.
You may need a prescription for other NSAIDs. In most cases, these are taken orally, but they can also be applied transdermally. Here think of naproxen sodium, ketoprofen, and ibuprofen.
Importantly, while these drugs may make people with RA feel better temporarily, they do not prevent the joint damage or long-term complications of RA. As such there is a need for drugs in RA that act as ‘disease modifying’ or DMARDS. These are discussed below.
Medications that reduce or slow down RA damage:
Drugs shown below are commonly prescribed to help slow down or prevent damage caused by rheumatoid arthritis:
- DMARDs: Short for disease-modifying antirheumatic drugs, DMARDs help “modify” the course of your condition. As such, these medications help stop or slow down rheumatoid. They work by blocking the response of your immune system, stopping RA right at the gate. Methotrexate is the most commonly prescribed DMARD, but others like leflunomide, hydroxychloroquine, and sulfasalazine are also commonly prescribed.
- Steroids: Drugs like prednisone can work quickly to control the inflammation in RA, and they can act as DMARDS. However, steroids have many side-effects and as such nowadays many health-care providers try and limit the dose and duration that steroids are used for RA.
- Biologics: They belong to the same group as DMARDs; however, unlike traditional DMARDs that are in pill form, many biologics can be administered via injection or infusion. The special thing about biologics is that they tackle inflammation at a specific step, which means they don’t eliminate the entire immune system response. Those on biologic medications can develop other autoimmune disorders.
- Janus kinase (JAK) inhibitors: These are a newer set of drugs that help block specific immune responses. In many patients with RA, JAK inhibitors can help stop joint damage and prevent inflammation.
Surgery is a corrective treatment option that is recommended if your joints are seriously damaged or the inflammation is unbearable. In a lot of cases, your doctor may recommend the replacement of one or more of your affected joints. You can also have your knees and hips replaced, and even the shoulders. Ideally, surgery should help improve mobility, reduce pain, and eliminate inflammation. A number of patients don’t get surgery until they are 50 or older. And, good news is that with modern medications for RA, joint surgery in RA is becoming much less common!
Your physician may recommend that you work with an occupational therapist and/or physiotherapist to help you deal with your RA symptoms. In some instances, you may have to see a cognitive therapist or podiatrist.
- Occupational therapy: RA and its symptoms can impact your daily life, and seeing an occupational therapist can come in handy. Occupational therapy will help you train and learn how to protect your joints, both while at work, on the commute, and at home. Using supportive devices may also help you.
- Podiatry: If your RA has affected your feet, ankles, or toes, podiatry may be what the doctor prescribed. You may be prescribed a device that will support your foot joints and relieve pain.
- Physical therapy: When you have RA, it is important to stay on top for your muscle strength, fitness, joint flexibility, and overall well-being. A physical therapist can help you every step of the way.
- Psychotherapy: RA can subject you to immense pain, discomfort, and emotional stress. A psychotherapist will help you improve your psychological and emotional well-being so you can pace yourself, relax, and better deal with stress.
When you’re experiencing intense joint pain, inflammation, and stiffness, exercise may not jump to your mind. However, it could be the answer to improving your flexibility, getting rid of pain, increasing mobility, and helping your joints regain their range of motion.
Low-impact workouts and exercises can also help you build muscle strength, and reduce the impact on your joints. Mindful exercises like yoga, shiatsu, and meditation can help you reinforce your mental and emotional strength.
You may also need to get in touch with a good dietician or nutritionist. No matter who you work with, you will need to embrace an anti-inflammatory diet such as the Mediterranean diet. There are some variations but in general anti-inflammatory diets are rich in whole grains, fruits and vegetables, omega-3 fatty acid rich foods including including oily fish (mackerel, herring, tuna, river trout, and salmon), walnuts, flax seeds, and chia seeds, and contain limited animal products such as red meat and dairy.
When to call a doctor
Pain, swelling, and stiffness in your joints can all be signs of RA. However, they can be symptoms of a whole range of conditions.
The only way to be sure is to get a conclusive diagnosis. Early diagnosis and treatment can make a huge difference.
Remember, it’s important to see a physician right away if you suspect you have symptoms of rheumatoid arthritis, especially persistent pain and swelling in your joints.
Diagnosing RA quickly is crucial because early treatment can help reduce the risk of further joint damage, deformity, and disability, as well as prevent symptoms from getting worse.