Expertise Details





• RA is a chronic inflammatory joint disease with multisystem involvement.

• Females are affected three times more often than males (3: 1).

• Onset is usually during fourth and fifth decades of life.

• Factors producing RA include infectious trigger, genetic predisposition and autoimmune response. The role of genetic influences in the aetiology of RA is marked by association with HLA-DR4 in 70% of patients.

Clinical Features


• Insidious onset with fatigue, anorexia, weakness and vague musculoskeletal symptoms.

• Acute onset with rapid development of polyarthritis accompanied by constitutional symptoms including fever, lymphadenopathy and splenomegaly.

• Palindromic onset where recurrent acute episodes of joint pain and stiffness occur in individual joints lasting only a few hours or days.

Articular Manifestations

• Joint involvement is usually symmetric. It is characterised by pain, swelling, tenderness and painful limitation of movements.

The metacarpophalangeal and proximal interphalangeal joints of the hands, wrists, knees, and the metatarsophalangeal and proximal interphalangeal joints of the feet are the most common joints involved.

• Generalised stiffness may occur but "morning stiffness" lasting more than l hour is a characteristic feature. The intensity and duration of morning stiffness is a measure of disease activity. Some of these patients eventually develop a well-defined rheumatic disease, the most common being rheumatoid arthritis.

Hand and Wrist

• Swelling of the proximal, but not the distal interphalangeal joints result in "spindling" of the fingers.

• Hyperextension of the proximal interphalangealjoints with flexion of the distal interphalangealjoints results in "swan-neck" deformity.

• Flexion of the proximal interphalangeal joints and extension of the distal interphalangeal joints result in "boutonniere" or buttonhole deformity.

• Hyperextension of the first interphalangeal joint and flexion of the first metacarpophalangeal joint with a consequent loss of thumb mobility and pinch can occur.

• Extensor tendon rheumatoid granulomata and tendon rupture result in "dropped finger".

• Radial deviation of the wrist with ulnar deviation of the digits often with palmar subluxation of the proximal phalanges results in the "Z" deformity.

• Wrist synovitis with median nerve entrapment can result in carpal tunnel syndrome.

• Whole of hand may be swollen in very acute cases with pitting oedema over dorsum giving rise to the "boxing glove" appearance.

Foot and Ankle

• Swelling of the metatarsophalangeal joints results in "broadening" of the forefoot.

• Lateral deviation and dorsal subluxation of the toes.

• Plantar subluxation of the metatarsal heads.

• Eversion at the hindfoot (subtalar joint).

• Hallus valgus deformity.

Other Joints

• Flexion contractures of elbows, wrists, knees and hips.

• Shoulder joint involvement can occur as glenohumeral arthritis, rotator cuff fraying and rupture.

• Cervical spine involvement can result in atlanto-axial subluxation with progressive spastic quadriparesis.

• Cricoarytenoid joint involvement results in hoarseness of voice and stridor.

• Pain and swelling behind the knee can result from extension of inflamed synovium into the popliteal space (popliteal cyst or Baker's cyst).

Rheumatoid Nodules

• These develop in 25% of persons with RA. They are firm, round masses felt in the subcutaneous tissues-e.g. the olecranon bursa, the proximal ulna, the Achilles tendon and the occiput Visceral structures like heart, lungs and pleura may also be involved.

• Rheumatoid nodules are clinical predictors of more severe arthritis, seropositivity, joint erosions and rheumatoid vasculitis.


• Diagnosis of RA should be considered in patients with bilateral, symmetric, inflammatory polyarthritis involving small and large joints, with sparing of the axial skeleton except the cervical spine.


• Markers of acute inflammation-raised ESR, anaemia, thrombocytosis, increased levels of acute phase proteins [e.g. C-reactive protein (CRP)] and increased plasma viscosity.

• Rheumatoid factor.

• Anti-citrullinated protein antibodies (ACPA), usually detected by anticyclic citrullinated peptide (CCP) antibodies.



• Radiographs of the affected joints may be useful. The characteristic radiological changes are symmetrical pattern of involvement, juxta-articular osteoporosis, soft tissue swelling, bone erosions and joint space narrowing.

• Ultrasonography and MRI have greater sensitivity than plain radiographs for the detection of soft tissue synovitis before joint damage.


• Rest and splinting of the joints should be instituted in the acute stage of illness.

• Active and passive physiotherapy helps in mobilisation and prevention of contractures.



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