Understanding Rheumatoid Arthritis Signs and Symptoms

Rheumatoid arthritis (RA) is an autoimmune disease that primarily affects the joints but can also affect other body areas, including the skin, eyes, lungs, heart, and nerves. It will affect the same joints on both sides of the body, with the hands and wrists as the most affected joints.

RA causes the joints to be swollen, tender, and stiff. Additional symptoms include fatigue and fever. Symptoms of RA typically come on gradually and will worsen over weeks and months. They will improve over time with treatment.

This article will cover early RA symptoms, common and uncommon symptoms, flare-ups, getting a diagnosis, and more.

How Do Early Rheumatoid Arthritis Symptoms Start?

RA symptoms occur because the immune system mistakenly attacks its own healthy tissues. Researchers don't know what starts this process, but they suspect genetics and different environmental factors play a part. 

For many people, RA symptoms may start in one joint, but it almost always affects multiple joints in a symmetrical fashion. It can affect the fingers, hands, wrists, toes, feet, and ankles. Symptoms of RA often start between the ages of 20 and 50, but they can also affect young children and older adults.

Location

The earliest signs of RA will come gradually and sometimes before joint pain and stiffness become evident. These early signs are systemic (affecting the entire body) in nature and include fatigue, low-grade fever, weight loss, and malaise.

Fatigue is the body's response to inflammation. Most people with RA experience fatigue and find it to be one of the most challenging symptoms of the condition.

Low-grade fevers are the earliest subtle signs of RA and are considered a feature of systemic inflammation. Normal body temperature is between 97 and 99 degrees F, and a low-grade fever ranges from 100.4 to 102.2 degrees F.

Weight loss in RA is related to other disease symptoms. For example, early symptoms of RA include appetite loss and gastrointestinal (GI) symptoms like diarrhea, nausea, and vomiting. These symptoms can lead to unintentional weight loss. Weight loss once on treatment can also occur.

A 2016 Arthritis & Rheumatology study found that people with RA who took the disease-modifying antirheumatic drug (DMARD) Arava (leflunomide) to treat RA were more likely to experience weight loss compared to other treatments, including methotrexate and prednisone.

Malaise is a general feeling of unwellness. It occurs because your immune system is attacking healthy tissues, which leads to inflammation, pain, and swelling in the joints and body tissues.

Early joint symptoms include pain with the movement of small joints, such as the fingers of the hands. Pain and stiffness in RA will affect the same joints on both sides of the body, although that may not always be the case early on.

Morning stiffness is another early sign of RA. You might find your joints stiff and immobile when you first wake up. Stiffness will last 30 or more minutes and improve as you move and warm up your joints. Morning stiffness can affect any of your joints, but it most commonly affects the hands, feet, and knees.

Feeling

Joint pain in early RA starts as mild and intermittent discomfort. When RA flares up, the joints will swell up due to the thickening of the synovium (joint lining).

The most commonly affected joints in RA are:

• Hands and fingers 
  
• Wrists 
• Ankles 
• Feet 
• Neck
• Shoulders 
• Elbows 
• Hips 
• Knees
  

Joint symptoms in RA can occur with rest and movement. Symptoms include joint swelling, burning sensations around joints, and warmth and redness around affected joints.

Joint stiffness may interfere with daily activity, including activities that require coordination (buttoning clothing) and grip (holding a comb). If your knees, ankles, or feet are swollen, walking and standing might be painful and increase fall risk.

Systemic symptoms like fatigue, fever, and malaise can present with RA inflammation and joint symptoms. These symptoms tend to show up before joint inflammation and vary throughout the day and from day to day. People who experience a low-grade fever might also feel cold and sweaty and have headaches, body aches, loss of appetite, or flushed skin.

RA fatigue can be quite severe and debilitating, and it affects up to 75% of people with RA. Fatigue linked to RA inflammation is more than just being tired. It causes you to feel depleted mentally and physically. 

People who experience malaise in RA might describe it as mild flu-like symptoms or what a person feels when they start to feel sick. Malaise might be accompanied by weakness, unease, fatigue, mild nausea, and lack of appetite. 

When RA progresses, it can lead to inflammation in other body areas, including: 

• Eyes
• Skin 
• Heart
• Lungs 
• Kidneys 
• Blood vessels 

Common and Uncommon RA Symptoms

The symptoms of RA vary in severity and may come and go. You may experience periods of flare-ups, when symptoms are present, and periods of remission, when symptoms ease. 

Common RA symptoms are:

• Pain and stiffness of more than one joint 
• Morning joint stiffness
• Joint tenderness and swelling 
• Decreased range of motion
• Fatigue 
• Malaise 
• Low-grade fever  

RA is also known for causing symptoms called extra-articular manifestations. These symptoms affect other body areas and result from ongoing, uncontrolled inflammation.

Such symptoms include:

• Skin rash: This includes rheumatoid nodules—small lumps of tissue just below the skin over bony (i.e., the heels, elbows, knees, and fingers) areas.
• Numbness and tingling: RA leads to nerve conditions that cause these symptoms, or blood vessel problems from a condition called rheumatoid vasculitis.
• Eye irritation: The same inflammation that affects the joints can also affect the eyes and cause blurred vision, eye pain, and dry eyes.
• Breathing troubles: Lung inflammation from RA can lead to conditions like interstitial lung disease, pulmonary fibrosis, and pleuritis, which cause shortness of breath, dry cough, and chest pain.
• Sleep problems: RA can affect your ability to get a good night's sleep. This might be due to pain, as a side effect of the medications used to treat the condition, or as a symptom of the condition.
• Cognitive issues: RA and the medications used to treat it can affect concentration and memory loss.
• Digestive troubles: RA can affect the liver, pancreas, and other organs in the digestive system, leading to symptoms like abdominal pain, diarrhea, and constipation. 
• Mood disorders: People with RA are more likely to experience depression and anxiety compared to others in the general population. These mood disorders can affect treatment response and lead to higher disease activity, mainly fatigue and body pain.
• Heart troubles: Chronic inflammation can increase your risk for heart problems. It can damage blood vessels and lead to plaque buildup in the arteries. Having additional risk factors like high blood pressure and obesity can add further risk for people with RA. Cardiovascular disease is the most common cause of death in people with RA.
  

Flares: When RA Symptoms Get Worse 

RA is characterized by periods of flare-ups, which are unpredictable. They can come on suddenly and get worse quickly. They may last a day or two, weeks, or months. Signs of a flare may include painful joints, morning stiffness, increased fatigue, malaise, or a low-grade fever. 

Most times, it is hard to predict what has caused a flare. Still, in some cases, an RA flare can be triggered by a cause, such as mental stress, physical overexertion, illness, weather changes, or by eating foods considered inflammatory. 

Most flares can be managed with rest, medication, and home remedies, such as hot and cold therapies.

Getting a Rheumatologist Referral to Diagnose Symptoms 

Seeing a rheumatologist is essential if your joints have been sore and stiff for several weeks. A rheumatologist is a medical doctor (M.D.) specializing in musculoskeletal and autoimmune joint disorders. 

Your insurance company might require a referral from your primary care provider. You will want to check their referral requirements and what your plan will pay for visits and treatments. 

You'll want to prepare for your visit with the rheumatologist in the following ways:

• Keep a symptom log: Try to be specific by listing affected joints and what pain in those joints feels like (i.e., throbbing, aching, burning, intermittent, contact, etc.). If you have other symptoms, such as fatigue and low-grade fever, you will want to log those, too.
• Know your medical history: Write down all medical problems, past and present, including surgeries, illness, broken bones, and allergies. You will also want to have a list of prescription and over-the-counter (OTC) medicines on you so you won't have to rely on your memory. 
• Write down questions: You will not recall what you want to ask once you are at your appointment, so having a short list of important questions can help.
• Take someone you trust with you: Taking a loved one with you for your first rheumatology visit is helpful. Having someone with you who can take notes and remind you of questions you may have forgotten can help you make the most of the visit.

How to Manage Undiagnosed RA Symptoms

RA inflammation can lead to severe joint damage. Treatment is vital to slowing down joint damage and improving health outcomes, but getting a diagnosis can take some time. 

If you are living with joint symptoms and awaiting an accurate diagnosis, you can take the following measures to manage joint symptoms:  

• Keep moving: Exercise can help strengthen the muscles around the joints and help you to manage fatigue. Try gentle exercises like yoga, tai chi, and simple stretching to ease pain and improve balance and flexibility. 
• Apply cold or heat. Cold can bring down inflammation and dull pain, while heat can ease joint pain and muscle tension.
• Manage stress. Find healthy ways to cope with pain and other stressors in your life.
• Pay attention to your diet. Although there is no solid evidence of a link between RA and diet, many studies show that inflammation caused by RA can be reduced by adding and removing certain foods from your diet. For example, processed foods are believed to increase inflammation, while foods like fatty fish and olive oil can reduce inflammation. Consider increasing your consumption of fruits, vegetables, and cold water fish (i.e., salmon, mackerel, etc.) to improve RA symptoms and reduce the risk for flare-ups.
• Try OTC pain relievers: OTC nonsteroidal anti-inflammatory drugs (NSAIDs) like Advil or Motrin (ibuprofen) and Aleve (naproxen sodium) can relieve pain and reduce inflammation. Take these medications according to the product's labeling and only as needed. Overuse and long-term use can lead to adverse effects, including stomach irritation and heart and kidney troubles.

Treatment Overview With Diagnosed RA Symptoms 

RA is a progressive condition that will worsen over time. Fortunately, healthcare providers know the disease will go through stages if not adequately treated. They also know how to treat RA successfully.

Disease stages are:

• Stage 1 or early RA: In this stage, you will experience the earliest symptoms, such as morning stiffness and pain in the small joints of the hands and feet. You will not have visible joint damage on imaging, and RA can be difficult to diagnose at this stage.
• Stage 2 or moderate RA: With this stage, inflammation of the synovial linings has caused some joint damage, and you will start experiencing pain and limited range of motion in affected joints. You may also experience inflammation of the eyes, skin, heart, or lungs. For most people, a diagnosis usually occurs in this stage.
• Stage 3 or severe RA: At this stage, damage has extended beyond the joints and into the cartilage between the bones. You will have more pain and swelling and may experience joint deformity, usually in the fingers. Fortunately, this type of damage is rare due to newer and more aggressive treatment options. 
• Stage 4 or end-stage RA: At this stage, affected joints no longer work, and you will experience severe pain, swelling, stiffness, and disability. Joint damage at this stage can only be corrected with surgery. Progression to this stage takes years or even decades, and most people who are treating RA effectively never progress to this stage.

The main goals of treating RA are to control inflammation, relieve pain, and reduce joint damage and disability. This typically involves a multifaceted approach that includes medications, physical and occupational therapies, and a variety of lifestyle changes. 

Medications used to treat RA include:

• OTC and prescription NSAIDs to manage pain and inflammation
• Corticosteroids given in pill or injectable form to manage flares and bring down systemic inflammation
• Traditional DMARDs, like methotrexate, to slow down disease progression
• Biologic DMARDs, such as Humira (adalimumab), to stop the overactive effects of the immune system that would lead to chronic inflammation 
• Janus kinase (JAK) inhibitors, including Xeljanz (tofacitinib), to ease inflammation and prevent joint damage 

Both physical and occupational therapies can help keep joints strong, flexible, and mobile. An occupational therapist can help you find ways to protect your joints in daily life, including with the use of assistive devices. 

Lifestyle therapies to help you manage RA include:

• Being active
• Learning to cope with pain and manage stressors 
• Not smoking as smoking can lead to more severe disease, reduce the potential for remission, and decrease the effectiveness of medications

Surgery is considered a last resort treatment for managing RA. It is done to repair or replace damaged joints, manage pain, and improve joint function.

Summary 

Rheumatoid arthritis is an autoimmune disease that primarily affects the joints' synovial linings. While rare, it can also affect the skin, eyes, heart, lungs, and other organs and tissues throughout the body. 

RA can affect any joint in the body but seems to mainly attack the small joints of the hands and wrists. Early symptoms of RA include fatigue, low-grade fever, weight loss, loss of appetite, malaise, and mild joint pain and stiffness. As the disease progresses, you will experience more severe symptoms.

People with RA will experience periods of flare-up and remission. That means you will not always be in pain and have disease symptoms. 

Treating RA is vital to reduce the potential for joint damage and more severe symptoms, like skin rash, rheumatoid vasculitis, eye inflammation, and lung or heart problems. Your primary care provider can refer you to a rheumatologist who can provide an accurate diagnosis and get you on a treatment plan.