A patient with arthritic symptoms: typical symptoms and signs

Essentials

Osteoarthritis

  • Osteoarthritis is the most common type of arthritis. Its prevalence increases with an ageing population. Even though the causes are unknown, genetic factors, overweight, mechanical loading, muscle weakness and joint injuries are significant for its development.
  • Clinically, osteoarthritis starts as mild joint inflammation, which may initially arouse a suspicion of, for example, recent onset rheumatoid arthritis. It may therefore be confused with proper inflammatory diseases. However, over time the nature of osteoarthritis proves to be different.
  • Characteristic symptoms are pain on exertion, followed by aching.
  • Morning stiffness can occur, but it lasts for no longer than 15 minutes. The intensity of morning stiffness is also less marked than in inflammatory conditions, such as rheumatoid arthritis, where morning stiffness often lasts for several hours and is of high intensity. Osteoarthritis is associated with joint stiffness at the initiation of movement.
  • In osteoarthritis of the knee, early symptoms may include pain caused by joint loading, pain aggravated by walking down stairs, and minor joint effusion. The overlying skin remains cool to the touch, or at the most slightly warm. Thickened synovium is rare, and it feels flexible on palpation. Only a small number of leucocytes (usually less than 2,000 × 106/l) are present in the synovial fluid, with a predominance of mononuclear cells.
  • Osteoarthritis of the fingers causes pain and reduced functioning. Sharp pain occurs during or after use in the affected small joints, occasionally accompanied by aggressive inflammation, the end result being a deterioration in the ability to perform activities of daily living. Hard, bony thickening will gradually form around the joints; at the distal interphalangeal (DIP) joints these are called Heberden's nodes and at the proximal interphalangeal (PIP) joints Bouchard's nodes. Flexion deficit is usually small (usually not more than 20 mm) at first, but in some cases the fingers may later become crooked and the grip power is diminished. ESR and CRP are normal. Rheumatoid factor (RF) and anti-cyclic citrullinated peptide (anti-CCP) antibodies are usually negative.
  • One of the typical sites for osteoarthritis is the first carpometacarpal joint (CMC 1). The thumb is turned into adduction and the back of the hand takes a squarish shape.
  • Osteoarthritis can be roughly divided into two groups: oligoarticular large joint osteoarthritis and osteoarthritis of the small joints of the hand. Moreover, it is possible for osteoarthritis to affect the entire skeleton or any single joint. Unlike rheumatoid arthritis, osteoarthritis seldom affects the radiocarpal joint of the wrist.
  • Analgesia and improving muscle condition and physical condition are essential for treatment.
  • See (Osteoarthritis of the hand and wrist) (Shoulder osteoarthritis) (Osteoarthritis of the hip and knee).

Rheumatoid arthritis

  • Rheumatoid arthritis is a chronic systemic inflammatory condition where the joints are the main organ affected.
  • Globally, more than 0.2% of the population are affected (for more details, see e.g. https://www.thelancet.com/journals/lanrhe/article/PIIS2665-9913(23)00211-4... https://www.sciencedirect.com/science/article/abs/pii/S152169422500004X). The disorder is more common in women (2–3:1).
  • If untreated, joints will be permanently damaged. Rheumatoid arthritis involves a clear risk of cardiovascular disease.
  • Initially, symptoms usually develop gradually in the fingers, balls of the feet or wrists, but any joint may be the first one to be affected. Fusiform tight swelling around the PIP joints caused by synovitis is characteristic of rheumatoid arthritis but may also be seen in other inflammatory joint diseases, especially in psoriatic arthritis and chronic juvenile arthritis. Affected joints are warm.
  • The symptoms usually develop fairly slowly as the inflammation becomes more widespread but the onset may also be acute and fulminant. If so, the inflammatory joint symptoms may be accompanied by generalised symptoms such as fatigue, loss of appetite or fever.
  • A symmetric distribution of the inflammatory joint symptoms is characteristic of rheumatoid arthritis.
  • The inflamed joints are painful when moved, but pain at rest is not characteristic of rheumatoid arthritis.
  • The more active the inflammation, the longer the duration of morning stiffness, i.e. a limitation of motion at the affected joints. The stiffness may affect the entire body and return during the day after a prolonged period of sitting down.
  • Approximately two thirds of patients with fresh rheumatoid arthritis are positive for the classic blood parameter, rheumatoid factor (RF) or have anti-cyclic citrullinated peptide (anti-CCP) antibodies. These are autoantibodies specific to rheumatoid arthritis. Some patients who are negative for RF test positive for anti-CCP antibodies. Clearly positive RF and increased anti-CCP antibody concentrations in a patient with arthritis strongly suggest rheumatoid arthritis but they are not a precondition for the diagnosis. Some patients are seronegative.
    • In the diagnostic work-up of a patient with arthritis it is sufficient to perform either one of the tests. Nowadays, the determination of anti-CCP antibodies is the test used in most cases.
    • Markedly increased RF or anti-CCP antibody concentrations are associated with a more severe disease type.
    • With advanced age, RF often turns positive without rheumatoid arthritis. Particularly in elderly patients with arthritis, the determination of anti-CCP antibodies is important because aging has not been found to affect their occurrence.
    • The determination of RF or anti-CCP antibodies is usually not warranted if no arthritis has been detected.
  • ESR and often also CRP are at least slightly elevated.
  • Erosive osteoarthritis of the PIP and DIP joints in the fingers may greatly resemble chronic rheumatoid arthritis but can be distinguished by its typical location (it spares the balls of the feet and wrists), absence of RF and anti-CCP antibodies and often the low ESR or CRP concentration. It should be borne in mind that rheumatoid arthritis is nowadays encountered in patients around the age of 60, and at that age both conditions may occur concurrently. Particularly in these situations an elevated anti-CCP antibody concentration will assist in the diagnosis of rheumatoid arthritis. Joint X-ray examinations or MRI will help to make the correct diagnosis.
  • For differential diagnosis, other polyarthritic conditions, such as psoriatic arthritis (PsA), spondyloarthritis (SpA), early-stage gout and osteoarthritis-associated finger arthritis and chondrocalcinosis should be considered.
  • If rheumatoid arthritis is suspected, specialized care should be consulted without delay and the patient referred to a rheumatoid arthritis team. The treatment of rheumatoid arthritis aims at remission and should be started before the development of bony lesions.
  • See (Clinical diagnosis of joint inflammation in the adult).

Spondylarthritis

  • Classification of spondylarthritides (SpA)
    • Classic ankylosing spondylitis
    • Axial SpA associated with psoriatic arthritis
    • SpA diseases associated with IBDs
    • Reactive SpA (= former Reiter's disease)
    • SpA of unknown cause

Axial spondyloarthritis and classic ankylosing spondylitis

  • If a patient presents with back pain that has lasted ≥ 3 months, there are 5 criteria that may suggest ankylosing spondylitis: age at onset < 40 years, insidious onset of back pain, back pain waking the patient in the early morning hours, symptoms improved with exercise, no improvement with rest.
  • It is associated with the HLA-B27 antigen in 95% of cases, in which case predisposition to the disease is inherited. Family history may reveal cases of ankylosing spondylitis in close family members.
    • HLA-B27 testing has the highest information value in patients whose pretest probability of ankylosing spondylitis is around 50% (e.g. a young man with symptoms in the lower back in the early morning hours, but with as yet normal X-ray findings of the sacroiliac joints). The probability of the disease is 92% if the test result is positive and only 8% if the result is negative. If the pretest probability based on history and clinical findings is near zero, a positive test result does not confirm ankylosing spondylitis; the patient probably belongs to the normal population that tests positive for HLA-B27 but has no diseases associated with this antigen.
    • The HLA-B27 test is not used to estimate a patient’s general risk of ankylosing spondylitis in the absence of appropriate clinical signs and symptoms, since only less than 1% of those who test positive will go on to develop any spondyloarthritis.
    • The classic rheumatoid factor (RF) or anti-CCP antibodies have no significance at all in the diagnosis of the diseases in the ankylosing spondylitis group. They should thus not be determined in such cases.
  • In about one third of the patients, the condition is associated with isolated limb arthritis, usually oligo- or monoarthritis. In rare cases, the patient may also have symmetric polyarthritis resembling rheumatoid arthritis.
  • Back stiffness in the morning and after a period of sitting is typical. Symptomatic sacroiliitis can be revealed by clinical examination of the sacroiliac joints (Clinical diagnosis of joint inflammation in the adult).
  • If the patient is under 35 years old, the first-line imaging study is MRI of the SI joints.
  • Some patients have attacks of acute iritis.
  • Enthesopathies may develop.
  • See (Axial spondyloarthritis and ankylosing spondylitis).

Psoriatic arthritis

  • On a population level, 1–3% of people have psoriasis, and 10–40% of these have arthritis. In about 15% of cases joint inflammation develops before psoriasis.
  • There are many different types of psoriatic arthritis.
    • The most common type is asymmetric oligoarticular arthritis, which affects the knees and other large joints. Asymmetric arthritis can also occur in the sternoclavicular joints, sacroiliac joints or the temporomandibular joints.
    • Polyarthritis of small joints is also asymmetric. It may initially resemble rheumatoid arthritis. In the fingers, it often affects the DIP joints.
    • Arthritis mutilans causes resorption of bone, leading principally to the destruction of small bones in the fingers. The condition is rare.
    • The type that resembles ankylosing spondylitis is characterised by the asymmetry of signs and symptoms. This type of disease may be HLA-B27-positive.
  • Inflammation of small joints is often associated with psoriatic nail changes, and in these cases psoriatic skin changes may sometimes be totally absent.
  • Dactylitis of a finger or toe is often associated with psoriatic arthritis.
  • Enthesitis is very common in psoriatic arthritis.
  • Family history may reveal cases of psoriatic arthritis in close family members.
  • Rheumatoid factor (RF) and anti-cyclic citrullinated peptide (anti-CCP) antibodies are usually negative.
  • Radiological changes differ from those in rheumatoid arthritis.
  • The treatment of psoriatic arthritis is individual, aiming at the lowest possible level of inflammation. A rheumatologist and a dermatologist, together with the patient, are responsible for the treatment.
  • See (Psoriatic arthritis).

Reactive arthritis

  • Arthritis most commonly occurs after an intestinal or urogenital infection. It is often associated with the HLA-B27 antigen. Family history may reveal cases of reactive arthritis in close family members. The disease is more common in men.
  • In 2 out of 3 cases, the inflammation will subside. The disease usually presents predominantly as either mono- or oligoarthritis of the lower limbs, and the condition progresses relatively slowly from joint to joint. It can be migratory or additive in nature.
  • In addition to inflammatory joint symptoms, enthesopathy (tenderness at the muscle or fascia attachment sites) and dactylitis (sausage-like swelling of fingers or toes) are often seen. The disease may affect the skeleton, too.
  • Some patients have ocular inflammation (uveitis) and additionally possibly symptoms of urethritis (Reiter's syndrome). Inflammatory bowel disease (IBD) is also possible.
  • Reactive arthritis is rarely encountered in elderly individuals.
  • If the patient presents with clear symptoms and fever and the ESR and/or CRP are markedly elevated, it may be difficult to distinguish reactive monoarthritis from septic arthritis. In this case, the patient should be referred to the hospital emergency department for more detailed sampling and to confirm the diagnosis.
  • See (Reactive arthritis).

Gout

  • Usually starts in middle age, and is more common among men. The metatarsophalangeal joint of the great toe is often the first to become inflamed, but any joint can be affected.
  • Prevalence is on the rise (metabolic syndrome, beer and diuretics). Based on a clinical estimation, the incidence of polyarticular gout is also on the rise, and in these cases, gout may resemble rheumatoid arthritis. However, gout usually causes significantly more pain, and anti-CCP antibodies are usually not encountered in gout or their concentrations are lower than in rheumatoid arthritis. X-rays show gout changes, and ultrasound examination can reveal typical gout opacification on the cartilage surface. Rheumatoid arthritis and osteoarthritis often occur in patients aged 60 years or older. It should be borne in mind that it is possible for a patient to have two different conditions.
  • Starts from the first metatarsophalangeal joint in over half of cases.
  • Joint trauma may elicit an attack of gout.
  • An attack usually begins at night and peaks within 24 hours. The signs of inflammation, i.e. soreness, swelling and redness, are usually markedly prominent.
  • If the condition remains untreated, the attacks recur with increased frequency and gradually lead to chronic destructive polyarthritis.
  • During an acute attack, the patient may have fever, ESR and/or CRP may be moderately elevated and the plasma urate concentration is usually above the upper limit of normal, but it may also be within the reference range.
  • Often associated with metabolic syndrome (truncal obesity).
  • Dietary treatment is particularly important in the treatment of gout. Oral glucocorticoids, such as 30–40 mg/day of prednisolone for 3–5 days, and intra-articular glucocorticoid treatment of joints are used to treat gout attacks. In the case of recurring and prolonged gout, allopurinol is usually started.
  • See (Gout and pseudogout).

Polymyalgia rheumatica

  • Tenderness and restriction of movement most typically around the shoulders and thighs
  • Synovitis is sometimes seen, particularly at shoulder joints and hips but also at more peripheral joints, usually at the knees or wrists.
  • Stiffness and difficulty moving the joints after rest or staying still at any time of the day is particularly pronounced.
  • Age over 50 years. Note that rheumatoid arthritis in the elderly may start with shoulder pain that resembles polymyalgia.
  • ESR > 40–50
  • Prednisone at a dose of 12.5–25 mg is usually enough to eliminate the symptoms within a few days. Treatment should be continued for at least 12 months. It can be carried out in primary health care. If there is no response, a rheumatologist should be consulted.
  • Headache, visual disturbances, jaw claudication induced by swallowing or chewing as well as severe general symptoms with markedly increased CRP levels are suggestive of concurrent giant cell arteritis (temporal arteritis) (Giant cell (temporal) arteritis). This involves a risk of permanent blindness. In such cases, the patient should be referred to a hospital emergency department to confirm the diagnosis.
  • See (Polymyalgia rheumatica).

Sarcoidosis

  • Sarcoidosis may involve acute arthritis of large joints, most commonly the knees, that often subsides spontaneously. Arthritis may also be associated with Löfgren's syndrome (an acute form of sarcoidosis), involving enlarged lymph nodes in the hilar area, cutaneous erythema nodosum, and pain and swelling of ankles that is in most cases symmetric. A typical finding is diffuse bluish red periarticular swelling.
  • ESR is usually increased.
  • Initial investigations can be performed in primary health care.
  • See (Sarcoidosis).

Systemic lupus erythematosus (SLE)

  • Systemic autoimmune disease typically occurring in young women (Systemic lupus erythematosus (SLE))
  • Antinuclear antibody concentrations usually increased
  • Joint symptoms are often more severe than a clinical investigation of the joints suggests.
  • The patient usually presents with non-erosive symmetrical polyarthritis/arthralgia, or Jaccoud arthritis.
  • Joint symptoms are associated with general symptoms, significant fatigue and lack of strength, weight loss, fever, various cutaneous manifestations (especially in spring, a butterfly-like erythema of the malar eminences) and frequently signs of other organ involvement (headache in central nervous system involvement, proteinuria or haematuria in nephritis, thrombocytopenia, leukopenia, sometimes venous thromboses as well as pleuritis or pericarditis).
  • ESR is usually elevated, but the CRP may be normal.
  • A patient with suspected SLE should be referred to specialized care to confirm the diagnosis and to define treatment.
  • See (Systemic lupus erythematosus (SLE)).

Calcium pyrophosphate deposition disease (CPPD)

  • Calcium pyrophosphate crystals collect in joints and synovia.
  • The joint symptoms may appear intermittently or they may be sustained, and the clinical picture may therefore resemble that of either gout, osteoarthritis or rheumatoid arthritis.
  • The diagnosis can be confirmed by X-ray (to detect calcification of the joint cartilage, chondrocalcinosis) and by ultrasound examination to see the typical crystals. Typical crystals (pyrophosphate crystals) are also found in the synovial fluid (Investigation of synovial fluid).
  • CPPD can manifest as severely symptomatic polyarthritis.
  • Treatment is usually symptomatic; no specific treatment exists.
    • Often a glucocorticoid is injected into the joints. Oral glucocorticoid therapy may also be used to treat severe symptoms.
    • Colchicine is effective in the treatment of acute attacks.
    • Prolonged inflammation should be treated in specialized care. Methotrexate, hydroxychloroquine, colchicine and biological agents such as tocilizumab and anakinra can be used.
  • See (Gout and pseudogout).

Joint infection (septic arthritis)

  • Usually acute onset. The patient has marked general symptoms and septic fever. Fever and other signs of infection may, however, be absent in elderly individuals, in patients receiving immunosuppressant therapy and in chronic infections involving prosthetic joints.
  • Acute monoarthritis with fever should be regarded as bacterial in origin until proven otherwise. Oligoarthritis may also be septic in origin.
  • In case of suspected joint infection, the patient should be referred to the hospital emergency department without delay.
  • Diagnosis: clinical picture, puncture sample (staining + culture) (Investigation of synovial fluid), laboratory tests, X-ray, MRI and other required investigations at the hospital
    • CRP and/or ESR are usually markedly elevated, but blood leucocyte count is often normal.
    • Crystal-induced arthritis may be fulminant and resemble infectious arthritis (remember to take samples too for the analysis of synovial fluid crystals!).

Viral arthritis

  • Viral arthritis usually manifests itself either as acute but mild poly- or oligoarthritis, and it usually resolves spontaneously fairly quickly.
  • Joint inflammation is particularly associated with rubella, arbovirus arthritis (Pogosta disease) and erythema infectiosum (fifth disease), which can be identified by their characteristic rashes.
    • Arbovirus arthritis (Pogosta disease) occurs late in the summer in Eastern and Central Finland. The rash is pruritic.
    • Parvovirus causes erythema infectiosum (Erythema infectiosum) in children. In adults it quite often causes symptoms of joint inflammation.
    • Arthritis in small joints has been seen after COVID-19 vaccination and COVID-19 infection (COVID-19 and other coronavirus infections). It is not yet clear whether this represents reactive inflammation.
  • In viral arthritis, ESR and CRP are at most slightly elevated, and the synovial fluid cell count usually (but not always) reveals a predominance of mononuclear cells.
  • Treatment, as necessary, with an intra-articular glucocorticoid, an NSAID, less frequently an oral glucocorticoid
  • Consultation of specialized care in protracted cases

Lyme borreliosis

  • A multi-faceted infectious disease caused by the spirochete Borrelia burgdorferi, which is spread by tick bites.
  • In the acute phase, a rash, called erythema migrans, usually appears at the site of the tick bite. No rash, however, occurs in a considerable number of people who will go on to develop borrelia arthritis. At the start of the disease, the patient usually develops fever, headache, myalgia and lymphadenopathy.
  • Late manifestations of the disease include joint inflammation starting an average of about 6 months after the rash, neurological symptoms and, more rarely, carditis.
  • Joint inflammation usually presents as recurrent episodes of swelling involving one or a few joints. In association with knee inflammation, Baker's cyst (Baker's cyst) may develop, and this should be treated as well.
  • The diagnosis of Lyme arthritis is based on a positive IgG antibody finding; IgM antibody levels may also be elevated in some cases. Antibody levels may remain elevated for several years after treatment.
  • For a favourable outcome early diagnosis is essential.
  • Joint borreliosis should be treated by a rheumatologist.
  • See (Lyme borreliosis (LB)).

Rheumatic fever

  • A disease secondary to untreated pharyngitis caused by group A streptococci; today rare in many countries
  • The disease is associated with fever and most commonly flitting polyarthritis or joint pain.
  • Carditis, which manifests as pancarditis or valvular lesions, is an important prognostic factor. A cardiologist should be consulted.
  • ESR and CRP are often markedly elevated, and the same applies to antistreptolysin AST. Streptococcus can be found in throat culture.
  • See https://www.orpha.net/en/disease

Hypertrophic osteoarthropathy

  • A paraneoplastic phenomenon that, in addition to symmetric polysynovitis, is accompanied by periostitis of the long bones and digital clubbing in fingers and toes.
  • The underlying disease is in most cases small cell lung carcinoma or its metastases, and the cancer determines the treatment.
  • If hypertrophic osteoarthropathy is suspected the patient should be referred to specialized care to a cancer unit.

HIV infection

  • Patients infected with HIV often develop reactive arthritis–like arthritis and arthralgia. The patient should be referred to specialized care.
  • See (HIV infection)

Injury

  • The patient may have forgotten an earlier joint injury, which may make the diagnostic work-up more difficult.
  • It should be borne in mind that psoriatic arthritis (Psoriatic arthritis) often develops after injury (note Köbner phenomenon).
  • If the injury is recent, fresh haemarthrosis can be detected. When more time has passed, a puncture no longer provides fresh blood from an injured joint that is already healing without treatment.
  • Haemarthrosis should always be carefully examined. The cause may be, for example, a malignancy in the bone or synovial membrane.
    • X-ray, MRI and, depending on the case, further investigations in specialized care

References

1. Kim SY, Afroz S, Gillespie H, et al. A Narrative Review of Chondrocalcinosis: Clinical Presentation, Diagnosis, and Therapies. Cureus 2024;16(5):e60434  [PMID:38882993]
2. Voulgari PV, Venetsanopoulou AI, Drosos AA. Recent advances in the therapeutic management of calcium pyrophosphate deposition disease. Front Med (Lausanne) 2024;11():1327715  [PMID:38529115]
3. Cowley S, McCarthy G. Diagnosis and Treatment of Calcium Pyrophosphate Deposition (CPPD) Disease: A Review. Open Access Rheumatol 2023;15():33-41  [PMID:36987530]
4. Slouma M, Ben Dhia S, Dhahri R, et al. Cutaneous and rheumatological manifestations of reactive arthritis: A case report. Clin Case Rep 2022;10(11):e6542  [PMID:36381024]
5. Arvikar SL, Steere AC. Lyme Arthritis. Infect Dis Clin North Am 2022;36(3):563-577  [PMID:36116835]
6. Hasbani GE, Uthman I, Jawad AS. Musculoskeletal Manifestations of Sarcoidosis. Clin Med Insights Arthritis Musculoskelet Disord 2022;15():11795441211072475  [PMID:35185345]
7. Ananthanathorn P, Sukharomana M, Charuvanij S. Clinical profiles of post-infectious arthritis and transient synovitis of the hip in children. Pediatr Int 2022;64(1):e15237  [PMID:35938590]
8. Rosenberg H, Halman S, Yadav K. Polymyalgia rheumatica. CMAJ 2021;193(46):E1770  [PMID:34810164]
9. Fragata I, Mourão AF. Coronavirus Disease 19 (COVID-19) complicated with post-viral arthritis. Acta Reumatol Port 2020;45(4):278-280  [PMID:33420769]
10. García-Kutzbach A, Chacón-Súchite J, García-Ferrer H, et al. Reactive arthritis: update 2018. Clin Rheumatol 2018;37(4):869-874  [PMID:29455267]
11. Napolitano M, Caso F, Scarpa R, et al. Psoriatic arthritis and psoriasis: differential diagnosis. Clin Rheumatol 2016;35(8):1893-1901  [PMID:27156076]
12. Davis MC, Sherry V. Hypertrophic osteoarthropathy as a clinical manifestation of lung cancer. Clin J Oncol Nurs 2011;15(5):561-3  [PMID:21951743]
13. Mathews CJ, Weston VC, Jones A, et al. Bacterial septic arthritis in adults. Lancet 2010;375(9717):846-55  [PMID:20206778]
14. Sieper J, van der Heijde D, Landewé R, et al. New criteria for inflammatory back pain in patients with chronic back pain: a real patient exercise by experts from the Assessment of SpondyloArthritis international Society (ASAS). Ann Rheum Dis 2009;68(6):784-8  [PMID:19147614]
15. Franssila R, Hedman K. Infection and musculoskeletal conditions: Viral causes of arthritis. Best Pract Res Clin Rheumatol 2006;20(6):1139-57  [PMID:17127201]
16. Felson DT, Lawrence RC, Dieppe PA, et al. Osteoarthritis: new insights. Part 1: the disease and its risk factors. Ann Intern Med 2000;133(8):635-46  [PMID:11033593]
17. Turunen M, Kuusisto P, Uggeldahl PE, et al. Pogosta disease: clinical observations during an outbreak in the province of North Karelia, Finland. Br J Rheumatol 1998;37(11):1177-80  [PMID:9851265]
18. Healey LA. Long-term follow-up of polymyalgia rheumatica: evidence for synovitis. Semin Arthritis Rheum 1984;13(4):322-8.  [PMID:6729485]
19. Khan MA, Khan MK. Diagnostic value of HLA-B27 testing ankylosing spondylitis and Reiter's syndrome. Ann Intern Med 1982;96(1):70-6.  [PMID:7053711]
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