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Rheumatoid arthritis

Rheumatoid arthritis is a chronic autoimmune disorder resulting in a symmetrical deforming polyarthropathy and various extra-articular features.

Risk factors

  • Female gender
  • Age 30-50
  • Genetic factors
  • Smoking

Clinical features

  • Polyarthritis
  • Morning stiffness
  • Tender, erythematous inflamed joints
  • Usually symmetrical
  • Any synovial joint can be affected
    • Mostly small joints (hands, feet, cervical spine)
    • MCP joints most commonly affected; DIP joints rarely affected
    • Cervical spine – odontoid peg erosion can result in fracture and atlanto-axial subluxation
  • Joint deformities
    • Loss of knuckle guttering
    • Swan neck deformity (PIP joint hyperextension + DIP joint flexion)
    • BoutonniΓ¨re deformity (PIP joint flexion + DIP joint hyperextension)
    • Z-shaped thumb (IP joint hyperextension + MCP joint flexion)
    • Ulnar deviation
    • Palmar subluxation of MCP joints
  • Others, e.g. palmar erythema, small muscle wasting, reduced range of movement, carpal tunnel syndrome signs

Extra-articular features


  • Bloods 
    • Raised inflammatory markers (ESR, CRP) 
    • Rheumatoid factor (autoantibody to Fc portion of IgG)
    • Anti-cyclic citrullinated peptide (CCP) β€“ more specific
  • X-Rays


  • NSAIDs: for symptomatic relief with PPI cover
  • Steroids: short course prednisolone at diagnosis to induce remission
  • Conventional Disease Modifying Anti-Rheumatic Drugs (DMARDs) (e.g. methotrexate, leflunomide, sulfasalazine, hydroxychloroquine): commenced early – monotherapy initially, with additional DMARD added if uncontrolled
  • Biological DMARDs (anti-TNFΞ±, e.g. adalimumab, etanercept, infliximab; or anti-IL6, e.g. sarilumab): can halt or even reverse disease process; offered to patients with severe disease who have not responded to combination DMARDs
  • Other therapies
    • Surgery: can improve mobility and reduce pain in patients with deformities
    • Physiotherapy
    • Occupational therapy

Reference: NICE β€˜NG100 Rheumatoid arthritis in adults: management’ 2020


What are the classical features of rheumatoid arthritis on a radiograph?

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Which HLA genes are associated with inherited susceptibility to rheumatoid arthritis?

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Try some stations

  1. Hand and wrist exam
  2. Rheumatoid hand exam
  3. Rheumatoid arthritis viva
  4. Find more here!

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