Rheumatoid Arthritis Disease Progression and Symptoms: An Overview

Rheumatoid arthritis (RA) is an inflammatory autoimmune disease that usually affects the joints first. But because RA is systemic — meaning it can affect the whole body — people can also experience non-joint-related symptoms at the beginning of the disease, and the course of the chronic illness may differ from person to person, says rheumatologist Jonathan Greer, MD, an affiliate clinical professor of medicine at Nova Southeastern University in Fort Lauderdale and affiliate clinical professor of biomedical sciences at Florida Atlantic University in Boca Raton.

There are two main ways that rheumatoid arthritis announces itself when it first begins: small joint inflammation and, sometimes, systemic, flu-like symptoms.

Small Joint Inflammation: Symptoms in the Fingers, Wrists, Toes, and Ankles

For more than half of RA patients, the first symptoms will occur in one or more of the small joints of the fingers (the base and middle fingers), the wrists, the toes (commonly at the base), or the ankles. Symptoms can begin slowly and subtly over a period of weeks or months, worsening over time.

In the majority of patients, this swelling and pain is symmetrical, meaning the same joints are affected on both sides of the body.

But this is not always the case. “It’s important not to wait to treat until the disease becomes symmetric. Early diagnosis and treatment are key to prevent joint damage even if only one joint on one side of the body is affected,” notes Rebecca Manno, MD, a rheumatologist and adjunct assistant professor of medicine at the Johns Hopkins University School of Medicine in Baltimore.

Early Symptoms: Joint Pain, Stiffness, Numbness 

The pain of early RA is unique. “Your joints will hurt in a way they never did before, and feel puffy and tight and hot to the touch,” says Dr. Manno. “Moving the fingers and wrists can feel like they need a quart of oil,” she adds.

Patients often describe the pain of the toes and feet “as walking on marbles.” Affected joints are generally stiff for about 30 minutes or longer in the morning.

Some people develop a complication of RA, carpal tunnel syndrome, which can cause feelings of numbness and tingling in the hands and fingers, making it even more difficult to use them.

Chronic Swelling and Inflammation in Synovial Lining in Joints

No one knows exactly why RA targets the small joints of the feet and hands first, but experts do know that the synovial lining is involved.

The synovial lining is the thin layer of cells between all joints. A joint is where two bones meet, and the synovial lining is the thin layer of cells between them. Joints are covered in cartilage to cushions them, and the synovial lining between joints nourishes both the cartilage and bones.

Experts believe that RA develops when the white blood cells that normally protect the body turn on the joints instead, causing inflammation. This may occur because a person is predisposed, due to genes or environmental factors.

This inflammation is why people with RA experience pain, heat, and swelling early in the disease process (although certain patients can have swelling without pain).

Chronic Joint Pain in the Knees, Elbows, Hips, and Shoulders

Some RA patients may also experience inflammation in the joints of the knees, elbows, and hips. One or both shoulders might also become swollen, lessening range of motion so lifting or reaching becomes painful.

Rheumatoid arthritis typically does not affect the lower back, though a person may experience back pain if they are having difficulty moving other joints or walking, says Manno.

In a small percentage of people, the joint swelling can come and go, sometimes moving around to different joints and even disappearing for a time, a condition known as palindromic rheumatism. But in the vast majority of people, the joint swelling persists and worsens until it’s treated with medication. With treatment, the majority of people can achieve a significant lessening of symptoms or possibly even remission.

Some People Experience Fatigue and Other Flu-like Symptoms Early On, Too

Up to a third of patients have more systemic symptoms before or along with joint pain and inflammation. This can include fatigue, muscle pain, mood changes, and low-grade fever. As the digital arthritis community CreakyJoints puts it, "Some patients describe the symptoms of RA as being 'flu-like' — that general yucky feeling you get when you are on the verge of getting sick."

Although these symptoms can be an early sign of RA, because they overlap with other illnesses, RA usually isn't the first thing the doctor considers, especially without joint pain.

Other symptoms many don't realize can also indicate RA include rashes, easily bruising, itchy and dry eyes, and sharp chest pain brought on my irritation of the costosternal joints, which connect the ribs to the breastbone.

Clues That Can Lead to RA Testing and Diagnosis

If RA is suspected, doctors will do blood tests looking at inflammatory markers (such as C-reactive protein or the erythrocyte sedimentation rate) and imaging to confirm an RA diagnosis. These tests also help to rule out other conditions that also involve inflammation of the synovial lining (such as psoriatic arthritis, tuberculosis, lupus, or Lyme disease).

Joint Damage, Pain, Deformities, Loss of Function: Late-Stage RA Symptoms

It is important for people with these symptoms to be diagnosed as soon as possible, because if RA isn’t diagnosed and treated early (or if drugs stop working) the synovial lining can become so inflamed that it damages and erodes the cartilage; this makes bone loss more likely.

Moving joints becomes more difficult, and flare-ups can occur with greater frequency. “These joint changes are called erosions, and they can lead to deformities of the bone, such as crooked fingers,” says Daniel Solomon, MD, MPH, chief of the section of clinical sciences in the division of rheumatology at Brigham and Women’s Hospital in Boston. In severe cases, bones may eventually fuse together. All of this further contributes to pain and loss of function.

How Late-Stage RA Can Cause Joint Damage in Hands and Feet

Here are some of the ways that unchecked inflammation can affect the small joints of the hands and feet, which are typically the first ones to be affected by rheumatoid arthritis:

Hands and Wrists

• Ulnar Drift This swelling of the joints moves weakening tendons and ligaments out of position and causes the fingers to bend toward the little finger.
• Swan-Neck Deformities Changes in the tissues around finger joints result in abnormal bending and straightening of the fingers.
• Mallet Finger In this deformity, the fingertip is curled in and cannot straighten itself.
• Bumps in the Joints when small blood vessels become inflamed, people with RA can develop painless bumps under the skin of the joints. Known as rheumatoid nodules, this is thought to occur in up to 30 percent of people with the disease, according to research published in the journal Autoimmunity Reviews.
• Locked or Catching Joints (aka Trigger Vinger) Deformities or thickening of the synovial lining can cause the fingers to lock in unusual positions as the person tries to bend them. This can sometimes occur in early-stage RA as well as in late-stage. Trigger finger can also occur with multiple other diseases, including carpal tunnel syndrome.
• Tendon Loosening or Ruptures Caused by inflammation in the joints, this is normally seen in very-late stage, untreated RA.

Ways in Which Rheumatoid Arthritis Can Affect Feet

• Hammertoes Changes in the tissues around the toe joints cause an abnormal bending of the toes called hammertoe.
• Bunions Changes in the tissues around joints of the big toe cause it to bend toward the little toe and develop a bony nodule.
• Pes Planus This loosening of the arch joint in the middle of the foot may result in a painful flat foot.
• Hindfoot Valgus The loosening of the joint below the ankle causes the foot to bend outward.

Neck Joints Are Not Spared RA Joint Pain and Damage

• The Neck Someone with RA can also experience inflammation and pain in the neck. This can cause stiffness, weakness, and loss of motion. If not treated, severe inflammation in the neck can lead to instability of the cervical spine.
• The Throat Although rare, the cricoarytenoid joint near the windpipe may also swell from the disease, affecting breathing.

Heart Disease Risk Increases With RA

One of the most concerning conditions that can evolve in people with RA is cardiovascular disease, especially ischemic heart disease, in which there's a reduced blood supply in the heart.

Other cardiovascular issues people with RA are at increased risk for include heart attack, stroke, congestive heart failure, peripheral vascular disease, and atrial fibrillation.

It’s crucial that people with RA continue to be monitored for heart disease risks by their general practitioner or cardiologist. In a review of preventative measures for people with RA, published in June 2020 in the journal Nature Reviews Rheumatology, the authors noted that catching risk factors early, such as high blood pressure or high blood lipids, is especially important for preventing a serious cardiac event.

In addition, people with RA are more likely to develop type 2 diabetes — another cardiovascular risk factor — as those without RA, possibly because the inflammation of RA affects blood sugar levels and insulin resistance.

Rheumatoid Arthritis Can Impact a Large Number of Other Organs

RA can significantly affect a number of other organs as it progresses, especially if the disease is not controlled with medications, including:

• The Eyes Episcleritis, an inflammation of the episclera — a tissue in the white part of the eye — can occur.
• The Lungs Lungs can show scarring or develop interstitial lung disease, which can cause difficulty breathing, breathlessness, or a mild cough. “Usually this is seen as the disease progresses, but it can show up in some early-stage patients,” says Mannon.
• The Skin Some patients may develop blisters or nodules under the skin that are caused by inflamed blood vessels. Rashes and skin ulcers can erupt as well.
• The Mouth People with RA are twice as likely to have gum disease as those without RA. Research suggests that underlying gum disease may be a trigger for developing RA, and that getting treated for gum disease can improve joint symptoms.
• The Heart Heart failure is twice as common in people with RA, and they’re also 50 percent more likely to have a heart attack.
• The Kidneys RA can also damage the kidneys, especially when RA is not well controlled.

How to Manage Symptoms to Slow or Halt RA Joint Damage and DiseaseProgression

Getting on medication right away is the No. 1 thing people can do to improve RA symptoms and stop the disease from progressing. Your doctor should start you on methotrexate, according to guidelines published in July 2021 by the American College of Rheumatology (ACR).

If this treatment alone doesn't yield the desired results, biologics should be added, the ACR advises.

"There is a window of opportunity at the beginning of the disease when you have the best chance of treating with drugs to stop RA from causing damage — and the earlier a person starts aggressive drug therapy, the better,” says Dr. Greer.

Lifestyle Changes That Help Ease RA Symptoms

In addition to treatment with drugs, the following remedies and lifestyle approaches can help alleviate symptoms at any stage of RA:

Occupational or Physical Therapy Rheumatologists frequently refer patients to occupational or physical therapy practitioners to help patients find ways of moving that are less painful, and that strengthen muscles, says Manno. Decreased movement can cause muscles to atrophy and can reduce a person’s cardiovascular fitness.

Splinting the Wrists Wearing splints can improve hand function in people with RA, study authors conclude in research published in 2018 in Rheumatologia.

Wearing Supports and Inserts Inside Shoes These help keep the arches up and ankles stable when walking so you release pressure from the ball and forefoot, where inflammation tends to flare up. Your doctor will likely refer you to a podiatrist or occupational therapist if she feels you could benefit from orthotics.

Surgery “If hand deformities occur as a result of RA, some patients can benefit from surgery,” says Dr. Solomon, who says it’s key to find a hand surgeon experienced with RA patients. Severe pain or limited mobility may be reasons to consider hand surgery.

Other Conditions That People With RA Can Develop

People with RA must sometimes manage other serious diseases and conditions that can go along with RA. In addition to heart disease and diabetes, two very common conditions for which people with RA are at increased risk, those with RA may also develop the following:

Depression There is a clear link between depression and RA, but the connection isn’t well understood, says Solomon. “We don’t know how much is a result of RA’s inflammation and how much is a person’s response to the disease, although both are involved somehow,” he says.

Fibromyalgia Some people with RA also suffer from fibromyalgia, says Solomon. Researchers aren’t sure exactly why, but it may have to do with pain pathways and the depression that can go along with RA.

Osteoarthritis (OA) Compared with people without RA, people with RA are 25 to 50 percent more likely to have osteoarthritis, says Solomon. That’s because the inflammation of RA can accelerate the bone reabsorption of osteoarthritis; steroids sometimes used as a bridge treatment for RA can also accelerate this process, which is why the ACR says people on this medicine should take the lowest dose of steroids for the shortest time possible.