Rheumatoid Arthritis Symptoms and Diagnosis

The symptoms of rheumatoid arthritis vary widely from person to person. In many cases, it can start in a few joints then spread to other joints over a few weeks to months. Rheumatoid arthritis can also progress extremely quickly, with some people reporting waking up one morning just not able to get out of bed.

The earliest symptoms of rheumatoid arthritis can be non-specific, including feeling unwell or tired, soreness around joints and muscles, low-grade fever, and weight loss or poor appetite. As time goes on, rheumatoid arthritis can involve more and more joints on both sides of the body, often in a symmetrical pattern.

More than 250,000 people living in Canada have rheumatoid arthritis and people can develop symptoms at any age. Children can have a form of rheumatoid arthritis called Juvenile Rheumatoid Arthritis (JRA).

Females are affected by rheumatoid arthritis two to three times more often than males. Though the reasons for this are not entirely clear, the connection between hormones and the immune system, as well as genetics associated with the X chromosome are being considered as possible contributing factors. The prevalence and impact of rheumatoid arthritis in people who are intersex or trans is largely unknown, as is the impact of gender-affirming hormone therapy.

There is no cure for rheumatoid arthritis, however, people who receive a diagnosis and begin treatment early are more likely to limit damage to their joints and continue to live active lives.

Early signs and symptoms

---

Rheumatoid arthritis usually starts over a period of weeks to months, with more joints becoming affected over time. You should see your doctor if you experience one or more of the following symptoms for more than six weeks:

• Pain or stiffness in multiple joints

• “Gelling” or stiffness of joints, especially in the morning, that lasts 30 minutes or more

• Warmth or redness over joints

• Reduced ability to move the joints (such as difficulty making a fist, twisting objects, opening objects, climbing stairs)

• Fever, fatigue, weight loss or decreased appetite

• Lumpy growths that form under your skin, most commonly on the elbows, hands or feet

Any joint can be affected in rheumatoid arthritis, but the joints most commonly involved include:

• Knuckles and small joints of the hand

• Toes

• Wrists

• Elbows

• Shoulders

• Knees

• Ankles

What are the risk factors for rheumatoid arthritis?

---

The exact causes of rheumatoid arthritis are unknown, but research has shown there are several things that may contribute:

• Family/genetic history

  Some people who develop rheumatoid arthritis have specific genes that may predispose them to developing rheumatoid arthritis, though this does not necessarily mean you will develop rheumatoid arthritis if you carry these genes.

• Sex

  Rheumatoid arthritis is two to three times more likely to affect females than males.

• Hormones

  Some hormonal changes appear to be linked to rheumatoid arthritis. Hormone changes during and after pregnancy, during breast or chest feeding and even oral contraception use may be linked to the development of rheumatoid arthritis or may relieve or trigger rheumatoid arthritis symptoms. There is not currently enough research to indicate how symptoms of rheumatoid arthritis in trans people taking hormone replacement therapy (HRT) might be impacted, or if taking HRT would lessen or worsen symptoms of rheumatoid arthritis.

• Age

  Rheumatoid arthritis can affect people any age, but the risk of developing the disease increases with age, commonly developing between 40 and 60 years.

• Environment

  Infection can trigger rheumatoid arthritis in people who have genetic links to the disease. However, it is important to remember that you cannot catch or spread rheumatoid arthritis and it is not contagious.

• Traumatic events

  Major trauma or physical or emotional stress can also act as a trigger for symptom onset. 

• Smoking

  Numerous studies have shown that cigarette smoking is the strongest environmental risk for the development of rheumatoid arthritis and for having a more severe form of the disease.

• Gum disease

  Gum disease can change your immune responses and make you more susceptible to inflammatory arthritis. While it is not yet known if gum disease can cause rheumatoid arthritis, or if having rheumatoid arthritis can cause gum disease, gum disease is more common in people who have rheumatoid arthritis, and vice versa. Gum disease is also associated with having more severe rheumatoid arthritis. Good dental hygiene is important for everyone, but especially if you have symptoms of rheumatoid arthritis, another inflammatory condition, or have symptoms of gum disease. Gum disease is also a risk factor for many other conditions, such as heart disease, diabetes, and kidney disease.

Rheumatoid arthritis flares

---

A flare is a sudden onset of rheumatoid arthritis symptoms after having a period of time either without symptoms (sometimes called remission), or with less bothersome symptoms. Sometimes symptoms of rheumatoid arthritis will flare (come on suddenly) during a time of stress, illness or life changes. Since no two people are the same, it can be helpful to track what type of symptoms you have during a flare, and how long they last. This will help you discuss symptoms with your doctor and find ways to manage symptoms when they appear. In general, a flare is temporary and should only last a few weeks. If symptoms last longer, speak with your doctor.

How is rheumatoid arthritis diagnosed?

---

An accurate diagnosis is very important because there are many ways to treat and manage rheumatoid arthritis. Early diagnosis and treatment can reduce the pain and disability associated with this disease.

There is no single test to determine if you have rheumatoid arthritis. If you have signs and symptoms of rheumatoid arthritis, your doctor will examine your joints and take your medical history. If indicated, a blood tests that detect inflammation may be ordered that may help confirm the diagnosis. Your healthcare provider may also order X-rays to look for any signs of joint damage. If your family doctor suspects you have rheumatoid arthritis, you will be referred to a specialist called a rheumatologist.

Rheumatologist visit and tests

---

Your appointment with a rheumatologist will include:

• A review of your medical history, including your new joint symptoms.

• A general physical examination.

• A joint examination and counting of tender and swollen joints to determine how many are inflamed

• An examination of your skin, heart, lungs to see if the inflammation affects any other areas of your body.

• Ordering any additional blood tests and imaging (e.g., X-rays or ultrasound) that may help with making a diagnosis or determining the correct path of treatment for your symptoms.

It can take some time to identify the exact cause of your symptoms and confirm a diagnosis. While some people may be diagnosed right away, for most people, it may take multiple visits and several tests before your rheumatologist and other members of your healthcare team are able to provide you with a diagnosis and discuss treatment options with you.

• Blood Tests

  Ordering a blood test is a common step in the diagnostic process, though it only makes up one part of the many factors doctors consider when making a diagnosis of rheumatoid arthritis. Rheumatologists check the antibody levels of two different proteins that are often elevated in people with rheumatoid arthritis. The first is called rheumatoid factor, and the other is a set of antibodies called anti-citrullinated protein antibodies (ACPAs), or more specifically, anti-cyclic citrullinated peptide antibodies (anti-CCPs).

• Rheumatoid Factor and Anti-Cyclic Citrullinated Peptide Antibodies (Anti-CCPs)

  Rheumatoid factor and anti-CCPs are both antibodies made by the immune system that can sometimes attack healthy tissue instead of germs and harmful bacteria. When there are more of these antibodies present in the blood than typical, it can be a sign that the body is attacking itself.

  Since rheumatoid factor can also come back positive in people who are fighting infections, or have other autoimmune conditions, rheumatologists also check anti-CCP levels, since this test is more specific than rheumatoid factor and can help provide more information to your doctors.

  Test results are considered seropositive when blood levels are elevated for rheumatoid factor or anti-CCPs, though not everyone with seropositive test results will have symptoms of rheumatoid arthritis, and there are some people who have other symptoms of rheumatoid arthritis who have no antibodies in their blood (i.e., 20-25% of people with symptoms will have a seronegative test result). Before making a diagnosis, your doctor will also evaluate the symptoms you have in addition to your blood test results.

  Someone who has seronegative test results may still be diagnosed with rheumatoid arthritis based on their symptoms. However, individuals who are seropositive have a higher chance of having inflammation affecting other parts of their body (e.g., lungs, skin) and may have a more aggressive form of the disease.

  Knowing your test results will help your doctors understand which medications might work best to treat your symptoms.

Discover More

---

This information was last updated September 2023, with expert advice from:

Bindee Kuriya, MD, SM, FRCPC
Assistant Professor, Department of Medicine
Division of Rheumatology University of Toronto