Rheumatoid Arthritis

The most common type of inflammatory arthritis is Rheumatoid Arthritis, which affects approximately 3% of women and 1% of men in Northern Europe.

Features of rheumatoid arthritis are not seen in historical Western art and literature, suggesting that it is a modern disease in Europe.  Changes of the disease are recognised in ancient Native American skeletons, leading to speculation that it was exported back to the Old World after colonialisation.  The precise cause is unclear, but related to an auto-immune response.  The disease also appears to be genetically linked, and possibly to an unknown infectious agent.  Once the response is triggered, there is a release of toxic hormones and chemicals within the body, such as Tumour Necrosis Factor (TNF).

The disease affects any joint and also has other manifestations around the body.  There is inflammation of the soft tissues and joint lining tissue, known as synovium, and the bone and cartilage around joints is eroded.

Rheumatoid factor (RF) is an antibody found in approximately 80% of cases (and in 1-5% of the unaffected population).

Other features often seen around the body are:

Skin – subcutaneous nodules (20% of patients)

Eye – painful red eye.

Nerves – especially compression of median nerve at the wrist (Carpal Tunnel Syndrome) and ulnar nerve behind the elbow (Cubital Tunnel Syndrome).

Common features are: 

  1. Morning stiffness, lasting at least one hour.
  2. Active arthritis of 3 or more joints simultaneously
  3. Active arthritis of at least one hand joint
  4. Symmetrical arthritis
  5. Subcutaneous rheumatoid nodules.
  6. Rheumatoid Factor
  7. Xray changes of rheumatoid arthritis.

Hands and feet are commonly affected early in the disease.

Examination may show features of arthritis, with swelling, warmth, and stiffness, with pain on movement.

There are very characteristic patterns of disease and deformity seen in the hand and wrist.

Inflammation of the tendons “tenosynovitis” commonly affects tendons of the hand and wrist, with swelling and difficulty in movement.  Eventually tendons may rupture.


Longstanding, stable, mild cases can be treated with simple pain-killers and Non-Steroidal Anti-Inflammatory Drugs (NSAIDs).  However, it is now believed that the disease is best treated aggressively in its early phase (first two years), before erosions and other problems can occur.  This treatment is with “Disease Modifying Drugs” such as Methotrexate, Gold, Sulphasalazine, and the most recent development of Anti-TNF drugs.

Corticosteroid by local injection into joints or around tendons is often very helpful.

Splintage can be helpful to reduce pain and improve function.  They probably do not prevent deformity in most cases.

Surgery is still very important for rheumatoid arthritis, although hopefully its role will continue to diminish as medical therapy, especially anti-TNF improves in efficacy.

Surgical options for joints include fusions, especially for finger joints and the wrist, and replacement (for major joints including the elbow, knuckle joints and occasionally even the wrist – where we are particurly involved in research).

Inflamed tendons sometimes need surgical treatment, if medical treatment has not helped, in order to prevent rupture.  If tendons do rupture, then transferring another less important tendon is often helpful.