What to know about rheumatoid arthritis in the hands

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RA symptoms differ between individuals and can be unpredictable. However, RA typically has a relapsing-remitting pattern, meaning that a person will have periods of worsening symptoms, or flare-ups, that are followed by periods of remission.

More than 50% of RA cases begin slowly and without any apparent symptoms, so an individual is not aware of it developing. However, in up to 25% of cases, the onset of symptoms is abrupt.

RA symptoms stem from inflammation and affect the synovial tissues that line the joints. The symptoms usually develop in the left and right side equally and are worse after a period of immobility, such as after waking up.

Over time, RA progresses, and the symptoms worsen. The condition may also affect more joints, leading to joint malformation, which may reduce a person’s range of mobility.

Doctors distinguish between four stages of RA:

• stage 1, or early stage RA
• stage 2, or moderate RA
• stage 3, or severe RA
• stage 4, or end stage RA

Progression through the stages may take many years, and with the right treatment, some individuals will not progress through all stages.

Stage 1

In early stage RA, the joint capsule becomes inflamed, and the synovial tissues swell. This process causes joint pain, visible swelling, and stiffness.

If a primary care physician or rheumatologist diagnoses RA at this early stage, before joint damage begins, the chances of having extended periods with no symptoms increase significantly.

The best outcomes occur when a person receives an RA diagnosis and appropriate treatment within 12 weeks of developing symptoms. Around 10–15% of individuals with RA experience remission if they get the right treatment quickly.

In addition to performing a physical examination, doctors use blood tests to look for high levels of inflammatory markers and changes in the blood that can confirm an RA diagnosis.

These tests can look for two specific antibodies: rheumatoid factor (RF) and anti-citrullinated protein antibody (ACPA), which people with RA typically have in elevated amounts. Tests can detect RF in up to 80% of people with RA, and ACPAs in up to 90% of cases.

Stage 2

In moderate RA, the inflammation of the synovial tissue is severe enough to damage the joint cartilage. Cartilage is a protective, cushioning tissue that covers the ends of bones in the joints.

As a result of this damage, a person will experience further pain and loss of mobility and will find that it further limits their range of motion. Additionally, many individuals with RA feel excessively tired and have a low-grade fever.

Individuals with RA may go undiagnosed in the initial stage, because they have seronegative RA, meaning that blood tests do not show any sign of the RA antibodies.

Only when the joints become damaged in later stages of the condition can doctors confirm an RA diagnosis using imaging such as X-rays, ultrasound scans, and MRI scans.

Doctors may only see the joint erosion up to 2 years after an individual’s symptoms begin, and they may not detect soft tissue involvement at all.

Stage 3

When someone progresses to stage 3, or severe, RA, the inflammation destroys the bone and cartilage. As a result, people may experience increased pain and joint swelling.

The chronic inflammation can also cause permanent physical deformities, such as the fingers twisting or curving outward, with thickened, nodular formations around the joints. Additionally, if the tendons of the wrist become compressed by these nodules, an individual may also experience symptoms of carpal tunnel syndrome.

Stage 4

In stage 4, or end stage, RA, the inflammatory process stops, and the joints cease to function altogether. This stage has the same symptoms as the previous stages, but the loss of function may be more severe and disabling.

In rare cases, as RA destroys the joints, the joints may fuse together. Doctors call this ankylosis, and this affects around 0.8% of all individuals with RA.

People with end stage RA may lose many physical abilities and may need to rely on mobility devices to help them in their daily lives.

RA is a highly variable condition, and it does not progress in the same way for everyone. Some people can manage their symptoms, while in others, symptoms may worsen and progress.

Some factors that indicate an individual’s RA is progressing include:

• worsening joint pain and swelling
• increasing frequency and duration of flares
• ongoing damage, based on imaging tests
• increasing levels of inflammatory markers in the blood
• other symptoms, such as fatigue or dry, painful eyes
• the appearance of rheumatoid nodules

If a person notices any changes to their symptoms, they should immediately contact a doctor.

Although RA is a life-changing condition for many people, various medications can help manage its symptoms and minimize its impact.

Doctors typically recommend methotrexate (Trexall) as the first-line medication for RA. This chemotherapy medication changes how the immune system responds, and alters the course of the condition over time. For this reason, doctors also refer to it as a disease-modifying antirheumatic drug (DMARD).

Other DMARD options include:

• hydroxychloroquine (Plaquenil)
• sulfasalazine (Azulfidine)
• leflunomide (Arava)
• Janus kinase inhibitors

Doctors may also recommend additional medications, including nonsteroidal anti-inflammatory drugs, and prescription corticosteroids, such as methylprednisolone (Medrol) or prednisone (Rayos).

Depending on how a person responds to DMARD treatment, doctors may also prescribe another drug type called biologic response modifiers, or biologics, in addition to the DMARD.

Biologics such as abatacept (Orencia) and golimumab (Simponi) block specific actions of immune cells, which then modify the inflammatory response.

People may find that making changes to their habits, diet, and lifestyle can help minimize the impact of RA.

Some suggestions include:

• eating a balanced diet
• reaching or maintaining a moderate body weight
• stopping smoking, if applicable
• increasing physical activity to at least 30 minutes five times per week
• resting when symptoms cause discomfort
• using heating pads when joints feel stiff and tired
• using cool or ice packs to reduce swelling in painful joints
• managing stress using mindfulness techniques or yoga
• attending physical therapy and occupational therapy sessions

Living with any chronic condition may feel overwhelming, and therefore individuals should seek support from family, friends, or a support group.

Nonprofit groups, such as the Arthritis Foundation, provide both virtual and location-based support groups. People with RA can share information, tips, insights, and personal experiences in group meetings.

RA commonly affects the hands and wrists, causing symptoms such as pain, swelling, loss of function, and deformities.

The condition progresses through four stages, although not everyone will experience each stage.

Anyone who notices RA symptoms in the fingers, hands, or wrists should consult a doctor. This is essential, because early diagnosis and treatment are vital for minimizing the impact of RA and helping prevent disease progression.