Rheumatoid arthritis is a serious chronic, systemic, progressive and autoimmune disease that has various symptoms, including inflammation of the joints and other areas of the body, but the cause is still unknown.
Autoimmune diseases are diseases that occur when the body’s tissues are mistakenly attacked by its own immune system.
The immune system consists of a complex organization of cells and antibodies designed to detect and destroy invaders in the body, especially viruses, fungi and bacteria.
Rheumatoid arthritis (RA) mainly affects joints, but can also cause systemic effects (for example on the organs).
The consequence of the disease is an accumulation of fluid in the joints, which leads to joint pain and systemic inflammation, that is, it can affect the whole body.
Juvenile (or infantile) rheumatoid arthritis is a form similar to the one that affects adults, but those affected are children under the age of 16.
This variant can pass by itself over time.
Even though rheumatoid arthritis can involve different areas of the body, the joints are always affected. With renewed acute of the disease, the joints become inflamed. Inflammation is the body’s natural response to infection or other threats, but with this pathology it occurs unjustifiably and for unknown reasons.
Rheumatoid arthritis causes chronic inflammation and hypertrophy of the synovial membrane, which damages soft tissues (tendons, ligaments, muscle, etc.), cartilage and bones. The consequences are cartilage loss, bone erosion and damage to tendons, ligaments and the joint capsule.
In the final stage, one sees deformations and destruction of the joints, as well as a loss of function.
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The first signs of rheumatoid arthritis:
- Periarticular soft tissue swelling (result of effusion)
- Regional osteoporosis (caused by non-use and local hyperthermia)
- Subluxation of the joint between atlas and axis (i.e. vertebrae C1 – C2)
- Expansion of synovial cysts
- Marginal and central bone erosion in the small joints of the hands and wrists, less often on the large joints
Progressive erosion on the proximal phalanges of the fourth finger is most common. It begins with inflammation of the synovial membrane and soft tissues, but the cortical layer of the underlying bone is intact.
The synovial membrane changes its shape and is enriched with proliferating cells, fibrin (connective tissue) and proteolytic enzymes (protein-destroying enzymes).
These enzymes “eat” the articular cartilage, while a large amount of fibrin is deposited in the cartilage and subchondral bone (i.e. in contact with the cartilage).
This process also causes activation of osteoclasts: cells that destroy bone. The result is bone erosion.
Meanwhile, the synovial membrane also attacks and destroys the other soft tissue: joint capsule, bursa, tendons and ligaments.
The final stage of rheumatoid arthritis is bone erosion, the destruction of the joints, and the union of the two bones that make up the joint.
The lesion of the capsule, tendons and ligaments leads to dislocation of the joint, while bone erosion leads to ankylosis and disability.
The inclusion of the joints in descending order is:
- Finger base joint (metacarpophalangeal joint, MCP)
- Wrist
- Middle finger joint (proximal interphalangeal joint, PIP)
- Knee
- Metatarsophalangeal joint (MTP)
- Shoulder
- Ankle
- Cervical vertebrae
- Hip
- Elbow
- Temporomandibular joint (temporomandibular joint, TMG)
The affected joints have inflammation with swelling, numbness, overheating and restricted movement.
Atrophy of the interosseous muscles of the hands is a typical early symptom.
The destruction of the joint and tendons can lead to deformities such as ulnardeviation, buttonhole and gooseneck deformation, hammer toes and ankylosis.
Other diseases of the musculoskeletal system:
- Tenosynovitis is the inflammation of the vagina that surrounds the tendon. It can lead to rupture of the tendon and most affected are the extensor tendons of the fourth and fifth fingers at the level of the wrist.
- Local or generalized osteoporosis due to chronic inflammation, immobilization or therapy with corticosteroids.
- Carpal tunnel syndrome.
- The majority of patients with RA suffer from muscle atrophy, which often occurs after joint inflammation, due to lack of exercise.
Who is affected by rheumatoid arthritis?
Rheumatoid arthritis can affect people of all ages.
Rheumatoid arthritis is more common in women than in men.
In fact, 70% of rheumatoid arthritis patients are women. In addition, the risk of rheumatoid arthritis increases in women who have never been pregnant or have recently given birth.
Causes of rheumatoid arthritis
The causes of rheumatoid arthritis are still unknown. Most scientists believe that it is a combination of hereditary factors and environmental conditions.
Scientists have identified genetic markers that play a crucial role in the development of this condition.
Those who have these markers are ten times more likely to develop rheumatoid arthritis.
The genetic markers affect the immune system and promote chronic inflammation or the development and progression of rheumatoid arthritis.
Not all people with these genes develop rheumatoid arthritis and not all people with this condition have these genes.
The researchers are also looking for infectious causes, such as viruses and bacteria, that can trigger this condition in a person who already has the genetic prerequisites.
Other assumptions concern female hormones (70 percent of people with rheumatoid arthritis are women) and the reaction of the organism to possible stressful situations such as physical or emotional trauma.
Smoking can be a risk factor. Not only does it increase the risk of developing rheumatoid arthritis in people with a specific gene, but it can also increase the severity of the condition and reduce the effectiveness of a therapy.
Some environmental factors also appear to play a role in the cause of rheumatoid arthritis. For example, scientists have drawn attention to the fact that tobacco smoke, contact with minerals high in silicon dioxide, and chronic periodontal disease increase the risk of developing rheumatoid arthritis.
Symptoms of rheumatoid arthritis
Rheumatoid arthritis is a chronic (long-lasting) disease. Every person with RA has different symptoms that can come and go. Some people experience long periods of remission when rheumatoid arthritis is inactive and shows few symptoms. Other people can be in pain for months.
Inflammation of the joints is a distinguishing feature of rheumatoid arthritis, which also includes:
Stiffening. Moving the joints becomes more and more painful because there could be a limitation of the range of motion.
“Morning stiffness” is one of the characteristic signs of this disease. Many people with other types of arthritis have stiff joints in the morning, but those with rheumatoid arthritis experience these symptoms for more than an hour (sometimes several hours) before the joints warm up.
swelling. Fluid enters the joint, which then swells. This also contributes to stiffness.
Pain. The inflammation inside a joint makes it sensitive and numb. Long-lasting inflammation causes damage that helps increase the pain.
Redness and overheating. The joints may appear warmer and redder than the adjacent areas of the skin.
Other symptoms:
- Fever
- Urticaria vasculitis
- Anemia and fatigue
- Weight loss
Which joints are affected by rheumatoid arthritis?
The hands are almost always affected, but any other joint can also be affected by rheumatoid arthritis: knees, hips, wrists, neck, shoulders, elbows and jaws.
Normally, the joints are affected symmetrically or bilaterally, that is, the same joints on both sides of the body.
The symptoms of rheumatoid arthritis affect the entire body. These effects arise from the general process of inflammation and provoke different symptoms:
- Exhaustion
- malaise (feeling sick)
- Loss of appetite, which can lead to weight loss
- Muscle
These sensations are similar to those of influenza, although they are usually less intense and last longer.
Examination of the joints
Finger
Buttonhole deformity. It consists of a finger malposition with flexion of the proximal interphalangeal joint with simultaneous overextension of the distal interphalangeal joint.
There are some tendons that preserve the alignment of the finger bones. The tendon of the long finger extensor consists of a central part, which ends in the middle phalanx, but is previously divided into two further lateral branches, which attach in the distal phalanx (fingertip).
Rheumatoid arthritis causes a lesion of the middle tract approximately at the level of the joint between the first and second phalanx.
Over time, there is a retraction of the lateral branches of the finger extensor tendon, which has two consequences:
- The middle joint of the finger bends,
- the distal joint is overstretched.
One effect of buttonhole deformity is loss of mobility and ability to grasp objects.
Gooseneck deformity consists of overextension of the proximal interphalangeal joint (middle finger joint) together with flexion of the distal interphalangeal joint (finger end joint).
The formation of this deformity begins with the rupture of the finger extensor tendon at the level of the distal interphalangeal joint.
As a result, there is a shortening of the middle extensor tendon and the overextension of the joint between the first and second phalanx, or the joint capsule shifts towards the little finger due to weakness caused by chronic synovitis.
The collateral ligaments can shorten over time and shift to the back of the finger. They thus restrict finger flexion between the first and second phalanx and prevent the extension of the joint between the second and third phalanx.
The stiffness of the intrinsic muscles (for example, inter-bone muscle and lumbrical muscle) can cause a restriction of movement of the fingers.
Tenosynovitis of the finger flexors is common and refers to an infaust prognosis.
The rapid finger or snap finger occurs when the tendon stiffens or a lump forms along with tenosynovitis.
The tendon rupture can occur as a result of synovitis or by bone erosion on the tendon at the level of the wrist (especially the long thumb flexor).
Arthritis mutilans is the result of serious and extensive destruction with erosion of bone tissue. In the small joints of the hand, the finger limbs can shorten and the joints become severely unstable.
Metacarpophalangeal joint
Two typical malformations that change the orientation of the bony palmar arches and the stability of the fingers can occur at the base joints: subluxation and ulnar deviation (deviation after ulnar).
Most cases of ulnar deviation are accompanied by a radial deviation of the wrist of approximately the same extent.
The proximal phalanx moves towards the ulna through synovial inflammation, which has weakened the ligament and tendon attachments on the capsule of the base joint.
The supporting structures of the extensor tendons and collateral ligaments may be destroyed or torn off by the increase in volume and invasion of the synovial membrane. As a result, the tendons loosen and shift from the center and back of the metacarpal bone head to the fissure between the base joints.
If the subluxation of the extensor tendon extends over the transverse axis of the finger base joint, the tendon becomes the flexor of this joint and thus limits the active finger extension.
Wrists
Multiple malformations can occur in the wrist.
The external deviation of the ulna with subluxation of the spoke-elbow joint is the most common deformity.
This malformation occurs along with the rotation of the carpal (wrist) and the displacement of the lunar bone, which – instead of maintaining contact with the radius – is located in front of the void between the two forearm bones.
This new alignment of the bones is called Z-deformity.
Elbow
The involvement of the elbow joint is often identified by synovial proliferation, which is palpable at the radio-humeral joint and is often accompanied by flexion formity. The bursa is often affected, as well as the rheumatism nodules in the bursa and on the posterior surface of the ulna.
Shoulder
Rheumatoid arthritis involves the shoulders and manifests itself in numbness, nocturnal pain and restriction of movement. Initially, there is swelling in the front area, but this can be difficult to detect and many patients do not have this sign.
Degeneration of the rotator cuff caused by synovitis can limit abduction (lateral lifting) and rotation of the arm. The upper and lateral migration of the humerus occurs in the case of a complete tear. Damage to the glenohumeral joint causes pain when moving and at rest. It is usually accompanied by severe restriction of movement or adhesive capsulitis (frozen shoulder).
Arthrosis of the acromioclavicular joint (between the shoulder blade and collarbone) is not as common and debilitating as other manifestations of this disease.
Ankles and feet
Ankles are rarely affected, because this is a trochlear joint.
Sharp structural changes can occur in the middle of the foot as a result of chronic synovitis and body weight load.
Injury or tear of the posterior tendon can lead to subluxation of the subtalar joint (posterior lower ankle). The result is the lateral displacement of the talus (ankle) and the outward rotation of the foot.
Other deformities that rheumatoid arthritis causes include flat feet, hallux valgus, and hammer toes.
Knee
Affected knees may have inflammation and synovitis. Over time, fluid accumulation in the joint can lead to loss of function of the quadriceps resulting in muscle atrophy.
Due to the progressive loss of cartilage and weakening of ligaments, instability may develop; the knee deformities can occur as valgus, vagus or in a bent position. The patient’s energy expenditure when standing or walking is considerably greater if he suffers from a flexion malposition of the knee.
Hips
The hips are often affected in rheumatoid arthritis. However, because of their low-lying position, the damage does not appear in the first stages of the disease, because the hips are difficult to examine by direct physical inspection or palpation.
Complications
Rheumatoid arthritis is not fatal, but the complications of the condition can shorten survival in some people.
As a rule, rheumatoid arthritis has a progressive course and cannot be definitively cured, but in some patients it gradually becomes less aggressive and the symptoms may improve.
However, after a destruction of the bones and ligaments with possible deformities, the consequences are permanent.
Rheumatoid arthritis is a systemic disease that can affect parts of the body other than the joints.
Involvement of multiple areas of the body usually occurs in cases of moderate or severe RA.
Rheumatism nodules are elevations under the skin that often occur on the elbows and hands. Sometimes they are painful.
The involvement of the lungs can lead to damage to the lungs, pleurisy or pleural effusion. These consequences are common, but usually do not cause symptoms. If it comes to shortness of breath, you can use drugs that reduce the inflammation in the lungs.
Rheumatoid arthritis can also affect a joint of the larynx (articulatio cricoarytaenoidea), causing a deeper pitch.
Rheumatoid arthritis can cause inflammation of the pericardium (pericarditis), but usually this does not cause symptoms.
If symptoms develop, shortness of breath or chest pain may occur.
People with rheumatoid arthritis are more likely to develop atherosclerosis (atherosclerosis) of the coronary arteries, which can lead to angina (chest pain) and heart attack.
That’s one reason why a person with untreated RA is at greater risk of premature death.
The eyes are involved in less than 5% of people affected by rheumatoid arthritis. In these cases, the symptoms may be eye redness, aching eyes or possibly dry eyes.
When rheumatoid arthritis is diagnosed, an early and aggressive therapy program can help prevent the onset of new symptoms and halt the progression of rheumatoid arthritis.
Infections. Patients with RA are at greater risk for infections, in part because they are taking immunosuppressive medications.
Digestive problems. Patients with RA may suffer from stomach and intestinal problems. However, lower rates of cancers of the colon, rectum and stomach have also been reported in patients with rheumatoid arthritis.
Osteoporosis. This condition is much more common compared to the average of women with postmenopausal RA. First of all, the hip is affected. The risk of osteoporosis appears to be higher than the average of men with rheumatoid arthritis older than 60 years.
Sjögren’s syndrome with keratoconjunctivitis secca is a common complication of rheumatoid arthritis.
Felty syndrome. This condition is characterized by enlargement of the spleen, leukopenia and recurrent bacterial infections.
Systemic lupus erythematosus is an autoimmune disease that affects connective tissue.
Lymphoma and other tumors. Aggressive treatments for rheumatoid arthritis can help prevent these neoplasms. The changes in the immune system associated with RA can have an impact.
