Early inflammatory arthritis: why the first weeks matter

Inflammatory arthritis is inflammation of the lining of a joint, the synovium, which doctors call synovitis. The lining becomes inflamed and the joint fills with extra fluid, so it swells, feels warm and tender to press, and stiffens after rest. "Early" means the first weeks and months of it, before anyone has worked out what is driving it; "persistent" means it has lasted a few weeks rather than days. Put together, early inflammatory arthritis is persistent synovitis whose cause is not yet known: a stage rather than a diagnosis, and the stage at which what happens next matters most.

The term takes in several conditions that look alike at the start. Rheumatoid arthritis is the commonest of them, but psoriatic arthritis, the reactive arthritis that follows an infection, palindromic rheumatism and a viral arthritis can all begin the same way, and some clear up without ever being given a name. Telling them apart is the work of the first assessment; treating the inflammation while that work goes on is what protects the joints.

It can begin at any adult age. Rheumatoid arthritis, its commonest cause, most often starts between 40 and 60 and affects two to three times as many women as men, but the same thing in a younger adult, in a man or in later life is no less real and is assessed the same way.

The pattern that points to inflammation in a joint lining, and not to wear or strain:

• Swelling that is soft and warm rather than hard and bony, most often in the fingers, the knuckles, the wrists and the toes, though any joint can be involved
• Stiffness after rest that is worst on waking, takes more than half an hour to loosen and often lasts an hour or more
• The same joints affected on the left and the right, as a rule though not always
• A hand that cannot close into a fist, or pain when the knuckles or the balls of the feet are squeezed together
• Tiredness, sweats or a poor appetite, and sometimes a fever; a fever with a painful joint, or feeling hot, cold or shivery or generally unwell with one, belongs in the same-day list further down, or, with shaking, confusion, rapid breathing, or feeling dramatically worse over hours, in the first list

It usually comes on gradually over several weeks, though in some people it arrives over a few days; one joint turning hot and very swollen suddenly is a case of its own, for the same-day list further down. Pain that is worse with activity and stiffness after it, morning stiffness that wears off inside half an hour, or hard knobbly swellings at the finger joints point to wear, not inflammation, the pattern our osteoarthritis guide covers, and joints that ache without any swelling at all have a guide of their own, joint pain without swelling.

Inflammatory arthritis does its damage most rapidly in its early stages, so treatment that alters its course should begin as soon as possible, and the standards set twelve weeks from the first symptoms as the window: started inside it, treatment raises the chance of remission and lowers the pain and the long-term damage to the joints. That is why the first GP appointment for swollen joints is not the place for wait-and-see, and why the guidelines set the pace that follows, a pace NHS services are audited against nationally.

• A GP should refer anyone whose joints have stayed swollen for weeks with no obvious cause, and refer urgently where the small joints of the hands or feet are involved, where more than one joint is affected, or where three months have already passed since it began. The urgency does not depend on the blood tests: it holds even when the inflammation markers and the antibodies are normal.
• A new inflammatory arthritis that does not resemble rheumatoid arthritis, gout or pseudogout is referred urgently as well, for the assessment the spondyloarthritis family needs: the group that takes in psoriatic and reactive arthritis and the inflammatory back conditions.
• Where more than one joint is affected, or the small joints of the hands or feet, the standard is a referral made within three working days of the GP appointment; whatever the pattern, any tests the GP orders should not hold the referral up.
• Where the specialist review confirms the inflammation, treatment with a disease-modifying medicine should start within six weeks of the referral. GPs are asked to refer within six weeks of the first symptoms so that treatment can begin inside twelve.

A GP's referral is the way into an NHS early arthritis clinic. A private assessment can be booked without one, and in this practice next-working-day appointments can almost always be arranged, and same-day appointments are sometimes possible.

The assessment is built from the history, the examination and a small set of tests, and no single test decides it. Dr Borukhson asks how it began, which joints are involved, how long the morning stiffness lasts and what came before it: an infection, a rash, psoriasis, a bowel condition, a relative with arthritis. Every joint that could be involved is then examined, for the soft, warm swelling of an inflamed lining and for what the joint can and cannot do.

Point-of-care ultrasound is part of the consultation with Dr Borukhson, and in the early weeks it does some of its most useful work. It can pick up inflammation in a joint lining or a tendon sheath before it shows on the outside, which matters because an examination on its own can miss it at this stage; it helps separate a joint whose lining is inflamed from one that is sore for another reason; and it can be repeated later where the examination leaves doubt about whether a joint is still inflamed. For the scan itself, see our ultrasound clinic page.

The blood is tested for the inflammation markers CRP and ESR, for rheumatoid factor and for anti-CCP antibodies, with a full blood count and kidney and liver tests as a baseline for any treatment to come. The results inform the assessment without settling it: rheumatoid factor is present in six or seven people in ten with rheumatoid arthritis and anti-CCP antibodies in about eight in ten, and the inflammation markers are normal in up to four in ten; early in the disease, normal results of every kind are commoner still. Our guides to rheumatoid factor and anti-CCP and raised inflammatory markers explain what each result does and does not mean. An X-ray of the hands and of the feet is taken where the inflammation has persisted, as a record of the joints at the start.

Where the cause is clear, the diagnosis is made at the first visit. Where it is not, you are given a working picture, named as one, with treatment for the inflammation where it persists and a further review, because time and a second examination are part of how these conditions declare themselves. Either way you leave knowing the plan; our guide to your first appointment describes the visit from your side.

• Rheumatoid arthritis, the commonest outcome: the knuckles, fingers and toes on both sides, prolonged morning stiffness, and often rheumatoid factor or anti-CCP antibodies in the blood, though not always.
• Psoriatic arthritis: joint inflammation with psoriasis, present in the great majority, with pitted or discoloured nails or a finger or toe swollen along its whole length as the clues, and less often the same joints on both sides. Those clues deserve an assessment even where there is no psoriasis.
• Reactive arthritis: joints that swell one to four weeks after an infection, most often food poisoning or a sexually transmitted infection, usually the knees and feet.
• Palindromic rheumatism: the joints are normal between attacks, and each attack of pain and swelling lasts from hours to several days before clearing fully; some people with this pattern go on to rheumatoid arthritis, which is why it is watched.
• A viral arthritis: painful, swollen wrists, ankles or knees in the weeks after a flu-like illness, and in adults after slapped cheek syndrome, the parvovirus infection that children mostly shrug off. It usually resolves by itself over several weeks or months, though the joint pain can outlast the rest of the illness by a long way, and a clue can be that others around you were ill at the same time.
• Enteropathic arthritis: the joint inflammation that goes with Crohn's disease and ulcerative colitis.

Joint inflammation that arrives with a rash, mouth ulcers, hair loss or fingers that blanch in the cold, or in later life with painful, stiff shoulders and hips, points towards conditions with guides of their own, lupus and the wider connective tissue diseases, polymyalgia rheumatica and sarcoidosis among them, and the same assessment looks for them.

Some early inflammatory arthritis, the viral kind especially, clears within weeks and is never given a name. It is still worth the assessment: a viral arthritis inflames the joint lining just as the lasting conditions do, and the ones that persist need treatment early. A single joint that turns hot and very swollen suddenly, over a day or a few days, is another matter, with gout, pseudogout and an infected joint (septic arthritis) among the answers. Where a fever or feeling ill comes with it, it is dealt with the same day, either at A&E or by calling NHS 111, and with shaking, confusion, rapid breathing, or feeling dramatically worse over hours it is a 999 or A&E emergency, as the first list says; without a fever or feeling ill, the route is an urgent GP appointment, NHS 111 or a specialist clinic that can see you that day. The same-day list below carries it.

Treatment begins once it is clear that the inflammation is not going to settle on its own, and it begins with a disease-modifying anti-rheumatic drug, a DMARD: a medicine that quietens the immune response driving the inflammation instead of masking the pain. The usual starting medicine is methotrexate, taken once a week with blood tests at intervals to keep it safe; our methotrexate and DMARDs in rheumatology guides cover it and the alternatives.

DMARDs take weeks to months to work. A short course of steroid tablets, or a steroid injection, is therefore often prescribed at the start to relieve the symptoms while the DMARD takes effect; the course is kept short, and the steroid is not the treatment itself. From the first prescription the aim is remission, or the lowest level of activity possible, and the medicines are adjusted at monthly reviews until it is reached; the rheumatoid arthritis guide follows the longer course. Where the first weeks show a different condition, psoriatic or reactive arthritis for instance, treatment follows its own guide. You and Dr Borukhson settle the plan together.

While you wait to be seen, and through the first weeks of treatment:

• Keep the joints moving, gently and within comfort: rest a joint that is sore, but do not stop moving it altogether, since a joint kept still stiffens further
• Cold soothes a sore, swollen joint: frozen peas in a cloth, twenty minutes at most, repeated every two or three hours
• A pharmacist can advise on painkillers, paracetamol and, where it is safe for you, an anti-inflammatory, to take the edge off until the assessment
• Write down which joints are involved, when the swelling comes and goes and how long the morning stiffness lasts, and photograph a swollen joint when you see it: the history is the foundation of the assessment, and the swelling is often down again by the time you are seen
• Tell the GP and the clinic about anyone in your family with rheumatoid arthritis or another autoimmune condition, and about any psoriasis, bowel condition or recent infection of your own
• If you smoke, this is the moment to stop: smoking raises the risk of rheumatoid arthritis, makes its symptoms worse and makes a good response to treatment less likely

Steroids are best left until after the first assessment where the wait is short, because a steroid can hide what the examination and the scan are looking for.

Days rather than hours is the usual pace for early inflammatory arthritis. Five pictures are the exceptions: an infection that may have led to sepsis, or one that has reached the lining of the brain; a joint that cannot be used or has been injured; a joint that may be infected; an eye that is newly red or painful, has changed in what it sees, or has suddenly lost its sight; and a severe allergic reaction to a medicine.

Treat any of these as a 999 or A&E emergency: call 999 and do not drive yourself to A&E.

• Severe illness with suspected sepsis: a high fever with shaking, confusion, rapid breathing, or feeling dramatically worse over hours
• With a fever or feeling unwell, a rash that does not fade when you press it, a stiff neck with eyes that cannot bear bright light, or skin, lips or tongue turning blue, grey, pale or blotchy, since these can be signs of meningitis or sepsis, as can a very bad headache, confusion or a first seizure with a fever or feeling unwell; on black or brown skin the rash and the change of colour may be easier to see on the palms of the hands or the soles of the feet
• A joint you cannot put weight on or move, or that has moved out of place, or, after a fall or injury, very bad pain or any tingling or numbness
• Lips, mouth, throat or tongue that suddenly swell, a throat that feels tight, very fast breathing or a struggle to breathe or to swallow, skin, tongue or lips turning blue, grey or pale (on black or brown skin this may be easier to see on the palms of the hands or the soles of the feet), becoming suddenly very confused, drowsy or dizzy, or fainting and not being able to be woken, since this can be a severe allergic reaction, anaphylaxis, which can follow a dose of any medicine
• An eye that suddenly and completely loses its sight

Any of these needs an assessment that is urgent, on the same day, from your GP or NHS 111:

• A joint that is hot and swollen, with a fever or feeling unwell, since an infected joint has to be ruled out at once, at A&E or through NHS 111
• A joint that has become hot and very swollen suddenly, or is worsening quickly, even without a fever, since an infected joint does not always announce itself with one
• Joint pain with a fever, or feeling hot, cold or shivery, or generally unwell, since an infection in or around a joint has to be found the same day
• A new red, painful eye, or sight that has blurred, dimmed or changed, which needs an eye casualty or urgent eye clinic the same day, as does an eye that light hurts, since the conditions this can turn out to be, psoriatic and reactive arthritis among them, can inflame the eye, as our uveitis guide explains

A joint that has been swollen for more than a couple of weeks, morning stiffness that outlasts half an hour, pain that is stopping you doing normal things or waking you, or a picture that is worsening or keeps returning: each of these is a reason to see a GP within days, or to book a specialist assessment directly. If you cannot tell how urgent something is, asking is never a mistake.

Inflammatory arthritis is at its most destructive in its first months, which is why the twelve-week window carries so much weight: treatment started inside it lowers the long-term damage to the joints, and early treatment is what allows many people with rheumatoid arthritis to live with months or years between flares. A name for the condition is not needed before the assessment begins, and not always before treatment does. Joints that have been swollen and stiff for a couple of weeks are reason enough to be seen.

Is early inflammatory arthritis the same as rheumatoid arthritis?

No. It is the name given to persistent inflammation of the joint lining, called synovitis, in the weeks before its cause has been established. Of the conditions that begin this way rheumatoid arthritis is the commonest, but the same picture can be psoriatic arthritis, the reactive arthritis that follows an infection, the first attacks of palindromic rheumatism or a viral arthritis that fades over some weeks or months. The first assessment sets out to tell these apart, and where a name cannot be fixed at once the joints are treated and reviewed, not left.

How fast should things move?

In days, not months. Joints that have stayed swollen for weeks with no obvious cause call for a referral from the GP, an urgent one where the small joints of the hands or feet are involved, more than one joint is affected or three months have already gone by, and an urgent one too where the arthritis does not look like rheumatoid arthritis, gout or pseudogout; for the small joints, or for more than one joint, the standard is a referral made within three working days of the appointment. From there, once the specialist review has confirmed the inflammation, the target is to have a medicine that alters the course of the arthritis under way within six weeks of the referral, because the benefit is proven for treatment that begins inside twelve weeks of the first symptoms. In this practice next-working-day appointments can almost always be arranged, and same-day appointments are sometimes possible.

Do I need blood tests before I can be referred?

No. A GP may send off tests for rheumatoid factor, for anti-CCP antibodies and for the inflammation markers CRP and ESR, but the referral should not wait for them, and a normal set of results does not mean the joints are fine: the inflammation markers are normal in up to four in ten people with rheumatoid arthritis, the antibodies are absent in a sizeable minority, and tests of every kind are more often normal early in the disease than later. In the first weeks, your account and the examination itself weigh more than any one test.

What will the first visit involve?

Dr Borukhson starts with the history: how it began, which joints are involved, how long the stiffness lasts in the morning and whether anything came before it, and then examines every joint that could be affected. Point-of-care ultrasound is part of the consultation with Dr Borukhson, so the joint linings and tendons can be scanned in the same visit and inflammation too subtle to see or feel can be looked for directly. Blood tests follow, for the markers of inflammation and the antibodies of rheumatoid arthritis, with X-rays of the hands and feet where the inflammation has persisted, and the findings are talked through with you before you leave, with a plan agreed for what comes next.

What if my joints ache but are not swollen?

Then the picture is different and usually less pressing, and our guide to joint pain without swelling covers it. The exception is morning stiffness that outlasts half an hour, which is the inflammatory pattern even before anything is visibly swollen; ultrasound can find inflammation in a joint lining before it shows on the outside, which is why that pattern deserves an assessment of its own, from a GP within days, or booked directly with a specialist.

Should I start steroids while I wait?

Not without advice, and ideally not before the first specialist assessment where the wait is short, because steroid tablets or a steroid injection can damp down the very signs the assessment relies on and leave the diagnosis less certain. If a GP has already prescribed a course because the joints were unbearable, that was a reasonable decision and not one to undo; tell the clinic when you book, so the timing can be allowed for. Ordinary painkillers, and an anti-inflammatory where a pharmacist confirms it is safe for you, can be taken in the meantime.