Rheumatology Revision Guide ✅

🦴 Rheumatology is pattern recognition plus immunology. Start with the pattern: inflammatory vs mechanical pain, monoarthritis vs oligoarthritis vs polyarthritis, joint vs tendon/enthesis, and local disease vs systemic autoimmune disease. The key exam skill is not memorising every antibody - it is linking symptoms, examination, inflammatory markers, imaging and autoantibodies into a coherent syndrome.

✅ 1. Core Rheumatology Concepts

🔥 1.1 Inflammatory versus Mechanical Pain

• Inflammatory pain: worse after rest, prolonged morning stiffness, improves with movement, may wake patient in second half of night.
• Mechanical pain: worse with use, improves with rest, short-lived stiffness, localised to damaged joint or tendon.
• Inflammatory arthritis usually has swelling, warmth and tenderness from synovitis.
• Mechanical pain may have crepitus, bony enlargement and reduced range due to structural change.
• Always ask about systemic features: fever, weight loss, rash, eye symptoms, mouth ulcers, bowel symptoms, psoriasis and Raynaud’s.

🧠 Exam pearl: Morning stiffness lasting more than 30–60 minutes strongly suggests inflammatory disease. Stiffness lasting only a few minutes after sitting is more typical of osteoarthritis.

🦠 1.2 Synovitis, Enthesitis and Dactylitis

• Synovitis: inflamed joint lining; swelling is often soft and “boggy”.
• Enthesitis: inflammation where tendon/ligament inserts into bone; classic in spondyloarthritis.
• Dactylitis: whole digit swelling, “sausage digit”; seen in psoriatic arthritis and reactive arthritis.
• Tenosynovitis: tendon sheath inflammation; common in RA and can cause triggering or carpal tunnel syndrome.
• Bursitis: inflamed bursa; localised swelling over olecranon, prepatellar or trochanteric areas.

🧪 2. Rheumatology Investigations

🩸 2.1 Blood Tests

• FBC: anaemia of chronic disease, cytopenias in SLE, thrombocytosis in inflammation, neutropenia with drugs or Felty syndrome.
• CRP/ESR: markers of inflammation; may be normal in some active autoimmune disease.
• U&E/LFT: baseline before DMARDs/NSAIDs and to detect organ involvement.
• Urate: supports gout risk but can be normal during an acute flare.
• CK: raised in inflammatory myopathy, rhabdomyolysis or statin myopathy.
• Urinalysis: vital in SLE/vasculitis to detect proteinuria or haematuria.

🧬 2.2 Autoantibodies

⚠️ Clinical caution: Autoantibodies are not screening tests for vague aches. A positive ANA in a low-probability patient can mislead; use antibodies to support a clinical diagnosis, not to replace history and examination.

🩻 2.3 Imaging

• X-ray: joint space narrowing, erosions, osteophytes, chondrocalcinosis, sacroiliitis.
• Ultrasound: synovitis, tenosynovitis, erosions, power Doppler inflammation, guided aspiration/injection.
• MRI: early erosions, bone marrow oedema, sacroiliitis, spinal inflammation, avascular necrosis.
• DEXA: osteoporosis assessment in steroid use, fragility fracture or high fracture risk.
• CT chest: ILD assessment in systemic sclerosis, RA, myositis or vasculitis.

🚨 3. Acute Hot Swollen Joint

An acutely hot swollen joint is septic arthritis until proven otherwise. Crystal arthritis can look identical, and crystals do not exclude infection.

• Causes: septic arthritis, gout, pseudogout, trauma, haemarthrosis, reactive arthritis, flare of inflammatory arthritis.
• Risk factors for septic arthritis: prosthetic joint, RA, diabetes, immunosuppression, IV drug use, skin infection, older age.
• Symptoms: acute severe pain, swelling, warmth, restricted movement, fever may be absent.
• Investigations: FBC, CRP, blood cultures, X-ray if trauma/prosthesis, urgent joint aspiration.
• Synovial fluid: Gram stain, culture, white cell count, polarised microscopy for crystals.
• Treatment if septic arthritis suspected: urgent senior/orthopaedic/rheumatology input, IV antibiotics after cultures if safe, joint washout/drainage.

🚨 Exam pearl: Never inject steroids into a joint until infection has been excluded. Steroids can worsen septic arthritis and delay diagnosis.

🧱 4. Osteoarthritis

Osteoarthritis is a whole-joint disease involving cartilage loss, subchondral bone change, synovial inflammation and osteophyte formation. It is not simply “wear and tear”; inflammatory and metabolic factors also contribute.

🔍 4.1 Clinical Features

• Pain worsens with activity and improves with rest.
• Morning stiffness is usually brief, often less than 30 minutes.
• Common sites: knees, hips, hands, first CMC joint, cervical/lumbar spine.
• Hand OA: Heberden’s nodes at DIP joints, Bouchard’s nodes at PIP joints, thumb base pain.
• Knee OA: crepitus, bony enlargement, reduced range, varus deformity in advanced disease.
• Hip OA: groin pain, reduced internal rotation, difficulty putting on socks/shoes.

💊 4.2 Management

• Core treatments: education, exercise, weight loss if overweight, pacing and self-management.
• Exercise should include strengthening and aerobic activity; pain during exercise does not necessarily mean harm.
• Topical NSAIDs are useful for knee/hand OA and have fewer systemic risks than oral NSAIDs.
• Oral NSAIDs may help but require GI, renal and cardiovascular risk assessment.
• Consider aids, physiotherapy, occupational therapy and joint replacement referral for severe pain/function loss.
• Routine glucosamine/chondroitin and long-term opioids are generally poor-value strategies.

🔥 5. Rheumatoid Arthritis

Rheumatoid arthritis is a chronic autoimmune inflammatory synovitis that can cause cartilage destruction, bone erosions, tendon damage and systemic disease. Early DMARD treatment reduces irreversible joint damage.

🔍 5.1 Clinical Features

• Symmetrical small-joint polyarthritis: MCP, PIP, wrists, MTP joints.
• DIP joints are usually spared, helping distinguish RA from hand OA or psoriatic arthritis.
• Morning stiffness often lasts more than 1 hour.
• Synovitis feels soft, warm and boggy.
• Systemic features: fatigue, weight loss, low-grade fever, anaemia.
• Extra-articular disease: nodules, episcleritis/scleritis, ILD, pleural disease, pericarditis, vasculitis, carpal tunnel.

🧪 5.2 Diagnosis and Monitoring

• Diagnosis is clinical, supported by RF, anti-CCP, inflammatory markers and imaging.
• Anti-CCP positivity suggests higher likelihood of erosive disease.
• X-rays may be normal early; ultrasound/MRI can detect early synovitis and erosions.
• Disease activity is monitored using joint counts, inflammatory markers and patient global assessment.
• Refer urgently if persistent synovitis affects small joints, multiple joints, or symptoms started recently.

💊 5.3 Treatment

• Treat-to-target approach: aim for remission or low disease activity.
• Start conventional synthetic DMARD promptly, commonly methotrexate, sulfasalazine or leflunomide under specialist care.
• Hydroxychloroquine may be used in milder disease or combination therapy.
• Short-term steroids may bridge symptoms but should not replace DMARDs.
• Biologics/JAK inhibitors are used for active disease despite conventional DMARDs according to specialist pathways.
• Monitor DMARD toxicity: FBC, LFT, renal function; counsel about infection risk and contraception where relevant.

🧠 Exam pearl: RA is a synovitis diagnosis, not just a “positive rheumatoid factor” diagnosis. RF can be positive in older people and infections; anti-CCP is more specific.

🧬 6. Spondyloarthritis

🧍 6.1 Axial Spondyloarthritis

• Inflammatory back pain starting before age 45 is the classic clue.
• Features: gradual onset, night pain, morning stiffness, improvement with exercise, poor improvement with rest.
• Associated features: uveitis, psoriasis, IBD, enthesitis, dactylitis, family history, good NSAID response.
• HLA-B27 supports diagnosis but is not diagnostic alone.
• MRI sacroiliac joints can detect early inflammatory sacroiliitis before X-ray changes.
• Management: exercise/physiotherapy, NSAIDs if safe, biologics for active disease under specialist care.

🖐️ 6.2 Psoriatic Arthritis

• Can present as asymmetric oligoarthritis, DIP arthritis, symmetrical polyarthritis, axial disease or arthritis mutilans.
• Look for psoriasis hidden in scalp, umbilicus, natal cleft and behind ears.
• Nail pitting, onycholysis and dactylitis are important clues.
• RF is usually negative, but serology does not exclude disease.
• Management: NSAIDs, local steroid injections, DMARDs such as methotrexate, biologics depending on pattern/severity.

🦠 6.3 Reactive Arthritis

• Occurs after GI or GU infection, commonly Chlamydia, Salmonella, Shigella, Campylobacter or Yersinia.
• Features: asymmetric lower-limb arthritis, enthesitis, dactylitis, conjunctivitis/uveitis, urethritis, mucocutaneous lesions.
• Usually self-limiting but can become chronic.
• Management: treat triggering infection if present, NSAIDs, local steroids, rheumatology follow-up if persistent.

💎 7. Crystal Arthritis: Gout and Pseudogout

💎 7.1 Gout

Gout is caused by deposition of monosodium urate crystals in and around joints. Hyperuricaemia is necessary for crystal formation, but serum urate can be normal during an acute attack.

• Classic site: first MTP joint, also midfoot, ankle, knee, wrist and elbow.
• Attack: sudden severe pain, swelling, redness, heat; often overnight.
• Risk factors: male sex, age, CKD, diuretics, alcohol, obesity, high purine intake, metabolic syndrome.
• Diagnosis: clinical pattern plus urate; joint aspiration shows negatively birefringent needle-shaped crystals.
• Acute treatment: NSAID, colchicine or corticosteroid depending on comorbidities.
• Urate-lowering therapy: allopurinol first-line for many patients; start low and titrate to target urate.
• Give flare prophylaxis when starting urate-lowering therapy, commonly colchicine if suitable.

🧊 7.2 Pseudogout / CPPD

• Calcium pyrophosphate deposition disease commonly affects knees, wrists and shoulders.
• Associated with age, OA, haemochromatosis, hyperparathyroidism, hypomagnesaemia and hypothyroidism.
• X-ray may show chondrocalcinosis.
• Joint aspiration shows positively birefringent rhomboid crystals.
• Treatment: NSAID, colchicine or steroid; treat underlying metabolic trigger if found.

🦋 8. Systemic Lupus Erythematosus

SLE is a multisystem autoimmune disease caused by loss of immune tolerance and immune complex deposition. It can affect skin, joints, kidneys, CNS, blood cells, serosa and pregnancy outcomes.

• Common features: fatigue, fever, arthralgia/arthritis, photosensitive rash, malar rash, oral ulcers, alopecia.
• Serositis: pleuritis or pericarditis.
• Renal disease: proteinuria, haematuria, nephritic/nephrotic syndrome; may be silent early.
• Haematological: anaemia, leukopenia, lymphopenia, thrombocytopenia.
• Antibodies: ANA sensitive; anti-dsDNA and anti-Sm more specific; low complement suggests active immune complex disease.
• Antiphospholipid antibodies increase risk of thrombosis and pregnancy morbidity.
• Management: sun protection, hydroxychloroquine for most, steroids/immunosuppression for organ-threatening disease.

⚠️ Safety pearl: In suspected lupus flare, always check urine dip, U&E, blood pressure and protein:creatinine ratio. Lupus nephritis can be clinically subtle but organ-threatening.

🌵 9. Sjögren’s Syndrome

• Autoimmune disease of exocrine glands causing dry eyes and dry mouth.
• Primary Sjögren’s occurs alone; secondary Sjögren’s occurs with RA, SLE or systemic sclerosis.
• Features: gritty eyes, dental caries, oral candidiasis, parotid swelling, fatigue, arthralgia.
• Systemic features: neuropathy, interstitial lung disease, renal tubular acidosis, vasculitis.
• Antibodies: anti-Ro/SSA and anti-La/SSB; ANA and RF may be positive.
• Management: artificial tears, saliva substitutes, dental care, pilocarpine in selected patients, systemic therapy if organ disease.
• Complication: increased risk of lymphoma, especially with persistent parotid swelling or lymphadenopathy.

🧤 10. Systemic Sclerosis

🧤 10.1 Clinical Features

• Pathology: vasculopathy, immune activation and fibrosis of skin/internal organs.
• Raynaud’s phenomenon is often the earliest feature.
• Skin: sclerodactyly, digital ulcers, calcinosis, telangiectasia, tight shiny skin.
• GI: reflux, oesophageal dysmotility, bacterial overgrowth, constipation/diarrhoea.
• Lung: interstitial lung disease and pulmonary arterial hypertension.
• Renal: scleroderma renal crisis - severe hypertension and AKI.

🧬 10.2 Limited versus Diffuse Disease

🚨 Emergency pearl: New severe hypertension in systemic sclerosis is scleroderma renal crisis until proven otherwise. ACE inhibitor treatment is urgent, even if renal function is impaired, with specialist input.

💪 11. Inflammatory Myopathies

• Includes polymyositis, dermatomyositis, immune-mediated necrotising myopathy and inclusion body myositis.
• Features: symmetrical proximal muscle weakness - difficulty climbing stairs, rising from chair, lifting arms.
• CK is usually raised, often markedly.
• Dermatomyositis: heliotrope rash, Gottron’s papules, photosensitive rash, shawl sign.
• Complications: interstitial lung disease, dysphagia, aspiration, myocarditis.
• Dermatomyositis in adults can be associated with malignancy; age-appropriate cancer screening is important.
• Management: high-dose steroids, steroid-sparing immunosuppression, physiotherapy and treatment of complications.

🩸 12. Vasculitis

🧠 12.1 Giant Cell Arteritis

• Large-vessel vasculitis usually affecting people over 50.
• Features: new headache, scalp tenderness, jaw claudication, visual symptoms, constitutional symptoms.
• Associated with polymyalgia rheumatica.
• Investigations: ESR/CRP often raised, temporal artery ultrasound/biopsy depending on pathway.
• Treatment: immediate high-dose glucocorticoids if suspected; do not wait for biopsy if vision at risk.
• Visual loss can be sudden and irreversible.

🦵 12.2 Polymyalgia Rheumatica

• Inflammatory syndrome in older adults causing bilateral shoulder and hip girdle pain/stiffness.
• Morning stiffness is prominent; true muscle weakness is not typical.
• ESR/CRP usually raised.
• Responds dramatically to moderate-dose steroids.
• Always ask about GCA symptoms: headache, jaw claudication, scalp tenderness and visual disturbance.

🫁 12.3 ANCA-Associated Vasculitis

• Red flags: haematuria/proteinuria, pulmonary haemorrhage, mononeuritis multiplex, purpura, systemic illness.
• Management is specialist-led with high-dose steroids plus rituximab/cyclophosphamide for organ-threatening disease.

🦴 13. Osteoporosis and Bone Health

• Osteoporosis is reduced bone strength with increased fragility fracture risk.
• Risk factors: age, female sex, low BMI, smoking, alcohol, glucocorticoids, early menopause, previous fragility fracture, parental hip fracture.
• Common fracture sites: hip, vertebra, distal radius and humerus.
• DEXA gives T-score: osteoporosis is T-score ≤ -2.5.
• FRAX/QFracture estimate fracture risk and guide treatment thresholds.
• Management: falls prevention, weight-bearing exercise, vitamin D/calcium if deficient, oral bisphosphonate first-line in many patients.
• Long-term steroid users need fracture risk assessment and prophylaxis where indicated.

🧪 13.1 Paget’s Disease of Bone

• Disordered bone remodelling causing enlarged, weak and vascular bone.
• Often asymptomatic with isolated raised ALP.
• Symptoms: bone pain, deformity, hearing loss, fracture, osteoarthritis from altered mechanics.
• Treatment: bisphosphonates if symptomatic or high-risk site.

💊 14. Rheumatology Drugs

⚠️ Prescribing pearl: Before DMARDs/biologics, check baseline bloods, infection risk, vaccination status, pregnancy plans and monitoring arrangements. Many rheumatology drugs are safe and effective, but harm occurs when monitoring is missed.

🚨 15. Rheumatology Emergencies

• Septic arthritis: hot swollen joint; aspirate urgently and treat.
• Giant cell arteritis: new headache/jaw claudication/visual symptoms; start steroids immediately if suspected.
• Scleroderma renal crisis: systemic sclerosis plus severe hypertension/AKI; urgent ACE inhibitor and specialist input.
• Cauda equina in axial disease: new bladder/bowel dysfunction, saddle anaesthesia, severe neurological symptoms; emergency imaging.
• Atlantoaxial subluxation in RA: neck pain, neurological symptoms, pre-operative airway risk.
• Vasculitic pulmonary haemorrhage: haemoptysis, anaemia, hypoxia, renal findings; urgent immunosuppression pathway.
• Macrophage activation syndrome: fever, cytopenias, liver dysfunction, high ferritin in systemic inflammatory disease.

📚 16. OSCE / Exam Pearls

• Inflammatory pain improves with movement; mechanical pain worsens with use.
• RA affects MCP/PIP/wrists; OA often affects DIP, thumb base, hips and knees.
• DIP arthritis plus psoriasis/nail pitting suggests psoriatic arthritis.
• Hot swollen joint is septic arthritis until proven otherwise.
• Serum urate can be normal during acute gout.
• GCA is treated before confirmation if vision is threatened.
• PMR causes pain and stiffness, not true objective weakness.
• Proximal true weakness plus high CK suggests inflammatory myopathy.
• Raynaud’s plus reflux plus skin thickening suggests systemic sclerosis.
• Urine dip is essential in suspected SLE or vasculitis.

📌 17. Quick Differentials Table

📚 References

• NICE. Rheumatoid arthritis in adults: management. NG100.
• NICE. Osteoarthritis in over 16s: diagnosis and management. NG226.
• NICE. Spondyloarthritis in over 16s: diagnosis and management. NG65.
• NICE. Gout: diagnosis and management. NG219.
• British Society for Rheumatology guidance should be checked for specialist drug monitoring, biologic therapy and complex connective tissue disease pathways.

⚠️ Disclaimer

This article is for medical education and exam revision. Clinical decisions should follow current local guidelines, shared-care protocols, DMARD monitoring schedules, pregnancy guidance, infection risk assessment, specialist advice and national guidance. Rheumatology emergencies such as septic arthritis, GCA, vasculitis and scleroderma renal crisis require urgent senior input.