Challenges Associated With the Early, Accurate Diagnosis of Inflammatory Arthritis

Researchers reported the incidence of self-reported inflammatory joint symptoms, such as joint pain, stiffness and swelling, in UK primary care patients who presented with both musculoskeletal and non-musculoskeletal complaints.

Despite the presence of symptoms largely predictive of inflammatory arthritis, it can be challenging for general practitioners to diagnose inflammatory arthritis in an accurate and timely manner, according to research published in Rheumatology.

Researchers conducted a cross-sectional survey of adults to determine the prevalence of self-reported joint symptoms among primary care patients with and without musculoskeletal concerns but without a diagnosis of inflammatory arthritis. A questionnaire was sent to patients from 56 different general practices within the UK National Institute for Health Research Clinical Research Network. The questionnaire collected data evaluating the presence of 13 symptoms, including joint pain, stiffness, swelling, fatigue, and emotional distress. Participants also completed an 11-item early inflammatory arthritis (EIA) detection tool.

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In total, the survey was sent to 10,161 adults. Adults who had consulted for musculoskeletal conditions (n = 5050) were matched by age and sex to patients who had not. Ultimately, 4549 adults responded to the questionnaire. Responders were older (mean age 61.6 ± 14.8 years) and were more likely to have been a part of the consultation group (52.3% from the consultation group vs 47.6% from the nonconsultation group; P <.0001).

Although symptoms of joint pain were common in both groups (81.5% in consultation vs 65% in nonconsultation groups), only 42% of participants in the nonconsultation group reported joint pain on more than half of the days in the past month compared with 62% of participants in the consultation group (P <.001). Members of the consulting group were more likely to report moderate or severe symptoms compared with nonconsulting group patients (75% and 62%, respectively).

Symptoms of joint swelling were less frequent but still common, with 18% of nonconsulters and 24% of consulters reporting. Similar symptom frequency and severity was noted for joint stiffness. The researchers noted there was “significant missing data,” which they wrote may have been indicative of questionnaire fatigue.

Results of the EIA detection tool indicated that 70.4% of the nonconsulters and 44.7% of consulters reported joint pain and hand and wrist pain. These numbers were significantly higher among participants with musculoskeletal consultations. Using a weighted score for EIA detection, 74% of individuals without musculoskeletal consultation had a positive score, but the majority of symptoms were more commonly reported in the consultation group. Mean total scores for each group were 4.13 ± 2.41 vs 3.39 ± 2.55 in the consultation and nonconsultation groups, respectively.

“Early diagnosis of [rheumatoid arthritis (RA)] is key to improving outcomes… This study highlights that primary care patients, whether consulting for [a musculoskeletal] indication or not, commonly report… symptoms that may be suggestive of inflammatory arthritis,” the researchers wrote. “The burden of symptoms reported by participants in this study highlight the challenges of successfully implementing public health campaigns designed to raise awareness of early symptoms of RA.”

One limitation for this study is the significant lack of missing data, attributable to the study’s nature as a large, unselected cohort surveyed via mail. Generalizability of these results may be limited by the location and race of the majority of participants.

The researchers concluded that “[f]urther studies are required to determine which patients with symptoms are at highest risk to ensure effective early referral and treatment of patients with RA.”

One investigator received honoraria from Eli Lilly and Company.


Hider SL, Muller S, Helliwell T, et al. Symptoms associated with inflammatory arthritis are common in the primary care population: results from the joint symptoms survey [published online May 11, 2019]. Rheumatology. doi:10.1093.rheumatology/kez184