Rheumatoid arthritis (RA) is an autoimmune disease that damages joints and ligaments when the immune system attacks the body’s own tissues.
While the inflammation caused by RA can occur throughout your body, the effects of the disease are often most noticeable in the hands of people with RA.
This damage can result in twisted joints, gnarled ligaments, and ultimately destruction of the joints in later stages of the disease.
Joint deformities in people diagnosed with RA are becoming less frequent and less severe, thanks to earlier diagnosis and more effective treatments.
However, in addition to being painful, these changes in the hands can make it difficult to perform everyday tasks.
A major misconception about RA is that it’s solely a joint disease, according to Alejandro Badia, MD, FACS, founder of the Badia Hand and Shoulder Center in Miami, Florida.
“It’s largely a disease of the soft tissues,” he explained. This includes ligaments and tendons, he said, although joints also are severely affected.
That’s especially true in your hands. They contain a large number of small bones, called phalanges and metacarpals, that are connected by joints. These joints are responsible for movement of your fingers.
In people with RA, the lining of these joints, called the synovium, is attacked by immune system cells. The synovium normally produces fluid that allows the joints to smoothly glide on their cartilage covers.
When inflammation causes the synovium to swell, a fibrous layer of abnormal tissue, called pannus, forms. In turn, this releases chemicals that cause:
- bone erosion
- cartilage destruction
- ligament damage
The destruction makes ligaments and joint capsules — dense, fibrous connective tissue that forms a sleeve around the joint — less able to support the joints. This causes joints to lose their shape and alignment.
As a result, your joints:
- become dysfunctional
- cause pain
- result in visible abnormalities
People with RA generally have high levels of acute phase reactants — C-reactive protein (CRP) and erythrocyte sedimentation rate (ESR) — which are markers of inflammation in the body.
People with RA can also demonstrate positive antibodies, such as the rheumatoid factor (RF) and cyclic citrullinated peptide (CCP) antibodies. The presence of anti-CCP antibodies is associated with a risk of more severe disease.
Individuals with RA may experience different types of hand conditions, depending on the rate and manner in which their joints and ligaments deteriorate due to the disease.
“All of these changes result from the inflammatory destruction to the joints of the fingers that occur with arthritis, causing increased pain, stiffness, swelling, and limited functional use of the hand for gripping, grasping, and pinching,” said Kristen Gasnick, PT, DPT, whose outpatient rehabilitation practice includes people with RA.
The most common manifestations of RA-caused hand concerns identified by researchers include the following:
Boutonniere deformity occurs when the middle or proximal interphalangeal joint of a finger is flexed and the distal joint is extended.
Swan-neck deformity, the most common change in people with RA, occurs when there’s weakness or tearing of a ligament due to inflammation. This results in laxity of the middle joint of the finger and flexion of the distal joint.
Hitchhiker’s thumb occurs when the thumb flexes at the metacarpophalangeal joint (connecting the thumb to the palm of the hand) and hyperextends at the interphalangeal joint (the one just below your thumbnail).
This is sometimes also called the Z-shaped deformity.
Rheumatoid nodules are hard lumps that form under the skin near the joints. These are another common symptom of RA in the hands.
They can also occur in multiple areas, most commonly near your elbows. The nodules usually aren’t painful or debilitating, but some people might not like how they look.
Less common among people with RA are Heberden nodes and Bouchard nodes. These are visible bumps at the joints that are more typical of osteoarthritis.
The availability of effective drugs that limit the progression of RA has helped reduce the severity of RA-related hand deformities.
Known as disease-modifying antirheumatic drugs (DMARDs), some of the medications commonly prescribed to treat RA include:
- hydroxychloroquine (Plaquenil)
- leflunomide (Arava)
- methotrexate (Trexall)
- sulfasalazine (Azulfidine)
- minocycline (Minocin)
A subset of DMARDs, called biologic response modifiers, specifically target the areas of the immune system that trigger inflammation and joint damage.
These are usually prescribed in combination with other RA medications. Some examples include:
- abatacept (Orencia)
- adalimumab (Humira)
- etanercept (Enbrel)
- rituximab (Rituxan)
- tocilizumab (Actemra)
In some cases, rheumatoid nodules have been found to be more common among people receiving methotrexate treatment. They may be reduced in size by changing medications, receiving corticosteroid injections, or undergoing surgery.
In general, occupational therapy, including exercise and splinting, can slow the progression of hand deformities caused by RA. It can also improve function of your hands, fingers, and wrists.
Splints, including specially designed rings, can be used to stabilize affected finger joints.
Surgery is no longer common for people with RA because of the effectiveness of current treatment options. Plus, RA-related nodules often return after surgery.
However, surgery may be required to correct severe hand conditions. Options include finger joint replacement surgery, which is similar to the replacement surgery more commonly performed on knees and hips.
Such surgery can restore some functionality in the joints and improve appearance, although it doesn’t cure the underlying RA condition.
Wrist surgery may be used to reduce ligament tension on the fingers. The wrist also can be surgically fused to keep it straight and reduce pain, although this results in loss of strength and function.
Wrist replacement surgery is an alternative for people with RA that may result in greater retention of wrist motion.
The damage from the systematic inflammation caused by RA can be particularly visible, painful, and debilitating in your wrists and hands.
However, joint deformities are less common than they used to be as a result of early diagnosis and the availability of more effective treatments, such as DMARDs and biologic response modifiers.