Rheumatoid arthritis is a chronic systematic disease marked by inflammatory changes in joints and related structures which often result in crippling deformities.

The cause is unknown. The pathological changes in the joints are thought to be caused by an autoimmune disease. Environmental and familial factors may or may not be important. The condition occurs more often in women than men. The onset is usually between 25 and 50 years; however, it may occur at any age.

The onset can be slow without awareness of the condition, or it may also have an abrupt onset. There is progressive joint involvement with simultaneous inflammation in multiple joints. The initial signs and symptoms may occur in any joint. Tenderness in most all of the inflamed joints is the most sensitive sign.

Other signs and symptoms may include:

• weight loss

• stiffness on arising in the morning or after synovial thickening in most involved joints

• symmetrical involvement of the joints of the

  • hands

  • feet

  • wrists

  • elbows, and

  • ankles.

There is usually stiffness lasting more than 30 minutes after prolonged inactivity. Early afternoon fatigue, general discomfort, and deformities of flexion contractures may develop rapidly. Ulnar deviation of the fingers occurs later. Carpal tunnel syndrome may also occur from synovitis. There may be a low-grade fever and the rheumatoid factor is usually present. Progressive destruction of articular and periarticular structures, with or without generalized signs and symptoms, may be present.

Diagnostic measures include complete blood studies (CBC) which may show a normochromic-normocyctic anemia; an erythrocyte sedimentation rate (ESR) which is elevated; analysis of the synovial fluid; and x-ray. The tests may be nonspecific during the first six months. Other tests include: studies of renal and liver functions; antinuclear antibodies (ANA); Tine or purified protein derivative (PPD) applications; and arthrocentesis for synovial fluid analysis. Any four of the following criteria must be present 6 weeks or more to classify persons as having rheumatoid arthritis: morning stiffness of one hour or more; arthritis of three or more joints; arthritis of hand joints; symmetric arthritis; rheumatoid nodules; positive serum rheumatoid factor; and typical radiographic changes.

There is no specific treatment. Education and emotional support are significant considerations. Bed rest and a nutritious diet are encouraged. Drug therapy includes: coated aspirin; nonsteroidal anti-inflammatory drugs (NSAIDs); and brief use of corticosteroids because of the side effects. Other therapy considerations include: antimalarials; or gold therapy for persons who do not respond to other drugs. The individual must be monitored for toxic reactions when gold salt therapy and corticosteroids are used. Exercise and physical therapy to maintain the range of motion (ROM) of the affected joints is recommended. Passive exercises are done until the inflammatory response has subsided. The use of splints, and weight loss are recommended. Surgery, such as total joint replacement, may be used to treat severe forms of the condition.

The residuals will depend on the course the disease takes; either remission within two years, or persistence of the joint symptoms. Persons with negative rheumatoid factors usually have good functional status in activities of daily living (ADL). Ten percent or more of patients may eventually become severely disabled despite treatment. The disease greatly affects the life of the person living with rheumatoid arthritis. Assistive devices may be used such as raised toilet seats, a gripping bar or cane, large-handled eating utensils, or a wheelchair. Early death may occur, if risk factors are present. The factors include: a positive rheumatoid factor; poor functional status, such as the inability to perform personal care ADL; having more than 30 joints inflamed; and the presence of signs and symptoms of rheumatoid lung disease. Co-morbid conditions may be more frequent in individuals with severe disease including vasculitis skin lesions and neuritis, cardiac involvement, pericarditis, or ocular involvement.

• The rating schedule for musculoskeletal was updated on February 7, 2021. Protection still does apply and should be considered with existing evaluations (38 CFR 3.951(a)).

• May be entitled to special monthly compensation where the veteran has a single service-connected disability rated as 100% with additional service-connected disability or disabilities independently ratable at 60% or more, which are separate and distinct from the 100% service-connected disability and involves different anatomical segments or bodily systems. See  38 CFR 3.350(i)(1)  – Special Monthly Compensation (SMC).

• This disease shall be granted service connection although not otherwise established as incurred in or aggravated by service if manifested to a compensable degree within the applicable time limits under 38 CFR 3.307 following service in a period of war or following peacetime service on or after January 1, 1947, provided the rebuttable presumption provisions of 38 CFR 3.307 are also satisfied [38 CFR 3.309 [Disease subject to presumptive service connection], 38 CFR 3.309(a). [chronic disease].

• Multi-joint arthritis, including rheumatoid arthritis, is evaluated on the basis of the active process under DC 5002 or chronic residuals, under DC 5003.

• Rheumatoid arthritis and rheumatic fever are unrelated. During acute rheumatic fever there may be migratory joint pain and an "infectious arthritis" usually involving acute joint swelling and inflammation that resolves without permanent joint changes or damage; rheumatoid arthritis, though it has acute phases as well as its chronic residual joint degeneration, does not involve rheumatic fever at any time in either its acute or chronic phases.

• Examples of conditions rated using this diagnostic code include, but are not limited to, rheumatoid arthritis, psoriatic arthritis, and spondyloarthropathies.

• For chronic residuals, rate under diagnostic code 5003.

• The ratings for the active process will not be combined with the residual ratings for limitation of motion, ankylosis, or diagnostic code 5003. Instead, assign the higher evaluation.