Why are tender and swollen joints measured?

Assessing the number of tender and swollen joints is really important to help healthcare professionals calculate your disease activity. This tells them how active your RA is, and guides treatment.

Examining your own joints can be useful for your own understanding and to enable you to report to your health care professional.

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Which joints should I examine?

The 28 joints included in disease activity scores are the shoulders, elbows, wrists, knuckles, middle joints on the fingers, and the knees.

It’s not that the other joints aren’t important, especially from a patient viewpoint. It’s just that they are not included in the measure.

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What is DAS28?

The most commonly used score in clinics is the DAS28 score. DAS stands for disease activity score, while the 28 relates to the number of joints examined.

It is made up of four components including a tender joint count, a swollen joint count, a blood test measuring inflammation, and the patients’ assessment of their health over the last week.

Other disease activity scores such as the CDAI, or clinical disease activity score, do not include blood tests.

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Why are feet not included in the DAS28 score?

Research has found that the overall DAS28 score does not differ between using 28 joints and a greater number of joints, including the feet.

This is why the feet are not included in the measure. The 28-joint count has since become the standard measure used to assess disease activity in people with arthritis, and in clinical trials.

However, the feet are often affected in RA, and it is therefore really important that people with arthritis and their clinicians discuss and assess the feet, to make sure that inflammation, and other problems are addressed. If you have problems with your feet, please raise them with your rheumatology team.

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How do I know where to examine?

When examining the joint, you need for feel for the joint line which is where the ends of the two bones meet – this is where you will be able to feel swelling, if there is any.

The training video (YouTube) goes through each joint, and explains where the joint line is and how the patient can find it.

It will become easier to know whether you’re in the right place with time. Feeling where the bones move will help you determine whether you are in the right place.

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What is a swollen joint?

Joints might appear swollen for lots of reasons. In RA, healthcare professionals are looking for joint swelling caused by inflamed joint lining. This makes the joints feel soft and squidgy, like a grape. It is really important that only those joints which feel soft and squidgy are counted as swollen. This kind of swelling can last a long time, or can come and go quite quickly.

Joints can be swollen for other reasons apart from joint inflammation. Osteoarthritis is quite often present alongside RA. Osteoarthritic joints are very hard and bony, and don’t tend to change quickly. Although it will look swollen and can be tender to touch, this swelling is caused by bone, so will feel hard and not squidgy. These hard bony swellings do not count as a swollen joint.

There are other structures around the joints which might make you think they are swollen, when they are not. Swelling outside the joint can include pockets of fluid called bursitis. Bursitis does not count as a swollen joint.

Some people have rheumatoid nodules which are knobbly swellings attached to the skin. Nodules do not count as swollen joints.

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What is a tender joint?

Healthcare professionals use the word tender to describe joints that feel painful, or sore. Joints may be tender and swollen, just swollen, or just tender.

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How hard should I press on my joint?

You need to press on the joint either until it hurts, or until your fingernails go white. If your joint is tender to touch you don’t need to press any harder, but you will still need to feel for swelling.

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Why do I get swollen palms?

Swelling can occur in places other than the joints, including the palms and the back of the hands. This is important to pay attention to, but does not count as swelling in disease activity scores.

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Is it normal to get swelling in one shoulder or hand but not the other?

Although RA is often described as being symmetrical, it is very common for different sides of the body to be affected differently.

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Do nodules stay forever?

Nodules often stay for a long time. Sometimes they respond to medical treatment and may shrink, or go away.

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