Morning stiffness has long been recognized by both patients and rheumatologists as a characteristic feature of rheumatoid arthritis (RA) [rx] and was thus included in ACR 1981 remission criteria [rx] and 1987 diagnostic criteria for RA [rx]. Thereafter, morning stiffness has been widely used in decision-making on changing medication in daily practice [rx, rx] and in clinical trials [rx, rx]. Studies have also shown that stiffness has a considerable impact on patients’ daily life and work [8–11]
Joint stiffness is a highly prevalent symptom commonly associated with pain and arthritis, the leading causes of disability in the older population [rx, rx]. Approximately 30% of adults in the U.S. report joint stiffness, aching or pain in the preceding 30 days and 50% of these adults are over the age of 75[rx]. However, the ramifications of chronic joint stiffness in older adults are poorly understood because the information is limited on the impact of this condition on health, activity limitations, and health-related quality of life in the older population [rx, rx]. Joint stiffness and pain can be caused by a number of highly prevalent chronic musculoskeletal conditions associated with aging, including osteoarthritis (OA), rheumatoid arthritis (RA), spinal stenosis/disc disease and past injuries [rx].
Causes of Stiffness / Joint Stiffness
A number of common injuries can cause stiff joints. These injuries include
- Osteoarthritis – which is the degeneration of the cartilage over the parts of the bone involved in the joint (articular cartilage). It is often associated with long term wear and tear of the cartilage with reduced regenerative capacity of the cartilage. Osteoarthritis is the most common type of arthritis mainly seen in the elderly.
- Rheumatoid arthritis – is inflammation of the joint lining caused by the immune system attacking these tissues (an autoimmune disorder). The small joints of the hands and feet are more commonly affected. The exact cause is unknown but it appears to be linked to genetic factors and may be triggered by certain environmental factors or infections.
- Gout – or more correctly gouty arthritis, is an accumulation of uric acid crystals in the joint space. It presents with painful swelling and redness of the joint, mainly of the big toe. Gout arises when the uric acid levels in the blood are significantly elevated (hyperuricemia).
- Pseudogout – is similar to gout but is instead caused by an accumulation of calcium pyrophosphate crystals.
- Septic arthritis – is an infection within the joint most commonly caused by bacteria. The immune reaction coupled with the bacterial toxins can damage the joint lining within a short period of time. It is therefore considered to be the most serious form of arthritis warranting emergency medical attention.
- Reactive arthritis – is joint inflammation associated with an infection an a site other than the joint itself. It is a result of an immune response triggered by a bacterial infection that then leads to pronounced joint inflammation. Reactive arthritis is also known as Reiter’s syndrome.
- Arthrosis – is the wearing down of the cartilage that precedes osteoarthritis.
- Hemarthrosis – is an accumulation of blood in the joint space.
- Dislocation – where the bone slips out of its normal alignment in the joint.
- Osteomyelitis – which is an infection of the bone.
- Bone cancer – which is a malignant tumor of the bone.
- Fractures – are a break in the bone.
- Stress fracture – are small cracks in the bone.
- Tendonitis – which is stretching and inflammation of the connective tissue bands that attach muscle to bone.
- Muscle spasm – where the muscle is contracted at certain points and is stiff.
- Sprain – which is stretching of the ligament that supports a joint or muscles.
- Infections – like measles, mumps and the seasonal flu (influenza)
- Bursitis – which is inflammation of the fluid-filled pouches that reduce friction between different tissues.
- The systemic lupus erythematosus (SLE) – which is an autoimmune disease where the immune system attacks tissues throughout the body.
- Leukemia – which is a type of cancer of the bone marrow or blood cells formed in the marrow.
Traumatic causes of stiff joints
- Bleeding within the joint space (hemarthrosis)
- Broken bones
- Dislocation of bones
- Fragments of bone or cartilage within the joint space
- Overuse injury
- Repetitive motion disorders
- Sprains and strains
- Stress fractures
Infectious causes of stiff joints
A number of infectious diseases can cause stiff joints
- Lyme disease
- Measles (contagious viral infection is also known as rubeola)
- Mononucleosis (viral infection)
- Mumps (viral infection of the salivary glands in the neck)
- Septic arthritis (infectious arthritis)
|Age, mean ± SD years||58.4 ± 14.6|
|Female, n (%)||60 (78.9)|
|Disease duration, median (IQR) months||24 (8–63.75)|
|RF positive, n (%)||64 (84.2)|
|ACPA positive, n (%)||59 (77.6)|
|Concomitant autoimmune disease, n (%)||11 (14.5)|
|Treatment naïve, n (%)||17 (22.4)|
|Methotrexate, n (%)||39 (51.3)|
|Dose, median (IQR) mg/week||10 (8–12)|
|Salazosulfapyridine (Sulfasalazine), n (%)||19 (25.0)|
|Bucillamine, n (%)||4 (5.3)|
|Tacrolimus, n (%)||3 (3.9)|
|Auranofin, n (%)||1 (1.3)|
|TNF antagonist, n (%)||8 (10.5)|
|Tocilizumab, n (%)||4 (5.3)|
|Abatacept, n (%)||3 (3.9)|
|Corticosteroid, n (%)||22 (28.9)|
|Dose, median (IQR) mg/day (prednisolone equivalent)||4.5 (2.375–5)|
|NSAID, n (%)||42 (55.3)|
|Swollen joint count/ 28, median (IQR)||2.5 (1–4)|
|Tender joint count/ 28, median (IQR)||2 (0–4.75)|
|Patient’s global assessment VAS, mean ± SD mm||39.4 ± 23.1|
|Physician’s global assessment VAS, mean ± SD mm||36.3 ± 22.8|
|Serum C-reactive protein (CRP) level, median (IQR) mg/dL||0.3 (0.0–1.1)|
|DAS28-CRP, median (IQR)||3.1 (2.1–4.2)|
|SDAI, median (IQR)||12.8 (7–20.675)|
SD, standard deviation; IQR, interquartile range; RF, rheumatoid factor; ACPA, anti-citrullinated protein antibody; DMARD, disease-modifying anti-rheumatic drug; TNF, tumor necrosis factor; VAS, visual analog scale; DAS28, Disease Activity Score 28; SDAI, Simplified Disease Activity Index
Other causes of Stiffness / Joint Stiffness
- Bursitis (inflammation of a bursa sac that cushions a joint)
- Obesity, which places extra strain on joints an muscles
- Past injuries which have never adequately healed
- Excessive amounts of insulin in the system (often as a result of diets high in sugar and carbohydrates) which causes inflammation
- Excessive amounts of the stress hormone cortisol, which also causes inflammation
- Hormone imbalance or fluctuations
- Viral infections
- Post-exercise where the muscles are adjusting to new demands
- Medication side effects or allergic reaction to the medication
- Osteomyelitis (bone infection)
- Spondylitis (infection or inflammation of the spinal joints)
- The systemic lupus erythematosus (a disorder in which the body attacks its own healthy cells and tissues)
- Cancers of the bone or soft tissues
- Septic arthritis (infectious arthritis)
Symptoms of Stiffness / Joint Stiffness
Stiffness may be either the symptom of pain on moving a joint, the symptom of loss of range of motion or the physical sign of a reduced range of motion.
- Pain on movement – is commonly caused by osteoarthritis, often in quite minor degrees, and other forms of arthritis. It may also be caused by injury or overuse and rarely by more complex causes of pain such as infection or neoplasm. The range of motion may be normal or limited by pain. “Morning stiffness” pain which eases up after the joint has been used, is characteristic of rheumatoid arthritis.
- Loss of motion – the patient notices that the joint (or many joints) do not move as far as they used to or need to. Loss of motion is a feature of more advanced stages of arthritis including osteoarthritis, rheumatoid arthritis, and ankylosing spondylitis.
- Loss of range of motion – the examining medical professional notes that the range of motion of the joint is less than normal. A routine examination by an orthopedic surgeon or rheumatologist will often pay particular attention to this. The range of motion may be measured and compared to the other side and to normal ranges. This sign is associated with the same causes as the symptom. In extreme cases when the joint does not move at all it is said to be ankylosed.
- Pain – Pain from arthritis can be constant or it may come and go. It may occur when at rest or while moving. Pain may be in one part of the body or in many different parts.
- Swelling – Some types of arthritis cause the skin over the affected joint to become red and swollen, feeling warm to the touch. Swelling that lasts for three days or longer or occurs more than three times a month should prompt a visit to the doctor.
- Difficulty moving a joint – It shouldn’t be that hard or painful to get up from your favorite chair.
Diagnosis of Stiffness / Joint Stiffness
Tests to confirm or exclude joint stiffness may include
- blood tests to check for inflammation in the body by measuring the erythrocyte sedimentation rate (ESR) or the level of C-reactive protein (CRP)
- tests to check for giant cell arteritis – for example, a biopsy of the temple arteries.
- Blood tests for rheumatoid arthritis
- X-rays to take images of the bones
- CT scans to get an even more detailed look at the bones
- MRIs to look at soft tissues such as muscles, cartilage, ligaments, and tendons
Treatment of Stiffness / Joint Stiffness
- Stretching and toning exercises are especially important if you suffer from stiffness. These exercises can help to warm and stretch the muscles and are especially useful after long periods of rest.
- Many people suffer from stiffness in the morning after the long rest period. Try start off your morning with a hot bath or shower to warm and loosen stiff muscles and joints.
- Regular exercise to improve muscle tone and fitness can be very beneficial. Choose a gentle exercise that won’t cause pain such as yoga or swimming.
- If stiffness is the result of muscle tension or stress, treat yourself to a monthly massage and learn to manage stress levels better.
- Make sure that you adopt a good posture at all times and check that your furniture such as sofas and your mattress is conducive to a healthy posture.
- Use a hot water bottle or heat pad to provide relief for sore joints in cold weather.
- DMARDs – These antirheumatic drugs work to reduce the inflammation RA brings on. Some traditional DMARDs accomplish this by wiping out the whole immune response. More recent versions of these drugs, known as biologics, target particular steps along the inflammation process. DMARDs may be injected, taken orally, or give at the doctor’s office via infusion.
- NSAIDs –These common pain relievers help reduce pain and inflammation. This class of drugs includes ibuprofen, naproxen, and the prescription drug celecoxib. A patient may be instructed to take these orally or on the skin as a patch or cream.
- Corticosteroids – These anti-inflammatory medicines act quickly. They can help control inflammation as DMARDs NSAIDs take effect.
- Biologics – These medications target the specific portion of the body’s immune system that is abnormally active in rheumatoid arthritis.
- Physical or occupational therapy
- Using a splint to immobilize the affected joint and allow healing
- Using heat or cold
- Reducing workload and increasing rest
- Reducing stress through relaxation and biofeedback techniques
- Acupuncture or acupressure
- Injections with an anesthetic or anti-inflammatory medications in or around the painful sites
- Strengthening and conditioning exercises
- Stretching exercises
- Chiropractic care
- Therapeutic massage
- If diagnosed with arthritis, follow the doctor’s recommendations to manage the condition
- Keep weight in a healthy range
- Exercising regularly
- Warming up and down before and after exercise
- Stretching the muscles
- Wearing the correct footwear during exercise
- Wearing warm clothing in cold weather
- Practicing good posture
- Ensuring furniture at home and work gives comfort and support
- Avoiding long periods of inactivity
- Practice yoga
- Avoid spending too much time sitting down
- Apply hot compresses to affected joint (warmth alleviates stiffness)
- Get enough sleep
- Do some easy stretches before getting out of bed
- Eat a well-balanced diet
- Do exercises while sitting behind your desk
- Get up every 30 minutes and walk
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