What Tests Are Used to Diagnose

Rheumatoid Arthritis?
Several tests are typically used to determine whether your
symptoms are caused by RA.

By Elaine K. Howley, Contributor March 22, 2019, at 9:00 a.m.

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Tests That Diagnose Rheumatoid Arthritis

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ALTHOUGH THERE ARE MORE than 100 conditions that fall under the
umbrella term "arthritis," an autoimmune disease called rheumatoid arthritis is
one of the more common. According to the Arthritis Foundation, more than 1.5
million Americans have the condition, which causes swelling, pain and
stiffness in certain joints which can lead to lasting damage of those joints.
Over time, rheumatoid arthritis can be disabling and debilitating.

What Is Rheumatoid Arthritis?

In rheumatoid arthritis, the body's immune system attacks its own healthy cells
inside certain joints, leading to an inflammatory response. This typically shows
up as:

 Pain, redness or swelling in one or more joints throughout the body

(although symptoms usually are symmetrical, so showing in the same
hand, finger or ankle joint on both the right and left side of the body).
 Joint stiffness and pain in the morning that lasts for a while, but loosens
up as you move.
 Tingling or numbness in the extremities.
 Fever.
 Fatigue.
  Decreased range of motion.
 Joint deformity.

"Over time, if that inflammation goes unchecked, it does what it's supposed to
do, which is destroy stuff," says Dr. David Pugliese, a rheumatologist
at Geisinger in Danville, Pennsylvania. "But it also starts destroying the joint,
and in time it can turn into a structural problem because the joint and tendons
can get damaged," leading to deformities and loss of range of motion or
function.

Rheumatoid arthritis can be very aggressive and may lead to other

systemic complications and health problems, including heart disease,
diabetes and osteoporosis. That's why it's so important to see a doctor if you
have symptoms that could be associated with rheumatoid arthritis as soon as
possible – early intervention and aggressive management are important to
preserving mobility, function and a higher quality of life.

"Early diagnosis leads to earlier treatment and obviously better outcomes,"

says Dr. Hareth Madhoun, assistant professor of clinical medicine in the
department of internal medicine division of rheumatology at The Ohio State
University Wexner Medical Center. "The sooner we get to see patients and
treat them, hopefully we can avoid them developing joint damage."

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How Is Rheumatoid Arthritis Diagnosed?

Making a precise diagnosis of rheumatoid arthritis isn't always easy.

Sometimes, the symptoms may be vague or mistaken for those of another
condition. "My job is hard because joint swelling and synovitis (swelling and
inflammation of the membrane that encases a joint) look the same in all sorts
of conditions," Madhoun says. Therefore, it's not uncommon for a case of
rheumatoid arthritis to look like lupus (a systemic inflammatory disease that
affects the joints, skin, blood cells, heart, kidneys, brain and lungs) or another
autoimmune condition initially.

But an accurate diagnosis is possible, and your doctor will likely apply a range
of tests and exams to sort out what's causing your symptoms. "There are
some nuances here and there that can help you distinguish between one and
another," Madhoun says.

Physical Exam

First, your doctor will likely perform an extensive physical exam. This will
include careful observation of your affected joints to check for:

 Swelling.
 Redness.
 Warmth.
 Reflexes.
 Muscle strength.

Your doctor will also ask for a careful recounting of when and how symptoms
began and whether you've had any flare ups or improvement of symptoms
over that time. All of this information can provide clues as to what condition
you may be facing.

"The physical exam is really key" in helping make an accurate diagnosis,

Madhoun says. Rheumatoid arthritis tends to target the small joints of the
hands, wrists and feet. Therefore, which joints are symptomatic can be a big
clue as to which type of arthritis you have. Other symptoms, such as fatigue
and fever may also be present with other types of arthritis, but when
considered in the wider context of symptoms and family history may be
evidence of rheumatoid arthritis instead of something else.
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Family History

In addition to carefully examining you, your doctor will ask lots of questions
about your family's medical history, because "genes certainly do play a role in
patients developing rheumatoid arthritis," Madhoun says. Dr. Esther Lipstein-
Kresch, chief of rheumatology at ProHEALTH Care in New York agrees:
"There's definitely a genetic component. There are some genes that have
been identified that give people an increased risk for the development of
rheumatoid arthritis." If you have a close relative such as a parent, sibling or
child who has rheumatoid arthritis, that may increase your risk of developing
the disease, too.

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Blood Tests

Once the physical exam and the family history have been completed, you'll
likely have blood drawn to look for certain markers that can signify whether
inflammation is present. As Pugliese notes, because "the starting point for RA
is an autoimmune or inflammatory problem," many of these tests look for
signs of inflammation in the body. Not all of these tests are specific for
rheumatoid arthritis, as other autoimmune diseases may also produce similar
elevations of inflammatory markers, so bloodwork results should be
considered in the context of family history, imaging studies and a thorough
physical exam.

Blood tests commonly used to diagnose rheumatoid arthritis include:

 Rheumatoid factor. Most patients who have rheumatoid arthritis have

measurable levels of an inflammatory marker called rheumatoid factor in
their blood. RF is found in about 85 percent of cases, but some may not
have elevated levels of RF and still be diagnosed with rheumatoid
arthritis. "We've been doing that test for decades.However, if you have a
negative rheumatoid factor test, it doesn't completely exclude (a
diagnosis of) rheumatoid arthritis. There are people who have zero-
negative RA where the rheumatoid factor is negative but (have) same
classic findings of the disease," Lipstein-Kresch says. This test will very
likely be one of the first tests your rheumatologist runs when an
inflammatory form of arthritis like rheumatoid arthritis is suspected.
 Anti-Cyclic Citrullinated Peptide. When your body responds to injury
or infection, it produces certain proteins, called antibodies, to help heal
the problem. With the inflammation that results from rheumatoid
arthritis, an antibody called anti-cyclic citrullinated peptide often
 increases in the patient's blood. An anti-CCP test looks for those
antibodies to determine whether the body is undergoing an
inflammatory response. About 60 to 80 percent of patients with
rheumatoid arthritis test positive for these antibodies, and this test may
be able to pinpoint a diagnosis early in the disease's progression. "The
anti-CCP test can be somewhat predictive for RA," Lipstein-Kresch
says. An elevated anti-CCP test "could indicate that person could
develop RA in the next five or 10 years."
 C-Reactive Protein (CRP). Your doctor may also order a C-reactive
protein test, to look for this protein in the blood that indicates chronic
inflammation is present, such as occurs with rheumatoid arthritis. This
test may also help your doctor understand the extent of the disease
based on how high the levels of CRP are in your blood. High levels of
CRP may also be associated with infections, cancer, heart disease and
even obesity, so this test isn't specific just to RA, but it can tell your
doctor a lot about how much inflammation is present in your body.
 Erythrocyte Sedimentation Rate (ESR). An erythrocyte sedimentation
rate test (ESR or sed rate) looks at how quickly erythrocytes (red blood
cells) in a sample of blood fall in a thin, vertical tube. ESR is a non-
specific test, so high rates of sedimentation simply mean the sample
contains more proteins, which are heavier and fall out of solution faster.
This result is typically associated with higher levels of inflammation in
the blood, which could point to rheumatoid arthritis. It might also indicate
you're dealing with another autoimmune or inflammatory condition, so a
high sed rate doesn't necessarily mean you have rheumatoid arthritis.
Conversely, a normal result also does not rule out the possibility of a
rheumatoid arthritis diagnosis.
 Antinuclear Antibody (ANA). In autoimmune diseases, such as
rheumatoid arthritis, the immune system targets normal cells rather than
the foreign invaders they're designed to fight. Antibodies proliferate as
part of this process, and antinuclear antibodies specifically target
proteins in the nucleus of a cell. Higher than normal levels of ANA can
be a marker of autoimmune disease and these higher levels are often
detectable in patients with rheumatoid arthritis.

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Imaging Tests

Many patients also undergo imaging tests so that their doctor can get a closer
look at what's going on inside the joints. The Rheumatoid Arthritis Support
Network reports that imaging tests can "help identify signs and progression of
RA. These tests essentially look inside the patient's body so that doctors and
other specialists may assess the joint damage as well as detect and interpret
specific abnormalities."

These imaging tests may include:

 X-rays. X-rays use radiation to create images of the

body. Rheumatologists use X-rays to look at affected joints and
determine how much bone erosion has occurred. "In rheumatoid
arthritis, we're looking for a soft tissue swelling, narrowing of the joint
space and bone erosion," Madhoun says. An X-ray only shows bones,
so this type of imaging can be very helpful for seeing what's happening
with the bones, and your doctor may take X-rays regularly to track the
rate of bone erosion and joint space shrinkage. While X-rays can tell
your doctor a lot about the progression of the disease, it's not always
the best option for detecting RA early because it takes a while for the
disease to erode bone.
 Ultrasound imaging. Ultrasound imaging uses high-frequency sound
waves to generate pictures of the affected joint. Unlike X-rays,
ultrasound technology does not involve radiation but is often better at
showing inflammation and early evidence of the disease. Ultrasounds
may also be used regularly to monitor the progression of the disease.
Given that there are a variety of inflammatory arthritis conditions,
pinpointing the right one is helpful for managing it appropriately, and
ultrasounds can help do that. "Ultrasounds can be very helpful in
distinguishing one condition from another," Madhoun says.
 Magnetic resonance imaging. While X-rays offer your doctor a look at
your bones, MRI machines offer a detailed view of soft tissues in the
body. Because of this, MRIs are often better at detecting early signs of
rheumatoid arthritis. Madhoun says MRI is helpful in picking up soft
tissue swelling and synovitis, a swelling of the synovium – the
membrane that encases the joint that becomes inflamed as part of the
rheumatoid arthritis disease process. "MRI tends to be more sensitive
and it can help us pick up the synovitis a little better than X-rays can,"
he says.
 Computed tomography scanning. CT scans are a type of X-ray that
produce cross-sectional images of the body. CT scanning can help your
doctor get a better view of joints deeper in the body that may be harder
to see on an X-ray.