Quick answer: Palindromic rheumatism causes repeated, sudden attacks of pain, swelling and stiffness, usually in one joint at a time, that clear completely within hours or a few days, leaving the joint normal between attacks. Some people later develop rheumatoid arthritis. A rheumatologist may recommend a medicine such as hydroxychloroquine to reduce attacks. Photos and a diary of attacks help diagnosis.
What is palindromic rheumatism?
A palindrome reads the same forwards and backwards. Palindromic rheumatism gets its name because joints return to normal after each attack, as if it had never happened. It is a type of inflammatory arthritis in which the immune system triggers short bursts of inflammation in or around a joint.
It can start at any adult age but most often begins between the ages of 20 and 50. It is thought to be uncommon, and it may be under-recognised because attacks are often over by the time someone sees a doctor.
What an attack is like
- Pain comes on quickly, often over a few hours, and can be severe.
- Usually one joint is affected at a time, commonly a knuckle, finger, wrist, knee or shoulder, but attacks can move between joints.
- The joint or the area around it may become swollen, red and warm. Sometimes the tissues next to the joint, such as the back of the hand or a heel pad, are affected.
- Attacks usually last from a few hours to two or three days, then disappear completely.
- Between attacks, the joints feel normal and there is no lasting damage.
- Attacks can happen weekly, monthly or with long gaps. Some people notice triggers such as stress or illness, but often there is no clear cause.
The link with rheumatoid arthritis
Palindromic rheumatism is closely linked to rheumatoid arthritis. Some people with palindromic rheumatism go on to develop rheumatoid arthritis, some continue to have palindromic attacks, and in some the attacks settle over time. People who test positive for anti-CCP antibodies or rheumatoid factor appear more likely to progress. This is one reason your rheumatologist will want to follow you up regularly, and why treatment may be suggested even though the joints are normal between attacks.
How it is diagnosed
There is no single test. The diagnosis is based on the pattern of attacks and on ruling out other causes, such as gout, pseudogout or infection. Because attacks come and go, the doctor may not see one. You can help by:
- Taking photos of the affected joint during an attack.
- Keeping a diary of attacks: date, joint, how long it lasted, how severe it was and any possible trigger.
- Asking your GP whether you can have blood tests during an attack, when inflammation markers are more likely to be raised.
Tests may include CRP and ESR, rheumatoid factor, anti-CCP antibodies, urate levels, and sometimes X-rays or ultrasound. Our guide to how arthritis is diagnosed explains these tests.
Treatment during an attack
- Rest the joint and use an ice pack wrapped in a towel, or warmth if you find it more soothing.
- Anti-inflammatory painkillers (NSAIDs), if they are safe for you, can reduce pain and swelling. Ask your GP or pharmacist. See our painkillers and NSAIDs guide.
- Your doctor may occasionally suggest a steroid injection or a short course of steroid tablets for severe attacks.
Treatment to prevent attacks
If attacks are frequent or disruptive, a rheumatologist may recommend a disease-modifying medicine. Hydroxychloroquine is commonly used and can reduce the number and severity of attacks. It works slowly and needs regular eye screening with long-term use. Other DMARDs, such as methotrexate or sulfasalazine, are sometimes used, especially if there are signs of progression towards rheumatoid arthritis. Your team will talk through the options with you. Always follow your own team's advice and never change doses yourself.
Living with palindromic rheumatism
The unpredictability can be one of the hardest parts. Not knowing when an attack will happen can make it difficult to plan work, travel or social events. These ideas may help:
- Agree a flare plan with your GP or rheumatology team, so you know what to take and when to seek help.
- Keep suitable painkillers, an ice pack and any splints to hand.
- Talk to your employer about flexible working during attacks. Our guide to working with arthritis covers your rights and reasonable adjustments.
- Stay active between attacks. Regular exercise supports joints, sleep and mood.
- If the uncertainty is affecting your mood, talk to your GP. Our guide to anxiety and arthritis may help.
- Do not smoke. Smoking is linked to rheumatoid arthritis and may make progression more likely.
When to seek help
Contact your GP or rheumatology team if attacks are becoming more frequent, last longer, or if joints stay swollen or stiff between attacks, as this may mean the condition is changing. Get urgent same-day help, or call NHS 111, if a joint is hot and swollen and you have a fever or feel unwell, as this could be an infection.
Questions to ask your rheumatologist
- Do my blood tests suggest a higher chance of developing rheumatoid arthritis?
- Would a preventive medicine help me, and how long would I take it for?
- What should I take during an attack, and when should I contact you?
- How often will you review me, and what changes should prompt an earlier appointment?
- Is there anything I can do myself to lower the chance of progression, such as stopping smoking?
Writing your questions down before the appointment, and taking your attack diary and photos, helps you make the most of the time. Our guide to questions to ask about a new medicine may also help.
Frequently asked questions
Is palindromic rheumatism the same as rheumatoid arthritis?
No, but they are linked. Some people with palindromic rheumatism later develop rheumatoid arthritis, particularly if they have certain antibodies.
How long do palindromic rheumatism attacks last?
Usually from a few hours to two or three days. The joint then returns to normal.
Can palindromic rheumatism go away?
In some people attacks become less frequent or stop over time. Treatment can also reduce attacks.
Why take hydroxychloroquine if my joints are normal between attacks?
It can reduce how often attacks happen and may lower the chance of progressing to rheumatoid arthritis. Your rheumatologist will discuss whether it suits you.
What can I do to help my doctor diagnose it?
Take photos of affected joints during attacks and keep a diary of when attacks happen, which joints are involved and how long they last.
Sources and further reading
This guide is for general education and is not a substitute for personal medical advice. Everyone's situation is different, so always follow the advice of your own GP, pharmacist or rheumatology team. If you feel very unwell, call 999 or go to A&E. For urgent advice, contact NHS 111.