Guides › What is palindromic rheumatism?

Palindromic rheumatism: what it is, and what the research says

Joints that swell up out of nowhere, hurt for a day or two, and then go back to normal as if nothing happened. That is the pattern palindromic rheumatism is named for: it reads the same coming and going.

By Peter Barnett, who makes Aura · Updated 25 October 2026 · Not medical advice

What an attack looks like

An attack usually comes on over a few hours, often in a single joint, sometimes in two or three. The joint, or the tissue around it, becomes painful, swollen and sometimes red and warm. The pain can be severe: in a 2025 interview study, people with the condition compared it to a serious physical injury.⁶

Then it stops. In most published series attacks last under three days, and most commonly somewhere between 12 and 48 hours, though the occasional one runs to a week or more.¹ The inflammation is often around the joint rather than inside it, which is part of what sets the condition apart.

Which joints it affects

Across five published patient series, the joints most often involved were the knuckles (metacarpophalangeal joints), wrists, knees and shoulders, with the hips, elbows, ankles and feet affected less often.¹ A different joint can be involved each time, which is one reason an attack can be hard to describe to a doctor weeks later.

Between attacks

Between episodes there is usually nothing to see. The joints look and move normally, ultrasound generally shows no lingering inflammation, and blood tests such as CRP and ESR are typically normal.¹ The gaps can be days or months long. This is why the condition is easy to dismiss, and why a record of what happened during the attacks matters so much.

How it is diagnosed

There is no single test. Diagnosis rests on the pattern of attacks, and on ruling out other causes such as gout and other crystal arthritis. Four sets of criteria have been proposed over the years and none has been validated.¹ Most of them have the same core: brief, sudden, recurring attacks; at least one attack seen by a doctor; several different joints involved over time; and normal X-rays.

That "seen by a doctor" part is the hard one, because an attack is often over before an appointment comes round. People in the 2025 interview study described long delays to diagnosis, and those who were seen mid-flare tended to be referred sooner.⁶ Photographs of a swollen joint, with the date, and a written log of attacks are the closest substitute. There is a guide to keeping a flare diary here.

Blood tests for rheumatoid factor (RF) and anti-CCP antibodies (also called ACPA) are usually part of the workup. They do not make the diagnosis, but they help with the outlook.

Does it turn into rheumatoid arthritis?

Sometimes. Published rates of progression to rheumatoid arthritis range from 10% to 66%, depending on how patients were selected, how long they were followed and how they were treated.¹ In one Barcelona clinic followed for an average of 7.6 years, 34% went on to a chronic condition: 22% rheumatoid arthritis, about 6% lupus and about 6% something else.⁵

Anti-CCP antibodies are the strongest known marker of risk. In a Canadian series, 83% of the people who progressed to rheumatoid arthritis had anti-CCP antibodies at the start.³ But a positive result is not a sentence: in the Barcelona series, most people who were antibody positive still had not developed RA after many years.⁵ Researchers now often describe palindromic rheumatism as one point on a path toward rheumatoid arthritis that many people never travel to the end.²

There is more on how the two conditions differ in palindromic rheumatism vs rheumatoid arthritis.

How it is treated

Treatment is decided with a rheumatologist, and the evidence base is thin: as of the most recent major review, no randomised controlled trial in palindromic rheumatism had been completed.¹ With that caveat:

• During an attack, anti-inflammatory painkillers (NSAIDs) are commonly used, with mixed results.
• To reduce attacks, antimalarials, mainly hydroxychloroquine, are the most studied and are described as probably the treatment of choice. They are the only drugs shown to reduce how often attacks happen and how bad they are.¹
• On progression, a retrospective study of 113 patients found that those who took antimalarials developed rheumatoid arthritis or another connective tissue disease later and less often. The estimated median time to a chronic condition was 162 months in the treated group and 56 months in the untreated group.⁴ It was an observational study, not a trial, so it shows an association rather than proof.
• Other medicines, including sulfasalazine, methotrexate, colchicine and biologics, have been used in particular situations, mostly on the strength of small or uncontrolled studies.¹

What sets attacks off?

Nobody knows, and the honest answer is that the research has barely looked. People with the condition name tiredness, poor sleep, stress, particular foods, alcohol, overexertion, joint strain and infections. A couple of people in one study noticed more attacks in winter. Many find no cause at all.⁶

If you want to test a suspicion of your own, the trick is to record the days you were fine as well as the days you flared. "I flared three times after a late night" means little without knowing how many late nights there were with no flare. The flare diary guide explains how.

This page summarises published research for general information. It is not medical advice, and it is no substitute for a rheumatologist who knows your history.