Morning stiffness: causes, red flags and when to see a doctor

Joints and muscles stiffen after rest, and everyone feels a little stiff on getting out of bed. In osteoarthritis, the stiffness is brief because it comes from mechanical wear and eases as the joint warms up. In inflammatory conditions the immune system drives swelling in and around the joints or muscles during the night, producing stiffness that takes much longer to ease.

The NHS captures this in its osteoarthritis diagnosis advice: a GP may suspect osteoarthritis if you are aged 45 or older, have joint pain that worsens with use, and have stiffness that is not there in the mornings or lasts less than 30 minutes. If your symptoms are slightly different, it notes this may indicate another joint condition, since prolonged morning stiffness can be a sign of rheumatoid arthritis.

• Fibromyalgia, which causes widespread pain and stiffness with fatigue and poor sleep, and is diagnosed after other conditions are excluded.

• An underactive thyroid, which the NHS links with tiredness, feeling cold, weight gain and low mood, and which a blood test can check.

• Gout and other crystal arthritis, which usually cause hot, red, very painful single joints rather than generalised stiffness.

• Medicines, such as statins, which can cause muscle aches in some people.

• Lower back problems and spinal stenosis that stiffen after rest.

• Inactivity and sleep position, particularly after a poor night or a new mattress.

• Get an urgent GP appointment or contact NHS 111 straight away if, with polymyalgia rheumatica or stiffness in an older person, you have a new or frequent headache that develops suddenly, a sore or tender scalp, pain in the jaw muscles or tongue when eating or talking, or problems with sight such as double vision or loss of vision in one or both eyes; the NHS says these may be temporal arteritis, which can lead to stroke or blindness if not treated quickly.

• Call 999 or go to A&E for sudden loss of vision, a drooping face, weakness on one side or difficulty speaking.

• A hot, red, swollen, very painful joint with fever needs same-day assessment because a joint infection must be excluded.

• Back pain with numbness or weakness in both legs, loss of feeling around the genitals or anus, or changes in bladder or bowel control needs 999 or A&E, according to the NHS back pain page.

• See a GP for pain and stiffness lasting more than a week, as the NHS advises for polymyalgia rheumatica.

• See a GP if joint pain, stiffness and swelling keep coming back, with or without psoriasis, or if you have persistent symptoms of ankylosing spondylitis, osteoarthritis or rheumatoid arthritis.

• Unexplained weight loss, fever, night sweats or marked tiredness alongside stiffness should be reported.

Key questions are how long the stiffness lasts after waking, which joints or muscles are involved, whether they are swollen or warm, whether symptoms improve with movement or worsen with it, whether pain wakes you in the second half of the night, any skin psoriasis or nail changes, back pain starting before 40, eye redness, bowel symptoms, and family history of arthritis or psoriasis. They will ask about tiredness, weight loss and mood.

The examination looks for joint swelling and tenderness, range of movement, deformity, spinal flexibility, skin and nails, and muscle strength around the shoulders and hips. The NHS says that in osteoarthritis X-rays or blood tests are not usually necessary, but may be used to rule out other conditions.

When inflammation is suspected, blood tests commonly include inflammatory markers (CRP and ESR), a full blood count, and antibody tests such as rheumatoid factor and anti-CCP. The NHS lists blood tests, joint fluid testing, X-rays, ultrasound and MRI scans among the tests for psoriatic arthritis, and says that if the GP suspects ankylosing spondylitis they should refer you to a rheumatologist for blood and imaging tests. For polymyalgia rheumatica other conditions, including rheumatoid arthritis, must be ruled out before the diagnosis is made.

The NHS says early diagnosis and treatment of rheumatoid arthritis enable many people to have periods of months or even years between flares. Treatments include long-term medicines, physiotherapy and occupational therapy, and sometimes surgery. For polymyalgia rheumatica the main treatment is prednisolone, a steroid, usually for 12 months to 2 years with a gradually reducing dose. Psoriatic arthritis is mainly treated with medicines including NSAIDs, steroid injections and DMARDs.

A warm shower on waking, gentle stretching before getting up, keeping moving through the day and avoiding long periods of rest help many people. The NHS notes that psoriatic arthritis symptoms may improve with exercise, and that supportive therapies such as physiotherapy keep people with rheumatoid arthritis mobile. Painkillers and anti-inflammatory medicines can help but should be used as advised by a pharmacist or doctor.

Keeping a simple diary of how many minutes stiffness lasts each morning, which joints are affected and any swelling gives the clinician objective information, particularly in distinguishing wear-and-tear from inflammatory causes.