Rheumatoid arthritis without deformities: fiction or reality?

Rheumatoid arthritis (RA) is the most common chronic inflammatory arthritis, characterised by persistent synovial inflammation, progressive joint damage, and a wide range of extra-articular manifestations. Historically, RA was associated with significant disability and deformities. However, over the past two to three decades, advances in early diagnosis and the introduction of disease-modifying antirheumatic drugs (DMARDs) have transformed disease outcomes.  Early recognition of inflammatory arthritis, prompt initiation of DMARD  therapy within the “window of opportunity,” and adoption of a treat-to-target strategy have enabled many patients to achieve sustained remission or low disease activity, thereby preventing irreversible joint damage. Consequently, the classical deforming phenotype of RA is now less frequently encountered in clinical practice. 
Methotrexate remains the cornerstone of therapy, with escalation to combination conventional DMARDs, biologic agents, or targeted synthetic therapies in patients with inadequate response.  Furthermore, RA is a systemic disease with significant extra-articular involvement and an increased burden of comorbidities, such as cardiovascular diseases, infections and osteoporosis. Therefore, comprehensive management requires not only control of inflammation but also proactive management of comorbidities and optimisation of overall health.  However, delays in referral, under-recognition of early disease and delayed optimisation of DMARD therapy considerably influence patient outcomes. This review summarises the clinical features, diagnostic approach, and contemporary management of RA, and highlights how current strategies have made rheumatoid arthritis without deformities an increasingly attainable goal.