ENRheumatology in Germany is the specialty for inflammatory diseases of the joints, spine, vessels and connective tissue, yet some patients go from orthopaedic surgeon to neurologist for years with joint pain, morning swelling, unexplained fatigue and a rash before they hear of it. It is internal medicine, not surgery. A rheumatologist does not operate on the joint but works out why the immune system is attacking the body’s own tissue, and puts together a drug regimen.
This is the section overview: individual diseases have their own pages, linked in the text. Below: which diseases a rheumatologist handles, how diagnosis works in Germany, which drugs are used, how many days a trip takes and what to do with records from a diagnosis made at home.
Which diseases a rheumatologist treats
A rheumatologist treats arthritis, spondyloarthritis and systemic inflammatory diseases. In rheumatoid arthritis the small joints of the hands become inflamed symmetrically, on both sides, and the fingers stay stiff long after waking: morning stiffness. Psoriatic arthritis affects people with psoriasis; reactive arthritis follows an infection. Gout is caused by uric acid crystals, not by the immune system, yet these patients also end up with a rheumatologist.
The second group, the spondyloarthritides, includes ankylosing spondylitis, now called axial spondyloarthritis: low back pain at night and towards morning that eases with movement, not rest. It is often mistaken for a slipped disc, since the same lower back hurts and a plain X-ray is normal early on. Yet disc pain is mechanical, worse with load and better with rest, and is treated with painkillers, exercise and sometimes surgery. Spondyloarthritis is inflammation: it needs anti-inflammatory drugs and, if these are not enough, biologics or JAK inhibitors.
The third group is systemic disease, affecting more than the joints: systemic lupus erythematosus, scleroderma with hardening of skin and internal organs, Sjögren’s syndrome with dry eyes and mouth, myositis (muscle inflammation) and vasculitis, inflammation of the vessel wall. These diseases can reach the kidneys, lungs, skin and nerves, so the rheumatologist works with a nephrologist, a pulmonologist and a dermatologist.
The fourth group lands in rheumatology by mistake or proximity. Fibromyalgia brings widespread pain, fatigue and poor sleep but no inflammation, and is treated differently. Osteoarthritis, cartilage wear, belongs to orthopaedics. Osteoporosis, fragile bones, is not an inflammation either, though it often accompanies rheumatic disease and steroid use. The distinction matters: it decides which doctor you need and which tests make sense.
How the diagnosis is made in Germany
In Germany a diagnosis is pieced together from conversation, examination, blood tests and imaging, starting with the conversation. The rheumatologist asks about the character and daily rhythm of the pain, how long morning stiffness lasts, rash, dry eyes, hair loss, breathlessness and family history, then examines the joints one by one, not «in general». This talk takes longer than the blood tests and matters more than any single value.
Blood tests say less than the printout suggests. ESR and C-reactive protein show whether there is inflammation, not which kind. Rheumatoid factor can be positive in healthy people, while antibodies against cyclic citrullinated peptide point more specifically to rheumatoid arthritis. Antinuclear antibodies are tested when systemic disease is suspected, ANCA when vasculitis is. No single test makes a diagnosis, and a starred value on a printout is not a disease.
Doppler ultrasound of the joints, in a rheumatologist’s hands, reveals active inflammation of the synovium, the joint lining, and fluid in joints that look calm. MRI of the sacroiliac joints, where spine meets pelvis, finds early spondyloarthritis while the X-ray is still normal. Nailfold capillaroscopy, a magnified look at the tiny vessels by the nail, separates a harmless cold reaction of the fingers from beginning scleroderma.
A German consultation may differ from what you know: the diagnosis follows international classification criteria and comes with a disease activity score. That number drives both the choice of therapy and the date of the next review. The current guideline of the German Society for Rheumatology and Clinical Immunology on treating rheumatoid arthritis on the AWMF portal works this way: treatment decisions follow measured disease activity within intervals agreed in advance.
What is used to treat it today
Today the mainstays are conventional disease-modifying drugs, biologics and targeted tablets, and the goal is remission or low disease activity, not «pain relief». If the goal is not reached within an agreed interval, the regimen changes before things deteriorate. Reviews are therefore booked in advance rather than «if things get worse», and disease activity is measured each time.
The first step is conventional disease-modifying drugs, which alter the course of the disease, not just the symptoms. Methotrexate remains the backbone in rheumatoid arthritis, alongside leflunomide, sulfasalazine and hydroxychloroquine; in systemic disease mycophenolate and azathioprine are used. They act slowly, over weeks, so at first they may seem useless. They need regular blood counts and liver tests, and skipping these is more dangerous than the drugs: the tests show in time when a dose must change.
If that is not enough, biologics or tablet inhibitors of signalling pathways are added. A biologic is a protein that intercepts one specific link in the inflammatory chain, such as tumour necrosis factor, interleukin-6 or interleukin-17; JAK inhibitors block signal transmission inside the cell. In 2023 the European Medicines Agency (EMA) confirmed the measures proposed by its safety committee PRAC: in people aged 65 or over, current or long-time past smokers and those at increased risk of heart attack, stroke or cancer, JAK inhibitors should be used only if no suitable alternative exists, and risk factors for blood clots in the veins or lungs call for caution. Before any of these drugs, latent tuberculosis and hepatitis are ruled out and vaccinations checked; the decision is made with the patient.
Part of treatment is not a drug. Measured exercise therapy and patient education help people understand their disease and recognise a flare. Occupational therapy keeps the hands working and teaches joint-sparing habits. In spondyloarthritis and vasculitis, stopping smoking is part of treatment. In fibromyalgia, pain without inflammation, the pain is treated along with what sustains it: poor sleep, stress, lack of movement. The WHO fact sheet on musculoskeletal conditions gives an overview.
How the appointment works and how long it takes
The first block of tests usually takes several consecutive working days in a specialist department of a university or large municipal hospital, with outpatient clinics and day units where an infusion takes a few hours, without an overnight stay. Inpatient rheumatology in Germany is usually for working up a difficult case or a flare of systemic disease, not for a «course of drips».
For a patient from abroad, the first visit means conversation, examination, ultrasound and a blood draw; some results come the same day, immunological ones after several days. Sometimes a biopsy or another specialist’s opinion is needed. So several consecutive working days are planned for the first block, not one visit. The hospital states the cost and exact schedule in its reply.
If you were diagnosed at home, bring reports with the date the complaints began, all previous test results in the original, MRI and X-ray discs, a list of current and previously tried drugs with doses and dates, and records of vaccinations and past infections. The list of what has been tried matters most: it decides which line of therapy the doctor may propose at all, since guidelines reserve many drugs for cases where earlier ones failed or were not tolerated.
Where rheumatology is strong in Germany
Strength in rheumatology belongs to a department, not a city. In systemic disease, nephrology, pulmonology and an immunology laboratory under the same roof matter more than a famous name.
A few partner departments, as examples rather than a ranking: the clinic for rheumatology and clinical immunology at the University Hospital Freiburg, headed by Professor Reinhard E. Voll, recognised as a specialist immunologist by the German Society for Immunology in 2007; the rheumatology section of Medical Clinic III at the University Hospital Dresden, where Professor Martin Aringer is deputy director; and the III. Medical Clinic of the University Hospital Hamburg-Eppendorf under Professor Tobias B. Huber, where nephrology and rheumatology are run together.
Frequently asked questions
How is a rheumatologist different from an orthopaedic surgeon?
A rheumatologist treats mainly with drugs, an orthopaedic surgeon also with operations. Rheumatology is internal medicine: the doctor looks for the cause of inflammation in the immune system, chooses a drug regimen and adjusts it by blood tests and activity scores. The orthopaedic surgeon deals with joint wear, injuries and deformities and operates when needed. In inflammatory disease the two often work together.
Can a rheumatologist in Germany look at my records before I travel?
Yes, and that is usually where it starts. Reports, test results and images are translated and sent to rheumatology departments, and a doctor replies whether a visit is needed and which tests would be done on site. This opinion does not replace an appointment: the final diagnosis and treatment plan come after conversation and examination. It helps avoid an unnecessary trip.
How many days should I plan for a rheumatology work-up?
Usually several consecutive working days for the first block; the hospital gives the exact schedule in its reply. The first day covers conversation, examination, ultrasound and blood tests. Some results are ready at once, immunological ones after several days. A biopsy, an MRI or another specialist’s opinion lengthens the stay, so a changeable return ticket is sensible.
Should I stop my medication before the trip?
No, do not stop prescribed drugs on your own: a break in treatment can trigger a flare. Bring enough medication for the whole stay and a list of doses with the date of the last tablet or injection. If the rheumatologist in Germany changes anything, you receive the new regimen in writing for your doctor at home.
How AlenMed organises treatment
AlenMed starts with your records: a medical interpreter translates reports and test results, which go to two or three rheumatology departments. The reply gives the doctor’s view on whether a visit is needed and how much diagnostic work it would involve, with proposed dates. The medical visa paperwork is prepared alongside.
AlenMed works with 86 partner hospitals in 38 cities and 345 doctors; the company office is in Munich. A coordinator books appointments, interprets at consultations, helps extend the stay if more tests are needed and makes sure the regimen and monitoring plan reach your doctor at home in writing.
This material is for information only and is not an offer; treatment is decided by a doctor at a face-to-face examination.