Joint and Muscle Pain in Systemic Lupus Erythematosus ( SLE )
Francisco P. Quismorio, Jr, MD, University of Southern California-Los Angeles
A reprint from Lupus Foundation of America Article Library 2001
Introduction
More than 90 percent of people with SLE will experience joint and/or muscle pain at some time during the course of their illness. At the onset of the disease, the major complaint of more than half of SLE patients is pain in the joints.
The major cause of joint pain in SLE is inflammation of the joints. The term for this is arthritis. In the affected joint, arthritis can cause:
- pain
- swelling
- tenderness
- a feeling of warmth
- fluid collection.
Pain in and around the joints is not always due to lupus arthritis. It also can be due to other medical disorders that may complicate or co-exist with SLE, including:
- fibromyalgia
- avascular necrosis of bone
- bursitis and tendonitis,
- other types of arthritis
- infection.
Inflammation of skeletal muscle also may develop in people with SLE. This condition, called myositis, causes progressive weakness and loss of strength of the extremities.
Lupus Arthritis
Lupus arthritis causes pain, stiffness, swelling, tenderness, and warmth of joints, and several joints are involved at one time. Joints farthest from the trunk of the body are affected most commonly, such as :
- fingers
- wrists
- elbows
- knees
- ankles
- toes
- The inflammation is symmetrical in distribution, which means it affects similar joints on both sides of the body.
- Generalized stiffness that occurs upon awakening in the morning will gradually improve as the day goes on
- Later in the day, joint pain and fatigue may return.
- Puffiness of the hands can occur.
- Recurrent attacks of arthritis are experienced by one-third of those with lupus.
Compared to rheumatoid arthritis, lupus arthritis is less disabling and it usually does not cause severe destruction of the joints. Fewer than 10 percent of people with lupus arthritis will develop deformities of the hands and feet. These are associated with weakening of cartilage and bone and can be seen in the x-ray of the joints. Referred to as "Jaccoud-type deformities," these are reversible conditions.
Diagnosis
The pattern of joint pain and the distribution of the inflamed joints are the best clues in determining whether the joint pain is caused by SLE. X-rays of the painful joints are usually normal in SLE. Fluid removed from a painful joint will show a low-grade inflammation.
When arthritis of several joints is the only symptom, establishing the diagnosis of SLE and differentiating it from other types of arthritis can be difficult. Careful observation and re-evaluation by the physician for other symptoms of SLE is essential in making the diagnosis.
- Neither a positive lab test for antinuclear antibodies or for rheumatoid factor in the blood are proof of SLE or rheumatoid arthritis. Both occur in either disease as well as in people with other medical conditions.
- However, a positive test for anti-DNA and/or anti-Sm is more specific for SLE and is helpful in the diagnosis.
Treatment
Proper and early treatment for most forms of arthritis, including SLE and rheumatoid arthritis, is available and can significantly slow down damage to the joints and lessen the pain and stiffness.
Lupus arthritis is treated with non-steroidal anti-inflammatory drugs ( NSAIDs ). These medications are effective for most people and usually are well-tolerated. They include:
- aspirin
- salsalate ( saliscylate )
- naproxen
- ibuprofen
- indomethacin
- When NSAIDs are not adequate to control arthritis, antimalarial agents such as hydroxychloroquine ( Plaquenil ) are added.
- Corticosteroids ( prednisone ) are used when the joints remain swollen and painful despite other treatment.
- Immunosuppressive medications can be effective for inflammatory arthritis. However, in general, these agents are not used solely or primarily for lupus arthritis. These drugs include:
- cyclophosphamide
- azathioprine
- methotrexate.
A program of physical and occupational therapy is an important part of the treatment of lupus arthritis, such as :
- range of motion exercises
- strengthening exercises
- joint protection strategies.
Fibromyalgia In SLE
Fibromyalgia is a chronic disorder. Its characteristics include:
- widespread pain in muscles and joints
- fatigue
- generalized weakness
- non-restful sleep.
Other symptoms of fibromyalgia include:
- headache
- changes in mood
- difficulty in thinking and concentration
- irritable bowel
- urinary urgency
- applying pressure to specific locations on the neck, back, chest, and limbs ( tender points ) will cause pain and tenderness.
Fibromyalgia is estimated to occur in up to 2 percent of the U.S. population.
Fibromyalgia may exist with other conditions, including SLE and rheumatoid arthritis.
The cause of fibromyalgia is not known.
Diagnosis
The symptoms - such as fatigue, musculoskeletal pain, mood and cognitive abnormalities - may be mistaken for increased disease activity ( also called a flare ). However, laboratory markers of lupus flare, including a low serum complement level and high levels of anti-DNA antibodies, do not occur in fibromyalgia.
Treatment
Fibromyalgia is treated with NSAIDs and other agents to relieve pain. Other medications can be used to help get restful sleep. A comprehensive program of aerobic exercise, physical therapy, relaxation techniques, and coping skills is beneficial for many people with this disease.
Avascular Necrosis of the Bone ( AVN )
Avascular necrosis of the bone - also called aseptic necrosis or osteonecrosis - is characterized by:
- diminished blood flow
- increased pressure within a portion of the bone.
There is weakening of the bone which causes tiny breaks, and eventually the bone surface collapses. The hips, shoulders, and knees are most commonly affected.
The initial symptom of AVN is pain in these joints, especially on movement and weight-bearing, such as:
- walking
- running
- lifting objects.
This leads to stiffness, muscle spasm, and limited movement of the affected joint. As the condition becomes more advanced, pain may occur at rest, especially at night.
Diagnosis
The diagnosis of AVN can be confirmed by magnetic resonance imaging ( MRI ) scan and/or X-ray of the joint. MRI is a more sensitive test and may be helpful in diagnosing the early stage of AVN. Early diagnosis is important so that steps can be taken to lessen damage to the bone.
The cause of AVN is not known. However, it is associated with several factors:
- prolonged use of high doses of corticosteroids
- alcohol abuse
- sickle cell anemia ( an inherited disease )
- pancreatitis
- trauma and other conditions.
Treatment
Currently there is no effective medical treatment that can reverse this condition.
- In the early stages of AVN, the person is advised to avoid unnecessary stress to the affected joint, such as prolonged walking and weight-bearing.
- The use of a cane or crutches helps to take weight off the affected extremity.
- NSAIDs and other medications are prescribed to relieve pain.
- In advanced cases of AVN, surgery ( including artificial joint replacement ) can be effective in relieving pain and improving mobility and function.
- High doses of steroids, taken for an extended period, will increase the risk for development of AVN. Whenever possible, the steroid dose is reduced to lessen the chance of developing this condition.
Tendonitis and Bursitis
A tendon is a strong ropelike structure made of tough fibers that attaches muscle to bone. A bursa is a small sac containing a slippery fluid that is usually found near a joint and allows muscles, bones, and tendons to move easily.
- Irritation of a tendon ( tendonitis ) and a bursa ( bursitis ) are usually due to physical trauma or overuse of a joint.
- Pain, especially when the affected part is moved, is the major symptom of both conditions.
- Different areas of the body may be affected, but commonly affected areas include:
- the elbow ( tennis elbow )
- the finger ( trigger finger )
- the shoulder.
Spontaneous rupture of the tendon in the knee cap ( patellar ) or ankle ( Achilles tendon ) is a rare complication of SLE. The person experiences a painful "snap" of the tendon which causes an inability to straighten the leg or to bend the foot.
Other Causes of Musculoskeletal Pain
Pressure on the median nerve in the wrist causes a condition called carpal tunnel syndrome. It is characterized by tingling, numbness, and pain in the fingers, which sometimes affects the entire hand. A number of medical conditions, including SLE, can cause carpal tunnel syndrome.
There are other types of arthritis that can occasionally exist with SLE, including osteoarthritis and gout. These conditions can be differentiated from lupus arthritis by clinical findings and appropriate laboratory tests.
Lupus Myositis
- Muscle pain ( myalgia ) and muscle tenderness are common, especially during periods of increased disease activity ( flare ), and occur in 50 percent of those with SLE.
- Some people develop inflammation of the skeletal muscles ( myositis ), which causes weakness and loss of strength.
- Lupus myositis commonly involves the muscles of :
- the neck
- pelvic girdle and thighs
- shoulder girdle and upper arms.
The onset of the weakness can be tricky to detect, but difficulty in climbing stairs and getting up from a chair are early symptoms. Later, there may be difficulty in :
- lifting objects onto a shelf
- combing the hair
- getting out of the bath
- raising the head
- turning over in bed.
Diagnosis
The diagnosis of lupus myositis is confirmed by:
- elevated levels of certain enzymes ( CPK, aldolase, SGPT and SGOT ) in the blood
- certain abnormalities in an electromyogram ( EMG ) test which measures electrical activity of the muscle fibers.
Another test that is sometimes used is a biopsy of the thigh or arm muscle. The tissue is examined under the microscope for evidence of inflammation and destruction of muscle fibers.
Treatment
Corticosteroids ( prednisone ) are the drug of choice in the treatment of lupus myositis.
- A high dose (50 mg per day of prednisone or equivalent) is given to suppress and control the muscle inflammation.
- Muscle strength will gradually improve and serum enzymes will fall to normal levels.
- With clinical improvement, the dose of prednisone is tapered gradually.
- The vast majority of people with lupus myositis respond promptly to corticosteroid therapy.
Those few individuals who fail to respond adequately to steroids will be prescribed an immunosuppressive agent such as methotrexate or azathioprine.
An exercise program supervised by a physical therapist is helpful in regaining normal muscle strength and function.
Drug-Induced Muscle Weakness
Muscle weakness can be a side effect of certain medications, including :
- prednisone and other corticosteroids
- cholesterol-lowering drugs
- hydroxychloroquine ( Plaquenil ).
Drug-induced muscle disease should be ruled out as a cause of weakness in a person with lupus who is taking any of these medications. Decrease of the corticosteroid dose or discontinuation of the offending agent usually results in an improvement of the muscle strength.
Disclaimer :
The Lupus Group of WA (Inc) does not recommend or endorse any products, drugs, treatments, procedures, medical or health professional in this article. We suggest you discuss this information with your doctor or specialist.