15 Questions - Musculoskeletal Issues and Lupus

(October 2012) More than 90 percent of people with lupus will experience joint and/or muscle pain at some time during the course of their illness. In fact, more than half of the people who develop lupus report joint pain as their first symptom. This month, Dr. Dafna D. Gladman answered your questions about joint pain and other musculoskeletal issues related to lupus.

1. Why is it that lupus attacks muscles and the joints? Tucson, AZ

That is a very good question. It is not known exactly why this happens, except that those are areas that appear to demonstrate the inflammation that occurs in lupus. It is possible that in the joint and muscle tissue there are factors to which the antibodies that occur in lupus react to thus leading to inflammation and the subsequent problems that arise – pain, limitation in mobility, and on occasion, damage.

2. Since being diagnosed I have ruptured 2 discs and have a 3rd that is bulging. Does lupus or the medications used to treat lupus contribute to degenerative disc disease? Moscow, ID

Lupus does not usually affect the discs. Of the medications used to treat lupus, the only one that may have a remote effect is corticosteroids. Patients that are overweight and do not exercise are more likely to develop degenerative disc disease. Corticosteroids add to this by promoting obesity, particularly what we call central obesity – the trunk, and thus extra pressure is put on the discs leading to these degenerative changes.

3. Is there a difference between the pain associated with lupus and the pain the doctors tell me is arthritis pain? Do the effects of lupus on joints lead to an increase in arthritis? Lowell, IN & Holt, MI

Arthritis means inflammation in the joints. Inflammation may be due to a variety of reasons.  Inflammatory type pain is associated with joint swelling, morning stiffness, worsening of the inflammation with rest or inactivity and improvement with activity and exercise. Patients with lupus may have inflammatory arthritis, but are not protected from the development of osteoarthritis, which is a more common form of arthritis which is mostly non-inflammatory, is associated with bony overgrowth, worsens with activity and improves with rest. Osteoarthritis can affect the joints of the hands as well as larger joints such as knees and hips, as well as the joints of the spine. Thus, if you have osteoarthritis as well as lupus, then sometimes the pain will not be due to lupus, but rather to the mechanical form of arthritis. In addition, over 20% of patients with lupus also suffer from fibromyalgia, which is not arthritis, but a condition where there is generalized pain; poor sleep quality, extreme fatigue, and a number of other associated features. Thus, some pain may be related to this, again different from lupus inflammation.

4. I was recently diagnosed with lupus. Besides the joint pain, fatigue, etc. I suffer with leg and foot cramps almost daily and several times/day. Is muscle cramping a part of lupus or do the medications cause this? Schertz, TX

The muscles can also get inflamed in lupus, and many patients suffer from myositis (inflammation in the muscle). This usually presents with weakness rather than pain. There are a number of causes of muscle cramps, some of which are biochemical and your physician might check your electrolytes and calcium to make sure that this is not the cause. Occasional medications can do that such as cholesterol lowering agents.

5. Can muscle and joint pain from lupus exist even when a patient is not experiencing a flare? (I have read that fatigue and cognitive problems can exist even when lupus is not active/flaring). I understand that this pain can be attributable to causes other than lupus, but was just curious if chronic pain can be present FROM LUPUS even when the lupus is not flaring. Chardon, OH

Generally the pain associated with lupus is related to inflammation. Usually once the inflammation of lupus is under control, if there is still significant pain present then other causes of pain need to be considered. Sometimes there may be damage as a consequence of the inflammation and that may lead to chronic pain. This can occur with joint deformities, the development of osteonecrosis, or fractures due to osteoporosis. Another common reason for pain in patients with lupus is fibromyalgia, where there is generalized pain, disrupted sleep, and a variety of other issues. This too can be addressed with an exercise program, proper sleep hygiene, as well as certain medications.

6. I have noticed my knees started hurting about 5 years ago. Since then they have rapidly gotten to the point I need knee replacement on both. Does lupus cause joint destruction? Is this going to continue with the rest of my joints? Eureka, KS

Lupus does not usually cause joint destruction. However, there may be two things that can happen as a consequence of lupus which may lead to joint destruction, especially in the hips and knees. The first is osteoarthritis, which is a mechanical form of arthritis, which may occur in any individual; therefore having lupus is not protective. Moreover, patients with lupus on corticosteroids are more likely to become obese which is a risk factor for osteoarthritis. The other problem is the development of osteonecrosis which is related to corticosteroid therapy and most commonly affects the hips and knees. The consequence of osteonecrosis is the development of osteoarthritis requiring joint replacement.

7. What is best way to treat joint and connective tissue pain? I feel like my medications are just not working. Fairview, NC

The management of joint and “connective tissue” pain is very much dependent on the underlying diagnosis. If there is demonstrable joint or muscle inflammation then the treatment would involve certain medications, which may need to be escalated if not effective. However, generalized pain is more likely to be related to fibromyalgia. This needs to be treated with a combination of exercise, proper sleep, as well as certain medications. Thus, your physician must identify the exact mechanism of the pain and devise an appropriate management program accordingly.

8. I as well as many lupus patients have daily joint and muscle pain. I'm trying not to totally rely on pain medication. How effective have some alternative methods been? Example: acupuncture, muscle activation, massage, UVA1 photo therapy. Nashport, OH

The management of joint and muscle pain is very much dependent on the mechanism of the pain. If there is true arthritis or myositis, then specific medications should be used, and the medication may need to be escalated if not effective. However, if the pain is due to mechanical factors, or fibromyalgia, the management would be very different. Acupuncture works for acute pain, but there is no evidence that it works for chronic pain. There is no evidence to support the use of the other modalities mentioned.

9. How can you tell if your muscle and joint pain is caused by your lupus or from something else like the normal aches and pains from aging? I'm a 45 year old letter carrier. When I get home its Tylenol and chair time - I don’t want to over/under react. Victoria, Canada

The physician should be able to assess the lupus inflammation. Based on the clinical history, the physical examination and laboratory evaluation the physician should be able to determine whether the lupus is active and whether the joint and muscle pain is related to lupus or to another cause. If the joint and muscle pain are worsened with activity, it may very well be that you are developing osteoarthritis and you may need to consider a different job.

10. How common is muscle weakness with lupus and what is the best treatment to deal with this symptom? Chelsea, NY

There are two possible reasons for muscle weakness in lupus. The first is myositis, or inflammation in the muscle, which occurs in a small proportion of patients with lupus. This usually responds well to the treatment of lupus, including corticosteroids, antimalarials, methotrexate and azathioprine. The second is related to toxicity from medications. This can result from high dose corticosteroid therapy, or occasionally from antimalarial therapy. Very occasionally a lupus patient may develop weakness due to cholesterol lowering medications.

11. My primary lupus symptoms have been chronic inflammation and pain in my muscles and connective tissue. Living with this condition for 30 years has taught me to use care in doing anything. But in the last few years my muscle condition has deteriorated in spite of my active lifestyle. Injuries happen with very little provocation such as tearing my right bicep last year. Is this because of the duration of the lupus inflammation? Will my muscles continue to degrade even with exercise? Linden, TX

The question is whether there is persistent inflammation which will require certain medications, or whether the problem is the result of previous inflammation or just “wear and tear”. Your physician should be able to determine whether the lupus is active and address it appropriately. If the lupus is not active, you should make sure you do not over do things. Exercise is important but you must make sure you do not over tax your muscles.

12. I have developed Avascular Necrosis of both femur heads. Is this common? What treatment is the best & most conservative treatment? Mohegan Lake, NY

Unfortunately avascular necrosis or osteonecrosis is a common complication in patients with lupus. Clinically apartment osteonecrosis has been reported in 12% of the patients. It is possible that more patients have osteonecrosis that is not detected clinically since when MRI studies are done, a much higher prevalence is noted. However, only 12% complain of pain which leads to the identification of the problem with imaging. The best treatment is individualized, since every patient has their own issues. Initially rest may be indicated or the use of cane or crutches. In more advance situations a joint replacement may be necessary. Pain control is certainly important.

13. I have been diagnosed with lupus and Fibromyalgia. How are they similar or different and is the treatment the same for both. Savannah, GA

Fibromyalgia complicates life for about 22% of patients with lupus. The difficulty is making the diagnosis and distinguishing features of lupus from those of fibromyalgia. Fibromyalgia is associated with generalized pain, poor sleep, and extreme fatigue. There are specific areas where there is localized tenderness. Some of these may be in the chest leading to perceived chest pain. In addition, there may be irritable bowel and bladder symptoms, cognitive impairment, and sensation of electric currents in the extremities. These may be confused with features of lupus. The physician should be able to determine whether the lupus is active based on the history, physical examination and laboratory tests and arrive at the correct diagnostic conclusion and proper management.

14. How can exercise help/hurt or increase/decrease muscle and joint pain? I've gained weight but an afraid to exercise because of the consequences of pain that can last for a week after even a light workout. What would you suggest? Stroudsburg, PA

Generally exercise is good for you. However, it needs to be done in moderation. Also, if you have not exercised in a while it needs to be graduated. If the problem is related to fibromyalgia, exercise is an important component of the treatment. However, if the problem is related to cartilage degeneration as occurs in osteoarthritis, then vigorous exercise may lead to more pain and may further deteriorate the cartilage. Thus, your physician needs to make this determination but making the correct diagnosis and providing the proper management plan.

15. What are the long term effects of inflammation from lupus on a person tendons and ligaments?

The long term effects of inflammation is specific sites is dependent on the duration and extent of inflammation. Tendons and ligaments may be shortened or stretched as a consequence of inflammation, depending on the site. Occasionally there may be tendon or ligament rupture which requires surgical intervention.