Methotrexate (MTX) is considered a “first-line” therapy for rheumatoid arthritis (RA) and is also used to treat psoriatic arthritis (PsA). But despite the well-known benefits of helping to reduce symptoms and prevent disease progression, methotrexate has a very mixed reputation among arthritis patients.
Perhaps because MTX is so commonly prescribed, many inflammatory arthritis patients start to worry about whether or not they’ll have to take it almost as soon as they’re diagnosed. “For anyone with RA, initiation into the MTX club seems particularly harrowing,” RA patient and Chronicwoman contributor Dibs Baer wrote about starting to take methotrexate. “I admit that I waited weeks to start taking it when I first got diagnosed with RA.”
In particular, many patients have questions, concerns, and fears about side effects from taking methotrexate — everything from hair loss to serious, though rare, issues like liver toxicity.
Do patients’ concerns about the bothersome effects of methotrexate have an impact on whether they take the medication consistently? The benefits of early and consistent treatment of inflammatory arthritis are well established, so the fact that a patient’s discomfort with methotrexate could prevent them from taking their prescription is a serious issue.
If doctors knew more about patients’ main concerns regarding methotrexate, could they do a better job at preparing patients for the potential side effects and giving advice for how to manage them? These are all issues the rheumatology community needs to know more about, so researchers, including those from our nonprofit organization, the Global Healthy Living Foundation, set out to study this.
In research presented at the 2019 American College of Rheumatology/Association of Rheumatology Professionals (ACR/ARP) Annual Meeting in Atlanta, researchers surveyed 371 patients with rheumatoid arthritis or psoriatic arthritis in the ArthritisPower research registry who were currently taking or had previously taken methotrexate. Here’s what we learned.
Not surprisingly, the majority of patients surveyed reported that they experienced one or more side effects while taking methotrexate: 58 percent of current methotrexate users and 79 percent of people who had taken methotrexate but stopped. More research is currently underway to understand the degree to which MTX side effects play a role in whether people stop taking it.
When patients in the survey were asked about specific MTX side effects and whether they experience them, the most commonly reported one was fatigue. About 44 percent of patients reported fatigue or tiredness from the medication, both among those currently taking methotrexate and those who had previously taken methotrexate.
Patients who stopped taking methotrexate reported having substantially more gastrointestinal issues — including nausea, abdominal pain, and loss of appetite — from methotrexate than current users did.
Just 26 percent of current MTX users reported nausea, compared with 40 percent of those who used it previously.
Just 9 percent of current MTX users reported abdominal pain, compared with 25 percent of those who used it previously.
Just 14 percent of current MTX users reported diarrhea, compared with 18 percent of those who used it previously.
Just 10 percent of current MTX users reported loss of appetite, compared with 17 percent of those who used it previously.
However, despite many patients reporting side effects, those who currently take methotrexate consider the drug important in managing their disease and health. Nearly two thirds (65 percent) of current MTX users agree that the medication “protects me from becoming worse.”
About half (47 percent) said that their health depends on methotrexate. Forty three percent agreed that “my life would be impossible without my methotrexate.”
If you’re taking methotrexate for your rheumatoid arthritis or psoriatic arthritis, it’s important to talk to your doctor about any side effects that you may be experiencing.
“We know many RA and PsA patients discontinue methotrexate with or without their physician’s knowledge,” says study coauthor W. Benjamin Nowell, PhD, director of Patient-Centered Research at the Global Healthy Living Foundation. “We hope this research provides insights to both patients and doctors about the side effects patients most often report and are most concerned about. Improving communication about these side effects and how to manage them may help patients to keep taking this beneficial medication or to request an effective alternative. Either way, it’s important to keep in mind that early, aggressive, and consistent treatment is the best way to improve their long-term outcomes.”
You and your doctor may discuss taking some of the following steps to reduce the side effects from taking methotrexate:
Take a folic acid supplement.Folic acid is a type of B vitamin that you need for your cells to divide and grow normally. Folic acid is also essential in the production of red blood cells. Methotrexate blocks some of the actions of folic acid, which can lead to side effects such as mouth sores, abdominal pain, liver problems, hair loss, and anemia. Taking folic acid supplements can help offset MTX side effects.
Take methotrexate after meals, which may reduce the risk of stomach upset. Your doctor may also consider prescribing other medication to help treat symptoms like nausea and vomiting.
Use a lower dose. According to the Hospital for Special Surgery, many MTX side effects can be resolved by lowering the dose. However, you should never lower the dose or stop taking methotrexate without the guidance of your doctor.
Take MTX close to the weekend. For patients who report fatigue to be an important side effect, taking the medication, which is often given weekly, on a Friday or Saturday can allow you to rest and recover over the weekend.
Consider the side effect profile of other medications you take. Many other drugs used to treat RA or PsA can also cause similar side effects. For example, some patients who use non-steroidal anti-inflammatory pain medication (NSAIDs) report gastrointestinal (GI) upset as a symptom. Make sure your doctor knows all of your medications and supplements, both over the counter and prescription, so they can help you minimize side effects and interactions.
One of the main reasons people with arthritis visit the rheumatologist frequently — every three months is common among patients with inflammatory arthritis — is for doctors and patients to assess how arthritis patients are managing their disease. Typical check-ins may include a doctor’s physical exam and assessment as well as reviewing the results of blood tests and imaging tests.
What’s also critical at these visits is something arthritis researchers and doctors call PROs, or patient-reported outcomes. PROs are a patient’s own assessments of how arthritis affects daily tasks — including how you rank or define the difficulty of simple activities like getting in and out of your car or buttoning your shirt — and are a very important tool for measuring and monitoring your disease.
PROs are also important during clinical trials for medications or other treatments, as they can assess how different therapies affect patients and the symptoms that matter to them.
There are many different PRO measures and questionnaires doctors and researchers can use, but which symptoms are most important to patients? This is an important topic that the rheumatology community needs to know more about, so researchers, including those from our non-profit organization, the Global Healthy Living Foundation (GHLF), set out to study this.
“PRO measures are important indicators of disease activity, but as we learn more about the importance of their role in evaluating treatment effectiveness, we need to also learn more about the specific symptoms that patients find most important to track,” says study co-author Kelly Gavigan, MPH, manager of research and data science at GHLF.
In research presented at the 2019 American College of Rheumatology/Association of Rheumatology Professionals (ACR/ARP) Annual Meeting in Atlanta, researchers surveyed 253 patients through our ArthritisPower research registry with various self-reported conditions, including rheumatoid arthritis (RA), psoriatic arthritis (PsA), ankylosing spondylitis (AS), systemic lupus erythematosus (SLE), osteoporosis (OP), osteoarthritis (OA), and fibromyalgia syndrome (FMS).
At the start of the study, patients could select up to 10 different symptoms they wanted to track via short health assessment questionnaires. Study participants would then go on to complete the assessments once a month for the next three months. The symptoms that patients could track included:
In evaluating the PROs that were most popular among study participants at baseline, three stood out:
Fatigue: 83 percent of patients chose fatigue as a PRO they wanted to track.
Pain: 83 percent of patients chose pain as a PRO they wanted to track.
Mental health: 82 percent of patients chose mental health as a PRO they wanted to track. Within mental health, 54 percent of patients wanted to track depression and 44 percent of patients wanted to track anxiety.
Here is the percentage of patients who wanted to track other PROs in the study:
Physical Function: 72 percent
RA Flare: 70 percent (only offered to RA patients)
Study participants were also asked to share any self-reported comorbidities, or other diseases they have along with their arthritis diagnosis. The most common comorbidity was depression, reported by 51 percent of participants. This may partly explain why so many participants were interested in tracking aspects of their mental health.
National data show that depression and anxiety are common among people living with arthritis. According to a 2018 CDC report, 23 percent of people with arthritis reported symptoms of anxiety and 12 percent reported depression. These rates are likely even higher among specific populations of arthritis patients. For example, a 2019 study found that people with ankylosing spondylitis were twice as likely to have depression as people without AS. Other research has indicated that depression rates are higher among people with psoriatic arthritis than other rheumatologic conditions.
“Our research shows us that mental health is a top priority for patients and they do want to keep track of it,” says Gavigan. “But we know it can be challenging for some people to discuss mental health issues with their rheumatologist or other providers.”
In fact, other GHLF data suggest patients aren’t talking about their mental health with their rheumatologist. In a 2018 poll of ArthritisPower users, 59 percent of nearly 1,000 respondents said that their rheumatologist or primary care doctor does not ask about their mental health.
“We hope that being able to log and track mental health symptoms through ArthritisPower can facilitate these discussions and ensure that patients get the care and support they need to cope better with chronic illness,” Gavigan adds.
As many patients — 83 percent — reported wanting to track their fatigue as they did pain, which is important for rheumatology clinicians and researchers alike to know.
“We often hear from our arthritis patient community that fatigue is difficult to talk about with care providers,” says Seth Ginsberg, president and co-founder of Chronicwoman, which is part of GHLF. Patients report that doctors don’t always take their fatigue as seriously as other symptoms. What makes this even more challenging is that loved ones and caregivers also often struggle to understand the impact of fatigue on someone living with arthritis — that it’s more than just feeling tired. People who have fatigue from chronic illness are not “lazy” or “just need to get more sleep.” Fatigue is a physical manifestation of their disease, just like pain, stiffness, or swelling.
“The more patients can quantify difficult-to-discuss symptoms like fatigue, and mental health concerns, the more we as a rheumatology community can evaluate disease activity, treatment effectiveness, and overall health in a broader context that more fully takes into account patients’ complex experiences living with complicated, lifelong chronic diseases,” says W. Benjamin Nowell, PhD, director of Patient-Centered Research at GHLF.
If you are diagnosed with arthritis or another musculoskeletal condition, we encourage you to participate in future studies by joining Chronicwoman’ patient research registry, ArthritisPower. ArthritisPower is the first-ever patient-led, patient-centered research registry for joint, bone, and inflammatory skin conditions.
Fibromyalgia and lupus are both chronic diseases with no cure, can both cause some similar symptoms, and can both take a long time to get the right diagnosis. But fibromyalgia — often called fibro — and lupus are two very distinct health conditions with very different causes and treatments, despite having some features in common.
Lupus is an autoimmune disorder that involves widespread inflammation and impacts many organs throughout the body. Fibromyalgia a disorder that causes widespread chronic pain and tenderness. Unlike lupus, fibromyalgia is not an inflammatory or autoimmune disease.
Still, many signs and symptoms of fibromyalgia and lupus overlap and it’s not uncommon for fibromyalgia to be misdiagnosed as lupus, says rheumatologist George Stojan, MD, an assistant professor of medicine at Johns Hopkins University School of Medicine and co-director of the Johns Hopkins Lupus Center in Baltimore, Maryland. Both fibromyalgia and lupus can cause muscle/joint pain, brain fog, and fatigue. Both are also more likely to occur in younger and middle-aged women.
Interestingly, another factor that makes fibromyalgia and lupus difficult to differentiate from each other is that some people have both at the same time. “Having both lupus and fibromyalgia is extremely common,” says Dr. Stojan. “In our cohort here at Hopkins about 30 percent of lupus patients have fibromyalgia too.”
People with other rheumatic diseases such as rheumatoid arthritis, osteoarthritis, and axial spondyloarthritis are also at an increased risk of also having fibromyalgia.
Read more to learn about the different symptoms of fibromyalgia vs. lupus, how fibromyalgia and lupus are each diagnosed, and how treatments for fibromyalgia and lupus differ.
The U.S. Centers for Disease Control and Prevention (CDC) estimates that about 4 million American adults have fibromyalgia. While doctors don’t know what causes fibromyalgia, it is a disorder in which people often experience widespread chronic pain and sensitivity to touch, in addition to many other symptoms (more on this below).
Unlike lupus, fibromyalgia is not an autoimmune disease, which occurs when then body’s immune system mistakenly attacks your own cells and tissues. Fibromyalgia is not related to inflammation, nor is it a joint or muscle disorder caused by physical injury.
People at higher risk of fibromyalgia include women, the middle-aged, and those with certain diseases, including different types of arthritis, or a family history of fibro. While fibro can impair your quality of life, it doesn’t damage your tissues and organs, or cause medical problems like heart disease. It is not life-threatening.
Fibro’s hallmark symptom is persistent pain in soft tissues and muscles all over the body. It may involve tender points, or areas of tenderness in specific parts of body. Frequently described as a deep ache, fibro pain may move around, persist for long periods, and disappear.
More than nine in 10 fibromyalgia patients experience exhaustion. Fatigue can be especially noticeable when you first wake up in the morning, even when you’ve gotten plenty of sleep; light activity can make pain and fatigue worse.
The Lupus Foundation estimates that 1.5 million people in America have a form of lupus. Lupus is an autoimmune disease that occurs when your immune system cells — which are supposed to protect the body from different germs — start treating normal, healthy cells like invaders, attacking them and causing flare-ups that can affect the joints, skin, heart, lungs, kidneys, and almost any other system in the body.
Women of childbearing age (between 15 and 44) are at the highest risk of developing lupus, according to the CDC; some 90 percent of people with lupus are women. People of color — particularly African Americans — are at a higher risk of lupus than white people are, and the disease tends to affect populations differently. Native American and black patients tend to have higher mortality rates than white patients, while Hispanic and Asian patients have a lower risk of lupus.
There are several types of lupus, but most people refer to the most common form: systemic lupus erythematosus, also known as SLE. About 70 percent of people with lupus have SLE, according to the Lupus Foundation of America. Lupus can cause a range of complications; some, such as heart disease and kidney disease, can be severe and even life-threatening without early and proper medical treatment. Regular medical care that utilizes an integrated team of specialists is important to help lupus patients avoid life-potentially serious complications.
Unexplained weight loss — not due to dieting, other illness, or medication side effects — can be a sign of lupus. On the other hand, weight gain caused by fluid retention can also be a sign of the disease.
The characteristic rash across the cheeks and nose (called a malar rash) is one of the most recognized symptoms of lupus, although a similar-looking rash can also occur in other skin issues. Another type of lupus skin issue is a discoid rash that causes raised, red, and scaly patches.
Sun exposure can cause a lupus rash to develop or flare. People with lupus are also at risk of developing Raynaud’s, a condition in which the small blood vessels in the hands and feet suddenly constrict when exposed to cold or stress.
Other lupus symptoms include fever; neuropsychiatric issues such as depression, anxiety, seizures, or psychosis; brain fog; fatigue; headaches (including migraine-like attacks); mouth ulcers; kidney problems; and chest pain.
Despite the similarities in some of the symptoms, there are a few clear differences doctors and patients should be on the lookout for, says Dr. Stojan.
1. The nature of fatigue:Fatigue is common during a lupus flare, but it will subside once the attack is over, says Dr. Stojan. In fibromyalgia, however, exhaustion is more chronic — it’s less likely to come and go.
2. The nature of pain: Although both fibromyalgia and lupus can cause muscle and joint pain, lupus pain persists until it’s treated, says Dr. Stojan. The pain of fibromyalgia comes and goes. “The transient quality of the symptoms is a reliable sign that pain is not related to lupus,” he says.
3. Whether skin is involved: Fibromyalgia doesn’t cause nose and/or mouth ulcers or rashes like lupus does, such as the typical “butterfly” rash on the cheeks and bridge of the nose that can pop up during a lupus flare.
4. Whether there is inflammation: In lupus, a patient’s immune system starts to attack organs and other body tissues, leading to widespread inflammation that will likely show up in lab tests or imaging, says Dr. Stojan. Fibromyalgia, on the other hand, does not cause inflammation.
There are no definitive tests for either fibromyalgia or lupus, so differentiating between the two relies mostly on a thorough history of your symptoms, a physical exam, and sometimes blood tests or imaging to rule out other conditions. Read more here about how fibromyalgia is diagnosed.
Your doctor will ask you to describe your pain — and if they suspect fibromyalgia, may perform a “tenderness” test, pressing on several parts of your body to gauge where the tenderness is, and how severe it is.
Your doctor will likely also ask whether you experience fatigue, wake up tired every morning, or have trouble concentrating or experience brain fog — and for how long you’ve had these symptoms.
Your doctor may order some blood tests in order to rule out diseases that can cause fatigue, such as hypothyroidism type 2 diabetes. They may order blood tests to check for levels of inflammation in the body or for antibodies that could signal an autoimmune disease. One test ordered to help confirm or rule out lupus is the blood test for antinuclear antibodies (ANA). A positive test can be one sign of lupus, but it doesn’t necessarily mean you have it. “ANA is a very common marker people have in the blood. Almost one-third of people in the U.S. will test positive — and that alone doesn’t mean you have lupus,” Dr. Stojan says. However, most people who have lupus will have a positive test.
If you have a positive ANA test and other signs that point to lupus, your doctor may do additional antibody tests that help confirm or rule out the illness.
Your doctor may also order imaging tests like X-rays or MRIs to narrow down the cause of your symptoms. Neither fibromyalgia or lupus cause erosion in the joints (the way rheumatoid arthritis does) or visible inflammation of the lower back (the way axial spondyloarthritis does).
Neither disease has a cure, but medication can treat symptoms and help prevent serious lupus complications. The medications used to treat lupus are very different from those used to treat fibromyalgia.
For fibro patients: Some drugs commonly used to treat depression, called antidepressants, may ease pain and fatigue; these include duloxetine (Cymbalta) and milnacipran (Savella). Anti-seizure medications, frequently prescribed to people with epilepsy, can also help manage pain in fibromyalgia. Among these, the FDA has specifically approved pregabalin (Lyrica) for the treatment of fibro.
For lupus patients: Many different types of medications can be used to treat lupus, including:
Non-steroidal anti-inflammatory drugs (NSAIDs) to relieve pain and inflammation
Hydroxychloroquine or chloroquine, a malaria drug that is also useful at treating lupus flares, joint pain, and skin rashes
Glucocorticoids, or steroids, to relieve inflammation and treat flares
Immunosuppressive medications, such as azathioprine, cyclophosphamide, methotrexate, mycophenalate mofetil
Targeted biologics, such as rituximab (Rituxan) and belimumab (Benlysta), which reduce the activity of the immune system by targeting specific immune cells
Other medications to help manage complications of lupus, including those for cholesterol, blood pressure, osteoporosis, and others
Patients with lupus and fibro can also benefit from healthy lifestyle practices, too, including:
Exercise: Regular physical activity can help manage symptoms of fibro or lupus, and may improve mood, fitness and function. Swimming, walking, tai chi, and yoga are smart options. Exercise can be very important in helping people with lupus reduce their risk of cardiovascular disease complications. Consult a health care provider or physical therapist about a new exercise regimen, so it can be adapted to individual needs.
Diet: Though there is no specific diet recommended for lupus or fibro, a healthy eating plan may boost your immune system, help manage co-existing conditions, and promote overall good health. Read more about a following a healthy diet for lupus and a healthy diet for fibromyalgia.
Sleep: Getting adequate rest is vital for both conditions. It’s recommended that adults between ages 18 and 64 should aim for seven to nine hours nightly.
Complementary practices: Some patients report that activities like meditation, acupuncture, deep breathing, and massage help them relax and ease symptoms.
While lupus and fibro may have some symptoms in common, they are ultimately distinct conditions with very different causes and treatments. Visiting a health care provider can help you get to the bottom of your symptoms quickly and begin the correct therapies. The faster you start, the faster you can start feeling better.
If you’ve had a nagging sore throat, your doctor may take a swab to check for strep. If you’re suffering from a high fever and bad cough, your doctor may order a chest X-ray to look for pneumonia. But not all diagnoses are that straightforward.
Case in point: Fibromyalgia, a condition that causes widespread chronic pain — as well as fatigue, sleep disturbances, and cognitive difficulties — is often challenging for a physician to pinpoint.
“Fibromyalgia can be difficult to diagnose because there’s no gold standard test like an X-ray or blood work,” says Lenore Brancato, MD, a board-certified rheumatologist at NYU Langone Ambulatory Care in New Hyde Park, New York. “It’s a diagnosis of exclusion, which means you first have to rule out other diseases that may be causing symptoms. It’s not a cookie-cutter condition.”
Fibromyalgia is also a diagnosis that’s been subject to change. Back in 1990, when the first diagnostic criteria were set by the American College of Rheumatology (ACR), a doctor had to find the following elements in order to say their patient had fibromyalgia: pain in at least 11 of 18 designated “tender points” throughout the body, plus a history of widespread pain lasting more than three months.
In 2010, however, those diagnostic criteria for fibromyalgia were updated to eliminate the tender point requirement and instead focus on findings that a patient has widespread pain, as well as sleep disruptions, fatigue, and cognitive difficulties.
Whereas the validity of fibromyalgia as a diagnosis was once questioned in the medical community — leading to a stigma it’s still overcoming — ongoing research has led to a number of possible explanations for physical causes of fibromyalgia (ranging from genetics to physical triggers) and mechanisms (involving the central nervous system).
What we know for sure is that fibromyalgia affects approximately 2 percent of adults in the United States, and your risk of developing the condition increases if you are middle-aged or older and have been diagnosed with lupus or rheumatoid arthritis, says the Centers for Disease Control and Prevention (CDC). You may also be at a higher risk if you are female (most fibromyalgia patient are women), have suffered a trauma or repetitive injury, or if you are obese.
But statistics and risk factors can’t describe how fibromyalgia actually feels to the person living with it. What follows are the descriptions doctors hear patients use when they talk about both usual and less common symptoms of fibromyalgia.
While every fibromyalgia patient is different, their descriptions of overwhelming, debilitating pain throughout the entire body are very common. “My patients report feeling sore and stiff with an achy pain that goes from the top of their head to their toenails,” says Christopher Morris, MD, a board-certified rheumatologist with Arthritis Associates in Kingsport, Tennessee, and a fellow of the American College of Rheumatology. “They tell me the pain is in the muscles and soft tissues rather than joints.” Dr. Brancato hears similar concerns, with some of her patients saying the pain is lacerating, “like being cut by knives.”
Fibromyalgia could also make you overly sensitive to touch and temperature. “If you’re a patient with fibromyalgia, and someone brushes up against you in a crowded room it can be very painful,” says Dr. Brancato. “I’ll hear that my female patients can’t tolerate a massage.” Even though the stimulus is taken away, like removing your hand from a hot stove, the pain can continue, she explains.
If you have fibromyalgia, you may have trouble falling asleep or staying asleep. “My patients say they toss and turn, or their mind wanders,” Dr. Brancato says. “I’ll hear that my patients wake up throughout the night and end up feeling as tired as when they went to bed,” Dr. Morris adds.
One of the most common issues for fibromyalgia patients is fatigue. “It’s exhausting for them,” says Dr. Brancato. “If you ask a patient how they feel in the morning, you’ll hear they felt awful, they never feel ready to go, they feel like they can’t get their head above water.”
“My patients describe having a ‘fibro fog,’” says Dr. Morris. “They have a hard time concentrating.” For her part, Dr. Brancato sees a lot of memory problems. “If you tell a fibromyalgia patient three things during an office visit, then ask them to recall them later during the same visit, they have difficulty,” she explains. “With fibromyalgia, short-term recall can be very poor.”
For many patients, fibromyalgia may also bring feelings of sadness and other negative moods. Some researchers suspect a connection between fibromyalgia and certain types of chronic anxiety and depression.
Though less common, headaches can occur among fibromyalgia symptoms. “Stress- and tension-type headaches tend to travel with fibromyalgia,” Dr. Brancato reports, adding that they can be triggered differently than in patients without fibromyalgia. “These headaches can be induced by regular sounds, background music, or even odors like perfumes.”
Fibromyalgia can sometimes occur alongside digestive problems, such as bloating, constipation, abdominal pain, and irritable bowel syndrome (IBS), says the CDC.
Some patients with fibromyalgia might also have an increased incidence of interstitial cystitis, says Dr. Brancato. This condition can cause chronic pain or pressure in the bladder and pelvis.
It’s possible for fibromyalgia to be linked to pain in the muscles of the jaw and face (temporomandibular joint disorder) or to myofascial (skeletal muscle) pain in one part of the body. Such occurrences could be considered forms of regional or localized or incomplete fibromyalgia.
The relationship between fibromyalgia and different types of arthritis can be complicated. For one thing, there’s misdiagnosis: Depending on how your symptoms present, you could be told you have fibromyalgia when you actually have a kind of arthritis, or vice versa. Read about how ankylosing spondylitis and fibromyalgia can be mistaken for each other, for example.
At the same time, having a painful chronic disease like arthritis may in turn trigger the onset of fibromyalgia. Inflammatory diseases like arthritis can affect the way your central nervous system processes pain, creating a double-whammy of having both diseases at the same time.
If you suspect your combination of symptoms could be fibromyalgia, it’s a good idea to start with your primary care doctor. Because fibromyalgia is a diagnosis of exclusion, you’ll likely need a through physical exam, blood tests, and imaging tests to figure out what could be causing your symptoms.
Having AS with psoriasis may have some things in common with psoriatic arthritis, but research shows these are two distinct conditions.
About 25% of people who have an autoimmune condition develop at least one more; some people live with three, four, or more. In fact, certain pairs of inflammatory diseases commonly occur together.
For one, people with ankylosing spondylitis (AS) (also known as axial spondyloarthritis) — which is best-known for causing chronic lower back pain — are also more likely to have psoriasis — an autoimmune disease that manifests in the form of scaly red and silvery skin patches. That combination might sound pretty similar to the autoimmune condition psoriatic arthritis (PsA), which, by definition, is a form of inflammatory arthritis that typically causes joint pain as well as skin plaques.
To further add to the confusion, PsA is considered part of the same family of rheumatic diseases as ankylosing spondylitis — they’re both considered types of spondyloarthritis, which is an umbrella term for a group of types of arthritis that have similar traits in common.
And while most psoriatic arthritis patients develop arthritis in the small joints of the fingers and toes, the joints in the back can sometimes be impacted. PsA patients who have arthritis in the back or sacroiliac joints in the pelvis may be told that they have “axial PsA.”
If the sometimes overlapping details of these conditions are making you wonder if people with AS and psoriasis really have axial PsA, you’re in good company. Researchers at the University of Toronto weren’t sure, either. To find out, they compared data on more than 2,000 patients. One group had been diagnosed with AS and psoriasis; another had been diagnosed with axial PsA; and a third had only been diagnosed with AS (without psoriasis).
According to their findings, which appear in the journal Rheumatology, axial PsA is not, in fact, the same thing as AS plus psoriasis.
The researchers found that AS patients (with or without psoriasis) were more apt to be male, more likely to be positive for HLA-B27 (a genetic marker), and much more likely than those with PsA to report back pain as a chief complaint.
“AS patients, with or without psoriasis, seem to be different demographically, genetically, clinically, and radiographically from [axial PsA] patients. [Axial PsA] seems to be a distinct entity,” they concluded.
When you’re dealing with knee pain that won’t go away, you might blame it on overuse or age-related wear and tear. But in some cases, knee pain can come from a form of inflammatory arthritis such as ankylosing spondylitis (AS).
AS is known for causing inflammation, pain, and stiffness predominantly in the spine and sacroiliac joints (where the spine meets the pelvis). People often equate ankylosing spondylitis with lower back pain, but it can affect other joints, including the knees.
What’s behind the inflammation in ankylosing spondylitis? Your body’s immune system is releasing chemicals into your blood and joints that cause pain, stiffness, and eventually joint damage.
Compared with many other forms of arthritis, AS symptoms usually begin young — before age 45 — and often as early as the teens and twenties. Lower back pain is worse after inactivity or when you wake up; it often strikes in the middle of the night and prevents you from getting a good night’s sleep. AS can present as an ongoing, dull pain that feels like it is coming from deep within the lower back or buttocks. Because back pain is incredibly common, it’s easy for people with inflammatory back pain from AS to chalk up their symptoms to other issues, such as athletic or overuse injuries.
Ankylosing spondylitis (AS) is a type of spondyloarthritis (SpA), which is an umbrella term for different types of arthritis — including psoriatic arthritis — that have some traits and symptoms in common. There are two main types of SpA:
Axial spondyloarthritis (AxSpA)
Peripheral spondyloarthritis
In axial spondyloarthritis, “the inflammation is more confined to the spine, and occasionally the shoulders and hips,” says Konstantinos Loupasakis, MD, a rheumatologist at MedStar Washington Hospital Center in Washington, D.C. “More distal joints, such as the knees, may also be affected although this is more commonly seen in peripheral spondyloarthritis.”
Ankylosing spondylitis is considered radiographic AxSpA, which means that evidence of joint damage is visible on X-rays.
Non-radiographic axial spondyloarthritis (nr-AxSpA) is essentially the same condition, but without joint damage being visible on X-rays.
A non-radiographic axial spondyloarthritis diagnosis can be made if the patient has sacroiliac changes on an MRI or is positive for the HLA-B27 gene (this gene gives instructions for making a protein that plays an important role in the immune system) with symptoms of inflammatory back pain (such as nighttime pain and morning stiffness, and improvement with physical activity), says Neal Birnbaum, MD, a rheumatologist, former president of the American College of Rheumatology, and founder of Pacific Rheumatology Associated Medical Group in San Francisco.
Peripheral spondyloarthritis means that inflammation and joint pain affects the limbs more than the spine. Sites include the knees, as well as the hands, wrists, elbows, shoulders, and ankles.
Despite formal classification of the spondyloarthropathies as above, in reality, people may have features of both axial and peripheral involvement, says Dr. Loupasakis. One recent study found that more than one-third of patients with axial spondyloarthritis also develop peripheral spondyloarthritis. Researchers studied more than 700 French patients from a group who had been diagnosed with early inflammatory back pain suggestive of AxSpA and followed them for five years. During that time, 36 percent developed arthritis in at least one peripheral joint — most often in the lower limbs.
Although AS is most common in the spine, any large joint can be affected — usually in an asymmetric distribution. This means that only one knee might hurt, as opposed to both knees. The pain is usually dull, often described by patients as soreness. It’s associated with stiffness that is worse in the morning and usually more intense after inactivity, he says. Pain and stiffness tend to improve with physical activity over an hour or more, Dr. Loupasakis says. The knee may feel warm to the touch and look swollen.
Still, how knee pain in AS feels is subjective and varies from patient to patient, says Erika Di Porto, DPT, MSPT, CI, department chairperson for the School of Health Sciences at Miami Dade College Medical Campus in Miami. “The joint hurts. The pain envelops the muscles, tendons, and the joints,” says Dr. Di Porto.
The pain in peripheral joints like the knee can be caused by arthritis (inflammation in the joint itself) or enthesitis (inflammation that occurs where tendons and ligaments attach to the bone), says Dr. Loupasakis. In arthritis, the knee can be swollen, warm, and tender. Enthesitis typically involves the Achilles tendons and the heels. But it can involve almost any part of the body at sites where tendons and ligaments attach to bones (front of the knees, pelvis, side of the hips or front of chest), he says. With enthesitis, the knee is not swollen but is tender to pressure, mostly at the front part around and below the kneecap.
Keep in mind that it’s rare to have knee pain due to AS without any other AS symptoms. If you or your doctor suspects you could have AS or peripheral spondyloarthritis, they will do more testing. This includes a blood test to see if you have the HLA-B27 gene, as well as blood tests to look for signs of systemic inflammation. The doctor may conduct different tests during a physical exam to assess your range of motion and flexibility in the spine and other joints. They may send you for imaging tests such as X-rays or MRIs. Read more here about how doctors diagnose AS and what to expect at the rheumatologist.
If you already have an AS diagnosis, it’s possible that your knee pain could be due to AS, but it could also be due to a different health issue.
For example, someone in their twenties or thirties who is physically active may have an injury-related pain syndrome like tendinitis (inflammation or irritation of a tendon) or bursitis (a painful condition that affects the bursae, which are the small, fluid-filled sacs that cushion the bones, tendons, and muscles near your joints). Someone middle-aged is more likely to start to develop osteoarthritis in their joints — from age-related wear and tear — even if they also have a type of inflammatory arthritis.
A thorough physical exam, medical history, and various imaging tests as needed may be necessary to determine whether your knee pain is due to AS or a different health issue.
There is no cure for AS, but you can ease its symptoms and slow its progression. Symptoms of AS knee pain are treated in a similar way to AS-related back pain.
Patients with peripheral spondyloarthritis are usually first given a combination of nonsteroidal anti-inflammatory drugs (NSAIDs) to reduce pain and inflammation along with oral disease-modifying anti-rheumatic drugs (DMARDs) like methotrexate or sulfasalazine, says Dr. Loupasakis. Though NSAIDs are available over the counter, they can cause side effects such as stomach ulcers and kidney dysfunction, especially when taken for the long term and/or in high doses. You may also be prescribed topical NSAID creams or gels like diclofenac or salicylate cream that may be effective for enthesitis.
These conventional DMARDs are only recommended for peripheral spondyloarthritis. If you have axial spondyloarthritis and are not responding to NSAIDs, biologic drugs are the next step rather than conventional DMARDs, says Brett Smith, DO, a rheumatologist with Blount Memorial Physicians in Alcoa, Tennessee.
If you have axial disease, the biologics will usually help the peripheral disease, too, he says.
Biologics are medications — either given by IV infusion or injection — that target certain immune system proteins and pathways to reduce inflammation.
The first-line biologic drugs recommended for axial spondyloarthritis are called tumor necrosis factor (TNF) inhibitors, which block certain proteins made by the immune system. These include adalimumab (Humira), certolizumab (Cimzia), etanercept (Enbrel), infliximab (Remicade), and golimumab (Simponi).
Newer biologics for axial spondyloarthritis block other immune system proteins called interleukins. These include secukinumab (Cosentyx) and ixekizumab (Taltz).
Steroid injections may occasionally be given in inflamed large joints in the knees to alleviate pain. “Steroid injections are not to be used more than three to four times a year in the same joint since excessive steroid use may accelerate cartilage thinning and be harmful to the joint,” says Dr. Loupasakis.
Cold therapy can provide relief for inflamed joints in the wrist. Cold constricts the blood vessels in the muscles, which decreases blood flow to the joint area to help reduce swelling and inflammation. Ice the joint and area for 15 minutes at a time to reduce inflammation, says Dr. Di Porto. Heat therapy warms the skin and the joints, which causes blood vessels to dilate, and sends more oxygen and nutrients to the joints and muscles. Try both and see which makes you feel best.
Hydrotherapy can also benefit patients with knee pain from AS, says Dr. Di Porto. Hydrotherapy uses water at varying temperatures for health purposes at a health center, spa, or at home. “It increases your flexibility and blood flow and loosens the tightness in your muscles,” says Dr. Di Porto.
Exercise, especially with help from a physical therapist, can also be key in keeping pain at bay. “Physical therapy is crucial to maintaining range of motion and preventing the development of contractures, where the joint gets stiff permanently,” says Dr. Loupasakis. Stretching exercises are also shown to be effective, he says. Check out these daily stretches for AS.
He recommends swimming or water exercises since the water makes it easier to exercise with less strain on your joints. He also suggests postural training, where you learn how to maintain proper posture to help prevent you from developing stiff joints.
Surgery is a rarely used in the management of ankylosing spondylitis in the knee. It’s a last resort if knee joints are damaged to the point where daily activities become compromised, if your disease worsens, or you develop less motion and more pain. “You wouldn’t do a knee replacement until you’re at the point where symptoms are severe, your quality of life has been decreased significantly, and your activities of daily living are diminished,” says Dr. Di Porto.
The most common surgery if surgery is done is total knee arthroplasty, also known as knee replacement. Knee surgeries typically have successful and lasting outcomes. A study in the Journal of Bone and Joint Surgery evaluated the results in a group of patients with ankylosing spondylitis who underwent total knee arthroplasty. The surgery was found to give excellent pain relief and a durable fix at an average of 11.2 years postoperatively. However, since people typically have this surgery at a relatively young age, Dr. Di Porto says they’ll likely need a revision (another) procedure done.
When you think of arthritis, you might think of creaky knees, stiff hips, or painful, swollen fingers. Yes, arthritis commonly attacks joints in the hands, knees, and hips. But it can happen anywhere you have joints — including the toes. So, if you can’t bend your big toe or have swelling around your toes, this toe pain may be caused by arthritis too.
Toe arthritis can be caused by wear and tear of the cartilage in your toe joints, as well as inflammation of the toe joints. Arthritis most often attacks the big toe, but the other toes may be affected, too. Learn more about what causes toe arthritis and how it is treated.
With osteoarthritis, there is more bone enlargement of the toe joints as a result of bone spur formation, says podiatrist Krista A. Archer, DPM, a podiatric surgeon who is on staff at Lenox Hill Hospital in New York City. Bone spurs are bony projections that develop along bone edges, often due to joint damage from arthritis.
You have restricted range of motion due to swelling or damage to cartilage (a rubbery substance on the edges of bones that lubricates the joint) in any joints that are in the toes, midfoot, rearfoot, and ankle, says Dr. Archer. Bone spurs will often develop around the joint, restricting movement.
You may be unable to bend your big toe upward and have pain when doing so, says Chadwick Hampton, MD, an orthopedic surgeon at Palm Beach Gardens Medical Center in Palm Beach Gardens, Florida. That can make it difficult and painful to walk.
Your toe may become bent permanently downward and can’t be positioned flat on the floor.
Your pain worsens with weight-bearing activities like jogging, walking, and climbing stairs. “It depends on how severe the deformity is to predict what kind of activities will be painful,” says Dr. Archer.
You may have a bump form (a pressure sore) when the joints rub together. It resembles a callus or bunion.
You may have pitted, separated, or thick toenails.
You may have curling of the toes, such claw toe or hammertoe.
You may have pain in joints in the in the midfoot (cuboid, cuneiform, metcuneiform) and rearfoot (talonavicular, calcaneocuboid).
You may have numbness, burning, or tingling in the foot or ankle.
If you have arthritis in your toes, it’s important to understand the type of arthritis that might be causing it, because each type of arthritis has specific medications and treatments. Here are some of the more common types of arthritis that strike in toes.
Osteoarthritis (OA) is a degenerative joint disease where the cartilage that cushions the ends of a joint wears away gradually. Osteoarthritis often occurs because of typical wear and tear on a joint that happens with age; it can also occur as a result of injury to the joint. OA most commonly occurs in the joint at the bottom of the big toe, which is called the metatarsophalangeal or MTP joint.
Rheumatoid arthritis (RA) is a chronic inflammatory disease in which the body’s immune system attacks itself, causing inflammation and pain in the joints. RA can affect several small joints in the foot at the same time, including those in the toes. RA often occurs in the small joints of the hands and feet first, though it can affect other joints, such as the knees, elbows, hip, and neck. Around 90 percent of people with RA will have foot problems.
For many people, pain and swelling in the big toe, especially at the joint where the toe meets with the foot, is the first symptom of gout. Gout is a type of arthritis that occurs because elevated levels of uric acid in the blood accumulate in and aggravate joints, causing inflammation. Gout attacks can affect other joints aside from the big toe, including the ankles, foot, knees, or elbows. Lumps of uric acid, called gout tophi, may become visible underneath the skin around the toes, ankles, and other joints after you’ve had gout for years or if you have severe gout that is not well controlled.
Psoriatic arthritis is an inflammatory arthritis linked to psoriasis, an autoimmune skin disease that causes red, silver, scaly rashes on the skin. It’s characterized by pain, stiffness, and swelling in the joints. People with psoriatic arthritis might notice pain, stiffness, and swelling in the “knuckles” of the toes, says rheumatologist Arthur M. Mandelin, MD, PhD, associate professor of medicine at the Northwestern Medicine Feinberg School of Medicine in Chicago. People with PsA are likely to have problems with their toenails, such as pitting and crumbling, as well as swollen fingers and toes, a condition called dactylitis that makes them appear sausage-like. Enthesitis, or inflammation at the sites where tendons and ligaments attach to bones, is also common in PsA. This can affect the Achilles tendon at the heel or cause plantar fasciitis along the bottom of the foot.
Also called septic arthritis, this type of arthritis typically causes extreme pain and difficulty using the affected join. Septic arthritis is caused by bacteria or fungi that are carried through the bloodstream from another area of the body, usually settling in one joint. A bacterial infection from an injury or opening from a surgical procedure can also cause infectious arthritis by bringing germs directly to the joint. Pain worsens with movement and comes on rapidly in hours or days. It may include a swollen, red, and warm joint accompanied by fever, chills, fatigue/weakness, and the inability to move the affected joint.
The diagnosis of arthritis in toes begins with taking your medical history and a physical exam of your foot. The doctor will look at your entire foot, not just your toes. They’re looking for pain, deformity, and loss of function, says Dr. Archer. Your doctor will likely order an X-ray of the foot to help determine whether there is joint damage or changes in the alignment of bones in the foot.
If your doctor suspects you could have a type of inflammatory arthritis, such as RA or PsA, they may order blood tests to look for signs of inflammation (such as C-reactive protein or erythrocyte sedimentation rate) as well as antibodies (such as rheumatoid factor or anti-CCP). If your doctor suspects you could have gout, they may give you a blood test to look for elevated levels of uric acid and draw fluid from the joint to look for uric acid crystals.
Over-the-counter medications like ibuprofen (Advil) and naproxen (Aleve), as well as prescription NSAIDs, can help relieve pain and swelling in the joints. However, even though many NSAIDs are available over the counter, they can have side effects (such as causing stomach ulcers, increased heart attack risk, and kidney problems) especially when taken for the long term and/or in high doses. NSAIDs are a first-line of treatment in OA to reduce pain and stiffness. In inflammatory arthritis and gout, they can be used along with other kinds of medication to treat inflammation, pain, and swelling.
A topical gel like diclofenac (Voltaren) may be prescribed for toe arthritis, says Dr. Hampton. Topicals are good if you can’t take oral medications or medications aren’t helping with the pain.
This medication can help treat and relieve inflammation. An occasional shot can be given in any toe and offer temporary pain relief and reduce inflammation. Injections shouldn’t be done repeatedly; frequent injections can damage cartilage. “I give a certain dose and I won’t give it more than three times a year or no more than once every four months,” says Dr. Hampton.
If you have an inflammatory arthritis like rheumatoid arthritis, disease-modifying anti-rheumatic drugs (DMARDs) such as methotrexate are used as a first-line therapy to help reduce the immune system activity that triggers inflammation and pain. DMARDs are not used for osteoarthritis.
Biologics are a newer class of DMARDs that target specific immune system pathways to reduce immune system activity that is causing inflammation and pain. They’re used to treat inflammatory types of arthritis, such as rheumatoid arthritis and psoriatic arthritis, and are typically offered after patients haven’t responded to conventional DMARDs like methotrexate.
There are two main kinds of drugs used to treat gout: those used during a flare to reduce inflammation and pain and those used preventively to lower uric acid levels and prevent future flares from occurring. Medications used to treat inflammation in an acute gout flare include NSAIDs, oral corticosteroids or steroid injections, or a drug called colchicine. Medications called xanthine oxidase inhibitors limit the amount of uric acid your body produces. These include allopurinol (Zyloprim and Aloprim) and febuxostat (Uloric). Another class of drugs called uricosurics help your kidneys remove uric acid from the body. These include probenecid (Probalan) and lesinurad (Zurampic). An infused drug called pegloticase (Krystexxa) can help the body eliminate uric acid in people whose gout hasn’t been well controlled with other medication.
If your gout attack is limited to one or two joints and your pain is mild to moderate, you may only need one of these medications to control the inflammation. However, if your pain is severe, and if one or more of your larger joints (not just a toe) are involved, you may need a combination of treatments to get it under control. Also, if one drug doesn’t work well enough to treat your gout attack symptoms, your doctor may switch you to a different medication or try a combination of medications.
Your doctor may send you for physical therapy to help improve your range of motion and strengthen the muscles around your foot. “Physical therapy can increase pain-free range of motion and strengthen the muscles of the foot to take pressure off the painful joint,” says David Geier, MD, an orthopedic surgeon, sports medicine specialist, and author of That’s Gotta Hurt: The Injuries That Changed Sports Forever. These exercises relieve stiffness and increase your ability to move your joints through their full range of motion.
You want to wear shoes that take pressure of your toe joints to relieve some of the stress from arthritis of the toes. Look for footwear with a more rigid, stiff sole (which will provide support) and wide toe box to help prevent excessive stress and bending forces on the toe joints. Ditch high heels; they put your foot in an unnatural position that takes a toll over time.
Cold therapy can provide relief for inflamed joints in the wrist. Cold constricts the blood vessels in the muscles, which decreases blood flow to the joint area to help reduce swelling and inflammation. Heat therapy warms the skin and the joints, which causes blood vessels to dilate, and sends more oxygen and nutrients to the joints and muscles. Try both and see which makes you feel best.
Control your weight with regular, low-impact aerobic exercise that doesn’t hurt your toes. Cycling on a recumbent bike or swimming are good options. Keeping your weight close to your ideal body mass index (BMI) is one of the best things you can do to control your toe pain. Being at a healthy weight “balances the pathomechanics [the mechanics of damaged bones, tendons] of the entire foot and relieves stress on toes,” says Dr. Archer. It’s also a good idea to do specific exercises that strengthen your Achilles tendon (the cord at the back of your heel) as well as the tendons in the balls of your feet and toes. You can even simply wiggle your toes.
Maintaining a healthy weight helps reduce stress on the joints. Feet are a weight-bearing joint, so obesity makes arthritis worse. Losing excess pounds can lead to less pain and better function. You especially want to eat healthfully since your exercise abilities may be limited if you have a lot of pain in your toes. Aim to eat foods that may help reduce inflammation, called anti-inflammatory foods.
Surgery isn’t usually necessary for arthritis of the toes. It’s usually a last resort since you may still have discomfort and have an increased risk of infection after surgery. But several surgical procedures outlined below can be done if other treatments for toe arthritis have not helped.
The most common surgery, cheilectomy, involves removing bone spurs that have formed around joints that have become arthritic. It’s typically done when arthritis is in the big toe. It can help relieve discomfort around the joint and improve the movement of the joint. The toe may stay swollen for several months, but you’ll likely experience long-term relief. However, removing bone spurs doesn’t address the worn-out cartilage within the joint. So bone spurs often return in the future. “This surgery has a high revision rate because you’re treating the arthritis as it’s in progression. So [the condition] continues to progress.” says Dr. Hampton. “You’ve removed the bad parts of the bone but you don’t actually replace the joint.”
This surgical procedure stimulates bone growth across the joint. The joint is fused together permanently with pins, screws, or a plate. When bone grows across the toe joint, it won’t bend anymore. But since the joint is fused, pain is also relieved. Dr. Archer says that she rarely does this type of surgery. “It’s usually done in active laborers, like carpenters and mechanics, to give them a stable joint with no pain,” says Dr. Geier.
If you have ankylosing spondylitis or psoriatic arthritis, you may be familiar with the pain of enthesitis, an inflammation where tendons and ligaments attach to the bone — even if you aren’t aware it has a name. “I didn’t know what it was called!” Monica D. told us on Facebook. “I have pain all the time. Makes it difficult to walk very far.”
“Enthesitis is inflammation of the ‘enthesis,’ which is where a tendon or ligament attaches to bone,” says Joan Appleyard, MD, a rheumatologist at Baylor College of Medicine in Houston, Texas. “Symptoms are pain sometimes accompanied by swelling.”
There’s a reason the enthesis is susceptible to this problem. “The enthesis has a lot of blood flow and [thus] is subject to both infection and inflammation,” says Theodore R. Fields, MD, a professor of clinical medicine at Weill Cornell Medical College and an attending rheumatologist at Hospital for Special Surgery in New York City. “Two of the most common entheses are the area where the Achilles’ tendon inserts on the back of the heel, which causes Achilles’ tendonitis, and where the sheet of connective tissue, or fascia, inserts on the bottom of the heel, which causes plantar fasciitis.”
If you have rheumatoid arthritis or osteoarthritis, chances are you won’t experience enthesitis, because it generally only occurs with certain types of arthritis called spondyloarthropathies (SpA), which include non-radiographic axial spondyloarthritis, ankylosing spondylitis, psoriatic arthritis, enteropathic arthritis (a type that occurs in people with inflammatory bowel disease), and reactive arthritis (which can occur after infection, formerly called Reiter’s syndrome).
Enthesitis is actually one of the hallmark traits of SpA. “It is not a feature of rheumatoid arthritis — this is one of the ways in which SpA differs from RA,” Dr. Appleyard says.
Doctors aren’t exactly sure why SpA targets the enthesis, but it may be that a specific inflammatory response occurs in areas under biomechanical stress (stress on the joint from movement).
“About half of people with psoriatic arthritis and ankylosing spondylitis have enthesitis,” says Dr. Fields. “In both psoriatic arthritis and ankylosing spondylitis, the back and under portions of the heel are common sites of enthesitis.”
There are many other areas where enthesitis can occur, he says, including the inner and outer sides of the elbows, the area where the ribs meet the breastbone, the back of the head where it meets the neck, and in the spine in the area closest to the skin.
The main symptom of enthesis is pain, which Chronicwoman patients described as “horrible” or “burning.”
“Quite a bit of my PsA pain is due to enthesitis,” Ruth O. shared on Facebook. “It moves around from ball of my foot, to left shoulder, hands, wrists and left hip.”
Marcia G. told us, “I have [enthesitis] in my right ankle and heel mostly. My feet hurt randomly and the right toes and top of foot swell up.” Although many patients noted that enthesitis occurs in their feet, Kelly C. says it hurts “especially around my rib cage.”
Enthesitis might not mean your disease is progressing. “Enthesitis can be part of both severe and relatively mild cases of psoriatic arthritis or ankylosing spondylitis,” Dr. Fields says. It may indicate active disease, but not necessarily worsening disease, says Dr. Appleyard.
Your doctor will diagnose enthesitis based on a physical exam, in which they’ll note the location of pain, tenderness, or swelling. “Ultrasound can also be helpful in diagnosing enthesitis, and at times MRI can also be used,” Dr. Fields says.
“Managing enthesitis is important since it can cause a lot of discomforts,” Dr. Fields says. Some specific biologic therapies used to treat SpA seem to improve symptoms of enthesitis. “Treating the underlying disease with anti-TNF agents [a type of biologic] often helps with enthesitis, but traditional DMARDs such as sulfasalazine don’t treat enthesitis,” Dr. Appleyard says. Non-steroidal anti-inflammatory agents (NSAIDs) can be used for mild cases.
When deciding on a treatment regimen for SpA, Dr. Fields says it’s important to take into account all the affected areas. “In patients where enthesitis is the major issue, and more severe than the arthritis, we may skip the non-biologic agents and go directly to biologic therapies, since they tend to be more effective for enthesitis,” he says.
In addition to TNF blockers, other biologic options include blockers of the proteins IL-17, IL-12, or IL-23. “One exception is the non-biologic agent apremilast, which does not appear to cause infection and can be used in psoriatic arthritis, and which has been shown to have effectiveness in some people with enthesitis,” says Dr. Fields.
In addition, “local injection of corticosteroids can be used in enthesitis at times, but needs to be used carefully to avoid weakening of the surrounding tendons and ligaments,” Dr. Fields says.
Talk to your doctor about which medications are right for your individual case. (Here’s what one study found about picking the right treatment for enthesitis in PsA.)
A physical therapist can give you gentle stretches to do at home to help relieve the pain of enthesitis, Dr. Fields says. In addition, the doctors and patients we talked to suggested:
Apply heat or ice to affected areas
Maintain a healthy weight. “Weight loss can take pressure off the involved areas,” Dr. Fields says.
Rest and elevate the affected foot. “I try to keep the swelling down by icing it, and keeping my leg and foot elevated,” Lesley P. told us on Facebook.
Wear special shoes. “People with plantar fasciitis can benefit from shoe inserts to cushion the heel and may be helped by a consultation with a podiatrist,” Dr. Fields says.
Wear compression socks, braces, wraps, or even a medical boot.
Watch salt intake to control swelling. “Salt intake does make a difference,” Ruth says.
Over-the-counter remedies (check with your doctor first). “I love using Biofreeze on the bone in my foot — it helps!” Caroline P. told us on Facebook. Other Chronicwoman members recommended Epsom salt soaks, diclofenac gel, magnesium, or CBD products.
When you think of arthritis, you might think of creaky knees or painful, swollen fingers. But if your wrist is feeling swollen and stiff, this wrist pain may be caused by arthritis too.
The wrist is a complex joint that connects the hand to the forearm. It is formed by the two bones of the forearm — the radius and the ulna — and eight small carpal bones that sit between your fingers and your arm. The carpal bones are arranged in two rows at the base of the hand, with four bones in each row. The joint surface of each bone is covered with articular cartilage, which is a slippery substance that protects and cushions the bones as you move your hand and wrist.
Arthritis in the wrist is often the cause of wrist pain. According to one estimate, one in seven people, or 13.6 percent, in the United States has wrist arthritis. But the kind of arthritis that affects your wrist might not be so obvious. Two of the most common forms of arthritis — osteoarthritis (OA, or degenerative arthritis caused by wear and tear on the joints) and rheumatoid arthritis (RA, an inflammatory type of arthritis caused by inflammation in the joint) — share many symptoms in common. Plus, other, less common forms of inflammatory arthritis affect the wrist that your doctor will need to consider as well.
“Besides pain, loss of flexibility in the wrist may affect your ability to use your hands to dress, eat, and do many work tasks,” says Steven Eyanson, MD, a retired rheumatologist who was in private practice at Physicians Clinic of Iowa in Cedar Rapids and a clinical assistant professor at the University of Iowa in Iowa City.
Learn more about what causes arthritis in the wrist and how arthritis in the wrist is treated.
Not everyone with arthritis in the wrist will experience symptoms. When symptoms do occur, the severity can vary greatly from person to person. For some patients, wrist arthritis symptoms aren’t constant, but may come and go depending on their level of activity and other factors. You may have done something to the wrist — such as repeated overuse, lifting, carrying, or bending — that aggravates it and causes a flare. Then it returns to its baseline.
“The number one symptom of wrist arthritis is pain,” says Chadwick Hampton, MD, an orthopedic surgeon at Palm Beach Gardens Medical Center in Palm Beach Gardens, Florida. The pain may be sharp, depending on the motion, says Dr. Eyanson. Or it may be dull and deep if it’s an inflammatory type of arthritis like rheumatoid arthritis.
The other main symptom of wrist arthritis is a change in your grip strength, such as an inability to open jars, use keys, or turn doorknobs.
About 30 million Americans have osteoarthritis, which makes it the most common type of arthritis. It’s more common with older age, but it can occur in younger people too, depending on such factors as injuries and genetic risk. In osteoarthritis of the wrist, the smooth, slippery articular cartilage that covers the ends of the bones gradually wears away over time. Since cartilage has little to no blood supply, it has little ability to heal or regenerate when it gets injured or worn down.
Osteoarthritis in the wrist can also develop from a condition called Kienböck’s disease. Here, the blood supply to one of the carpal bones — the lunate — is disrupted. That causes the bone to deteriorate. Over time, this can lead to structural changes and arthritis in the joints around the lunate.
Post-traumatic arthritis is a common form of osteoarthritis that happens as a result of physical injury to a joint such as from sports, a car accident, a fall, or other trauma. Injuries can damage the bone and/or cartilage, which changes the joint mechanics and makes it wear out more quickly. Post-traumatic arthritis symptoms in the wrist may appear within a few years, or it can take decades for joint damage from an injury to cause pain.
About 1.5 million people in the U.S. have rheumatoid arthritis (RA). RA is a chronic inflammatory disease that causes pain, stiffness, swelling, and loss of function in joints throughout the body.
Rheumatoid arthritis is caused by autoimmunity, which is a malfunction in your immune system. Normally, your immune system reacts to any external threats (such as viruses, bacteria, or parasites that could cause disease) by releasing antibodies, white blood cells of various types, and other defense systems. But in autoimmune diseases like RA, your body’s immune system is confused for some reason. It attacks your own healthy tissue when there’s no reason to.
RA often starts in smaller joints, such as those found in the fingers and wrist. RA is often symmetrical, which means it affects the same joint on both sides of the body. OA, for example, might affect only your right wrist, but RA is more likely to affect both your wrists.
As RA progresses, it can affect the range of motion and flexibility of the wrist joints. Because RA causes widespread inflammation in your body, it’s not common that wrist pain would be your only symptom. You’re also likely to experience pain in other joints, especially your fingers or toes, as well as fatigue, low-grade fever, and these other rheumatoid arthritis symptoms.
Psoriatic arthritis (PsA) is another kind of inflammatory arthritis linked to psoriasis (a disease that causes red, scaly rashes on the skin). Psoriatic arthritis in the wrist might cause similar symptoms to those of RA — pain, stiffness, swelling, and loss of function — but there may be additional PsA symptoms that occur that are more unique to PsA. People with PsA are likely to have problems with their nails, such as pitting and crumbling, as well as swollen fingers and toes, a condition called dactylitis that makes them appear sausage-like. PsA joint pain is also less likely to be symmetrical than that of RA.
Carpal tunnel occurs when a major nerve in the hand — the median nerve — becomes compressed in the carpal tunnel, a narrow passageway on the palm side of your wrist that also houses the tendons that bend the fingers. Interestingly, having arthritis raises your risk of developing carpal tunnel, so you could have both conditions at the same time. The nature of the pain in carpal tunnel usually sets it apart from arthritis, though: It often causes numbness and tingling in the first three fingers (thumb, index, and middle finger), as well as these other carpal tunnel symptoms.
Tendons are thick cords that join your muscles to your bones. When tendons become irritated or inflamed, that’s called tendinitis. Tendinitis causes acute pain and tenderness that makes it difficult to move the affected joint. Any tendon can develop tendonitis, but you’re more likely to develop it in your shoulder, knee, elbow, heel, or wrist. The most common cause of tendonitis is a repetitive action. You may develop tendinitis if you make the same motion frequently while playing sports, for example.
First, your doctor will ask about your symptoms and medical history and perform a physical exam. During your physical exam, your doctor will examine your wrist for swelling and pain.
Next, your doctor will examine the range of motion of the wrist itself. Your doctor may have you twist and flex both wrists in every direction to assess your range of motion. They will manipulate your wrist and thumb joints and ask if you feel pain in your wrists and thumbs. This exam can show how mild or severe the arthritis is, or if another condition is causing symptoms, such as carpal tunnel syndrome or tendinitis.
If your doctor suspects inflammatory arthritis, they will order blood tests to detect the presence of certain antibodies, such as rheumatoid factor or anti-CCP, which help identify RA and other types of inflammatory arthritis. They may also order blood tests that look for levels of inflammation, such as C-reactive protein (CRP) and erythrocyte sedimentation rate (ESR).
Your doctor may order imaging tests, such as X-rays or MRIs, to assess whether you have joint damage in the wrist.
Nonsteroidal anti-inflammatory medications (NSAIDs) like aspirin, naproxen, and ibuprofen (all available over the counter) can help relieve pain and inflammation. They’re commonly used to treat pain and stiffness in OA and inflammatory arthritis. NSAIDS don’t slow the progression of arthritis. But they do help treat acute symptoms like pain and inflammation. NSAIDs are also available by prescription at stronger doses for shorter-term use. All NSAIDs, both OTC and prescription, can have significant side effects, including gastrointestinal complications and an increased risk of heart disease, so talk to your doctor about the right dosage and duration for you. Your doctor might also prescribe a topical gel NSAID, which can be helpful if oral medications aren’t helping with the pain. A common one is diclofenac (Voltaren), says Dr. Hampton.
If you have an inflammatory arthritis like rheumatoid arthritis, disease-modifying anti-rheumatic drugs (DMARDs) such as methotrexate are used as a first-line therapy to help reduce the immune system activity that triggers inflammation and pain. DMARDs are not used for osteoarthritis.
Corticosteroids like prednisone are powerful anti-inflammatory agents that can quickly relieve pain and swelling. “This type of therapy is often employed as a temporary or ‘bridge’ therapy [for inflammatory arthritis] while patients wait for DMARDs to take effect,” says Brian Golden, MD, a rheumatologist and clinical associate professor in the department of medicine at NYU Langone Health in New York City. It’s best to use corticosteroids in the lowest possible does for short periods of time, as they can cause a range of serious side effects, including bone thinning and high blood sugar.
An occasional steroid shot in the wrist can offer temporary pain relief and reduce inflammation. Shots shouldn’t be done repeatedly, as frequent injections can damage cartilage. Many doctors limit cortisone injections in a joint to no more than three or four times a year.
Biologics are a newer class of DMARD that targets specific immune system pathways to reduce immune system activity that is causing inflammation and pain. They’re used to treat inflammatory types of arthritis, such as rheumatoid arthritis and psoriatic arthritis, and are typically offered after patients haven’t responded to “conventional” DMARDs like methotrexate.
It’s important to exercise your wrist joints to promote range of motion, improve flexibility, and prevent additional damage. Your doctor will likely send you for physical therapy so you can do these exercises under supervision and then repeat them at home. Your physical therapist can develop a program that’s right for you. “The stronger the muscles are around the joint, the better you’ll feel,” says Dr. Hampton. Here are some range-of-motion exercises, including some for your wrist, which you can try at home.
In addition to physical therapy, it’s a good idea to do regular cardiovascular and strength training exercises that don’t put too much pressure on your wrist joints. Swimming and water exercises, for example, places less pressure on the joints since water helps supports the body. Tai chi and yoga involve gentle, flowing movements. (Be sure to ask your yoga teacher for modifications that don’t stress your wrist.) Walking is low-impact exercise that’s well-suited to people with arthritis. Avoid any exercises with a pushing movement or that put weight on the wrist (such as a handstand or a bench press) as that could exacerbate your wrist pain, says Dr. Hampton. “You want to stay active,” he says. “Keep the muscles and tendons around the joint strong. That will help with pain.”
Support braces can help support wrist movements and ease physical stress. They can’t prevent severe injuries, but they can help you do daily activities with less discomfort. You can get a custom-made or over-the-counter splint to cover your wrist or forearm. Dr. Hampton suggests to his patients that they wear the splint at night while they sleep. He says its compression offers pain relief.
Some people have found that their symptoms improve when wearing special arthritis gloves. They’re tight, often fingerless, gloves that may improve symptoms.
Cold therapy can provide relief for inflamed joints in the wrist. Cold constricts the blood vessels in the muscles, which decreases blood flow to the joint area to help reduce swelling and inflammation. Heat therapy warms the skin and the joints, which causes blood vessels to dilate, and sends more oxygen and nutrients to the joints and muscles. Try both and see which makes you feel best.
Surgery isn’t often needed to treat arthritis in the wrist. But surgery is considered when other treatments don’t relieve pain, wrist arthritis symptoms are severe, or when you can’t use your wrist or hand well. Surgical procedures include the following.
This is the least invasive of the three kinds of wrist surgery, says Dr. Hampton. The arthritic bones of the wrist joint are removed, which diminishes pain. Motion is preserved because there is no fusion. Proximal row carpectomy is only an option for some types of wrist arthritis. “Not everybody is a candidate,” says Dr. Hampton. It depends on where the arthritis is located. You have two rows of four bones in the wrist. If your arthritis is in the proximal row (the one closer to your arm), then you’re a candidate. If it’s in your distal row (the one closer to your hand), then you’re not a candidate. If your arthritis is in both the distal and proximal rows, then you’ll need a wrist fusion. This surgery can provide pain relief while preserving motion.
This procedure eliminates all movement at the wrist joint. Wrist fusion secures the bones of the forearm to the bones in the wrist and hand. “You’re trying to fuse all the bones together so they don’t move anymore,” says Dr. Hampton. “Fusions heal, but you lose movement in the wrist. If you’re at the point of getting this surgery, you’re in debilitating pain and you have no other choice. Either you keep living like this or you get rid of the pain and lose your motion.” The surgery provides pain relief, but the loss of motion can prevent you from doing some daily activities like lifting and manual work that involves your hands like carpentry, says David Geier, MD, an orthopedic surgeon, sports medicine specialist, and author of That’s Gotta Hurt: The Injuries That Changed Sports Forever.
This is the most invasive of the three surgeries, says Dr. Hampton. Here, damaged bone is removed and replaced with a metal and plastic implant. Dr. Hampton says this surgery isn’t done often as the implant in the wrist joint hasn’t been perfected like it has been in hip or knee joint replacements. It was done more in the past and not found to always be successful. “The rare circumstances where this procedure is performed involves older, less active patients who are in excruciating pain that’s not relieved by less invasive treatments,” says Dr. Geier.
Say study authors: ‘Patient–reported joint assessment may aid in capturing flares between routine clinical visits.’
No one knows how you’re feeling better than you, but do your symptoms actually correlate to objective measures of disease activity? A new study points to yes.
In the study, which was published in the journal Rheumatology, researchers followed 80 rheumatoid arthritis (RA) patients for one year. At the beginning of the study, all participants were either in remission or had low levels of disease activity (DAS28-CRP <3.2). Throughout the year, 36 percent of patients reported a hand flare — and clinical exams and ultrasounds confirmed that what the patients were sensing was accurately reflecting what was happening inside their bodies.
“Self-reported flares were associated with increased disease activity as determined by clinical examination and [ultrasound],” the authors wrote. “Patient-reported joint assessment may aid in capturing flares between routine clinical visits.”
