What is lupus tendinitis (also spelled lupus tendonitis)?
Just as lupus can cause inflammation of the joints, it can also cause inflammation of the tendons (lupus tendonitis or lupus tendonitis). Tendonitis usually causes pain around and between the joints of the body. The joint pains seen in SLE are commonly due to lupus tendonitis (lupus tendonitis) rather than arthritis. One Japanese study in 2017 showed that 94% of their SLE patients with joint pains had tendon involvement (tendonitis and tenosynovitis), while 80% had joint (arthritis) involvement. Many patients had a combination of both. The photo above shows the hands of Dr. Thomas’ patients with severe damage to her tendons from lupus tendinitis and lupus tenosynovitis. We call this “Jaccoud’s arthropathy.” Jaccoud’s arthropathy was first seen in people affected by rheumatic fever. Today, SLE is the most common cause. Make sure to read my “Lupus Secrets” to learn to take care of and prevent problems such as lupus tendinitis.
Lupus tenosynovitis
A lubricating sheath surrounds some tendons. This sheath is called the tenosynovium, and it helps tendons glide more smoothly and help them stay in their place better. A typical example is the tendons in the palm that help to bend the fingers. When these become inflamed in SLE, it is called “lupus tenosynovitis.” Ultrasound (see below) studies show that 20% to 40% of SLE patients with joint pain with no detectible joint swelling have inflammatory tenosynovitis. When this occurs with the fingers, the affected person may need to use the other hand to straighten out the finger. This problem is called “trigger finger” (see the photo above).
Damage of the tendons from lupus can cause the tendons to slip around the joints and become unstable in some people. When this occurs, it can cause deformed joints (see the 1st photo above) called “Jaccoud’s arthropathy.” Jaccoud’s arthropathy was first described in people with rheumatic fever (due to infection). However, today, the most common cause is SLE.
Lupus Enthesitis: An Underdiagnosed Lupus Problem
Ultrasound: Best Test to Diagnose Lupus Tendinitis
With the increasing use of ultrasound (also called sonography or a sonogram) by rheumatologists to look for inflammation in the joints of patients with lupus, we are noting that many patients labeled as having arthralgias actually have real inflammation. In other words, they actually do have inflammatory arthritis (or lupus tendonitis, lupus tendonitis, tenosynovitis, or enthesitis, as discussed later) as the cause of their joint pains. Suppose someone with SLE has joint pains, but the doctor cannot find inflammation on the physical exam. In that case, ultrasound demonstrates lupus inflammation in 25% to 75% of them. This is an important distinction.
The photo above shows what the ultrasound can look like from lupus tenosynovitis. This is an ultrasound of the tendon that bends the woman’s index finger that you see in the previous photo (Jaccoud’s arthropathy is mainly due to tendon inflammation and damage). This ultrasound image uses Doppler technology to identify areas of inflammation. The red and blue dots are areas of inflammation occurring around the tendon. The thin parallel lines you see under the dots (they look like strands of white hair) are the actual tendons. Note that the two dots of inflammation sit within a dark gray cavity. This is swelling around the tendon, and the white line above the dots is the tendon sheath. When there is inflammation such as this, bending the finger becomes painful. Also, note that the tendon towards the left of the two dots is quite a bit more swollen than the part of the tendon towards the right. This is an example of damage to the tendon due to many years of uncontrolled inflammation.
Ultrasound by Rheumatology Can See Lupus Inflammation
Treatments for Lupus Tendinitis
As with all problems in SLE, please read and abide by all my “Lupus Secrets” to keep the best control of your SLE problems like lupus tendonitis. Make sure to download all my free handouts from the Lupus Secrets page of my website. Just as with arthritis, the tendonitis of SLE is treated with nonsteroidal anti-inflammatory drugs (NSAIDs such as ibuprofen and naproxen), steroids, and hydroxychloroquine (Plaquenil), while stronger medications such as methotrexate, mycophenolate, and belimumab are used for severe cases. Resting the tendon to allow the body to heal is one of the most important things to learn. If you have tendonitis, it is crucial to abide by joint protection measures. Joint protection measures can easily be found on the internet.
Cortisone Injections for Lupus Tendinitis
An injection with a corticosteroid (a cortisone injection) is also one of the safest and quickest ways to treat lupus tendonitis and tenosynovitis. Using an ice pack as needed can also help to decrease the severity of pain from lupus tendonitis.
Cold Therapy For Lupus Tendinitis
Cold therapy (cryotherapy): Icing can be helpful for injuries, tendonitis, bursitis, and inflammation (such as lupus inflammatory arthritis pain). Ice therapy can be applied in many ways, including raw ice (like an ice cube), ice frozen in a Styrofoam cup, commercial ice or gel wraps, and packs. Do not use bare ice for more than 1-3 minutes. Follow the rule of thumb “when you’re numb, you’re done.” Cold compresses with a barrier between the ice and the skin (such as cups, wraps, and packs) may be applied longer, but when “you’re numb, you’re done.” Do not apply ice on areas of broken skin. If you have neuropathy (nerve damage), be careful as you could freeze your skin if the ice source is too cold (you may not feel it), and make sure not to use it for more than 1-3 minutes.
Joint Protection for Lupus Tendinitis
Whenever pain persists, it is vital to consider the possibility that you may be overstressing your joints and tendons. Think carefully about what you do at your job, at home, and while engaging in sports that may be aggravating your condition. For example, a person may keep getting wrist pain and then realize that this seems to occur most often the day after she crochets, one of her favorite hobbies. Repetitive tasks such as crocheting are some of the most common contributors to joint and tendon damage. Some of the most common repetitive-use tendon injuries occur from using computers and texting on cell phones. It is essential to identify activities that exacerbate your joint pain and do them less and for shorter periods. Another example would be a mother who keeps getting severe pain at the base of her thumb and then realizes that this often happens after picking up her baby. Holding the thumb back while holding a baby can put a lot of stress on the tendons that move the thumb, so severe tendonitis can result. Learning to pick up a baby while not stressing the tendons can make a big difference in relieving the inflammation and pain. Using a wrist splint to help rest those tendons can also be helpful.
Personality assessment is also essential. The person who is a compulsive worker and perfectionist may have the attitude of “I’m going to finish this job if it kills me.” This type of person needs to learn to respect their aches and pains, pay attention to what their body is telling them, and recognize this potentially self-destructive behavior. People who feel that they must do everything or are the only ones who will get something done right can be particularly guilty of this.
For example, a mother may insist that the house stay clean and organized differently (after all, this is what her husband and children expect). Even though she may have severe lupus tendonitis pain, she pushes herself to clean everything to meet her expectations, thereby causing her body more damage and pain. At the same time, her resentment toward her loved ones builds, and she ends up feeling that they do not care enough to help her. It becomes a vicious cycle where the pain, mental frustration, stress, and resentment continue to worsen over time. This damages not only the person’s tendons but also her relationships with the ones she loves. It can be important to learn how to change your expectations, how not to be a perfectionist, and realize that there is more than one way to live or work (such as cleaning the house). Learning to avoid certain tasks can be just as important as learning to perform a job in a way that puts less stress on the joints.
Personality assessment is also essential. The person who is a compulsive worker and perfectionist may have the attitude of “I’m going to finish this job if it kills me.” This type of person needs to learn to respect their aches and pains, pay attention to what their body is telling them, and recognize this potentially self-destructive behavior. People who feel that they must do everything or are the only ones who will get something done right can be particularly guilty of this. For example, a mother may insist that the house stay clean and organized differently (after all, this is what her husband and children expect). Even though she may have severe lupus tendonitis pain, she pushes herself to clean everything to meet her expectations, thereby causing her body more damage and pain. At the same time, her resentment toward her loved ones builds, and she ends up feeling that they do not care enough to help her. It becomes a vicious cycle where the pain, mental frustration, stress, and resentment continue to worsen over time. This damages not only the person’s tendons but also her relationships with the ones she loves. It can be important to learn how to change your expectations, how not to be a perfectionist, and realize that there is more than one way to live or work (such as cleaning the house). Learning to avoid certain tasks can be just as important as learning to perform a job in a way that puts less stress on the joints.
NOTE: The above is an amended version of the Musculoskeletal section of “The Lupus Encyclopedia“, 2nd edition prior to editor review and acceptance (Johns Hopkins Press).
Author
Don Thomas, MD, author of “The Lupus Encyclopedia” and “The Lupus Secrets”
Special thanks to Dr. Jemima Felicity L Albayda, M.D., Director, Musculoskeletal Ultrasound and Injection Clinic
Assistant Professor of Medicine, Johns Hopkins Hospital, Baltimore, Maryland who helped write this for inclusion in “The Lupus Encyclopedia”, 2nd edition.
NOTE: All opinions and interpretations of the medical literature are our own. We get no compensation from any industry for our blog posts. Our intent is to motivate patients to become knowledgeable and proactive in their health care.
Di Matteo, A., Isidori, M., Corradini, D., Cipolletta, E., McShane, A., De Angelis, R., … Grassi, W. (2019). Ultrasound in the assessment of musculoskeletal involvement in systemic lupus erythematosus: state of the art and perspectives. Lupus, 28(5), 583–590. https://doi.org/10.1177/0961203319834671Di Matteo A, Emilio Filippucci, Edoardo Cipolletta, Iulia Satulu, Jana Hurnakova, Valentina Lato, Rossella De Angelis, Rudolf Horvath, Karel Pavelka, Fausto Salaffi, Walter Grassi, Entheseal involvement in patients with systemic lupus erythematosus: an ultrasound study, Rheumatolgy, Volume 57, Issue 10, October 2018, Pages 1822–1829, https://doi.org/10.1093/rheumatology/key189
Iagnocco T, et al. Ultrasound evaluation of hand, wrist and foot joint synovitis in systemic lupus erythematosus. Rheumatology (Oxford, England) 2014;53:465-472.Leeuwenberg KE, Albayda J (2019) Muscle Ultrasound in Inflammatory Myopathies: A Critical Review. J Rheum Dis Treat 5:069. doi.org/10.23937/2469-5726/1510069Ogura, T., Hirata, A., Hayashi, N., Takenaka, S., Ito, H., Mizushina, K., … Kameda, H. (2017). Comparison of ultrasonographic joint and tendon findings in hands between early, treatment-naïve patients with systemic lupus erythematosus and rheumatoid arthritis. Lupus, 26(7), 707–714. https://doi.org/10.1177/0961203316676375
Ruano CA, Malheiro R, Oliveira JF, Pinheiro S, Vieira LS, Moraes-Fontes MF. Ultrasound detects subclinical joint inflammation in the hands and wrists of patients with systemic lupus erythematosus without musculoskeletal symptoms. Lupus Sci Med. 2017;4(1):e000184. Published 2017 Jan 19. doi:10.1136/lupus-2016-000184Zickuhr L, et al. Collapsing glomerulopathy, extensor tendon ruptures and autoimmune ILD. Rheumatology Connections Summer 2018:3-4.
2 Comments
My tendons have been causing me pain for years. My doctor’s have all been calling it fibromyalgia (including all the rheumatologists I’ve seen). Sometimes they call it myifascial pain. It can be very hard to sleep, even with all of my pillows! I’d like to read your handouts in solutions, but I cannot open them. Any suggestions?
Best,
Dawn
Dear Dawn: If you are talking about the handouts at the bottom of the “Lupus Secrets” page, they do require Microsoft “Word” to open. I think you can get a Word Reader off the internet to help as well.
The best way to figure out if someone has pain in the tendons due to fibromyalgia vs inflammation from lupus is to have a doctor perform Doppler ultrasound of the joints and tendons. Many of us are able to do this these days. If you have never had this done, I’d recommend calling around to rheumatologists’ offices close to you and as the staff on the phone if the doctor does ultrasonography, and if they say, Yes, make an appointment and at the appointment mention that I stated this could be done to help figure it out. They’ll know what to do.
Good luck, I hope you do well… Donald Thomas, MD