Now Research Shows: Lupus tendinitis, common cause of lupus pain

A lupus patient with Jaccoud's arthropathy due to lupus tendinitis (lupus tendonitis) and lupus tenosynovitis

Jaccoud’s arthropathy due to lupus tendinitis (lupus tendonitis) and lupus tenosynovitis

Lupus tendinitis (lupus tendonitis) and tenosynovitis are common in systemic lupus erythematosus (SLE). The tendons are sinewy, inelastic fibrous tissue that connects the muscles to the bones. When muscles contract to move parts of the body, these strong tendons enable the muscles to move the much stronger bones. The movement of these tendons in unison with the body’s muscles and joints allows us to move. To demonstrate tendons to yourself, place your left fingers on the front bend of your right elbow. Then, bend your right elbow. The muscle just above this is your biceps. The hard, long structures just below the biceps that connect to the bone below the bend are the biceps tendons. If these were to become inflamed and painful, this would be  “biceps 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.

We rarely see Jaccoud’s arthropathy to this severity in more recently diagnosed patients. Our SLE treatments today are much better than two to three decades ago. When someone has had uncontrolled inflammation of the joints and tendons for such a long time (as in this patient of twenty-five years’ duration of having lupus), it becomes much more challenging to get it under control. Joint and tendon inflammation of recent onset are usually easier to treat. This is why rheumatologists want to see and treat patients with inflammatory arthritis as quickly as possible to get them into remission. Sometimes there can be swelling as well. Some examples of tendonitis that can occur in SLE include rotator cuff tendonitis (at the shoulder), epicondylitis at the elbow (commonly called tennis elbow and golfer’s elbow), flexor tenosynovitis in the palm, Achilles’ tendonitis (back of the ankle), and plantar fasciitis (bottom of the heel). 

A man with trigger finger due to tenosynovitis

Severe trigger finger from tenosynovitis. This man has to grab, pull on his finger to straighten it. He can feel a “pop” and this may be painful.

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

The location where any ligament or tendon attaches to a bone is called an enthesis. Inflammation of an enthesis in someone with SLE is called lupus enthesitis. Up until recently, enthesitis was primarily thought to occur in a type of arthritis called spondyloarthritis, including psoriatic arthritis, ankylosing spondylitis, reactive arthritis, and inflammatory bowel disease-associated arthritis. In 2018, an Italian group showed that many SLE patients had enthesitis on ultrasound (see below) examination. They showed that 25% to 67% of SLE patients who had joint pain had evidence for inflammation or damage of an enthesis. Enthesitis usually does not cause swelling of the joint. On physical examination, tenderness is found on the bony sides of the joints, away from the joint line. This high occurrence of enthesitis helps explain why many SLE patients with joint pain do not have joint swelling. 
These entheses (the plural of enthesis) also occur in the areas of tenderness that doctors push on to help diagnose fibromyalgia. This could help explain why so many SLE patients are diagnosed with fibromyalgia. I have had many SLE patients with “secondary fibromyalgia” improve dramatically after using medications (such as Benlysta and CellCept) that calm down the immune system. This has to make us wonder if some of our SLE patients with “fibromyalgia” may actually have inflammatory enthesitis as the cause of their fibromyalgia-like pain. This is another good reason why more rheumatologists should consider using ultrasound in their practices to figure out more accurately out what is causing the pain in their SLE patients. It would be interesting to know how many of our “fibromyalgia” patients are really “lupus enthesitis” patients.

Doppler ultrasound of lupus tenosynovitis and lupus tendinitis. The red and blue dots are areas of inflammation.

Doppler ultrasound of lupus tenosynovitis and lupus tendinitis. The red and blue dots are areas of inflammation.

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.
First, suppose a patient examined for possible lupus is correctly diagnosed with lupus arthritis, lupus tendonitis (lupus tendonitis) with ultrasound instead of arthralgia. In that case, it can help make a faster diagnosis of SLE. Second, lupus arthritis requires medications to calm down inflammation rather than just medicines that calm down pain. Many rheumatologists use ultrasound to help diagnose inflammation in the joints. The ultrasound machine can use a technique called “power Doppler” to identify inflammation in the tissues of the joints and surrounding structures (as shown in the previous photo above).
An advantage of using ultrasound is that it can be used right in the examination room while the doctor evaluates the patient. The use of ultrasound in SLE patients is an essential tool because there are often few clues on physical examination that someone with SLE has inflammation as the cause of the pain. In patients with joint pains but have no evidence for arthritis or lupus tendonitis on physical examination, ultrasound studies show that more than half have inflammation proven with ultrasound. Because of this, we believe that many patients with SLE are undertreated. We advise SLE patients in pain and are told they do not have inflammatory lupus arthritis or lupus tendonitis to consider seeing a rheumatologist who uses ultrasound for a second opinion.

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. 

Doppler ultrasound of lupus arthritis inflammation in a woman with systemic lupus

Doppler ultrasound of lupus arthritis inflammation in a woman with systemic lupus

Ultrasound by Rheumatology Can See Lupus Inflammation

Not only can Doppler ultrasound show inflammation from lupus tendinitis (lupus tendonitis), lupus tenosynovitis, and lupus enthesitis, but also lupus arthritis. The photo above shows what the ultrasound examination can demonstrate in a patient with active arthritis from SLE. This is an ultrasound of the left wrist. The top orange area is a vein located just beneath the skin (a normal finding). The large orange areas underneath it are areas of inflammation (synovitis) of the joint lining (the synovium). To the bottom right and bottom left of those orange areas, you can see two separate dark (black) areas, then a bright white line underneath the right dark area. Those dark areas are the swollen joint (fluid shows up as dark areas on ultrasound), while the white line is one of the wrist joint bones. In a healthy joint, these dark areas with the accompanying orange area of inflammation would not be here. This confirmed a diagnosis of active lupus arthritis (synovitis) in this patient with SLE. However, she did not have any swelling on the physical examination. This finding made it much easier to discuss increasing the treatment of her SLE. 

Anti-inflammatory drugs and immunosuppressants such as naproxen and methotrexate can help lupus tendinitis

Anti-inflammatory drugs and immunosuppressants such as naproxen and methotrexate can help lupus tendinitis

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 can help lupus tendinitis, lupus tenosynovitis, and lupus arthritis

Cortisone injections can help lupus tendinitis, lupus tenosynovitis, and lupus arthritis

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.

Ice pack for lupus tendinitis

An ice pack can be more helpful than heat therapy for inflammation problems like lupus tendinitis

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.

Protecting inA splint or brace helping lupus tendinitis

Protecting inflamed tendons, such as using a splint or brace, can help lupus tendinitis

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.

Housewife working

Learn to not over do activities when you have active lupus tendinitis and lupus arthritis

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.

REFERENCES:
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.

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