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RA Can Attack Connective Tissues in the Musculoskeletal System

In an earlier post, I outlined how RA can impact much more than bones including many organs and soft tissues. One group of soft tissues that can be damaged by RA includes those involved with the musculoskeletal system. The musculoskeletal system involves a complex interaction between muscles, bones, joints, and various connective soft tissues – all which can be the target of RA.

Can RA cause soft tissue damage?

Erosion of bone tissues in joints is one of the trademark symptoms of rheumatoid arthritis. Through complex autoimmune biochemical processes, the body’s immune system attacks its own tissues like it was a foreign invader. A cascade of signaling chemicals promotes the production of bone cells called osteoclasts that erode bone tissue and surrounding cartilage. This kind of gross damage shows up on medical imaging of joints and is used as a tool for diagnosing RA and for tracking the effectiveness of treatments. But in addition to hard bone, RA can also attack the associated soft connective tissues.

Synovium

The synovium is a complex sac-like system that surrounds certain joints in the body. It contains a wide variety of cells and tissues including blood, lymph cells, proteins, multiple biochemicals, and fluid.1 It helps to maintain lubrication of the joint. Unfortunately, it is one of the main targets in inflammatory autoimmune diseases like RA. During an autoimmune attack, the synovium can swell and contain an overabundance of inflammatory proteins called cytokines that turn on destructive processes, resulting in the break down of bone and cartilage.

Bone damage around synovium

It’s common for bones and cartilage around synovium to become damaged from RA. One of the first symptoms that led me to a rheumatologist was swelling in every middle joint of my fingers (called metacarpophalangeal or MCP joints). By the time an x-ray was taken, there was already bone erosion seen around the synovium.

Cartilage

Cartilage is soft, flexible connective tissue that occurs in various parts of the body including in the ears, nose, and joints. In joints, it occurs between bones to keep them from rubbing on each other. This type of cartilage is called articular.2 Articular cartilage can be damaged from physical activity like a meniscus tear in the knee during sports, breakdown from normal wear and tear like in osteoarthritis, or as the result of the destructive biochemical processes in autoimmune diseases like RA.

Treating cartilage damage

About the time of my RA diagnosis, I already had several years of knee pain. An MRI revealed damage to the articular cartilage including torn flaps of cartilage that cause my knee to lock up in pain. There are numerous accepted procedures for treating articular cartilage damage including steroid injections, microfracture, drilling, autograft transplant, and stem cells. If cartilage tears away to the point that bone is rubbing on bone, then a knee replacement may be necessary. This is a rather common surgical procedure with RA patients.

Tendons and ligaments

Tendons are connective tissue that holds muscles to bones. Chronic tenosynovitis, inflammation of the sheath of a tendon, is common in rheumatoid arthritis and can result in the permanent damage and tearing of the involved tendons. Such tendon problems caused by RA are well known by the scientific community and are linked to joint deformities.3,4  Tendon problems have even been posited as being one of the most powerful predictors of early RA.5 Sophisticated imaging techniques developed in the last few decades, such as MRIs and ultrasound, can reveal connective tissue damage in joints caused from RA including tenosynovitis and bursitis.6 Bursitis, inflammation of the fluid-filled sacs that protect joints, often accompanies tenosynovitis.7

Ligaments are connective tissue that holds bones to other bones.8 Since they tend to be in the area of a joint near the synovium, they are also subject to the destructive processes of RA. The breakdown of tendons and ligaments during RA is primarily through a process called enthesitis that involves the breakdown of the place where ligaments and tendons attach to bone.9

Soft tissue problems prior to diagnosis

Tendon problems have been one of the hallmarks of my struggles with RA. One of the first symptoms I experienced, even before official diagnosis, was Achilles tendon tearing in both ankles that resulted in three surgeries. The last surgery involved the removal of a bursa sac, reattaching the tendon to my heal bone, removal of damaged tendon tissue, and removal of a bone spur caused by a dime-sized bone erosion. Even after those procedures, my Achilles tendons continue to yell at me rather loudly everyday. I am now dealing with a 50% torn extensor tendon in my elbow and am facing surgery for that after steroid injections and physical therapy did not help.

Be aware of damage to cartilage, tendons, and ligaments

RA patients and doctors need to be aware of, and watchful of RA damage to cartilage, tendons, and ligaments. It can cause serious and debilitating destruction to the musculoskeletal system resulting in reduction of physical functioning, surgeries, and disability. Many, RA patients show connective tissue damage and genetics may play a role in what type of tissues are attacked by RA processes.10 Since the damage to these tissues can occur early in the disease progression, it is critical to diagnosis and treat RA as early as possible.

10.2174/1874312901105010100

This article represents the opinions, thoughts, and experiences of the author; none of this content has been paid for by any advertiser. The RheumatoidArthritis.net team does not recommend or endorse any products or treatments discussed herein. Learn more about how we maintain editorial integrity here.

  1. Smith M. D. (2011). The normal synovium. The open rheumatology journal, 5, 100–106. doi: 10.2174/1874312901105010100
  2. American Academy of Orthopaedic Surgeons. (n.d.). Retrieved from http://orthoinfo.aaos.org/topic.cfm?topic=a00422
  3. Sivakumar, B. et al. (2008). Synovial Hypoxia as a Cause of Tendon Rupture in Rheumatoid Arthritis. Journal of Hand Surgery, Volume 33, Issue 1, 49 - 58. Retrieved from http://www.jhandsurg.org/article/S0363-5023(07)00777-0/abstract
  4. http://onlinelibrary.wiley.com/doi/10.1002/art.23016/full
  5. http://rheumatology.oxfordjournals.org/content/48/8/887.full
  6. http://www.ajronline.org/doi/abs/10.2214/AJR.07.2548
  7. http://www.nlm.nih.gov/medlineplus/bursitis.html
  8. http://www.nlm.nih.gov/medlineplus/ency/imagepages/19089.htm
  9. http://www.arthritisresearchuk.org/health-professionals-and-students/reports/topical-reviews/topical-reviews-autumn-2009.aspx
  10. http://www.nature.com/nrrheum/journal/v9/n8/full/nrrheum.2013.111.htm

Comments

  • Jo J
    1 year ago

    What a great article! Many of my symptoms prior to diagnosis were related to soft tissue issues around my joints, I didn’t realize how significant it was to the joint itself. My PT was sure I had an auto-immune inflammatory process because of my tendency to getting enthesitis in multiple areas.
    I encourage people to speak with the Rheums about using ultrasound to diagnosis and follow synovitis as appropriate. Way cheaper than MRI or CT scans and show damage much earlier than x-rays. Luckily my Rheum has US available in his office with specially trained techs. We have found multiple sites of synovitis without joint erosion which guides my treatment,

  • Monica Y. Sengupta moderator
    1 year ago

    J0dspace, hey! I am so glad you spoke on your behalf and found a diagnosis! Your comment is a great reminder that we are our own best advocate. Thank you for sharing! ~Monica

  • Jane Burbach
    4 years ago

    I would like to know more about how it feels specifically for connective tissue problems. I am experience what I call slippage where it feels my joints slip. Mainly in my hands, involving middle finger, thumb or wrist, right wrist, right ankle through knee and hip. It doesn’t hurt per say but there is a feeling of odd slippage, I lose control of the joint and have to hold it back in place. My rheum doc is wait and see. No new imaging. Switching to Enbrel along with ongoing plaquenil now and will see how it goes. Can anyone explain the symptoms more? I don’t have pain as much as surprise when it happens.

  • Andrew Lumpe, PhD moderator author
    4 years ago

    Jane, for me I feel pain when tendons are tearing. It’s a burning and sometimes sharp pain that worsens when I move that joint a lot. There may be joint destruction going on and you might get a second opinion or see an orthopedic surgeon.

  • Kim Whitman
    4 years ago

    I have lots of tendon involvement with my RA in my wrists and achilles tendon with lots of pain. My question is, why does the flare move around and affect feet worse one month and hands the next? I do not understand the way the flare state has such a random pattern of movement.

  • Andrew Lumpe, PhD moderator author
    4 years ago

    Kim, it’s hard to tell why flare points move around. It seems to be random with me and others also. Keeps us on our toes! …well, maybe we shouldn’t be on our toes 🙂

  • Teresa Perret
    5 years ago

    I’m glad I stumbled on this article today. I like to think I’m an empowered patient, but I had a visit with my rheumatologist yesterday that was nothing short of frustrating. I told her that I have pain in a very specific place on both wrists and elbows and she pointed out that those spots were not joints, but rather the insertion points where the ligaments attach to the bone. She made it feel like that can’t be RA because it’s not the joint, but I don’t have any comorbidities that I know of, and it’s on both arms. So whatever is going on, she ordered x-rays to be completed before my next appointment in 2 months and hopefully that will be a better interaction, but It’s good to know that I’m not the odd one out with tendon and ligament issues.

  • Andrew Lumpe, PhD moderator author
    5 years ago

    Teresa, glad you found the article. I suppose that technically, a joint is where bones meet. However, all you need to do is look at a diagram of a joint and see that the tendons and ligaments are all closely connected and hold it all together. Damage to those insertion points is called enthesitis and can be caused by RA and other related autoimmune inflammatory diseases. Enthesitis tends to be more common in RA’s cousins ankylosing spondylitis, psoriatic arthritis, and the so-called seronegative RA (no positive RF or anti-CCP tests) but it can be present in good old fashioned RA. Not everyone presents a “textbook” case. Having it bi-symmetrical, on both arms, is a tip-off that it’s autoimmune and not just from common wear and tear. By the way, an x-ray won’t show soft tissue damage. Only more sophisticated imaging techniques like ultrasound, CT scan, and MRI can show that kind of damage. Perhaps you could ask for an MRI to see what’s really going on? This could also be a tip-off that your current RA treatment is not working. I encourage you to communicate with your rheumy openly and sooner rather than later.

  • Kristen
    5 years ago

    It’s worth mentioning that steroid injections are linked to increased risk of torn tendons. While the risk may be negligible for the general population, a risk versus benefit analysis should be done by anyone with RA before getting one. I have both RA and Ehlers-Danlos Syndrome, both contraindications, and yet several doctors have suggested steroid injections while clearly not even considering (let alone gaining informed consent) the risk to me.

  • Andrew Lumpe, PhD moderator author
    5 years ago

    Good point Kristen. Most docs won’t give more than 2-3 injections in a given year. And there are some tendons that should never get a steroid injection. The Achilles tendon is one that my orthopedic surgeon said he wouldn’t inject.

  • Wren moderator
    5 years ago

    Hi, Andrew,

    This is so interesting. I knew that RA attacked the tendons, ligaments, and cartilage associated with the synovium and the joint, but I really didn’t know how… Well, now I do. Your posts always educate me. I appreciate that. When I was a teenager, I experienced some severe heel pain that was bad enough to put me on crutches for a couple of weeks. It came out of the blue, and I had no idea what I might have done to cause it. No accidents, injuries, etc. The doc didn’t seem to know, either, because he told me it was “growing pains.” Hmmm. It would be more than a decade later before I was diagnosed with RA, but your post makes me wonder if that heel pain was associated with it. Probably was, somehow.

    I’m sorry to hear that surgery on your elbow may be in the works before long. I’ve had (knock wood!) only very rare problems from RA in those particular joints, but they sure made me aware of how quickly pain there causes disability.

    I hope you’re doing well otherwise, that your neck continues to heal, and that the pain continues to lessen as it does. Amazing what surgeons can do these days! Wishing you the best, as always.

  • Andrew Lumpe, PhD moderator author
    5 years ago

    Wren, thanks for the compliments. The neck is healing and pain is less and less everyday. It is pretty amazing what surgeons do and I wonder how people coped years ago without modern medicine. Of course, people will look back to these days and say medicine was archaic!

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