Are patients with Sjögren’s syndrome more susceptible to tendon injuries, and what is the recommended treatment?

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Last updated: August 20, 2026 • View editorial policy

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Sjögren's Syndrome and Tendon Injury Susceptibility

Yes, patients with Sjögren's syndrome do show evidence of increased tendon and enthesis involvement, though the clinical significance remains debated, and treatment should focus on conservative management with relative rest, eccentric strengthening exercises, and short-term NSAIDs, while addressing the underlying systemic disease when severe.

Evidence for Increased Tendon Susceptibility

Patients with primary Sjögren's syndrome (pSS) demonstrate significantly higher enthesopathy scores compared to healthy controls. Ultrasound studies reveal that the plantar fascia, Achilles tendon, and distal patellar tendons are significantly thicker in pSS patients, with elevated Madrid Sonographic Enthesitis Index (MASEI) scores 1. This suggests structural changes at tendon insertion sites that could predispose to injury.

However, there's a critical caveat: While 56% of pSS patients had clinical tender points on examination, ultrasound showed no structural or blood-flow abnormalities, suggesting the absence of active inflammation in tendons and entheses 2. This indicates that tendon pain in Sjögren's may be multifactorial and not purely inflammatory.

Treatment Algorithm for Tendon Injuries in Sjögren's Patients

First-Line Conservative Management

For tendon injuries in Sjögren's patients, follow standard tendinopathy protocols:

  • Relative rest: Reduce repetitive loading activities that stress the affected tendon 3
  • Cryotherapy: Apply melting ice water through a wet towel for 10-minute periods for acute pain relief 3
  • Eccentric strengthening exercises: This is the most effective intervention and may reverse degenerative changes 3. Begin after acute pain subsides (typically 3-6 months recovery expected in 80% of cases)

Pharmacologic Management

  • NSAIDs: Use for short-term pain relief (no longer than 7-10 days) 4, 3. Topical NSAIDs may have fewer systemic side effects
  • Avoid prolonged NSAID use: They provide no long-term benefit and carry significant risks 3
  • Corticosteroid injections: May provide better acute pain relief than oral NSAIDs but use with extreme caution—they don't alter long-term outcomes and may weaken tendons further 3

Managing Underlying Sjögren's Disease

When tendon issues occur in the context of active systemic disease:

  • Hydroxychloroquine 200 mg/day: Consider for patients with frequent episodes of musculoskeletal pain, though evidence is limited 4
  • For severe, refractory systemic disease: Glucocorticoids (short-term course whenever possible) plus immunosuppressive agents (no head-to-head comparisons available between methotrexate, azathioprine, mycophenolate, or leflunomide) 4
  • Rituximab: May be considered (1g IV every 15 days x2) for severe, refractory systemic manifestations, though not specifically indicated for isolated tendinopathy 4

Exercise and Rehabilitation

Resistance exercise appears particularly effective in Sjögren's patients, significantly improving pain, fatigue, quality of life, and disease activity 5. This aligns with eccentric strengthening recommendations for tendinopathy and should be a cornerstone of management.

When to Escalate Care

  • Surgery: Reserve for patients who fail 3-6 months of conservative therapy 3
  • Extracorporeal shock wave therapy: Consider as a noninvasive option for chronic tendinopathies before surgery, though expensive 3

Critical Clinical Pitfalls

  1. Don't assume inflammation: Most tendon pain in Sjögren's is degenerative, not inflammatory, despite the autoimmune nature of the disease 2. Avoid overuse of corticosteroids.

  2. Distinguish from fibromyalgia: Over half of pSS patients have fibromyalgia tender points 2, which requires different management than true tendinopathy.

  3. Avoid biologics for isolated tendon pain: The 2020 EULAR guidelines explicitly state that off-label use of biological agents to treat only musculoskeletal pain is not warranted 4. The evidence doesn't support rituximab or other biologics for isolated tendinopathy.

  4. Monitor for systemic disease: If tendon issues are part of broader systemic involvement (elevated ESSDAI score >5), treat the underlying disease more aggressively 4.

References

2
Research

Ultrasound assessment of the entheses in primary Sjögren syndrome.

Ultrasound in medicine & biology, 2013

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This information is intended for healthcare professionals. Any medical decision-making should rely on clinical judgment and independently verified information. The content provided herein does not replace professional discretion and should be considered supplementary to established clinical guidelines. Healthcare providers should verify all information against primary literature and current practice standards before application in patient care. Dr.Oracle assumes no liability for clinical decisions based on this content.