What type of joint pain is associated with celiac disease?

Joint Pain in Celiac Disease

Celiac disease most commonly presents with peripheral arthralgia and arthritis affecting large joints (knees, hips, ankles, wrists) in an asymmetric pattern, though axial involvement (spine and sacroiliac joints) and polyarticular small joint involvement also occur. 1, 2

Pattern and Distribution of Joint Involvement

Peripheral Arthropathy

• Large joints are predominantly affected, including knees, hips, lumbar spine, ankles, and wrists 1, 3
• The pattern is typically asymmetric and pauciarticular (affecting fewer than 5 joints) 2, 4
• Peripheral arthritis occurs in approximately 19-26% of celiac patients, significantly higher than the 7.5% prevalence in controls 2
• Joint pain may precede gastrointestinal symptoms by months to years, with some patients having no bowel symptoms at all 3, 5

Axial Arthropathy

• Axial involvement includes the lumbar spine and sacroiliac joints 2, 4
• Approximately 15 patients out of 200 in one study had purely axial arthritis, while 18 had overlap of both peripheral and axial involvement 2
• The pattern resembles seronegative spondyloarthropathy 3

Polyarticular Involvement

• Some patients present with polyarticular arthritis affecting multiple small and large joints simultaneously 2
• This pattern is less common but can occur, particularly in untreated disease 2

Clinical Characteristics

Key Features

• Arthralgia (joint pain without inflammation) is more common than frank arthritis 1, 5
• Patients are typically seronegative (negative rheumatoid factor and anti-CCP antibodies) 3
• Morning stiffness and inflammatory symptoms may be present 1
• Associated findings include myalgia, back pain, and bone pain from osteomalacia or osteoporosis 1

Relationship to Disease Activity

• Arthritis prevalence is significantly higher in untreated patients (41% on regular diet) compared to those on gluten-free diet (21.6%) 2
• Joint symptoms typically improve dramatically with gluten-free diet, often within weeks to months 2, 4, 3
• Up to 75% of celiac patients have reduced bone mineral density, contributing to musculoskeletal pain 1

Diagnostic Approach

When to Suspect Celiac Disease

• Consider celiac disease in patients with seronegative arthritis, particularly affecting large joints asymmetrically 3
• Screen patients with unexplained arthralgia, especially when accompanied by vitamin D deficiency, osteopenia, or anemia 1
• Test for tissue transglutaminase (tTG) antibodies with quantitative IgA levels to screen for celiac disease 6
• Confirm diagnosis with small bowel biopsy showing villous atrophy 6

Important Pitfalls

• Up to 3 patients in one series had no gastrointestinal symptoms, making diagnosis challenging 3
• Arthritis may be the sole presenting manifestation of celiac disease 5
• HLA-B8 and HLA-DR3 are commonly present (found in 5 of 6 patients in one study), but HLA-B27 can also occur 3

Management

Primary Treatment

• Strict gluten-free diet is the cornerstone of treatment and typically resolves joint symptoms within weeks to months 2, 4, 3
• Vitamin D and calcium supplementation are essential, particularly in patients with osteomalacia or osteoporosis 1
• Supplementation results in significant symptom and bone mineral density improvement over 6 months 1

Symptomatic Management

• Short-term NSAIDs may be used for pain control during the initial treatment phase, though caution is warranted given potential gastrointestinal effects 6
• Physiotherapy and rest can provide additional symptomatic relief 6
• Local corticosteroid injections may be considered for persistent monoarticular symptoms 6

Monitoring Response

• Joint symptoms should improve within weeks of starting gluten-free diet 2, 4
• If symptoms persist despite dietary adherence, consider refractory celiac disease or alternative diagnoses 6
• Regular monitoring of bone mineral density is recommended given the high prevalence of osteoporosis 1