This site is intended for healthcare professionals as a useful source of information on the diagnosis, treatment and support of patients with lupus and related connective tissue diseases.


Arthralgia is a very frequent symptom in patients with lupus and is often the presenting symptom. Not all patients with arthralgia will progress to a true arthritis. Arthritis is included as an item in the 1997 American College of Rheumatology (ACR) revised classification criteria for lupus and the 2012 Systemic Lupus International Collaborating Clinics (SLICC) classification criteria for SLE. Joint involvement in lupus was also included in the new 2019 European League Against Rheumatism/American College of Rheumatology (EULAR/ACR) classification criteria for SLE where it was defined as either (1) synovitis involving two or more joints characterised by swelling or effusion or (2) tenderness in two or more joints and at least 30 min of morning stiffness.


The musculoskeletal system is the most commonly involved system in patients with lupus. Different cohorts report the prevalence to be between 50-95%. Joint pain is the commonest initial symptom, being the presenting problem in 50% of patients. Fortunately, despite its frequency, joint disease is rarely serious and only 10% of lupus patients develop significant joint deformities. These include reducible or fixed hand deformities e.g. metacarpophalangeal (MCP) subluxation, ulnar drift, swan neck or boutonnière deformity and Z thumbs. In the absence of erosions on X-ray, this type of lupus arthritis is known as Jaccoud’s arthritis. The known risk factors for patients with lupus developing a deforming arthropathy include secondary Sjögren’s Syndrome, the presence of a positive anti-Ro antibody, an elevated Creactive protein (CRP) and a positive rheumatoid factor (RF). Approximately 2 3% of patients who are classified as having lupus and have erosive disease will also meet the ACR criteria for rheumatoid arthritis (RA). These patients are diagnosed as having RA/ SLE overlap, sometimes known as rhupus. It is very important to screen for extra-articular manifestations associated with a possible connective tissue disease when a patient develops an inflammatory arthritis so that the correct diagnosis is made.


The joint deformities in lupus are usually due to tenosynovitis, particularly of the flexor tendons, rather than intra-articular synovial hypertrophy and bony erosions and loss of joint space due to cartilage destruction, as in patients with RA. In lupus patients, there is also ligament laxity combined with muscle imbalance which contributes to the development of the deformity. Musculoskeletal ultrasound and MRI scans are more sensitive at detecting joint abnormalities compared with conventional radiography. MRI findings reported in lupus patients include tenosynovitis, capsular swelling, joint effusions and, sometimes, erosions. As in patients with RA, an MRI scan is more sensitive at detecting erosions in patients with lupus compared with conventional radiography. In some studies, a high proportion of patients with established lupus had erosions on MRI scan compared with 4% on conventional X-rays.

The synovium of patients with lupus has not been studied extensively but synovial membrane hyperplasia, microvascular changes, fibrin deposition and perivascular infiltrates have been documented. Interestingly, there is little cartilage or bone destruction, which reflects the altered cytokine profile, particularly reduced levels of 1L1 and 1L6. The low cytokine levels within the joint mean that there is little circulating pro-inflammatory cytokine and, therefore, the liver is not stimulated to produce an elevated CRP. A common differentiation between lupus and rheumatoid arthritis is that lupus patients usually have a normal CRP and elevated ESR whereas RA patients have both an elevated CRP and ESR.


Patients with lupus arthritis typically suffer from stiffness, pain and swelling. These symptoms are usually worse in the morning and reflect active inflammation. It is notable that some patients may experience inflammatory-sounding joint pains for a considerable time without objective physical signs of inflammation i.e. without swelling. This may delay diagnosis and can make treatment difficult. The arthritis or arthralgia may be persistent, intermittent or flitting from joint to joint, but is typically symmetrical. The metacarpophalangeal (MCP) and proximal interphalangeal PIP) joints are the most commonly affected. Other joints frequently involved include the wrists, knees, elbows and shoulders.

The hand

A patient with lupus may have rheumatoid-like deformities including ulnar deviation, swan neck deformities and subluxation of the thumb, MCP and PIP joints - see figures 1-3. This pattern of deformity is characteristic of Jaccoud’s arthropathy. The changes are usually reversible since they are due to tendon involvement rather than synovial damage and so the patient does not usually require or benefit from joint surgery. Importantly, X-rays of the hands of lupus patients rarely (approx 4%) show erosions – see figure 4.
Figure 1. MCP swelling. Z thumbs and swan necking in a lupus arthritis patient

Figure 2. Subluxation of MCPs and ulnar deviation

Figure 3. Reversibility of lupus arthritis:
a) voluntary induction of deformities

b) returning to almost normality

Figure 4. X-ray of hands of lupus patient showing non-erosive arthropathy including Z thumbs

The foot

The common deformities seen in the foot are hallux valgus, metatarsal phalangeal subluxation and hammer toes.

The neck

Atlanto-axial subluxation can occur as a rarity in lupus patients. It has been associated with corticosteroid use, longer disease duration, Jaccoud’s arthropathy and chronic renal failure.

Extra-articular associations

There is an increased prevalence of median nerve compression producing carpal tunnel syndrome in lupus patients, as in other patients with inflammatory arthropathies. Nodules occur infrequently in lupus patients. They are typically found in the small joints of the hand but also in the more characteristic areas for RA e.g. the extensor surface of the elbow. Calcinosis also occurs in patients with lupus but is less prevalent compared with patients with systemic sclerosis or dermatomyositis. Calcinosis is often only evident on X-ray.

Table 1 - Arthritis and its associated features in Lupus and RA

Peripheral symmetrical polyarthritis
Usually absent (present 4%)
Usually normal
Usually absent
Positive in minority
Positive in (>)90%
Positive in (>)80%
Often present (up to 100%)
Present in up to 30%
Positive in 70%
Positive in 20%

Practical Issues

Making the diagnosis

Lupus should be considered in the differential diagnosis in a patient presenting with a persistent inflammatory symmetrical arthritis. RA can also present in a similar way. Table 1 summarises the differences. A history of extra-articular manifestations e.g. a photosensitive rash, mouth ulcers, alopecia and Raynaud’s is in keeping with a diagnosis of lupus.

Monoarthritis in a lupus patient

If a lupus patient has one particularly active, i.e. hot, swollen and tender joint relative to the other joints, then the presence of a septic arthritis should be considered. The joint should be aspirated urgently and the synovial fluid should be sent for urgent microscopy, culture, staining and culture for alcohol and acid fast bacilli and Mycobacteria PCR analysis. Staphylococcus and streptococcus are the two most common causes of septic arthritis in lupus patients, but Mycobacterium tuberculosis and nontuberculous mycobacterial infections are becoming more prevalent and should be borne in mind, especially in the setting of immunosuppression.

Isolated hip pain

This should raise the suspicion of avascular necrosis (also known as aseptic necrosis or ischaemic necrosis of bone). It occurs in 4-9% of lupus patients. Most cases are associated with high corticosteroid use and can occur within 3 months of starting prednisolone. It is also more common in lupus patients with Raynaud’s, small vessel vasculitis, fat emboli and secondary antiphospholipid syndrome.The radiological changes are best detected on an MRI. It is treated by limiting weightbearing, adequate pain relief e.g. NSAIDs and, for a selected group of patients, by surgery. There is controversy over the value of the core decompression for early lesions but hip arthroplasty clearly has a place for end-stage lesions. Osteonecrosis also commonly occurs in the knees, in the tibial plateau and the humeral head in lupus patients.

The swollen calf: a ruptured Baker's cyst versus a deep vein thrombosis (DVT)

Both diagnoses can occur in lupus patients. Baker’s cysts are more prevalent in patients with an inflammatory arthropathy and the prevalence of DVTs is increased in lupus patients due to the increased prevalence of the secondary antiphospholipid syndrome.

See page – The Antiphospholipid (Hughes) Syndrome

The two conditions require different treatments and potential complications can occur if the wrong treatment is given e.g. haemorrhage into the calf, causing a compartment syndrome if a patient with a ruptured Baker’s cyst is inadvertently anti-coagulated. Diagnosis is aided by performing an early ultrasound/Doppler examination. The patient with a ruptured Baker’s cyst should receive an intraarticular corticosteroid injection and the patient with a DVT should be anticoagulated.

Tendon rupture

This tends to occur in the weight bearing areas e.g. the infra-patella tendon of the knee and the Achilles tendon of the ankle. This complication is associated with trauma, long-term therapy with oral glucocorticoids, intra-articular steroid injections, Jaccoud’s arthropathy, long disease duration and is more common in male patients.

Treatment of Lupus Arthritis


The priority is to provide adequate pain relief and, therefore, maintain normal function.


Education from the physiotherapist and occupational therapist regarding joint protection and exercise is valuable in preventing joint deformity and maintaining muscle strength. Swimming, walking and cycling should be encouraged, however, rest is important during times of marked joint inflammation. The topical application of heat or cold often provides symptomatic relief to a particularly active joint. Localised severe pain may also be helped by the application of a TENS machine (transcutaneous electrical joint stimulation) unit. Splints may occasionally be useful in correcting joint deformities. Corrective tendon surgery and joint replacement may be necessary on rare occasions in very severe cases.


Simple analgesics and non-steroidal anti-inflammatory drugs

Simple analgesics e.g. paracetamol, codeine phosphate and non-steroidal antiinflammatory drugs (NSAIDs) provide symptomatic relief and are the first line of therapy. There are numerous NSAIDs and most doctors tend to become familiar with just a few. NSAIDs can be used provided there are no contra indications e.g. hypertension, ischaemic heart disease and glomerulonephritis. NSAIDs can also cause renal toxicity and so a lupus patient’s renal function needs to be carefully monitored, particularly as these patients are prone to renal impairment per se. Choosing a NSAID with a relatively long half-life or modified release formulation has advantages for the control of chronic inflammatory pain. It reduces early morning stiffness and provides better symptomatic relief and compliance. If the optimal dose of a NSAID does not produce a significant improvement after three to four weeks, then a different NSAID should be tried. A patient presenting with new onset synovitis may experience complete relief of their symptoms after taking a NSAID, thus confirming the presence of an inflammatory arthritis. Co-presciption of a gastric protectant should be considered when using a NSAID.


Intra-articular, intra-muscular and/or oral glucocorticoids treat lupus arthritis effectively. If only one joint is affected then an intra-articular injection is probably the most appropriate mode of administration. Intra-muscular long acting glucocorticoids are very effective in treating a flare. If glucocorticoids are required regularly, then the background lupus therapy should be reviewed and a change in immunosuppressant drug should be considered or an additional drug added. Glucocorticoids should be used at the lowest effective dose in combination with antimalarials and/or other immunosuppressant drugs e.g. methotrexate, azathioprine, mycophenolate mofetil or leflunomide. Secondary osteoporosis is a particular risk in patients taking regular oral prednisolone and should be monitored with the FRAX (Fracture Risk Assessment) tool and DEXA scans. Preventative therapy e.g. calcium, vitamin D supplementation and a bisphosphonate should be considered according to guidelines and age of the patient, particularly with respect to whether they have completed their family.

Other drugs

Methotrexate, azathioprine and leflunomide are effective in lupus arthritis and are glucocorticoid-sparing. Patients taking these medications require regular monitoring for drug toxicity, particularly marrow suppression and liver inflammation. The British Society of Rheumatology (BSR) has published recommended drug safety monitoring guidelines. Some patients with more severe and active disease may be eligible for treatment with biologic drugs such as belimumab and rituximab.

See page - Drug Therapy of Lupus

Secondary fibromyalgia

Fibromyalgia is a syndrome of widespread pain and the presence of many tender points and is associated with a poor sleep pattern. Patients with lupus can develop secondary fibromyalgia.The control of pain can be very difficult in lupus patients, particularly if secondary fibromyalgia has developed. One approach is to develop stress management/coping strategies with an exercise regime and prescribe low dose amitriptyline to modify the pain pathway, in addition to prescribing analgesics.
Dr Bridget Griffiths
Consultant Rheumatologist
Freeman Hospital
Newcastle upon Tyne
Prof Paul Emery
arc Professor of Rheumatology
Academic Section of Musculoskeletal Disease
Chapel Allerton Hospital
Leeds LS7 4SA