Musculoskeletal manifestations of COVID-19

There has been quite a few papers recently on Covid-19 and it's involvement in the musculoskeletal (MSK) system. MSK relates to the musculature and skeleton together. I have brought the more salient points together for those with LC. To be honest the research currently is from the severe, hospitalised patients with Covid-19 but there are a few references to LC here and its nice (?) to know that the aching, sore muscles, fleeting joint pains and fatigue are now being noted.

Musculoskeletal manifestations of COVID-19

The extra-pulmonary (outside of the lung) involvements of SARS-COV-2, including musculoskeletal manifestations of the disease, have now become evident.

Musculoskeletal (MSK) symptoms of fatigue, myalgia, and arthralgia are common with COVID-19. This is especially true in the acute stages:

  • Fatigue - overwhelming lack of energy, exhaustion after mental and physical tasks. Rest boosts the immune system so we can fight the infection better.

  • Myalgia - muscular aches and pains

  • Arthralgia - joint pain

  • Arthritis - joint inflammation

Although the exact incidence of MSK affliction is unclear, Cipollaro et al. have reported clinical data on 12,046 patients (54% male and 46% females) looking at the prevalence of MSK symptoms and epidemiological characteristics in patients with COVID-19.

The total prevalence of fatigue symptoms was 25.6% while, the prevalence of arthralgia and myalgia was 15.5%. Eight studies have reported a higher prevalence of fatigue in more than 50% of patients. Some European studies have reported an even higher incidence of myalgia (59%) and arthralgia (31%).

The exact mechanism leading to the development of MSK manifestations in COVID-19 remains unclear. It is thought that Angiotensin-Converting Enzyme 2 (ACE-2) receptors found in the central, peripheral nervous systems and smooth muscles and expression of these in skeletal muscles and the synovium (the tissue lining a the joint) may act as a portal of entry for the Coronavirus SARS-CoV-2.

Once inside the cells co-fusion of viral structural spike (S) protein with the host cells results in subsequent viral replication, cell inflammation, cell death, altered immune response, and release of pro-inflammatory cytokine mediators.

Direct viral toxicity, endothelial cell damage, and dysregulation of the immune response lead to an abnormal, exaggerated inflammatory response. It appears to be the key mechanism in the pathophysiology of the variety of MSK clinical features associated with COVID-19.

Several short and long-term MSK manifestations of COVID-19 are reported in the literature. MSK manifestations are described in 25-50% of symptomatic patients with COVID-19.

These are usually present early in the course of the disease. Most of these symptoms are not severe but are disabling and manifest as fatigue, myalgia, or transient arthralgia. It appears to be found more commonly in females and associated with disease activity.

A more extended hospitalization period of about three weeks seems to increase Intensive Care Unit (ICU) acquired muscle weakness and deconditioning.

Soft tissue abnormalities such as limb gangrene, “COVID-19 toes,”, hematoma and pressure sores have been described primarily in patients with associated comorbidities such as diabetes mellitus.

Inflammatory-mediated thrombosis and endothelial injury are the responsible factors for it. Bone and joint involvement in COVID-19 also has a broad spectrum, with viral arthralgias being commoner rather than clinical arthritis.

“Long COVID” is a term used to describe the long-term effects of COVID-19 in people who have either suspected or confirmed COVID-19. These are seen in a group of people recovering from the disease but are still demonstrating ongoing symptoms of COVID-19 far longer than expected for the disease pattern. The commonly reported symptoms in these patients include fatigue (53%), dyspnoea (43%), joint pain (27%), and chest pain (22%).

Routine laboratory investigations to rule out other inflammatory joint pathology need to be carried out.

(I would initially recommend a full blood count FBC, a CRP and an ESR blood test from your GP if you are concerned).

Multimodality imaging may be required for the diagnosis and evaluation of MSK disorders in COVID-19 patients. Ramani et al. have reported MSK findings at various anatomical levels in patients with COVID-19 with characteristic abnormalities detected in soft tissues, muscles, bones, and joints.- see below.

The management of MSK symptoms requires NSAIDs (Non Steroidal Anti Inflammatory drugs) for pain relief and multi-disciplinary support, including orthopaedic rehabilitation.

Exercise-based regimes should be recommended to all patients following an in-hospital stay to reduce stiffness and disuse atrophy of muscles. Prevention of osteoporosis and osteonecrosis is crucial in every admitted patient, especially on high doses of steroids. Surveillance of symptoms is of paramount importance to minimize any progressive and long-term disability.

We need to wait and see if there are any long-term and permanent effects of COVID-19 on the bones and joints like conversion to inflammatory arthritis, and closed monitoring of these patients is therefore required.

Musculoskeletal involvement of COVID-19: review of imaging


This article aims to provide a first comprehensive summary of musculoskeletal manifestations of COVID-19 with review of imaging.

The global pandemic of coronavirus disease 2019 (COVID-19) has revealed a surprising number of extra-pulmonary manifestations of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection. While myalgia is a common clinical feature of COVID-19, other musculoskeletal manifestations of COVID-19 were infrequently described early during the pandemic. There have been emerging reports, however, of an array of neuromuscular and rheumatologic complications related to COVID-19 infection and disease course including :

  • Myositis - inflammation of muscles

  • Peripheral neuropathy - damage to the nerves in the body's extremities. This has been reported here as rare unless hospitalised. There have been few incidences of immune medicated peripheral neuropathy. As I am suffering from this myself, and have heard numerous reports of Long Haulers with tingling, burning and numbness in the hands and feet, I beg to differ! Seen as bright, enlarged nerves on imaging.

  • Arthropathy - Virus-induced arthritis can be challenging to confirm, but findings that suggest viral arthritis include onset of arthralgia within a few weeks following viral infection, a self-limiting course, and a good response to NSAIDs. Inflammatory arthropathies may be triggered by SARS-CoV-2 even in patients with mild or no respiratory symptoms with the acute viral infection, thereby necessitating correlation with COVID-19 testing to establish the association

Even in the absence of imaging findings characteristic of inflammatory arthritis, however, COVID-19 patients with acute arthritis may benefit from rheumatologic consultation.

  • Soft tissue abnormalities -“COVID toes” is a dermatologic manifestation of COVID-19 that warrants mention given potential clinical request for imaging. “COVID toes” is a chilblain-like phenomenon that manifests as erythema with vesicles or pustules, similar in appearance to frostbite and possibly due to a microvascular occlusive mechanism. While there are currently no publications regarding imaging findings of “COVID toes,” prior literature on the similar conditions of phalangeal microgeodic syndrome and Raynaud phenomenon have reported a distal-to-proximal phalangeal bone marrow edema pattern on MRI.

Many patients with Covid-19 related MSK disorders recover but for some individuals their MSK symptoms became serious and are deeply concerning to the patient or impact their quality of life which leads them to seek medical attention and screening

Imaging allows doctors to see if Covid-related muscle and joint pain are not just body aches but a MSK issue.

Rheumatic manifestations of COVID-19: a systematic review and meta-analysis

This article is essential saying that when a doctor is presented with a patient with a new MSK problem they need to consider Covid-19 a the root cause.


Background: Different proportions of musculoskeletal or autoimmune manifestations associated with COVID-19 have been reported in literature. We performed a systematic review and meta-analysis with the aim of assessing the prevalence of rheumatic manifestations in patients affected by COVID-19, as initial symptom or during disease course.

Methods: A database search was run on May 18th, 2020, using two distinct strategies. We were interested in the percentage of symptoms of potential rheumatologic interest observed in large population studies of COVID-19 cases, and in identifying uncommon autoimmune disorders described in patients with COVID-19. For manifestations individually reported, a meta-analysis was performed taking into consideration the proportion of COVID-19 patients presenting the symptom.

Results: Eighty eight original articles were included in the systematic review and 51 in the meta-analysis. We found pooled estimates of 19% for muscle pain and 32% for fatigue as initial symptom of COVID-19 presentation and, respectively, of 16 and 36% during the disease course. Only one article discussed arthralgia as unique symptom. Additionally, we found that vasculitis, chilblains, presence of autoantibodies commonly found in patients with rheumatic diseases, or autoimmune haematological and neurological disorders have all been reported in patients with COVID-19.

Conclusions: In conclusion, our review and meta-analysis emphasises that symptoms potentially leading to rheumatologic referral are common in patients with COVID-19. Therefore, COVID-19 is a new differential diagnosis to bear in mind when evaluating patients with musculoskeletal symptoms and rheumatologists might play a crucial role in identifying COVID-19 cases in early phases of the illness.


  • Musculoskeletal manifestations of COVID-19

  • Musculoskeletal involvement of COVID-19: review of imaging

  • Rheumatic manifestations of COVID-19: a systematic review and meta-analysis

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