Celiac disease, a gluten-free diet for difficult to treat joint pain

Ross Hauser MD, Marion Hauser, MS, RD

We are joint pain specialists, not gastroenterologists. Yet, we see a very large number of patients with symptoms of GI disturbances such as gas, bloating, indigestion, diarrhea, constipation, and other GI-related symptoms. This group of patients can be subdivided into two groups. Those with suspected cervical spine instability causing compression on nerves in the neck. Please see our article Nausea and gastroparesis caused by cervical spine instability, and those patients in our office for problems of joint pain, such as a knee, hip, shoulder, and ankle problems looking for non-surgical treatments and possible avoidance of surgery.

For some of these patients, and as you are now reading this article, probably like yourself,  joint pain and inflammatory disease has been connected as a problem with Celiac disease (the abnormal immune system responses to eating gluten, a protein found in wheat, barley, and rye) that damages the small intestine. Nutrients then quickly pass through the small intestine, rather than being absorbed.

To develop Celiac disease (CD) three (3) things must be present:

1) you must inherit the gene,

2) consume gluten, and

3) have the gene triggered.

Common triggers may include stress, trauma (surgeries, pregnancy, etc.), and viral infections. Gluten intolerance is a very common finding in the chronically ill. Many people with chronic fatigue, chronic pain, insomnia, digestive complaints, and stomach pains are found to be allergic to gluten (sensitive to it) when they undergo food blood allergy testing.

Up to 75% of patients with untreated celiac disease have osteopenia or osteoporosis.

For many people, undiagnosed celiac disease presents problems for their bones. Researchers at Sapienza University in Rome made the above finding that up to 75% of patients with untreated celiac disease have osteopenia (bone loss) or osteoporosis, and published this finding in the August 2018 issue of the United European Gastroenterology Journal. (1)

If you think that osteoporosis means just women, read what the researchers found:

• Bone Mass Density alterations were found in more than half (60%) of newly diagnosed adult celiac disease patients. Osteoporosis was significantly associated with men over the age of 45.
• The men in this study were suffering from significant bone loss and bone degeneration.

Celiac diseases cause bone damage and tendon damage

In the above study, the researchers pointed to the high risk of bone erosion and bone damage in diagnosed and untreated celiac disease. Clearly, if you have bone damage and bone loss, you will have joint and spine pain. According to other researchers, you will also have joint pain coming from the tendons. This pain too is caused by celiac disease.

How Celiac Disease attacks the point of tendon-bone attachment – The enthesis

The enthesis is the point at which the connective tissue structures, such as a joint capsule, fascia, ligament, tendon, or muscle attach to the bone. The term enthesopathy typically refers to a degenerated enthesis; though when some doctors use this term, they typically mean enthesitis (inflammation of the enthesis).

University medical researchers in Italy publishing in the journal Clinical Rheumatology (2) write about patients with pain originating from the enthesis attachments of joints.

• The aim of this study was to determine the prevalence of lower limb enthesopathy(weakness or injury to the attachment of a tendon or ligament to a bone.)
• Fifty-five untreated Celiac disease patients (group A) and 55 Celiac disease patients on a gluten-free diet for at least 1 year (group B), were matched for age and sex for the accuracy of results.
  • Among group A, 27 (49.8 %) patients presented at least one entheseal alteration as compared with 15 patients (27.2 %) of group B.
  • The Glasgow ultrasound enthesitis scoring system (GUESS) was significantly higher in patients of group A than in patients of group B.
• In conclusion, this study shows that enthesopathy is more frequent in untreated Celiac disease patients.

Now let’s look at an August 2018 study in the medical journal Rheumatology. (3) This is a multi-medical university research study led by the University of Ottawa Faculty of Medicine and includes teams from the United States, the United Kingdom, and Turkey. Watch the way the study ends.

• In this research, the doctors examined the higher subclinical enthesitis rates found on ultrasound in patients with Irritable Bowel Disease and celiac disease, separately. In other words, pre-clinical tendon tearing and damage.
• What the doctors were looking for ways to compare the symptoms and traits of irritable bowel disease and celiac disease and the tendon damage that these diseases were creating. Did they both create tendon damage the same way or did they create tendon damage differently? Knowing would make a big difference in the treatment of the disease and the secondary relief of the joint pain.
  • Irritable bowel disease is thought to create tendon damage by being a factor in the creation of generalized inflammation throughout the body. Treatment means anti-inflammatory protocols.
  • Celiac disease is thought to create tendon damage by abnormal gut permeability” Treatment by conservatively fixing the lining of the intestine through nutrition and other means.
• What they found was  the common factor between both diseases and enthesopathy is abnormal gut permeability (particles passing out of the intestinal tract and into the blood. The particles “permeate” through the intestinal lining and make their way around the body and could collect in the joints.) The immune system would see these particles as “invaders,” and respond by creating inflammation to destroy them. This would lead to clinical arthropathy or joint disease by way of indirect inflammation. That is an immune response to an invader, not an immune response to wound healing.

What does all this mean? The answer was not anti-inflammatory treatment, but diet. Change the diet to help seal up a “Leaky Gut.”

Joint pain improvements on a gluten-free diet, “more than just coincidental.”

In 2011, doctors in Turkey told the story of a 42-year-old woman in the prestigious journal Rheumatology International. (4) The title of their small case report was Celiac disease of the joint. Here is what they recorded:

• A 42-year-old woman presented with a 3-week history of left knee pain and swelling.
• She had suffered dermatitis herpetiformis (chronic itchy skin rash) for 12 years.
• She had never been on a gluten-free diet.
• Knee pain increased with motion and her gait was antalgic (in other words she altered the way she walked to avoid causing more knee pain).
• The 42-year-old was mainly dependent on a wheelchair due to pain and limitation.
• She responded well to a gluten-free diet. The Association of joint involvement and dermatitis herpetiformis is more than just coincidental.

The Turkish doctors emphasized that her joint pain and skin rashes improved when she went on a gluten-free diet, so much so that they stressed in their paper, that these improvements were “more than just coincidental.”

Understanding how devastating Celiac disease can be for your joint pain and your ability to repair joint damage

In the above paper, we have a case study significant enough to show the benefits of a gluten-free diet on a patient with joint pain and skin rashes. Doctors in the Czech Republic recently presented their research in their paper: “Bone and Joint Involvement in Celiac Disease,” (5) that showed what happened when a patients’ problems with gluten were not addressed.

Here are the bullet points of their research:

• Celiac disease (gluten-sensitive enteropathy) is currently regarded as a multisystem autoimmune disorder; its clinical signs and symptoms do not involve merely the gastrointestinal tract but are associated with several other medical specialties, including orthopaedics and traumatology (diseases of the musculoskeletal system such as arthritis).
• In orthopaedic and trauma patients, celiac disease should be suspected in the following diagnoses:
  • osteomalacia (softening of the bones),
  • premenopausal osteoporosis,
  • post-menopausal osteoporosis more severe than expected and unresponsive to most medications,
  • osteoporosis in men under 55 years of age,
  • recurrent bone fractures in the limbs,
  • pain in the large joints
  • or arthritis of unclear origins,
  • erosive spondyloarthropathy (chronic joint disease) particularly in patients with a history of chronic diarrhea, anemia, or associated autoimmune disorders (type 1 diabetes mellitus or autoimmune thyroid issues),
  • and in women with secondary amenorrhea or early menopause.

“A long-life gluten-free diet in these patients results in the alleviation of metabolic-related  joint and muscle problems, in reduced requirements of analgesic and anti-inflammatory drugs as well as in reduced risks of fracture.”

The Czech researchers recommend that the orthopedist or trauma surgeon should be aware of suspected celiac disease in patients who do not respond adequately to the standard treatment of pain related to the musculoskeletal system, in patients with recurrent fractures of the limb bones and in young patients with suspected secondary osteoporosis.

The good news about this research is, as stated above, the recommendation that: A long-life gluten-free diet in these patients results in the alleviation of metabolic-related joint and muscle problems, in reduced requirements of analgesic and anti-inflammatory drugs as well as in reduced risks of fracture.

Not all joint pain is driven by Celiac Disease

As mentioned above, celiac disease and gluten intolerance are underdiagnosed in many difficult-to-treat joint pain patients. However, just as it is under-diagnosed, self-diagnosis and starting a gluten-free diet may not be the answer to all joint pain.

A November 2017 paper in the Annals of Medicine entitled: “Gluten-related disorders: certainties, questions and doubts” (6) comes from Italian researchers and gives this warning:

• Many people follow a self-prescribed gluten-free diet, despite the fact that the majority have not first been previously excluded, or confirmed, as having gluten disorders.
• They rely on claims that a gluten-free diet improves general health.
• KEY MESSAGE Incidence of gluten-related disorders is increased in the last decade and self-diagnosis is frequent with inappropriate starting of a gluten-free diet.

In our many years putting together information on guiding patients to healthier eating, we found that one diet type did not fit all. Some patients are okay with wheat and grain products and in fact, can thrive on them, some cannot. A patient who tolerates and absorbs gluten well can be compromised if they go on a gluten-free diet.

Decisions about going gluten-free should be made with advice from your healthcare provider.

If you have questions about difficult to treat joint pain and treatment options, get help and information from Caring Medical

1 Galli G, Lahner E, Conti L, Esposito G, Sacchi MC, Annibale B. Risk factors associated with osteoporosis in a cohort of prospectively diagnosed adult coeliac patients. United European Gastroenterology Journal. 2018 Jun 12:2050640618784340. [Google Scholar]
2 Atteno M, Costa L, Cozzolino A, Tortora R, Caso F, Del Puente A, Cantarini L, Scarpa R, Ciacci C. The enthesopathy of celiac patients: effects of gluten-free diet. Clinical rheumatology. 2014 Apr 1;33(4):537-41. [Google Scholar]
3 Bakirci Ureyen S, Karacaer C, Toka B, Erturk Z, Eminler AT, Kaya M, Tascilar K, Tamer A, Uslan I, Kurum E, McGonagle D. Similar subclinical enthesitis in celiac and inflammatory bowel diseases by ultrasound suggests a gut enthesis axis independent of spondyloarthropathy spectrum. Rheumatology. 2018 May 8. [Google Scholar]
4 Ozyemisci-Taskiran O, Cengiz M, Atalay F. Celiac disease of the joint. Rheumatology international. 2011 May 1;31(5):573-6. [Google Scholar]
5 Hoffmanová I, Sánchez D, Džupa V. Bone and Joint Involvement in Celiac Disease. Acta chirurgiae orthopaedicae et traumatologiae Cechoslovaca. 2014 Dec;82(4):308-12. [Google Scholar]
6 Valenti S, Corica D, Ricciardi L, Romano C. Gluten-related disorders: certainties, questions and doubts. Annals of Medicine. 2017 May 11:1-3. [Google Scholar]

This page was updated October 30, 2021

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