Rheumatoid Arthritis and Fibromyalgia: What’s The Connection?

The pain, achiness, and deep desire to climb back into bed and pull up the covers: If you have either rheumatoid arthritis (RA) or fibromyalgia, you know these feelings well. Although they are two different conditions with distinct causes and treatments, RA and fibromyalgia can sometimes share similar symptoms.

While doctors have diagnostic tools that can easily differentiate fibro from RA, “it can be difficult for the average person to tell the two apart,” since both can cause widespread pain, explains Sreelakshmi Panginikkod, M.D., a rheumatologist at Tufts Medical Center in Boston, MA. Let’s look at what the two diagnoses have in common, how to distinguish them, and what to do if it turns out you have both.

Fibromyalgia and rheumatoid arthritis are both chronic conditions that can cause widespread pain and other symptoms like fatigue, headache, and sensitivity to temperature changes. Both are more common in women, especially those in their 30s and 40s, according to the American College of Rheumatology and the Office on Women’s Health.

And sometimes, the two conditions can exist together. People with RA are more likely to develop fibromyalgia compared to the general population, Dr. Panginikkod says.

“The chronic inflammation caused by RA can sometimes cause damage to nerves, and one of the things that can precipitate fibromyalgia is nerve damage. So nerve damage from RA can start the process that leads to fibromyalgia,” explains Kevin Hackshaw, M.D., a rheumatologist at the Rheumatology Clinic at UT Health Austin in Austin, TX.

Approximately 2% of the U.S. population (or 4 million adults) have fibromyalgia, per the Centers for Disease Control and Prevention (CDC). Around 1% of the U.S. population or 1.3 million adults has rheumatoid arthritis, notes a Journal of Clinical Medicine review.

It’s not unusual for the two conditions to coexist. Up to 24% of people with RA also have fibromyalgia, per paper published in Best Practice & Research Clinical Rheumatology.

Though fibromyalgia and RA cause some similar symptoms and can sometimes occur together, they have distinct causes and the pain they cause tends to affect different areas of the body.

RA is an autoimmune disorder that occurs when the immune system mistakenly attacks healthy joint tissue, causing inflammation and leading to pain, stiffness, swelling, per the Mayo Clinic. This can occur in just one spot or on one side of the body. Most people have their worst symptoms in the morning, with their discomfort easing as the day goes on and they continue to move around, Dr. Panginikkod says. The wrists, knees, ankles, elbows, hips, and shoulders are most often affected.

Fibromyalgia is a chronic pain condition that’s thought to occur when a person’s central nervous system becomes hypersensitive to external stimuli, causing widespread muscle aches and tenderness, per the Office on Women’s Health. The pain tends to be constant throughout the day, adds Dr. Panginikkod. Joints aren’t usually affected with fibro though. Instead, a person will have muscle pain on both sides of the body, both above and below the waist, per the Mayo Clinic.

Fibro pain tends to cluster with many other symptoms, while RA does not. The CDC notes that people with fibromyalgia often experience:

• Brain fog

• Depression or anxiety

• Digestive symptoms (like IBS)

• Face or jaw pain

• Frequent headaches

• Sleep problems

There are two hallmarks of both RA and fibro, according to Dr. Hacksaw: Chronic pain and fatigue. Even after sleeping or resting, it’s not uncommon for someone with RA or fibro to still feel wiped out. Some other symptoms that are more common in fibromyalgia can also occur for some people with RA. These include:

• Brain fog

• Depression

• GI symptoms

• Headaches

• Temperature sensitivity

• Trouble sleeping

Both fibro and RA can be diagnosed by a rheumatologist. Your doctor will start out by asking about your symptoms and conducting a physical exam. For RA, they might look to see if your joints look red or swollen, a sign of inflammation. For fibromyalgia, they’ll palpate (apply firm but gentle pressure) areas on the body that tend to be painful or tender. Areas of the body that your doctor may focus on with fibromyalgia include:

• Back of your upper shoulders

• Behind your knees

• Inner arms

• Neck

• Under your clavicles

• Upper buttocks area

Experts call these spots tender points, Dr. Hackshaw explains.

Your medical team will also conduct imaging tests, like an ultrasound or MRI, to look for joint inflammation, a key sign of RA, says Dr. Panginikkod. You’ll also have a blood test to look for additional markers of inflammation like C-reactive protein (CRP), the Mayo Clinic notes.

If the physical exam, imaging tests, and blood tests all show signs of joint inflammation, RA is the likely culprit. If your are experiencing tender point pain without showing signs of inflammation, the problem might be fibro. In that case, more blood tests might be needed to rule out other conditions that can cause fibro-like symptoms, like an underactive thyroid or celiac disease, says the Mayo Clinic.

Of course, it’s possible for a person to have both RA and fibro. “The most common scenario is that we treat someone for RA, and when they come back, we won’t see evidence of swollen joints but they’re still experiencing pain all over,” Dr. Hackshaw explains. “That’s a good indication that the RA is under control, but the fibro is not.”

A rheumatologist can help you manage your rheumatoid arthritis or fibromyalgia. But treatment for each condition will be different.

The main goal of treatment for RA is to reduce inflammation, which reduces pain and swelling and can help protect your joints from damage. That’s done with immunosuppressant drugs such as disease-modifying antirheumatic drugs (DMARDs), biologics, or small molecule medications. “All of these work by decreasing immune cells in one way or another to reduce inflammation,” Dr. Panginikkod says.

Meds aren’t a must for fibro. In fact, aerobic and muscle-strengthening activities are the most effective way to reduce pain and improve quality of life for people with fibromyalgia, found a Biomed Research International review of 14 randomized controlled trials. “It’s the cornerstone of treatment,” Dr. Panginikkod says. “We begin by telling patients to set up a daily activity target, starting with walking for 10 minutes a day and gradually increasing.”

Treatments aimed at improving mental health can also help fibromyalgia and RA. Cognitive behavioral therapy (CBT) has been shown to help people with fibro manage negative thoughts about their pain and make it easier to cope. CBT can even quell connections between areas of the brain associated with self-awareness, pain, and emotional processing, found one Arthritis & Rheumatology study.

Nevertheless, drugs can be an option if lifestyle changes haven’t done enough to help you manage your symptoms. Your rheumatologist might prescribe an antidepressant like duloxetine for symptoms of low mood or depression, or a nerve medication like pregabalin for pain. “We’ll target different approaches based on a person’s predominant symptoms, “ Dr. Hackshaw says.

“Having both rheumatoid arthritis and fibromyalgia together makes both conditions worse,” Dr. Panginikkod says. After all, if fibro makes you hypersensitive to pain, you’ll feel the effects of your RA more intensely. People with RA and fibro have been shown to have higher RA disease activity, even with treatment. They also have worse functioning than those who have only one or the other, so it’s harder to carry out daily activities, according to one BMJ Open study. Because of that, they often need to take more prescription meds, another study found.

Unsurprisingly, this can take a toll on your mental health. “Any chronic pain condition can predispose someone to becoming depressed. So if you have both, the risk is definitely higher,” Dr. Hackshaw says.

Managing both fibro and RA together can be challenging. But it’s doable with a supportive health care team. “See a rheumatologist early,” Dr. Hackshaw says. “A rheumatologist will be trained to differentiate between the two conditions and recognize that both of them need to be addressed.”

With your doctor’s help, you can decide on the best medication therapy for your RA. You can put together a plan for managing your fibro too, including making lifestyle changes like exercising more, or looking into drug options to address symptoms. If stiffness from your RA makes it harder to be active, a physical therapist can help.

You can also explore other modalities that may make it easier for you to cope with the pain and fatigue. “We encourage patients to do meditation, breathing exercises, yoga, or tai chi. You can explore them to see what works for you,” Dr. Panginikkod says.

None of these things will cure your RA or fibro. But finding effective ways to manage your symptoms can help you feel your best, so you have the stamina to do more of the things you love.