The musculoskeletal system includes bones, muscles, joints, ligaments, tendons, and bursae (fluid-filled sacs). Any of these components can be injured by trauma or affected by a number of diseases causing joint, tendon, and muscle problems.

Bodily movement is made possible by the interaction of the muscular and skeletal systems; for this reason, they are often grouped together as the musculoskeletal system. The skeletal system serves many important functions, including providing the structure for the body. The skeletal system comprises 206 bones that form a rigid framework. Muscles are connected to bones by tendons. Tendons are tough yet flexible bands of fibrous tissue. Bones are connected to each other by ligaments. Ligaments are fibrous bands or sheets of connective tissue linking two or more bones, cartilages, or structures together. Where bones meet one another is called a joint. Muscles that cause movement of a joint are connected to two different bones.

The muscles contract (get shorter) and relax (get longer) to cause movement. An example would be the contraction of the biceps (a muscle located on the front of the upper arm) and a relaxation of the triceps (a muscle located on the back of the upper arm). This produces a bend at the elbow. The contraction of the triceps and relaxation of the biceps produces the effect of straightening the arm.

Common symptoms of joint, tendon, and muscle problems include inflammation, pain, weakness, stiffness, joint noises, and decreased range of motion. Inflammation can result from many conditions, including musculoskeletal disorders, autoimmune disorders, obesity, and infections. When inflammation occurs in a joint, fluid may accumulate inside the joint, causing swelling and decreased range of motion.

CAUSES AND RISK FACTORS

General:

Individuals who are more susceptible to joint, tendon, and muscle problems are those who tend to maintain fixed positions for extended periods of time (such as sitting in a chair or standing), perform repetitive movements of the limbs (such as factory workers), overload particular muscle groups (such as movers or manual workers), and those who apply pressure on body parts and use forceful movements (such as athletes). Previous injury to a muscle or bone will cause susceptibility to joint, tendon, or muscle problems.

Joint, tendon, and muscle pain can be caused by injury to bones, joints, muscles, tendons, ligaments, bursae, or nerves. If pain occurs when there has been no injury to a joint, tendon, or muscle, or if pain from an injury persists for more than a few days, then another cause may be responsible, such as nutrient depletion of magnesium or Coenzyme Q10.

Muscle pain:

Muscle pain is known as myalgia. Muscle pain is often less intense than that of bone pain but can be very unpleasant. For example, a muscle spasm or cramp (a sustained painful muscle contraction) in the calf is an intense pain that is commonly called a charley horse.

The most common causes of muscle pain are: injury or trauma, overuse, and tension or stress. Other causes include: certain drugs, including ACE inhibitors for lowering blood pressure, cocaine, and statins for lowering cholesterol (these drugs may deplete certain nutrients from the body); dermatomyositis, a connective-tissue disease that is characterized by inflammation of the muscles and the skin; electrolyte imbalances, such as too little potassium or calcium; fibromyalgia, a condition that causes widespread muscular pain in the body; infections, including influenza, Lyme disease, and malaria; and a breakdown of muscle fibers called rhabdomyolysis, which results in the release of muscle fiber contents (myoglobin) into the bloodstream.

Joint pain:

Joint pain, also called arthralgia, is a symptom of injury, infection, illnesses (especially arthritis), or an allergic reaction to medication.

Causes of joint pain include: recent joint injury; joint strain; joint sprain; previous joint injury; infections such as influenza and the common cold; arthritis, including rheumatoid arthritis, osteoarthritis, and ankylosing spondylitis; gout; sickle cell disease; Lyme disease; acute rheumatic fever; and cancer.

Bone pain due to joint damage can be deep, penetrating, dull, or sharp. Bone pain, or ostealgia, refers to pain within the affected bone. Common causes of bone pain include underlying medical disorders or past bone traumas. Other causes are: viral illness, leukemia, sepsis/bacteraemia (infection of the blood), physical trauma to the bone (such as a fall), arthritic pain, fibromyalgia, neoplasm/cancer, Paget's disease, and osteoporosis.

Tendon pain:

Tendon pain, also called tendinopathy, affects joint areas, most commonly the shoulder, elbow, wrist, hip, knee, and ankle.

Common causes of tendon pain include tendonitis, bursitis, tenosynovitis (inflammation of the fluid-filled sheath that surrounds a tendon), lateral and medial epicondylitis (tennis elbow), and tendon injuries. Tendon and ligament pain is often worse when the affected and inflamed tendon or ligament is stretched or moved, which happens during walking. Common causes of ligament pain include injuries (sprains).

SIGNS AND SYMPTOMS

General:

Pain is the main symptom of most joint, tendon, and muscle disorders. The pain may be dull, sharp, radiating, or local and may be mild to severe. Although pain may be acute (immediate), as is the case with most injuries, it may become chronic (long-term) with illnesses such as rheumatoid arthritis.

Muscle pain:

Symptoms of muscle pain include pain, weakness, paralysis, muscle spasms, and coordination problems.

Joint pain:

Symptoms of joint problems include pain, swelling, stiffness, and/or fever in the joints. In the absence of an injury, pain in one or more of the joints is often caused by inflammation or infection.

Stiffness is the feeling that the range of motion of a joint or muscle is more limited than normal or difficult to move. Some people with stiffness are capable of moving the joint through its full range of motion, although with difficulty. Joint stiffness usually is worse immediately when arising after lying or sitting still. Joint stiffness is common with arthritis.

Joint noises, such as creaks and clicks, are common and harmless in many individuals, but they can also occur with specific problems of the joints. For example, the base of the knee cap may creak when it is damaged by osteoarthritis.

Tendon pain:

Symptoms of tendon problems include pain, tenderness, redness, warmth, and/or swelling near the injured tendon. Pain may increase with activity. Symptoms of tendon injury may affect the precise area where the injured tendon is located or may radiate out from the joint area, unlike arthritis pain, which tends to be confined to the joint. Other symptoms include crepitus, or a crunchy sound or feeling when the tendon is used. Crepitus is usually painful. Crepitus may occur in osteoarthritis when the cartilage around joints has eroded away and the joint ends grind against one another, or when the fracture surfaces of two broken bones rub together.

Pain and stiffness may be worse during the night or when getting up in the morning. Stiffness may occur in the joint near the affected tendon. Movement or mild exercise of the joint usually reduces the stiffness. However, a tendon injury typically gets worse if the affected tendon is not allowed to rest and heal. Too much movement may worsen existing symptoms or bring the pain and stiffness back after improvement.

COMPLICATIONS

Depression: Some individuals with joint, tendon, and muscle problems may suffer from depression. This may happen if the joint, tendon, or muscle disorder interferes significantly with the patient's lifestyle, including causing pain. Individuals should consult their healthcare providers if they experience feelings of sadness, low self-esteem, loss of pleasure, apathy, difficulty functioning, or thoughts of suicide for two weeks or longer with no known underlying cause. These may be signs of depression.

Joint damage: In some cases, joint disorders can lead to severe joint damage. In such cases, surgery, such as a joint replacement, may be necessary. Individuals should regularly visit their healthcare providers to monitor their conditions.

Joint deformity: Joint deformities, major changes in the shape of a joint compared to the average shape, are acquired after birth as the result of injury or disease. An example is hand deformities commonly seen with rheumatoid arthritis.

Decreased mobility: Patients with joint, tendon, and muscle disorders may have decreased mobility in their joints. Joint mobility decreases as the joint becomes more damaged.

Muscular atrophy: Muscle atrophy refers to a decrease in the size of skeletal muscle, which occurs due to age, lack of use, body wasting (such as in cancer), or diseases such as muscular dystrophy (a genetic, hereditary muscle disease caused by progressive muscle weakness). When a muscle atrophies, it necessarily becomes weaker, since the ability to exert force is related to mass.

DIAGNOSIS

A clinician can often diagnose a joint, tendon, and muscle disorder based on the symptoms and on the results of a physical examination. Laboratory tests, imaging tests, or other diagnostic procedures are sometimes necessary to help the clinician make or confirm a diagnosis.

Physical examination: When a person complains of muscle pain, the clinician checks muscles for bulk and texture and for tenderness. Muscles are also checked for twitches and involuntary movements, which may indicate a nerve disease rather than a muscle disease. Clinicians look for wasting away of muscle (atrophy), which can result from damage to the muscle or its nerves or from lack of use, as sometimes occurs with prolonged bed rest. Clinicians also look for muscle enlargement (hypertrophy), which normally occurs with an exercise such as weight lifting. However, when a person is injured, hypertrophy may result from one muscle working harder to compensate for the weakness of another.

Clinicians try to establish the muscles (if any) that are weak and how weak they are. The muscles can be tested systematically, usually beginning with the face and neck, then the arms, and finally the legs. Normally, a person should be able to hold the arms extended, with palms up, for one minute without any sagging, turning, or shaking. Downward drift of the arm with palms turning inward is one sign of weakness. Strength is tested by pushing or pulling while the clinician pushes and pulls in the opposite direction. Strength is also tested by having the person perform certain maneuvers, such as walking on the heels and tiptoes, rising from a squatting position, or getting up and down from a chair rapidly 10 times.

The clinician tests a joint's range of motion and muscle tone by moving the limb around a joint while the person is completely relaxed. Resistance to such movement may be decreased, resulting in observation of a larger range of motion than normal, if the nerve leading to the muscle is damaged. There may be more resistance to such movement and a smaller range of motion when the spinal cord or brain is damaged.

If a person complains of or has observable signs of weakness, clinicians will assess their reflexes using a rubber hammer to tap the person's muscle tendon. Reflexes are involuntary responses of the nerves in the muscles caused by outside stimulus, such as the rubber hammer. Reflexes may be slower than expected when the nerve leading to the muscle is damaged. Reflexes may be more rapid than expected when the spinal cord or brain is damaged.

Laboratory tests: Laboratory tests are often helpful in making the diagnosis of the underlying cause of joint, tendon, and/or muscle pain. A test called an erythrocyte sedimentation rate (ESR) test measures the rate at which red blood cells settle to the bottom of a test tube containing blood. The ESR is increased when inflammation is present. However, because inflammation occurs in so many conditions, the ESR alone does not establish a diagnosis.

The level of creatine kinase (a normal muscle enzyme that leaks out and is released into the bloodstream when muscle is damaged) may also be tested. Levels of creatine kinase may also be increased when there is widespread and ongoing destruction of muscle.

In autoimmune diseases such as rheumatoid arthritis and systemic lupus erythematosus (lupus), a blood test to identify autoimmune antibodies (antinuclear antibodies) is often used in making the diagnosis.

Nerve tests: Nerve conduction studies measure how well and how fast the nerves can send electrical signals. Nerves control the muscles in the body by electrical signals (impulses), and these impulses make the muscles react in specific ways. Nerve and muscle disorders cause the muscles to react in abnormal ways.

Nerve conduction studies, together with electromyography, help indicate the primary source of the problem causing pain. Electromyography, often performed at the same time as nerve conduction studies, is a test in which electrical impulses in the muscles are recorded to help determine how well the impulses from the nerves are reaching the connection between nerves and muscles (neuromuscular junction) and, from there, the muscles.

X-rays: X-ray imaging is used most often to evaluate painful, deformed, or suspected abnormal areas of bone. Often, X-ray images can help to diagnose fractures, tumors, injuries, infections, and deformities. Also, X-ray images may be helpful in showing changes that confirm a person has a certain kind of arthritis (for example, rheumatoid arthritis or osteoarthritis). X-ray images do not show soft tissues such as muscles, bursae, ligaments, tendons, or nerves.

Arthrography is an X-ray procedure in which a dye is injected into a joint space to outline the structures, such as ligaments, inside the joint. Arthrography can be used to view torn ligaments and fragmented cartilage in the joint.

Dual-energy X-ray absorptiometry (DEXA): The most accurate way to evaluate bone density, which is necessary when screening for or diagnosing osteoporosis, is with dual-energy X-ray absorptiometry (DEXA). In this test, low-dose X-rays are used to examine bone density at the lower spine, hip, wrist, or entire body. Measurements of bone density are very accurate at these sites. To help differentiate osteoporosis (the most common cause of an abnormal DEXA scan) from other bone disorders, doctors may need to consider the person's symptoms, medical conditions, medication use, and certain blood or urine test results as well as the DEXA results.

Computed tomography (CT) and magnetic resonance imaging (MRI): Computed tomography (CT) and magnetic resonance imaging (MRI) scans show more body detail than conventional X-rays. For this reason, CTs and MRIs may be performed to determine the extent and exact location of joint, tendon, or muscle damage. These tests can also be used to detect fractures that are not visible on X-rays. MRI is especially valuable for imaging muscles, ligaments, and tendons. MRI can be used if the cause of pain is thought to be a severe soft-tissue problem (for example, rupture of a major ligament or tendon or damage to important structures inside the knee joint). The amount of time needed to complete a CT is much less than for an MRI.

Bone scanning: Bone scanning is an imaging procedure that is occasionally used to diagnose a fracture, particularly if other tests, such as X-rays and CTs or MRIs, do not reveal the fracture. Fractures may be a cause of joint pain. Bone scanning involves the use of a radioactive substance (such as technetium-99m-labeled pyrophosphate) that is absorbed by any healing bone. The technique can also be used when a bone infection or a metastasis (spread of cancer) is suspected. The radioactive substance is given intravenously and is detected by a bone-scanning device, creating an image of the bone that can be viewed on a computer screen.

Joint aspiration: Joint aspiration is used to diagnose certain joint problems. A needle is inserted into a joint space and fluid (synovial fluid) is drawn out (aspirated) and examined under a microscope. A doctor can often make a diagnosis after microscopic analysis. For example, a sample of synovial fluid may contain bacteria, which confirms a diagnosis of infection. Joint aspiration is usually performed in a doctor's office and is generally quick, easy, and relatively painless. The risk of joint infection is minimal.

Arthroscopy: Arthroscopy is a procedure in which a small (diameter of a pencil) fiber optic scope is inserted into a joint space, allowing the doctor to look inside the joint and to project the image onto a television screen. The skin incision is very small. A person receives local, spinal, or general anesthesia to numb any pain during the procedure. During arthroscopy, doctors can take a piece of tissue for analysis (biopsy), and, if necessary, perform surgery to correct the condition. Disorders commonly found during arthroscopy include inflammation of the synovium lining (a thin, layer of tissue which lines the joint space) called synovitis; ligament, tendon, or cartilage tears; and loose pieces of bone or cartilage. Such conditions affect people with arthritis or previous joint injuries as well as athletes. All of these conditions can be repaired or removed during arthroscopy. There is a very small risk of joint infection with this procedure.

TREATMENT

General: Joint, tendon, and muscle problems are often managed with medications that reduce pain and inflammation. Treatment depends on the cause of the problem. In severe cases, surgery may be necessary to repair damage.

In order to properly manage pain and prevent joint damage, individuals should take their medications as prescribed by their healthcare providers. Individuals with joint, tendon, and muscle problems should also tell their healthcare providers if they are taking any other drugs (prescription, over-the-counter, or dietary supplements) because they may interfere with treatment.

Corticosteroids: Corticosteroids, such as prednisone (Deltasone©) and methylprednisolone (Medrol©), are occasionally used to reduce inflammation and pain and slow joint damage. These drugs are generally very effective when used short-term. However, if used for many months to years, these drugs may become less effective and serious side effects may develop. Side effects may include easy bruising, thinning of bones, cataracts, weight gain, a "moon" face (swelling of the face), and type 2 diabetes.

Corticosteroids are usually prescribed for a certain amount of time and then the individual is gradually tapered off the medication. Individuals should not stop taking corticosteroids suddenly or change their dosages without first consulting their healthcare providers.

Nonsteroidal anti-inflammatory drugs (NSAIDs): Nonsteroidal anti-inflammatory drugs (NSAIDs) have been used to relieve pain and inflammation caused by joint, tendon, and muscle problems. Some commonly used over-the-counter NSAIDs include ibuprofen (Advil© or Motrin©) and naproxen sodium (Aleve©). Higher doses of these drugs are also available by prescription. Commonly prescribed NSAIDs include diclofenac (Cataflam© or Voltaren©), nabumetone (Relafen©), and ketoprofen (Orudis©). NSAIDs may be taken by mouth, injected into a vein, or applied to the skin. These medications are generally taken long term to manage symptoms.

The frequency and severity of side effects vary between NSAIDs. The most common side effects include nausea, vomiting, diarrhea, constipation, decreased appetite, rash, dizziness, headache, and drowsiness. The most serious side effects include kidney failure, liver failure, ulcers, heart-related problems, and prolonged bleeding after an injury or surgery. About 15% of patients who receive long-term NSAID treatment develop ulcers in the stomach or duodenum.

Pain relievers: Over-the-counter (OTC) pain relievers used in the treatment of joint, tendon, and muscle pain include acetaminophen (Tylenol©). It is important to monitor the amount of acetaminophen taken, as greater than 4 grams daily may cause liver damage. Prescription pain relievers, including tramadol (Ultram©), have been used to reduce pain caused by joint, tendon, and muscle problems. Although this drug, which is available by prescription, does not reduce swelling, it has fewer side effects than NSAIDs. Tramadol is generally taken as a short-term treatment to reduce symptoms of flare-ups.

Narcotic pain relievers, such as acetaminophen/codeine (Tylenol with Codeine©), hydrocodone/acetaminophen (Lorcet©, Lortab©, or Vicodin©), or oxycodone (OxyContin© or Roxicodone©), may be prescribed to treat severe joint, tendon, and muscle pain. However, they do not reduce swelling. These medications are only used short-term to treat flare-ups. Common side effects include constipation, drowsiness, dry mouth, and difficulty urinating. Narcotic pain relievers should be used cautiously because individuals may become dependent upon them.

Selective COX-2 inhibitors: Celecoxib (Celebrex©) has been taken by mouth to reduce pain and inflammation caused by joint, tendon, and muscle problems such as osteoarthritis. Celecoxib is currently the only COX-2 inhibitor that is approved by the U.S. Food and Drug Administration (FDA). Celecoxib is generally taken long term to manage symptoms.

COX-2 inhibitors have been linked to an increased risk of serious heart-related side effects, including heart attack and stroke. Selective COX-2 inhibitors have also been shown to increase the risk of stomach bleeding, fluid retention, kidney problems, and liver damage. Less serious side effects may include headache, indigestion, upper respiratory tract infection, diarrhea, sinus inflammation, stomach pain, and nausea.

Topical pain relievers: Topical pain relievers are creams, ointments, gels, and sprays that are applied to the skin to alleviate pain. Many over-the-counter (OTC) pain relievers may temporarily help reduce the pain caused by joint, tendon, or muscle problems. Products such as Aspercreme©, Sportscreme©, Icy Hot©, and Ben-Gay© may help reduce arthritis pain. Capsaicin cream, which is made from the seeds of hot peppers, may reduce pain in joints that are close to the skin surface, such as the fingers, knees, and elbows. However, pain may worsen for a few weeks when beginning to use capsaicin cream. Lidocaine patches (Lidoderm©) may also be used. Lidocaine is an anesthetic and when applied topically may decrease pain associated with joint, tendon, and muscle problems.

Antidepressants: Some individuals with joint, tendon, and muscle problems may also suffer from depression. Commonly prescribed anti-depressants for arthritis patients include amitriptyline, nortriptyline (Aventyl©, Pamelor©), and trazodone (Desyrel©). These drugs may also help with nerve pain associated with joint, tendon, and muscle disorders. Side effects of antidepressant medications include drowsiness, fatigue (excessive tiredness), constipation, dry mouth, and blurred vision.

Lifestyle modifications: Many lifestyle changes, including regular exercise, weight management, and consumption of a healthy diet may help reduce symptoms of joint, tendon, and muscle problems. A healthcare provider may recommend a physical therapist, nutritionist, or registered dietician to help determine the best treatment plan for the individual.

Individuals with joint, tendon, and muscle problems, such as osteoarthritis or rheumatoid arthritis, should wear comfortable footwear that properly supports their weight. This may reduce the amount of strain put on the joints during walking.

Individuals with joint, tendon, and muscle problems may require canes, walkers, or other devices to help them get around. If the hands are severely affected, braces may be beneficial. Individuals should talk to their healthcare providers about assistive devices that are available.

Individuals with joint, tendon, and muscle problems should maintain good posture. This allows the body's weight to be evenly distributed among joints.

Cool compress or ice pack: Applying a cool compress or ice pack to the affected joint during a flare-up may help reduce swelling and pain.

Heat application: Applying a hot pack to affected joints may help reduce pain, relax muscles, and increase blood flow to the joint. It may also be an effective treatment before exercise. Alternatively, individuals may take a hot shower or bath before or after exercise to help reduce pain.

Joint replacement surgery: In some cases, individuals with joint disorders suffer from permanent joint damage. In such instances, joint replacement surgery may be necessary. During the procedure, the damaged joint is surgically removed and replaced with a plastic or metal device, called prosthesis. The most commonly replaced joints are the hip and knee, but other joints, including the elbow, shoulder, finger, or ankle joints, can be replaced.

Joint replacement surgeries are generally most successful for large joints, such as the hip or knee. Researchers estimate that hip or knee replacements last at least 20 years in 80% of patients. After a successful surgery and several months of rehabilitation, individuals are able to use their new joints without pain.

As with any major surgery, there are risks associated with joint replacements. Patients should discuss the potential health risks and benefits of surgery with their healthcare providers.

Viscosupplementation: Viscosupplementation is a type of therapy in which the hyaluronic acid in the affected joints can be changed through a series of injections. Hyaluronic acid (HA) is a substance found in the connective tissue of the body that cushions and lubricates the joints. Sometimes, either through the effects of aging, accident, or a disease, such as arthritis, components of the synovial fluid, including HA, may begin to break down. In patients with osteoarthritis, the concentration of HA in the synovial fluid is reduced, resulting in smaller and less effective molecules. The HA loses some of the lubricating and shock absorbing properties that protect the joint. Researchers believe that this can result in joint pain, stiffness, and perhaps an onset or worsening of osteoarthritis.

Viscosupplementation injections are administered in a clinician's office. Treatment consists of a series of three to five injections, one given each week, directly into the affected joint. Relief is often felt during the injection series but full effect should not be expected until the injection series is complete. Patients report reduced pain and increased joint mobility lasting from a few months to over a year.

Individuals should not receive HA viscosupplementation if they ever had an allergic reaction to any other hyaluronate preparations or are allergic to poultry products. Individuals should not receive the injections if infection or skin disease is present around the injection area. As with any injection, mild pain may occur at the injection site. Swelling, heat, and/or redness, rash, itching, or bruising around the joint may also be present. These reactions are generally mild and usually do not last long.

INTEGRATIVE THERAPIES

Strong scientific evidence:

Acupuncture: Acupuncture is commonly used throughout the world. According to Chinese medicine theory, the human body contains a network of energy pathways through which vital energy, called chi, circulates. These pathways contain specific "points" that function like gates, allowing chi to flow through the body. Needles are inserted into these points to regulate the flow of chi. There has been substantial research into the efficacy of acupuncture in the treatment of osteoarthritis (OA). Most studies focus on knee, cervical, and hip OA symptoms. In recent years, the evidence has improved and is now considered strong enough to recommend trying acupuncture in OA of the knee, which is one of the most common forms of this condition.

Needles must be sterile in order to avoid disease transmission. Avoid with valvular heart disease, infections, bleeding disorders, medical conditions of unknown origin, neurological disorders, or if taking anticoagulants. Avoid on areas that have received radiation therapy and during pregnancy. Avoid electroacupuncture with irregular heartbeat or in patients with pacemakers. Use cautiously with pulmonary disease (like asthma or emphysema). Use cautiously in elderly or medically compromised patients, diabetics or with a history of seizures.

Chondroitin: Multiple clinical trials have examined the use of oral chondroitin in patients with osteoarthritis of the knee and other joints (spine, hips, and finger joints). Most of these studies have reported significant benefits in terms of symptoms (such as pain), function (such as mobility), and reduced medication requirements (such as anti-inflammatory). The weight of scientific evidence points to a beneficial effect when chondroitin is used for six to 24 months. Longer-term effects are not clear. Preliminary studies of topical chondroitin have also been conducted.

Avoid with prostate cancer or an increased risk of prostate cancer. Use cautiously if allergic or hypersensitive to chondroitin sulfate products or with shellfish allergy. Use cautiously with bleeding disorders or if taking blood-thinners like warfarin (like Coumadin©). Avoid if pregnant or breastfeeding.

Glucosamine: Glucosamine is a natural compound that is found in healthy cartilage. Based on human research, there is strong evidence to support the use of glucosamine sulfate in the treatment of mild-to-moderate knee osteoarthritis. Most studies have used glucosamine sulfate supplied by one European manufacturer (Rotta Research Laboratorium), and it is not known if glucosamine preparations made by other manufacturers are equally effective. Although some studies of glucosamine have not found benefits, these have either included patients with severe osteoarthritis or used products other than glucosamine sulfate. The evidence for the effect of glycosaminoglycan polysulphate is conflicting and merits further investigation. More well-designed clinical trials are needed to confirm safety and effectiveness, and to test different formulations of glucosamine.

Avoid if allergic or hypersensitive to shellfish or iodine. Some reports suggest a link between glucosamine/chondroitin products and asthma. Use cautiously with diabetes or with a history of bleeding disorders. Avoid if pregnant or breastfeeding.

Willow bark: Willow (Salix alba) bark that contains salicin has been used to treat many different kinds of pain. Willow bark is a traditional analgesic (pain relieving) therapy for osteoarthritis. Several studied have confirmed this finding. Additional study comparing willow bark to conventional medicinal agents for safety and effectiveness is warranted.

Avoid if allergic/hypersensitive to aspirin, willow bark (Salix spp.), or any of its constituents, including salicylates. Avoid operating heavy machinery. Avoid in children with chickenpox and any other viral infections. Avoid with blood disorders or kidney disorders. Avoid if taking other NSAIDs, acetazolamide or other carbonic anhydrase inhibitors. Avoid with elevated serum cadmium levels. Use cautiously with gastrointestinal problems, such as ulcers, hepatic disorders, diabetes, gout, high blood pressure, hyperlipidemia, history of allergy or asthma, or leukemia. Use cautiously if taking protein-bound medications, antihyperlipidemia agents, alcohol, leukemia medications, beta-blockers, diuretics, Phenytoin (Dilantin©), probenecid, spironolactone, sulfonylureas, valproic acid, or methotrexate. Use cautiously if predisposed to headaches. Use cautiously with tannin-containing herbs or supplements. Avoid if pregnant or breastfeeding.

Good scientific evidence:

5-HTP (5-hydroxytryptophan): 5-HTP is the precursor of the neurotransmitter serotonin. It is obtained commercially from the seeds of the plant Griffonia simplicifolia. There is a small amount of research evaluating the use of 5-HTP for fibromyalgia, and early evidence suggests that 5-HTP may reduce the number of tender points, anxiety, and intensity of pain and may improve sleep, fatigue, and morning stiffness.

5-HTP may cause drug interaction with medications such as antidepressants and sleep medicines. 5-HTP is not recommended during pregnancy or breastfeeding, unless otherwise advised by a doctor.

Acupuncture: There is evidence from several studies suggesting acupuncture may help with pain relief in fibromyalgia. More high quality studies would help to confirm these study results.

Needles must be sterile in order to avoid disease transmission. Avoid with valvular heart disease, infections, bleeding disorders, medical conditions of unknown origin, neurological disorders, or if taking anticoagulants. Avoid on areas that have received radiation therapy and during pregnancy. Avoid electroacupuncture with irregular heartbeat or in patients with pacemakers. Use cautiously with pulmonary disease (like asthma or emphysema). Use cautiously in elderly or medically compromised patients, diabetics or with a history of seizures.

Avocado: A combination of avocado/soybean unsaponifiables (ASU) has been found beneficial in osteoarthritis of the knee and hip. Additional study using avocado (Persea Americana) alone in OA is needed.

Avoid if allergic or hypersensitive to avocado, banana, chestnut, or natural rubber latex. Avoid with monoamine oxidase inhibitors (MAOIs). Use cautiously with anticoagulants (like warfarin). Doses greater than found in a normal diet is not recommended if pregnant or breastfeeding. Some types of avocado may be unsafe when breastfeeding.

Borage seed oil: Preliminary evidence suggests that gamma linolenic acid (GLA) may have anti-inflammatory effects that may make it beneficial in treating rheumatoid arthritis. Additional research is needed to determine the optimal dose and administration.

Avoid if allergic or hypersensitive to borage, its constituents, or members of the Boraginaceae family. Use cautiously in patients with bleeding disorders or in those taking warfarin or other anticoagulant or antiplatelet (blood thinning) agents. Use cautiously in patients with epilepsy or in those taking anticonvulsants. Avoid in patients with compromised immune systems or similar immunological conditions. Avoid during pregnancy and breastfeeding.

Chlorella: A randomized controlled trial and one case series indicate that chlorella may reduce the tenderness associated with fibromyalgia's tender points. Although the results are promising, more high quality studies are needed to confirm these studies' findings.

Avoid in patients with known allergy/hypersensitivity to chlorella, its constituents, mold, or members of the Oocystaceae family. Use cautiously in patients with hypotension, altered immune function, cancer, or taking antihypertensives, or immunomodulators. Use cautiously in patients with photosensitivity, taking photosensitizers, or exposed to the sun. Avoid long-term supplementation or with manganese supplementation. Avoid in patients using warfarin or other anticoagulant therapy.

Devil's claw: Devil's claw (Harpagophytum procumbens) originates from the Kalahari and Savannah desert regions of South and Southeast Africa. There is increasing scientific evidence suggesting that devil's claw is safe and beneficial for the short-term treatment of pain related to degenerative joint disease or osteoarthritis (8-12 weeks), and may be equally effective as drug therapies such as non-steroidal anti-inflammatory drugs like ibuprofen (Advil©, Motrin©), or may allow for dose reductions or stopping of these drugs in some patients. However, most studies have been small with flaws in their designs. Additional well-designed trials are necessary.