Bone Pain

What Is Bone Pain?

[dropcap]B[/dropcap]one pain is pain or tenderness in bone tissue. Bone pain intensity and location depend on the causative disorder.

Q: What are causative disorders of bone pain?

A: Bone pain is a feature of various disorders that include malnutrition, bone disease such as osteoarthritis, infection, inflammation, hyperparathyroidism, immune mechanisms, fractures, adverse effects or toxic effects of certain medications, and cancer such as sarcoma, leukemia, multiple myeloma, and metastatic lesions from a primary tumor elsewhere.

What Is Bone Pain In Celiac Disease and/or Gluten Sensitivity?

• Bone pain is a complication of celiac disease that can be severe and can be a presenting feature of celiac disease.
• The most common bone pain affects the sacroiliac joint. Imaging revealed different morphological changes in the sacroiliac joint associated with celiac disease which include accumulation of synovial fluid, synovitis, erosion with concomitant sclerosis, sacroilitis or calcification of the ligament. These changes probably represent different clinical stages and/or manifestations of the same process in this joint.¹
• In a follow-up study of eight patients, after 11 years on a gluten-free diet, the great majority of patients had no clinical symptoms; yet, a subclinical progression of the sacroiliac joint involvement could be verified. Results suggest the importance of regular rheumatologic follow-up of patients with celiac disease.²

How Prevalent Is Bone Pain In Celiac Disease and/or Gluten Sensitivity?

• Bone pain has increased prevalence in untreated celiac disease.³ Researchers found that 70% of 21 adult celiac patients had bone pain from involvement of the sacroiliac joints.⁴
• Bone pain was found in 20% of the children with gluten sensitivity. Histology revealed normal to mildly inflamed mucosa (Marsh stage 0-1) in these children with gluten sensitivity.⁵

What Are The Symptoms Of Bone Pain?

Bone pain intensity and location depend on the causative disorder.  Here are some major disorders due to malnutrition in celiac disease causing bone pain:

• In osteomalacia due to vitamin D deficiency with subsequent calcium deficiency, pain occurs in spine, pelvis, hips and lower extremities. Bone tenderness  may result in severe pain with pressure or just by lightly touching or rubbing.
• In osteoporosis  due to calcium and phosphorus deficiency, pain is diffuse.
• In osteonecrosis due to calcium deficiency, pain changes from dull to severe in deteriorating joints, commonly the hip.
• In osteitis fibrosa cystica due to vitamin D deficiency with hyperparathyroidism, bones are tender to pressure and painful.

How Does Bone Pain Develop In Celiac Disease and/or Gluten Sensitivity?

• Bone pain results from malabsorption causing vitamin D deficiency, consequent hypocalcemia (low blood calcium) and hyperparathyroidism occurring at the same time.⁶

Does Bone Pain Respond To Gluten-Free Diet?

Yes. Celiac disease-related bone pain resolves with therapy on gluten free diet.⁷,⁶

6 Steps To Improve Bone Pain In Celiac Disease and/or Gluten Sensitivity:

• [dropcap]1[/dropcap]Remove the Trigger. Maintain a Strict, Nutritious Gluten Free Diet:

[box type=”shadow” ]Treatment. This condition responds to the complete elimination of gluten, which is the required treatment that improves both bone pain and gut health.

• Gut health is the foundation to restore ALL health. Restored health will enable you to maintain a strict gluten free diet, just as other life tasks will be easier.
• A strict gluten free diet means removing 100% of wheat, barley, rye and oats from the diet.
• Cutting out bread and other obvious sources of gluten is not good enough for recovery. Even 1/8th teaspoon of flour or bread crumb is enough to sustain the inflammation that is damaging your small intestine, causing increased permeability (leaky gut) and allowing undigested gluten to enter your body where it can damage structures and function, and instigate immune inflammatory responses.

Correct Your Individual Nutritional Needs.

• Eat foods that can replenish missing nutrients. Find them under NUTRIENT DEFICIENCIES.
• Take nutritional supplements as needed. Find them under NUTRIENT DEFICIENCIES.

Recovery. You should begin to feel better within a week and notice more energy as inflammation subsides and the  absorbing cells that make up the surface lining of your small intestine are better able to function.

• Intestinal lining cells are replaced every 5 days. The healing process is like sunburn where the damaged surface layer of skin sloughs off and is replaced with new normal cells.
• Leaky gut normally resolves in two month after starting a gluten free diet and brings about a big improvement in health. Improvement in intestinal permeability precedes morphometric recovery (cell appearance and structure) of the small intestine in celiac disease.⁸
• The intestinal lining may take up to a year to heal.[/box]

• [dropcap]2[/dropcap] Reduce Inflammation. Foods to Eat and Foods Not to Eat:

Because gluten is inflammatory, eliminate OTHER inflammatory foods from your diet to reduce an additive effect to gluten. At the same time, try to eat foods that reduce inflammation (anti-inflammatory).

[box type=”shadow” ]Here Are Major Inflammatory Food Types That Reduce Healing:

• Damaging Foods. In susceptible persons, includes corn, dairy (cow), and soy. Lactose, the sugar in any animal milk disrupts intestinal permeability causing leaky gut.⁹
• Allergenic Foods. Includes foods that trigger the immune sytem to produce IgE antibodies. Allergy testing is the usual way to discover these offending foods.
• Shelf Stable Processed Foods. Includes any that contain additives and preservatives. Look for them on the nutrition label of the box or package. Additives and preservatives also disrupt intestinal permeability causing leaky gut.⁹
• Fats. Limit deep fried foods, trans-fats, saturated fats (animal fat/butter), and EXCESSIVE omega-6 fatty acid oils like corn oil. Rancid fats, sodium caprate (a medium chain fat), and sucrose monester fatty acid (a food grade surfactant) induce significant disruption of the intestinal barrier that causes leaky gut.⁹.
• Excessive Refined White Flours (bran layer removed). Includes products made from them such as cookies, bread, cakes, pies. Bran contains the vitamins and minerals that metabolize grains and slows the otherwise rapid entry of sugar from their digestion into the bloodstream. Also disrupt intestinal permeability causing leaky gut.⁹
• Refined Sugars.  Includes white sugar, corn fructose and high fructose corn syrup.
• Certain Spices. Includes paprika and cayenne pepper which disrupt intestinal permeability causing leaky gut.⁹
• Alcohol and Caffeine. Disrupt intestinal permeability causing leaky gut.⁹[/box]

[box type=”shadow” ]Here Are Important Anti-Inflammatory Food Types to Promote Health:

• Fruits. Contain ample amounts of vitamins, minerals and phytochemicals which are naturally occuring components in plants that detoxify toxins, carcinogens (reducing the risk by 50%) and mutagens.
• Non-Starchy Vegetables. Support intestinal integrity and provide ample amounts of vitamins, minerals and phytochemicals. Includes lettuce, kale, onion, broccoli, garlic, and others.
• High Quality Complex Carbohydrates. Provide vitamins, minerals, and fiber while boosting serotonin levels to help you relax and feel calm. Includes whole grains, legumes, and root vegetables such as carrots, parsnips, sweet potatoes, turnips, red beets, and others.
• Antioxidants. Protect the body from inflammatory oxidant molecules that continually occur and help us handle stress and reduce irritability. Includes vitamin C-containing foods such as lemon, grapefruit, apricot, Brussels sprouts and strawberries, and others. Also, includes vitamin E-containing foods such as nuts, seeds, avocado, olive oil, and others. Cocoa is good, too.
• Omega-3 Fatty Acids. Balance opposing omega-6 fatty acids and bad fats. Fish sources includes tuna, salmon, cod, and others. Plants sources include flax, chia seeds, canola oil, and others.
• Probiotics. Supply normal microbes needed for colon health and health of the body such as these fermented foods: yogurt, kefir, and unpasteurized apple cider vinegar.
• Prebiotics/ High Fiber Foods.  Food with fiber keeps our population of colonic microbes healthy.
• Protective Herbs and Spices.  See below #6 below for examples.[/box]

 

• [dropcap]3[/dropcap] Information Sheet You Can Take to Your Doctor or Other Health Professional:

Click here.

 

• [dropcap]4[/dropcap] Manage Your Medications Safely:

[box type=”shadow” ]

Certain prescription drugs deplete nutrients vitamin D and calcium which cause bone pain. Ask your doctor or pharmacist about this possible adverse effect if you are taking any of the drugs listed below. Do not stop prescribed medications without supervision.

 This is not a complete listing.

ANTACIDS / ULCER MEDICATIONS

• Pepcid®, Tagamet®, Zantac® deplete Calcium, Vitamin D.
• Magnesium and Aluminum Antacid preparations (Gaviscon®, Maalox®, Mylanta®) deplete  Calcium, Vitamin D.

ANTIBIOTICS disrupt intestinal permeability.

•  Tetracyclines deplete Calcium.

ANTI-INFLAMMATORIES disrupt intestinal permeability.

• Corticosteroids (Prednisone, Medrol®, Aristocort®, Decadron) deplete Calcium, Vitamin D.
• Aspirin and Salicylates deplete Calcium.

ANTICONVULSANTS

• Phenobarbital and Barbituates; and Dilantin®, Tegretol®, Mysoline®, Depakane/Depacon® deplete Calcium, Vitamin D.

ANTIVIRAL AGENTS

• Foscanet depletes Calcium. 

CHOLESTEROL DRUGS

• Colestid® and Questran® deplete Vitamin D, Vitamin E.

DIURETICS

• Loop Diuretics (Lasix®, Bumex®, Edecrin®) depletes Calcium.
• Potassium Sparing Diuretics (Midamor®, Aldactone®, Dyrenium® and others) deplete Calcium.

WEIGHT LOSS DRUGS THAT BIND FAT also interfere with absorption of some nutrients.

• Zenicol (Orlistat®) depletes Vitamin D.

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• [dropcap]5[/dropcap]Nutritional Supplements To Help Correct Deficiencies:

[box type=”shadow” ]

The type and quantity of nutritional supplements that may be needed depend on which nutrients are deficient.

• Multivitamin/mineral combination once a day is useful to improve overall nutrient levels. This is a safe dose, but always check with your doctor to avoid interactions with medications.
• Calcium citrate is the best absorbed of calcium supplements. Calcium carbonate is a poor choice.
• Vitamin D3 as prescribed following blood test for status.

Storage Note: Store container tightly sealed, away from heat, moisture and direct light to avoid loss of potency. That is, in a safe kitchen cabinet – not in the bathroom or on the kitchen table.[/box]

• [dropcap]6[/dropcap]Manage Natural Remedies: 

[box type=”shadow” ]Hydration:

• Eight glasses of water are recommended per day unless there is a contraindication such as kidney or heart disease. The Institute of Medicine recommends approximately 2.7 liters (91 ounces) of total water, from all beverages and foods, each day for women and 3.7 liters (125 ounces) daily of total water for men.
• If you are thirsty, drink water. Add fresh, squeezed lemon to water. Lemon is anti-inflammatory, alkalizing and provides vitamin C.
• Hydration Test: Urine should be pale yellow. Fingertips should be plump, without pruning but this may not be reliable when fingers are swollen with edema. Lips should be plump, without puckering. The feeling of thirst can be unreliable.
• What is wrong with soda, coffee, tea, and alcohol? These drinks are dehydrating, increase acid, and deplete nutrients.[/box]

[box type=”shadow” ]Carminatives. The following  anti-inflammatory plant sources called carminitives help heal the digestive tract. They also tone the digestive muscles which improves peristalsis, thus aiding in the expulsion of gas from the stomach and intestine to relieve digestive colic and gastric discomfort.

Carminative Food Remedies:

• Raspberry.
• Carrot is also a cleansing digestive tonic.
• Grape is also bile stimulating and a cleansing remedy for sluggish digestion and laxative.
• Redbeets also stimulate and improve digestion and are easily digested.
• Cabbage also stimulates and improves digestion and is also a liver decongestant.
• Lettuce also stimulates and improves digestion and is also an alterative, meaning it improves the function of organs involved with the digestion and excretion of waste products to bring about a gradual change.
• Potatoes are antispasmodic (due to atropine like properties) and a liver remedy.

Carminative Herb Remedies:

• Sage is also a digestive, astringent, bile stimulant and energy tonic that heals the mucosa.  Drink as tea or use in cooking.
• Chamomile, lemon balm, and fennel, (as a tea) also help relieve nervous tension.
• Parsley also relieves indigestion.
• Rosemary as a tea and in cooking also is a nervous system tonic for stress and fatigue, bile stimulant, and can relieve headaches and indigestion.
• Thyme is also soothing remedy useful for stimulating digestion of rich, fatty foods.

Carminative Spice Remedies:

• Cloves are also antispasmodic.
• Nutmeg is also useful for indigestion.
• Ginger.[/box]

[box type=”shadow” ]Exercise Helps:

Exercise improves circulation and rids the body of toxins.

• Walking is aerobic exercise that reconditions the whole body to improve stamina. Read more about Exercise and Fitness.
• Weight training builds muscle. Read more about Exercise and Fitness.
• Stretching improves flexibilty. Read more about Exercise and Fitness.

Note: Exercise is important, but the amount and type of exercise undertaken depends on your health. Your first priority is to heal. [/box]

What Do Medical Research Studies Tell About Bone Pain In Celiac Disease and/or Gluten Sensitivity?

RESEARCH STUDY SUMMARIES

“Clinical, serologic, and histologic features of gluten sensitivity in children.”  This study seeking to describe the clinical, serologic, and histologic characteristics of children with gluten sensitivity demonstrated findings that support the existence of gluten sensitivity in children across all ages with clinical, serologic, genetic, and histologic features similar to those of adults. Bone pain was found in 20% of the children with gluten sensitivity.

 Subjects were 15 children (10 males and 5 females; mean age, 9.6 ± 3.9 years) with gluten sensitivity who were diagnosed based on a clear-cut relationship between wheat consumption and development of symptoms, after excluding celiac disease and wheat allergy, along with 15 children with active celiac disease (5 males and 10 females; mean age, 9.1 ± 3.1 years) and 15 controls with a functional gastrointestinal disorder (6 males and 9 females; mean age, 8.6 ± 2.7 years). All children underwent celiac disease panel testing (native antigliadin antibodies IgG and IgA, anti-tissue transglutaminase antibody IgA and IgG, and anti-endomysial antibody IgA), hematologic assessment (hemoglobin, iron, ferritin, aspartate aminotransferase, erythrocyte sedimentation rate), HLA typing, and small intestinal biopsy (on a voluntary basis in the children with gluten sensitivity).

Abdominal pain was the most prevalent symptom in the children with gluten sensitivity (80%), followed by chronic diarrhea in (73%), tiredness (33%), bloating (26%), limb pain, vomiting, constipation, headache (20%), and failure to thrive (13%). Native antigliadin antibodies IgG was positive in 66% of the children with gluten sensitivity. No differences in nutritional, biochemical, or inflammatory markers were found between the children with gluten sensitivity and controls. HLA-DQ2 was found in 7 children with gluten sensitivity. Histology revealed normal to mildly inflamed mucosa (Marsh stage 0-1) in the children with gluten sensitivity.¹⁰

“Back pain and sacroiliitis in long-standing adult celiac disease: a cross-sectional and follow-up study.” This study investigating rheumatic manifestations in 21 adult celiac patients using a comprehensive clinical, laboratory and radiological analysis found that the diagnosis of celiac disease was based on the histopathology of jejunal biopsy specimens. The mean duration of celiac disease was 15 (0-31) years. All patients were currently on gluten-free diet and none of the patients had gastrointestinal symptoms at the time of the study.

Imaging revealed different morphological changes in the sacroiliac joint, e.g. accumulation of synovial fluid, synovitis, erosion with concomitant sclerosis, sacroiliitis or calcification of the ligament. These changes probably represent different clinical stages and/or manifestations of the same process. In a follow-up study of eight patients, after 11 years on a gluten-free diet, the great majority of patients had no clinical symptoms; yet, a subclinical progression of the sacroiliac joint involvement could be verified. Results suggest the importance of regular rheumatologic follow-up of patients with celiac disease.¹¹

CASE REPORT SUMMARIES

“Bone pain and extremely low bone mineral density due to severe vitamin D deficiency in celiac disease.” This case study describes finding a non-detectible vitamin D blood level in a 29-year-old wheelchair-bound woman who had lived in the Netherlands all her life and was born of Moroccan parents. Her medical history revealed iron deficiency, growth retardation, and celiac disease, for which she was put on a gluten-free diet but did not follow.

She had progressive bone pain for 2 years, difficulty with walking, and about 15 kg weight loss. She had a short stature, scoliosis (curvature), and pronounced kyphosis of the spine with thoracic and lumbar percussion pain (pain on tapping). Pelvis and shoulders also were painful on touching. There was muscle atrophy and symmetrical loss of proximal muscle strength. She was short of breath during normal daily activities and poor condition of her teeth. She had a regular menstrual cycle, and her menarche was at 17 years of age. She had neither abdominal complaints nor diarrhea. On physical examination, she was pale. Her body height was 148 cm (previously 156 cm) and her weight, 38 kg.

Laboratory results showed hypocalcemia, an immeasurable serum 25-hydroxyvitamin D level, and elevated parathyroid hormone and alkaline phosphatase levels. Spinal rx-rays showed unsharp, low contrast vertebrae. Bone mineral density (bone scan) measurement at the lumbar spine and hip showed a T-score of -6.0 and -6.5, respectively. A bone scintigraphy showed multiple hotspots in ribs, sternum, mandible, and long bones. A bone biopsy showed severe osteomalacia but normal bone volume. A duodenal biopsy revealed villous atrophy (Marsh 3C) and positive antibodies against endomysium, transglutaminase, and gliadin, compatible with active celiac disease She was treated with calcium intravenously and later orally. Furthermore, she was treated with high oral doses of vitamin D and a gluten-free diet. After a few weeks of treatment, her bone pain decreased, and her muscle strength improved.¹²

“Severe osteomalacia in endemic sprue. An important differential diagnosis in osteoporosis.” This case report describes a 67 year old woman with a 20 year history of recurrent abdominal pain, diarrhea and diffuse bone pain. Diagnoses of iron deficiency disorder, iron absorption disorder, osteoporosis and hyperthyroidism had been made. Despite treatment with vitamin D3, calcium, fluorides and iron, patient’s condition deteriorated to the point where she needed constant care. Celiac disease with secondary intestinal osteopathy was identified. High-dose parenteral treatment with vitamin D3, oral calcium supplementation and a Gluten Free Diet resulted in improvement within 3 months, and the patient can largely look after herself again.¹³

“A woman with bone pain, fractures, and malabsorption.” This case report describes the course of a 35 year old woman with recent fracture of right arm a year after fracture of left shoulder, following complaints of pain in her right leg on walking and low back pain 5 years preceding. Radiographs (x-rays)  showed generalized demineralization and severe subperiostal bone resorption with typical brown tumors. Subsequently, she was diagnosed with celiac disease and hyperparathyroidism with severe bone involvement: osteitis fibrosa cystica, bone pains, and multiple fractures. A parathyroid adenoma was identified and removed. Untreated Celiac Disease, vitamin D deficiency, and concomitant hyperparathyroidism resulted in severe osteomalacia. The normal calcium values observed were likely to be a consequence of reduction of total body calcium content and vitamin D deficiency. Hypophosphatemia was present 10 years preceding, suggesting that there was hyperparathyroidism at that time.⁶

Sources:

1. Vereckei E, Mester A, Hodinka L, Temesvári P, Kiss E, Poór G. Back pain and sacroiliitis in long-standing adult celiac disease: a cross-sectional and follow-up study. Rheumatol Int. 2010 Feb;30(4):455-60. doi: 10.1007/s00296-009-0979-3. Epub 2009 Jun 6. [↩]
2. Vereckei E, Mester A, Hodinka L, Temesvári P, Kiss E, Poór G. Back pain and sacroiliitis in long-standing adult celiac disease: a cross-sectional and follow-up study. Rheumatol Int. 2010 Feb;30(4):455-60. doi: 10.1007/s00296-009-0979-3. Epub 2009 Jun 6. [↩]
3. Bertoli A, De Daniele N. A woman with bone pain, fractures, and malabsorption. Lancet. Feb. 3, 1996;347(8997):300, 3/4p,1 chart. [↩]
4. Vereckei E, Mester A, Hodinka L, Temesvári P, Kiss E, Poór G. Back pain and sacroiliitis in long-standing adult celiac disease: a cross-sectional and follow-up study. Rheumatol Int. 2010 Feb;30(4):455-60. doi: 10.1007/s00296-009-0979-3. [↩]
5. Francavilla R, Cristofori F, Castellaneta S, Polloni C, Albano V, Dellatte S, Indrio F, Cavallo L, Catassi C. Clinical, serologic, and histologic features of gluten sensitivity in children. J Pediatr. 2014 Mar;164(3):463-7.e1. doi: 10.1016/j.jpeds.2013.10.007. [↩]
6. Bertoli A, De Daniele N. A woman with bone pain, fractures, and malabsorption. Lancet. Feb. 3, 1996;347(8997):300, 3/4p,1 chart. [↩] [↩] [↩]
7. Dorst AJ, Ringe JD. Severe osteomalacia in endemic sprue. An important differential diagnosis in osteoporosis. Fortschritte der Medizin. Mar 20, 1998;116(8):42-5. [↩]
8. Cummins AG, Thompson FM, Butler RN, et al. Improvement in intestinal permeability precedes morphometric recovery of the small intestine in coeliac disease. Clinical Science. Apr 2001;100(4):379-86. [↩]
9. Farhadi A, Banan A, Fields J, Keshavarzian A. Intestinal barrier: an interface between health and disease. Journal of Gastroenterology and Hepatology. 2003;18:479-91. [↩] [↩] [↩] [↩] [↩] [↩]
10. Francavilla R, Cristofori F, Castellaneta S, Polloni C, Albano V, Dellatte S, Indrio F, Cavallo L, Catassi C. Clinical, serologic, and histologic features of gluten sensitivity in children. J Pediatr. 2014 Mar;164(3):463-7.e1. doi: 10.1016/j.jpeds.2013.10.007. [↩]
11. Vereckei E, Mester A, Hodinka L, Temesvári P, Kiss E, Poór G. Back pain and sacroiliitis in long-standing adult celiac disease: a cross-sectional and follow-up study. Rheumatol Int. 2010 Feb;30(4):455-60. doi: 10.1007/s00296-009-0979-3. [↩]
12. Rabelink NM, Westgeest HM, Bravenboer N, Jacobs MA, Lips P. Bone pain and extremely low bone mineral density due to severe vitamin D deficiency in celiac disease. Arch Osteoporos. 2011 Dec;6(1-2):209-13. doi: 10.1007/s11657-011-0059-7. [↩]
13. Dorst AJ, Ringe JD. Severe osteomalacia in endemic sprue. An important differential diagnosis in osteoporosis. Fortschritte der Medizin. Mar 20, 1998;116(8):42-5. [↩]