What is the cause of pseudogout?
Researchers believe that calcium pyrophosphate dihydrate (CPPD) deposits collect in the synovial joint cavity and that these deposits interact with parts of the immune system - causing an auto-inflammatory response. The resulting inflammatory attack can be local to a single joint or affect joints throughout the body.
How common is pseudogout?
Pseudogout is common but often goes unrecognized. It is more prevalent in the senior population and is strongly associated with osteoarthritis (OA). In fact, joint damage caused by OA can predispose the body to the formation of CPPD crystals.
What are the risk factors for pseudogout?
Certain diseases associated with the development of pseudogout include:
- Hereditary hemochromatosis, a condition resulting in iron overload
- An overactive parathyroid gland (hyperparathyroidism), leading to high levels of calcium in the blood.
- An underactive thyroid gland (hypothyroidism)
- Type 2 Diabetes
- Osteoarthritis (OA)
What are the warning/early signs of pseudogout?
Often a person may not experience symptoms of pseudogout before an attack (also known as asymptomatic). However, visible signs of joint inflammation can include redness, swelling and tenderness around the affected joints.
How is pseudogout diagnosed?
Physicians can diagnose pseudogout by looking at the synovial fluid in the joint cavity. The standard diagnostic test involves examining fluid from the joint under a microscope to look for the presence of CPPD crystals within inflammatory cells (known as neutrophils). X-rays can also be used in diagnosis. Radiologists can inspect joints for signs of CPPD crystal deposits within joint cartilage, known as chondrocalcinosis. However, this is a common finding and not enough to provide a differential diagnosis of pseudogout. Other features such as squaring of the bone ends and bony outgrowths (osteophytes) at certain joints, such as “hook-like” osteophytes at the knuckles of the hands, are common findings with CPPD-diseased joints.
What body parts are affected by pseudogout?
Pseudogout can result in acute or chronic joint inflammation in joints that are connected by cartilage such as the knee, ankle, hip and wrist. These are the most commonly affected joints, though theoretically pseudogout can impact any synovial joint.
What are the symptoms of pseudogout?
Many people may have pseudogout and not experience any symptoms. For those who do experience symptoms, these can include a low-grade fever and joint inflammation with acute attacks. People with chronic pseudogout experience more joint pain, deterioration of the (hyaline) cartilage that covers the ends of bones, and a decrease in range of motion.
Pseudogout is known as “the great mimic” and can mirror the symptoms of other inflammatory conditions such as gout (hence its name) and rheumatoid arthritis (RA).
Unlike gout, which is caused by monosodium urate (MSU) crystals and effectively managed with urate-lowering drugs, there are no anti-crystal agents for pseudogout/CPPD. Therefore, episodes of pseudogout tend to be managed on a symptomatic basis.
There are a wide range of therapies and treatments available for treating pseudogout. Colchicine is used to treat both gout and pseudogout. Research has shown that this medication can prevent inflammation and pain by blocking the interaction between CPPD in the joints and the immune system. A high percentage of patients cannot take colchicine due to its side effects, but for some people, when used in low doses, it is much better tolerated and can be very effective.
Conventional anti-inflammatory medications such as non-steroidal anti-inflammatory drugs (NSAIDs) and corticosteroids are also used in the treatment of pseudogout.
NSAIDs can provide symptom relief. The term “non-steroidal” means that these drugs do not contain steroids. They work by limiting the synthesis of prostaglandin, which is a specific protein in the body that plays a role in pain and inflammation. NSAIDs can be taken as needed or taken regularly to control symptoms. However, long-term use is associated with stomach and kidney damage and an increased risk of heart disease.
Corticosteroids may also be effective in controlling the inflammatory flares associated with pseudogout. The available forms of delivery include intra-articular injections, intramuscular preparations and oral tablets. Typically, the lowest effective dose that controls the symptoms of an acute attack should be used, and for the shortest time.
For patients who cannot take steroids, NSAIDS, or colchicine, there is some evidence for the biologic agent anakinra, which blocks the major inflammatory cell messenger involved in pseudogout (namely interleukin 1/IL1), but this is reserved for severe cases and is an ongoing area of research.
Regular low-impact exercise is an essential component of self-management for pseudogout. Along with other self-management techniques, such as eating well, individuals with pseudogout should be screened for associated metabolic conditions, especially hemochromatosis, as they can be treatable if caught early. Pseudogout should be treated much like osteoarthritis and a variety of techniques can be used to self-manage the condition.
A common misconception is that a painful joint requires rest. On the contrary, lack of movement can cause muscle weakness and worsen joint pain and stiffness. Light or moderate physical activity protects joints by strengthening the muscles around them, increasing blood flow to the joint and helping promote normal joint regeneration. Physical activity can also improve mood and lessen pain.
Physical activity refers to any movement that increases heart rate through the activation of your muscles, while exercise is considered a structured, planned, repetitive and purposeful activity with the goal of improving or maintaining a component of physical fitness (source: Canadian Society for Exercise Physiology). An increase in physical activity, even in small increments, can help relieve arthritis symptoms and improve your daily function.
Physical activity strengthens the muscles and connective tissues around your joints, helping support joints that have been damaged by arthritis. Physical activity includes all those activities that you do as a part of everyday life – such as vacuuming the floor, walking to work, even gardening. These kinds of activities can be very beneficial for your joints and can help you maintain and improve your mobility.
Exercise is physical activity that involves heavier, repetitive exertion, and is designed to improve or maintain physical fitness. Lifting weights, walking on a treadmill, taking a yoga class – these are the kinds of planned motions that we do specifically to improve our flexibility, strength or endurance. Being physically active can reduce pain and fatigue, improve mobility and overall fitness, and improve your state of mind by allowing you to actively participate in your own treatment. Participating in a properly- designed exercise program is a great way to help alleviate the discomfort caused by arthritis.
Targeted exercise for your joints may have added benefit. A qualified therapist, such as a physiotherapist, can work with you to develop a progressive exercise program that is tailored to your needs.
What types of exercise are recommended for pseudogout?
Therapeutic exercises improve connections and response time between your brain and your muscles, increasing coordination to help the joint remain stable during physical activity and reduce risk of injury. Components include neuromuscular control (developing ‘muscle memory’ by training your joints and muscles to move in healthy patterns), strengthening your muscles, balance and agility.
- Range of motion (also called stretching or flexibility exercises): Exercises that keep your joints moving can reduce pain and stiffness. To achieve the most benefit, these exercises should be done daily.
- Strengthening: Exercises that maintain or increase muscle tone and protect your joints. These resistance-based exercises include weight-training movements done with a set of free weights, your own body weight, resistance bands or weight machines. The frequency of strengthening exercises should be discussed with your doctor or physiotherapist.
- Endurance: Exercises that strengthen your heart, give you energy, control your weight and help improve your overall health. Examples include walking, swimming and cycling.
Many low-impact exercise options can benefit people living with arthritis. Consult your healthcare provider to identify suitable exercises for you and your particular condition. Examples include:
- Tai Chi: This ancient Chinese martial art is a combination of movements performed in a slow, focused manner. Though it has many variations and styles, Tai Chi is a low-impact exercise and is reminiscent of both yoga and meditation. Tai Chi could improve pain and physical function in some people as well as alleviate depression and contribute to health-related quality of life.
- Yoga: Numerous studies have shown the benefits of yoga for stress and anxiety. The practice of controlled breathing, simple meditation and stretching can improve a person’s state of mind and help them better manage pain. Regular yoga under the guidance of a certified instructor can also boost one’s general health and increase energy levels.
(NOTE: In some cases, people living with arthritis should avoid strenuous yoga routines, such as Bikram and power yoga.)
How much exercise is recommended for pseudogout?
Any increase in your physical activity or exercise may help if you are not active. The right frequency, intensity, type and duration varies from person to person. A gradual increase in exercise is recommended, with an eventual target for adults of 150 minutes of moderate- to vigorous-intensity exercise per week, in sessions of 10 minutes or more (if tolerated). If you are not currently active, you are advised to start with light activities, such as walking, and attempt to increase your speed and/or distance over time.
There is no conclusive evidence to suggest that what you eat can make arthritis either better or worse. However, being overweight can put excess strain on your joints. To work normally, your body needs food to supply energy, vitamins and minerals. Healthy eating will help you manage your weight and give you the energy to complete your daily activities, as well as promote a strong immune system, and bone and tissue health.
Four ways to improve your nutrition include:
- Limit saturated and trans fats: A healthy diet should include modest amounts of unsaturated fats. Saturated and trans fats should be limited.
- Choosing the right amount and types of fats can help you achieve and maintain a healthy body weight and improve your overall health. Olive oil and cold-water fish such as salmon, trout or herring are examples of healthy choices.
- Reduce sugar intake: Sugar contains “empty” calories and has no nutritional value. This includes honey and syrup as well as white, brown, cane and raw sugar. Limit or avoid adding sugar to drinks and cereals. Although artificial sweeteners contain fewer calories, it is best to get used to food being less sweet. Use dried, unsweetened fruit like raisins, cherries or dates to sweeten cereals since they provide vitamins, minerals and fibre.
- Eat more vegetables and fruit: Vegetables and fruit should make up the largest component of your diet. Keep in mind that the sweetest fruits have high sugar content so it’s best not to overdo it. Try to have at least one vegetable or fruit at every meal and while snacking. Besides being an excellent source of energy, vegetables and fruit boost your fibre intake, which helps with digestion and weight management. They are also loaded with antioxidants, which help boost the immune system and may help maintain healthy cartilage.
For more information, visit our Eating Well online module.
While it’s important to keep your joints moving, it’s also important to avoid situations that put excessive stress or strain on your joints, as that can increase your risk of injury and make your joints deteriorate faster. Avoiding joint stress will also lead to less pain and help your joints work better, longer.
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