Official reprint from UpToDate®
www.uptodate.com ©2017 UpToDate, Inc. and/or its affiliates. All Rights Reserved.

Musculoskeletal manifestations of Lyme disease

Robert T Schoen, MD
Section Editor
Allen C Steere, MD
Deputy Editor
Jennifer Mitty, MD, MPH


Lyme disease was first recognized in the United States in the 1970s, presenting as oligoarthritis during an outbreak in children in Lyme, Connecticut [1]. Lyme disease is now the most common vector-borne illness in North America and Europe. Arthritis is the most common manifestation of late Lyme disease [2]. Because antibiotic treatment of early infection is usually curative, arthritic complications have become less common [2].

The clinical features, diagnosis, and therapy of the musculoskeletal manifestations of Lyme disease will be reviewed here. General issues related to the clinical manifestations, diagnosis, and treatment of Lyme disease are discussed separately. (See "Clinical manifestations of Lyme disease in adults" and "Lyme disease: Clinical manifestations in children" and "Diagnosis of Lyme disease" and "Treatment of Lyme disease".)


The clinical manifestations of Lyme disease can generally be divided into three phases: early localized, early disseminated, and late disease (table 1). However, the clinical features of each stage can overlap and some patients present in a later stage of Lyme disease without a history of prior signs or symptoms suggestive of earlier disease [3]. (See "Clinical manifestations of Lyme disease in adults", section on 'Clinical stages'.)

Lyme arthritis is a late finding of Lyme disease, whereas migratory or transient arthralgias can occur during the early localized or early disseminated stages, as discussed below. (See 'Clinical features' below.)


Early Lyme disease occurs primarily during the late spring and early summer when nymphal Ixodes ticks are active (figure 1 and figure 2). In contrast, Lyme arthritis may begin in any season, weeks to months after initial infection. Affected individuals are typically active outdoors in locations endemic for Lyme disease (figure 3). (See "Epidemiology of Lyme disease".)

To continue reading this article, you must log in with your personal, hospital, or group practice subscription. For more information on subscription options, click below on the option that best describes you:

Subscribers log in here

Literature review current through: Nov 2017. | This topic last updated: Oct 02, 2017.
The content on the UpToDate website is not intended nor recommended as a substitute for medical advice, diagnosis, or treatment. Always seek the advice of your own physician or other qualified health care professional regarding any medical questions or conditions. The use of this website is governed by the UpToDate Terms of Use ©2017 UpToDate, Inc.
  1. Steere AC, Malawista SE, Snydman DR, et al. Lyme arthritis: an epidemic of oligoarticular arthritis in children and adults in three connecticut communities. Arthritis Rheum 1977; 20:7.
  2. Dennis DT, Hayes EB. Epidemiology of Lyme Borreliosis. In: Lyme borreliosis: biology, epidemiology and control, Kahl O, Gray JS, Lane RS, Stanek G (Eds), CABI Publishing, Oxford 2002. p.251.
  3. Steere AC. Lyme disease. N Engl J Med 1989; 321:586.
  4. Steere AC, Bartenhagen NH, Craft JE, et al. The early clinical manifestations of Lyme disease. Ann Intern Med 1983; 99:76.
  5. Smith RP, Schoen RT, Rahn DW, et al. Clinical characteristics and treatment outcome of early Lyme disease in patients with microbiologically confirmed erythema migrans. Ann Intern Med 2002; 136:421.
  6. Wormser GP, McKenna D, Carlin J, et al. Brief communication: hematogenous dissemination in early Lyme disease. Ann Intern Med 2005; 142:751.
  7. Wormser GP, Dattwyler RJ, Shapiro ED, et al. The clinical assessment, treatment, and prevention of lyme disease, human granulocytic anaplasmosis, and babesiosis: clinical practice guidelines by the Infectious Diseases Society of America. Clin Infect Dis 2006; 43:1089.
  8. Steere AC, Schoen RT, Taylor E. The clinical evolution of Lyme arthritis. Ann Intern Med 1987; 107:725.
  9. Bacon RM, Kugeler KJ, Mead PS, Centers for Disease Control and Prevention (CDC). Surveillance for Lyme disease--United States, 1992-2006. MMWR Surveill Summ 2008; 57:1.
  10. Puius YA, Kalish RA. Lyme arthritis: pathogenesis, clinical presentation, and management. Infect Dis Clin North Am 2008; 22:289.
  11. Shrestha M, Grodzicki RL, Steere AC. Diagnosing early Lyme disease. Am J Med 1985; 78:235.
  12. Craft JE, Grodzicki RL, Steere AC. Antibody response in Lyme disease: evaluation of diagnostic tests. J Infect Dis 1984; 149:789.
  13. Dressler F, Whalen JA, Reinhardt BN, Steere AC. Western blotting in the serodiagnosis of Lyme disease. J Infect Dis 1993; 167:392.
  14. Centers for Disease Control and Prevention (CDC). Recommendations for test performance and interpretation from the Second National Conference on Serologic Diagnosis of Lyme Disease. MMWR Morb Mortal Wkly Rep 1995; 44:590.
  15. Kalish RA, McHugh G, Granquist J, et al. Persistence of immunoglobulin M or immunoglobulin G antibody responses to Borrelia burgdorferi 10-20 years after active Lyme disease. Clin Infect Dis 2001; 33:780.
  16. Kannian P, McHugh G, Johnson BJ, et al. Antibody responses to Borrelia burgdorferi in patients with antibiotic-refractory, antibiotic-responsive, or non-antibiotic-treated Lyme arthritis. Arthritis Rheum 2007; 56:4216.
  17. Steere AC, Angelis SM. Therapy for Lyme arthritis: strategies for the treatment of antibiotic-refractory arthritis. Arthritis Rheum 2006; 54:3079.
  18. Snydman DR, Schenkein DP, Berardi VP, et al. Borrelia burgdorferi in joint fluid in chronic Lyme arthritis. Ann Intern Med 1986; 104:798.
  19. Schmidli J, Hunziker T, Moesli P, Schaad UB. Cultivation of Borrelia burgdorferi from joint fluid three months after treatment of facial palsy due to Lyme borreliosis. J Infect Dis 1988; 158:905.
  20. Berger BW, Kaplan MH, Rothenberg IR, Barbour AG. Isolation and characterization of the Lyme disease spirochete from the skin of patients with erythema chronicum migrans. J Am Acad Dermatol 1985; 13:444.
  21. Nocton JJ, Dressler F, Rutledge BJ, et al. Detection of Borrelia burgdorferi DNA by polymerase chain reaction in synovial fluid from patients with Lyme arthritis. N Engl J Med 1994; 330:229.
  22. Li X, McHugh GA, Damle N, et al. Burden and viability of Borrelia burgdorferi in skin and joints of patients with erythema migrans or lyme arthritis. Arthritis Rheum 2011; 63:2238.
  23. Steere AC, Levin RE, Molloy PJ, et al. Treatment of Lyme arthritis. Arthritis Rheum 1994; 37:878.
  24. Dattwyler RJ, Wormser GP, Rush TJ, et al. A comparison of two treatment regimens of ceftriaxone in late Lyme disease. Wien Klin Wochenschr 2005; 117:393.
  25. Steere AC, Green J, Schoen RT, et al. Successful parenteral penicillin therapy of established Lyme arthritis. N Engl J Med 1985; 312:869.
  26. Dattwyler RJ, Halperin JJ, Volkman DJ, Luft BJ. Treatment of late Lyme borreliosis--randomised comparison of ceftriaxone and penicillin. Lancet 1988; 1:1191.
  27. Steere AC. Reinfection versus relapse in Lyme disease. N Engl J Med 2012; 367:1950.
  28. Drouin EE, Seward RJ, Strle K, et al. A novel human autoantigen, endothelial cell growth factor, is a target of T and B cell responses in patients with Lyme disease. Arthritis Rheum 2013; 65:186.
  29. Bockenstedt LK, Gonzalez DG, Haberman AM, Belperron AA. Spirochete antigens persist near cartilage after murine Lyme borreliosis therapy. J Clin Invest 2012; 122:2652.
  30. Schoen RT, Aversa JM, Rahn DW, Steere AC. Treatment of refractory chronic Lyme arthritis with arthroscopic synovectomy. Arthritis Rheum 1991; 34:1056.
  31. Feder HM Jr, Johnson BJ, O'Connell S, et al. A critical appraisal of "chronic Lyme disease". N Engl J Med 2007; 357:1422.
  32. Sigal LH. Summary of the first 100 patients seen at a Lyme disease referral center. Am J Med 1990; 88:577.
  33. Steere AC, Taylor E, McHugh GL, Logigian EL. The overdiagnosis of Lyme disease. JAMA 1993; 269:1812.
  34. Feder HM Jr, Hunt MS. Pitfalls in the diagnosis and treatment of Lyme disease in children. JAMA 1995; 274:66.
  35. Reid MC, Schoen RT, Evans J, et al. The consequences of overdiagnosis and overtreatment of Lyme disease: an observational study. Ann Intern Med 1998; 128:354.
  36. Hsu VM, Patella SJ, Sigal LH. "Chronic Lyme disease" as the incorrect diagnosis in patients with fibromyalgia. Arthritis Rheum 1993; 36:1493.
  37. Wolfe F, Ross K, Anderson J, et al. The prevalence and characteristics of fibromyalgia in the general population. Arthritis Rheum 1995; 38:19.