To what degree is CRP/HS-CRP, or any other inflammatory marker, typically correlated with joint pain? From what I understand, 10+ is considered “clinically significant” (i.e. an autoimmune disorder), 5+ is considered “high”, and 1-5 is considered “low-grade inflammation”.
A cursory scan:
C-Reactive Protein and Pain Sensitivity: Findings from Female Twins
“The link between CRP and pain sensitivity may be due to non-shared environmental factors. CRP and pain sensitivity can be examined as potential biomarkers for chronic pain and other inflammatory conditions.”
Anecdotally, I’ve heard people who get it tested and make dietary adjustments that subsequently bring it down seem to have better subjective recovery and have old or chronic injuries/pain subside.
I’m interested in this now because joint pain has often been a struggle and a severely limiting factor in my progress with strength training. I’ve never really been able to do 4 day a week training without nagging issues, and I’ve never been able to progress main lifts terribly far (except upper body pulling). I’ve also had times in the past, when it was worse, that I had chronic low-grade anxiety during the day and when stressed significantly I’d experience inexplicable touch-sensitivity on my arms that felt like a burn. Some dietary elimination has since remedied that, but the joint sensitivity isn’t entirely gone.
I had it tested in the past to check for RA and my doctor (at the time) said it was “slightly elevated but probably due to a workout”. It’s only years later than I now see it was at 8.2, which is almost an order of magnitude outside what would be expected post-workout.
Would dietary adjustment via elimination and testing be a worthwhile pursuit? I’m also willing to accept I have crappy joints, but I do think I’ve been relatively careful and intentional with my programming in the past.
It depends on whether the individual’s joint pain is related to an inflammatory process at all (e.g., whether they have an inflammatory arthropathy). There are arguably more situations where an individual might have an elevated CRP for reasons completely independent of any musculoskeletal issue/joint pain, than there are where they’re tightly linked.
With that said, that are roles for inflammation in the experience of pain, both peripherally (e.g., via sensitization of nociceptors) and centrally (via other neuroinflammatory processes which are less well-understood).
This isn’t really accurate, and there’s a lot more complexity involved in interpreting these sorts of tests than I can get into here.
I suspect that many/most of the dietary and lifestyle behaviors involved in these anecdotes are the sorts of health-promoting things that we recommend for individuals regardless of their serum CRP levels. This sort of anecdote doesn’t really sway me too far, however, as there are numerous potential sources of confounding, placebo-type effects, and other biases that could come into play here without any sort of control.
I would not entertain the hypothesis that you just “have crappy joints” – especially given that the rheumatology evaluation was reassuring.
With that said, I don’t know anything about your current diet. You can certainly try something like this and see how you feel, although I’m still not sure such factors would be sufficient to explain everything you’re reporting.
Similarly, I also don’t know anything about your training history or programming. You say you’ve been “careful and intentional” with it, but I still try to avoid making assumptions on such matters. It may be that there is a better approach than the ones you’ve tried. This is the precise sort of thing our rehab team is quite good at addressing with folks.
Finally, as we’ve discussed elsewhere, the majority of pain issues are complex and multifactorial – and you allude to this with your mention of dealing with anxiety and chronic stress, which absolutely play a role in people’s pain experience as well. The point here being that while there may be some component of inflammation going on, I would avoid taking too myopic of a focus on the CRP number alone.
Is there a way to determine this beyond clinically diagnosable pathology?
Is this as likely even in an individual that’s active (1.5h workouts 3-4x a week), not overly stressed, and has no obvious injury or medical issue?
This isn’t really accurate, and there’s a lot more complexity involved in interpreting these sorts of tests than I can get into here.
It was certainly a gross oversimplification, and seemed to be a sort of “cursory” guide based on a number of studies and articles I encountered. But given what’s available in the literature, I would think a level of 8.2 would be concerning and at the very least would have follow up recommended given the correlation between CRP levels that high and problematic processes. Still not sure why my doc assumed it was simply due to a post-workout effect. I think Jordan mentioned that at worst it would raise up maybe to just beyond 1.
I suspect that many/most of the dietary and lifestyle behaviors involved in these anecdotes are the sorts of health-promoting things that we recommend for individuals regardless of their serum CRP levels. This sort of anecdote doesn’t really sway me too far, however, as there are numerous potential sources of confounding, placebo-type effects, and other biases that could come into play here without any sort of control.
For sure. But in my position, looking for a solution to a decade long problem that’s been frustrating in numerous areas (including my ability to play guitar), I’m inclined to pay attention to N=1 experiments whereby people get frequent CRP checks as they adjust their diet and end up with markedly lower levels after cutting some out and end up resolving some issues (preceded by improved subjective reports of i.e. how their joints/recovery feels). I’m not sure what else to do, honestly.
I would not entertain the hypothesis that you just “have crappy joints” – especially given that the rheumatology evaluation was reassuring.
All screenings I’ve had on relevant issues have come back negative – an MRI for patellofemoral syndrome (I know that’s a sort of non-diagnosis), Xrays and checks for RA, etc, which is why I suspect there’s another issue going on. I’d love to believe I don’t have an inherent connective tissue/structural resilience problem.
With that said, I don’t know anything about your current diet. You can certainly try something like this and see how you feel, although I’m still not sure such factors would be sufficient to explain everything you’re reporting.
Similarly, I also don’t know anything about your training history or programming. You say you’ve been “careful and intentional” with it, but I still try to avoid making assumptions on such matters. It may be that there is a better approach than the ones you’ve tried. This is the precise sort of thing our rehab team is quite good at addressing with folks.
That’s fair, although again, I’m not sure what other route to take. The dietary changes I have made do seem to make an anecdotal difference. I predominantly eat animal protein/eggs, fish (mostly raw), cooked rice, fruits and veg, and honey, mostly in an attempt to see if it makes a difference to cut things out. I do get eczema when I consume dairy regularly, as well as headaches if I eat bread or grain-based products on any sort of regular basis, but I have no idea if this has anything to do with joint pain. It was significantly worse, at least from what I recall, when I was eating bread, cereals/grains, potatoes, dairy, etc (while also counting macros), but it’s hard to say precisely how much worse.
Regarding programming – I certainly see where you’re coming from. That said, some years ago I was a strength coach working predominantly with team-sport athletes for a DC who’s now the head of player health for the Sacramento Kings. All that to say the programs were well written and in the case of my own, were relatively conservative with relatively little maximal-strength work, a large degree of variability and with reasonable progressions on most exercises. Didn’t go to failure often and given this issue I tended to be relatively careful with weights. I saw a significant amount of hockey players, a few fighters, football players, weightlifters, other athletes and gen pop go through similar programs with zero issues. My former boss (who I’m still in contact with) has believed for a few years that it’s non-mechanical (not to say pain is usually strictly biomedical, but that there isn’t an obvious training or load-based reason for the issues).
Finally, as we’ve discussed elsewhere, the majority of pain issues are complex and multifactorial – and you allude to this with your mention of dealing with anxiety and chronic stress, which absolutely play a role in people’s pain experience as well. The point here being that while there may be some component of inflammation going on, I would avoid taking too myopic of a focus on the CRP number alone.
I should clarify that I somewhat suspect diet had something to do with experienced stress and anxiety. Until I started making deliberate changes and completely eliminating certain things I would wake up with low-grade anxiety and occasional vert mild panic attacks that left me puzzled and had me seeking professional help. This was during a period of comparatively less stress than the last two years. I also struggled to sleep properly and was very noise sensitive while sleeping. The burning sensation on my arms during periods of high stress was also very strange.
Not to claim that this was all simply mediated by dietary changes in the least, I’m with you that this is multifactorial and complex, but they have certainly had a notably positive effect. Low-grade daily anxiety is gone, I sleep much better (despite having kids now) and I haven’t since experienced random touch-sensitive pain. Stress feels much more in control, despite working out less intensely and less frequently than before (not by choice mind you).
Apologies for the lengthy post, hopefully that gives some context. Do you have any other recommendations for what to pursue? Is CRP testing at least worthwhile to see if the elevated number is chronic for other health reasons?
You could have a common cold and see CRP elevations well above the upper limit of normal. I’m not saying that you have a cold, obviously, but my point is that CRP is not specific for any particular diagnosis. I use CRP measurements somewhat frequently in my clinical work in the hospital (most often in the setting of certain types of infections), but in none of those situations is the CRP test diagnostic for any particular condition. Additionally, there is variation across labs in how the results are reported (mg/dL vs. mg/L, which changes the reference range), as well as variation between regular CRP and hs-CRP levels.
Given your interest in the topic, I’ll quote some more detailed information on CRP for you here:
The level of CRP that is truly normal or clinically innocuous is not known. Data from a study conducted by the National Health and Nutrition Evaluation Survey of over 21,000 people in the United States revealed that CRP levels vary with age, sex, and race, with slightly higher levels seen with increased age, with female sex, and in African Americans (table 1) [63]. A rough correction of the CRP for age can be made by using the following formulas: the upper limit of the reference range (mg/dL) equals (age in years)/50 for men and (age in years/50) + 0.6 for women [64,65].
It is very important to note that there is no uniformity in the units that are used to report CRP levels. Some laboratories report CRP concentrations as mg/dL while others employ mg/L. Standard CRP determinations may be reported either in units of mg/dL or in units of mg/L, while determinations using a highly sensitive assay, generally referred to as “high-sensitivity CRP” (hs-CRP), are routinely reported in units of mg/L.
Population studies reveal a skewed, rather than Gaussian, distribution of plasma CRP concentrations. About 70 to 90 percent of samples from reference populations have CRP concentrations under 0.3 mg/dL (3 mg/L), but some individuals have minor elevations up to 1 mg/dL (10 mg/L). What we commonly call normal ranges (properly called reference ranges) reported for CRP vary greatly from one laboratory to another, to a degree that cannot be explained on a biologic or technical basis. What is thus regarded as “elevated” is often misleading. It would be best to regard CRP concentrations >1 mg/dL (10 mg/L) as indicating clinically significant inflammation while concentrations between 0.3 and 1 mg/dL (3 and 10 mg/L; minor CRP elevation) indicate what is commonly referred to as low-grade inflammation [66].
Low-grade inflammation is not accompanied by the classic signs of inflammation and may result from an immense number of metabolic stresses [5,67-69]. Some of these stresses are clinically apparent; examples include atherosclerosis, obesity, obstructive sleep apnea, insulin resistance, hypertension, and type 2 diabetes. Low-grade inflammation is, however, also associated with an astounding number of conditions and lifestyles known to be associated with poor health, including low levels of physical activity, prehypertension, a large variety of unhealthy diets, social isolation, and even being unmarried. This realization has led to a redefinition of inflammation as the innate immune response to harmful stimuli such as pathogens, injury, and metabolic stress [70].
It’s not clear from your original post what test it was, what the units/reference range was, and it doesn’t sound like you’ve had it re-checked. For all we know it could be normal right now, or there may have been some new developments in the intervening years that may be worth re-evaluation.
That’s great, and you should roll with it if it’s helping. I’m still not sure you need CRP to tell you what makes you feel better vs. worse, but go for it.
I don’t know any of your prior evaluation/testing history, but this situation is complex enough that pursuing some repeat testing and perhaps a second rhreumatology opinion is probably reasonable.
I can say anecdotally that cutting out grains and dairy lessens my RA symptoms considerably. 7 years ago I cut them out for several months and was able to halve my dosage of methotrexate.
Whenever I eat them now my RA flares up. I’d like to be able to continue eating these foods which is why I’m trying to get on a biologic in addition to methotrexate. If the biologics don’t work as well as I’d like, then I’ll have to cut out these foods. I’ve already failed Enbrel and Humira.
Dr. Baraki: Thanks for the reply, apologies as I thought I had responded.
Good points overall, will ensure changes are in place first and maybe see if anything comes up.
For reference: found the original report. For some reason the test type wasn’t listed online but it was an HS-CRP test after all. 8.2 mg/L, ref: 0-2mg/L.
No notable injury at the time of testing and no viral infection (other than back pain that comes and goes).
Main concerns with a chronically elevated level are longterm ASCVD and cancer risk, if that’s still robust. More immediate concerns, whether or not they’re related specifically to CRP (as you articulated) but broadly to chronic inflammation, are poor tolerance to activity (joint pain, suboptimal workout recovery, poor capacity for things like routine periods of playing instruments or things requiring fine motor skills, etc), and less frequent but still occasional bouts of low-grade chronic depression/anxiety (I realize this is in no way a conclusive “cause” but it’s an avenue I’ve seen some improvement in).
That said, given what you’ve cited above, I’m not sure how big an issue this is apart from felt symptoms or if it’s worth trying to eliminate more potential issues to improve (both subjective symptoms and markers). Apart from existing chronic illness risk, my biggest desire is to be able to lift and recover as “normally” as possible and to be able to play instruments for extended periods without abnormal levels of discomfort, within whatever range is possible for me individually, as well as eliminate a potential contributor to occasional low-level unexplained anxiety. Worth eliminating any other potential problems in diet or lifestyle? No sure if my white blood cell count is considered “low”, was the same the last time I tested.
As I previously mentioned, some of these symptoms have improved over time. Not conclusively sure what the contributors were, but the most significant reduction in obvious symptoms may have come from eliminating oats/wheat/dairy (which, if I consume now for any length of time, I get a burning sensation in my hands and develop eczema).
Short version: would you recommend continuing to pursue improvements beyond the obvious (i.e. bodyfat reduction) to address subjective symptoms, and follow that with a retest some months in the future? Any credence to taking high-quality fish oil or similar in my particular case (I realize it’s not normally recommended and doesn’t seem to significantly affect heart disease incidence, mostly looking at anti-inflammatory properties since it seems to be recommended to people with RA).
(Was fasting for both tests)
Previous (years ago) hs-CRP: 8.2mg/L
RF: Negative
Current:
Current lifestyle strategies: reduced sat fat from ~20+%/day to ~10-12%/day in an effort to lower an apoB number of 87 mg/dL to <20th percentile Framingham risk score (and to simply keep up with best research practices). Trying to get a better handle on consistent sleep and stress management, not sure how much these will affect CRP. Also trying to cut bodyfat from ~21% down to 15% or lower, so I imagine that will make a difference as well. Have a different relationship with pain now that I’m caught up thanks to you and the team, and work around back-pain and other flare ups without catastrophizing.
Thanks again for your time, and if this is far out of the scope of a forum post, please let me know.