Still aching weeks after chikungunya? What is happening in your joints, and what to do

Every year after the monsoon, the rheumatology OPD fills with the same story. The fever came and went in a week. The joints did not. Six weeks on, the wrists, hands and ankles are still stiff every morning, the fingers will not make a fist, and the painkillers are not doing what they did. If that is you or someone in your family, here is what is going on and what actually helps.

Why the joints keep hurting after the virus is gone

Chikungunya is a mosquito-borne virus, and its name, from a Makonde word meaning "that which bends up", describes the posture of someone whose joints are too painful to straighten. The fever and rash settle within about a week. The joint inflammation is a separate process. The virus triggers an immune response in the lining of the joints, and in a proportion of people that response carries on for weeks or months after the virus itself has been cleared.

Three phases are usually described. The acute phase is the first three weeks: fever, rash, severe joint pain. The post-acute phase runs from three weeks to three months, when most people are gradually improving. Pain that is still present beyond three months is called chronic post-chikungunya arthritis, and it is more common than most people expect: in different studies, somewhere between a quarter and a half of patients still have joint symptoms at three months, and a smaller group at one year. Age over 45, severe pain at the start, and pre-existing joint problems make persistent symptoms more likely.

What it typically feels like

• Pain and stiffness in the wrists, hands, ankles and feet, usually on both sides
• Morning stiffness that can last an hour or more, easing with movement
• Swelling of the fingers, wrists or ankles; sometimes a tender swelling over the back of the hand or the heel (tendon sheaths get involved too)
• Tiredness out of proportion to the activity of the day
• Flares that come and go, often worse in the cold or after a busy day

Older patients and people who already had osteoarthritis of the knees often find that the knees are the slowest to settle.

What helps in the first weeks

In the post-acute phase, the aim is to control inflammation and keep the joints moving while the immune response burns itself out.

• Anti-inflammatory medicine, used properly. A regular course of an anti-inflammatory painkiller for a few weeks, with food and with the stomach protected if needed, does more than taking one tablet whenever the pain gets bad. Paracetamol helps with pain but does little for the inflammation. People with kidney disease, heart disease or stomach ulcers need a doctor to choose the medicine.
• Movement. Rest for a day or two during a bad flare is reasonable, but resting the joints for weeks makes them stiffer and weaker. Gentle range-of-movement exercises for the hands and wrists, a short walk, warm water on the hands in the morning. The hand exercise routine on this site was written with exactly these patients in mind.
• Sleep and pacing. Fatigue is part of the illness. Spread tasks through the day rather than pushing through and crashing.
• Patience with the timeline. Most people are substantially better by three months. That is slow, but it is the usual course, and it is not a sign that something has gone wrong.

What does not help

Three things come up again and again in clinic. Stopping dal, curd and other foods on the belief that they worsen joint pain: they do not, and losing protein and calcium makes recovery slower (the myth-buster page goes through these one by one). Steroid injections or tablets taken from a chemist without a plan: steroids do have a place in post-chikungunya arthritis, but as a short, tapering course decided by a doctor, not as a dose repeated every time the pain returns. And a different painkiller from every visit to every doctor, which usually ends in a stomach or kidney problem. One doctor, one plan.

When it is time to see a rheumatologist

Most post-chikungunya joint pain settles with the measures above and does not need a specialist. See a rheumatologist if:

• Joint pain or swelling is still present three months after the fever
• You have visible swelling of the small joints of the hands or wrists at any stage, especially with morning stiffness over an hour
• The pain is stopping you from working or from caring for yourself, despite regular anti-inflammatory medicine
• You already have rheumatoid arthritis, lupus or another autoimmune condition and the virus has set off a flare
• You are not sure it was chikungunya at all. Dengue, other viruses and the first presentation of rheumatoid arthritis can all look similar in the first weeks

At that stage the questions are different. Is this still the post-viral process, or has it unmasked rheumatoid arthritis or spondyloarthritis that was going to appear anyway? Blood tests (ESR, CRP, rheumatoid factor, anti-CCP) and sometimes an ultrasound of the hands help answer that. For persistent inflammation, rheumatologists use the same disease-modifying medicines as in rheumatoid arthritis, most often methotrexate or hydroxychloroquine, for a limited period. Used this way, they are effective and safe, and they are stopped once the joints have settled.

A note for families

Chikungunya tends to run through a household and a neighbourhood at the same time, so there is often a grandparent, a parent and a child all aching together. Children usually recover fastest. The older members of the family are the ones to watch, particularly anyone with existing knee arthritis or who has become reluctant to walk. Keep them moving, keep them eating normally, and if they are still struggling at three months, bring them in.

The full condition page on post-chikungunya arthritis covers the medicines in more detail, and the symptom pattern check can help you tell whether a lingering joint problem looks post-viral or inflammatory.

Dr. Ashish JindalConsultant Rheumatologist & Faculty, AIMS Mohali · MD, FACP, FACR, EULAR Certified · PMC Reg. No. 50360