How to Deal With Musculoskeletal Pain in MS (And Why It Happens)

Living with multiple sclerosis (MS) often means dealing with different kinds of pain — some caused by damage to nerves, some by muscle stiffness or spasms, and some related to changes in how the body moves or supports itself, which is known as musculoskeletal (MSK) pain.

Musculoskeletal pain is one of the most common — and often unrecognized — sources of discomfort in people living with multiple sclerosis, says Charles Odonkor, MD, an assistant professor of orthopaedics and rehabilitation and a pain expert at Yale School of Medicine in New Haven, Connecticut.

“While MS is classically known for its neuropathic pain presentation — burning, tingling, numbness, paresthesia — MSK pain arises from altered biomechanics, weakness, and spasticity that place abnormal stress on muscles, joints, and connective tissues,” says Dr. Odonkor.

Understanding what musculoskeletal pain feels like and the many reasons it develops can help you and your healthcare team find the most effective mix of self-management strategies and treatments.

What Does Musculoskeletal Pain Feel Like?

Musculoskeletal pain can feel different from neuropathic pain, which is the burning, tingling, or electric-shock sensations caused directly by nerve damage.

MSK pain typically affects the neck, shoulders, back, and limbs, and it is often exacerbated by immobility, compensatory gait changes, or deconditioning, says Odonkor.

This pain can show up early in the disease or develop over time, and it often affects daily activities like walking, climbing stairs, sitting upright, or getting dressed. People with MS commonly describe musculoskeletal pain as a dull ache, stiffness, throbbing, or tenderness in muscles or around joints. It may feel similar to overuse pain after a tough workout — except it can happen even with normal activity.

While spasticity also causes muscle and joint discomfort, it’s considered a distinct MS symptom that feels different and has a different root cause from musculoskeletal pain.

• Stiffness in the neck, arms, or legs
• Joint pain, especially in weight-bearing joints like the knees or hips
• Localized discomfort, such as lower-back pain, after activity, standing, or maintaining one position for too long

Causes of Musculoskeletal Pain in MS

Musculoskeletal pain in MS has many possible causes, all of which stem from the way MS changes how your body moves, compensates, and supports itself.

Fatigue Fatigue is one of the most common MS symptoms, and it can alter movement patterns. When you’re tired, it’s harder to maintain good posture or steady gait, which increases strain on muscles and joints.

Balance Problems When balance is off, people often take shorter steps, widen their stance, or shift weight differently to feel safer. These instinctive adjustments can lead to pain in the hips, lower back, and knees, says Odonkor. “Degenerative joint disease can also be caused by abnormal weight-bearing,” he adds.

Other Mobility Challenges If you're having difficulty standing, moving from sitting to standing, or walking long distances, this can create a cycle of inactivity and weakness. That deconditioning can cause disuse atrophy and exacerbate pain, says Odonkor.

Chronic Spasticity Chronic spasticity may lead to muscle overuse, contractures, and trigger points, says Odonkor. Stiff, tight muscles from spasticity can change the way weight is distributed across the legs and feet. Over time, the joints and soft tissues absorb extra stress, causing pain.

How Is Musculoskeletal Pain Diagnosed?

Because MS causes several types of pain, a key part of treatment is identifying which kind you are experiencing. That takes a comprehensive assessment by an expert, says Odonkor.

To diagnose MSK your provider will:

• Ask detailed questions about what the pain feels like.
• Examine your posture, gait, strength, muscle tone, and flexibility.
• Gently press on sore muscles or joints.
• Ask about activity levels, falls, and daily function.

“The physical exam and history may be supplemented by imaging,” says Odonkor. That may include an MRI of the brain and spinal cord or an EMG (electromyography) as needed, he says. An EMG evaluates the health of muscles and the nerves that control them by measuring their electrical activity.

These tests can rule out other causes of the pain such as arthritis, fractures, or other conditions unrelated to MS.

“Distinguishing MSK pain from neuropathic or inflammatory pain is critical, as management strategies differ. Often, pain mapping and functional testing help pinpoint mechanical drivers, such as spasticity or joint overload,” he says.

Treatment for Musculoskeletal Pain

The most effective treatment plan is multimodal and targets both the pain itself and the movement issues that cause or worsen it, says Odonkor.

Physical Therapy (PT)

Odonkor calls physical therapy the foundation of treatment. PT can:

• Strengthen weak muscle groups.
• Improve posture.
• Increase flexibility.
• Rebalance gait.
• Correct compensatory movement patterns.

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Aquatic therapy and core strengthening may also help address underlying causes of pain.

Assistive Devices to Improve Gait

Assistive devices can provide an external means of support to improve walking ability, says Kameron Jacobson, PT, DPT, a physical therapist at the Cleveland Clinic Lou Ruvo Center for Brain Health in Las Vegas.

“This could be a brace or electronic device at the ankle to help a foot clear the ground or leg swing forward better, or a walker to improve walking quality through increased stability,” he says.

Improving balance and gait could help address some of the root causes of MSK, says Odonkor.

Complementary Therapies

The following complementary therapies may be used in conjunction with PT, says Odonkor.

• Massage Massage may help reduce muscle tension, improve circulation, and offer short-term pain relief.
• Myofascial Release This gentle, constant massage releases tightness and pain through trigger point pressure.
• Acupuncture This traditional Chinese medicine practice uses thin needles to provide pain relief.

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Medications

Both over-the-counter and prescription medications can be used to manage musculoskeletal pain, says Odonkor.

These include:

• NSAIDs or acetaminophen for nociceptive pain (pain that you feel after an injury that causes tissue damage)
• Muscle relaxants for spasticity
• Brain stimulants and antidepressants or anticonvulsants when central sensitization is present (central sensitization is when the central nervous system changes and makes people more sensitive to pain)
• Botox injections, which help with management of joint contractures and spasticity

Don’t Ignore Fatigue and Depression

Fatigue, anxiety, and depression are more common in people with MS, and all of them can amplify pain perception, reducing coping capacity and reinforcing a vicious cycle, says Odonkor. “Pain limits mobility, inactivity worsens fatigue, and mood symptoms heighten pain sensitivity,” he says.

Breaking this cycle requires coordinated behavioral and physical interventions, emphasizing restorative sleep, gradual conditioning, and psychological support, he says.

Move With Mindfulness

Odonkor encourages patients to “move with mindfulness.”

“For example, pacing activity, using assistive devices when needed, and practicing regular mobility exercises will help maintain function. Additionally, addressing mood and sleep early, optimizing spasticity management, and integrating relaxation or breathing techniques can profoundly improve quality of life,” he says.

Above all, care should be individualized, multidisciplinary, and centered on your goals for comfort, participation, and independence. Seeking expert care soon after your diagnosis may help prevent or minimize the impact of musculoskeletal pain in MS, says Odonkor.

The Takeaway

• Musculoskeletal pain is common in MS and often results from changes in movement, balance, strength, and posture.
• Physical therapy and assistive devices may improve pain by correcting movement patterns and reducing stress on muscles and joints.
• Fatigue, mood changes, and poor sleep can intensify pain, so caring for your mental health and energy levels is an important part of treatment.
• If pain begins to limit daily activities, let your MS care team know. Early, coordinated care can help keep musculoskeletal pain from worsening.