key: cord-332078-vl309ss7 authors: Cipollaro, Lucio; Giordano, Lorenzo; Padulo, Johnny; Oliva, Francesco; Maffulli, Nicola title: Musculoskeletal symptoms in SARS-CoV-2 (COVID-19) patients date: 2020-05-18 journal: J Orthop Surg Res DOI: 10.1186/s13018-020-01702-w sha: doc_id: 332078 cord_uid: vl309ss7 nan symptoms at onset is influenced by socio-geographical factors [64] . The most common symptoms in patients with mild to moderate clinical presentation of the condition are fever, fatigue, and dry cough, followed by other symptoms including headache, nasal congestion, sore throat, myalgia, and arthralgia [65, 66] . The evidence on the central role of inflammation during COVID-19 infection underlines the need to block this inflammatory cascade [30, [60] [61] [62] [67] [68] [69] [70] . The presence of musculoskeletal symptoms is worrying: there is a high rate of use, especially in the middle age and elderly population, of NSAIDs. The fact that patients therefore report musculoskeletal symptoms is even more worrying because it may imply that the inflammatory reactions overcome the antiinflammatory effect of such drugs. Clinical features have to be analyzed deeply, especially considering the new evidences on COVID-19. Musculoskeletal symptoms should be married with laboratory findings, such as inflammatory and infectionrelated parameters (Interleukin-6, Procalcitonin, Creactive protein). Understandably, the involvement of the musculoskeletal system has not been deeply investigated during this pandemic, but synovial and muscle biopsy, and joint fluid analysis, for example, should clarify how extensive the attack of the virus on the whole of the human body is. Until now, no report has been published on the presence of COVID-19 in the skeletal muscles, joint, or bones. The musculoskeletal symptoms are only anecdotally attributed to indirect effects, mainly arising from inflammatory and/or immune response, but other mechanisms can be hypothesized, such as direct damage by the virus on the endothelium or peripheral nerves. These findings could help to plan specific rehabilitation protocols in COVID-19 patients. As a new infectious disease, it is particularly important to underline the clinical features of COVID-19, especially in the early stage of the illness, to help clinicians to individuate and isolate patients earlier, and then minimize its diffusion. From the onset of the symptoms and to the most severe stages of COVID-19 disease, musculoskeletal symptoms, including myalgia, arthralgia, and fatigue, are a nearly constant presence. It is still unclear how the effects of COVID-19 on the musculoskeletal system are mediated. 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