Association between pain and sarcopenia in middle-aged and older adults: a systematic review and meta-analysis

Sarcopenia contributes substantially to functional decline in middle-aged and older adults. Pain is common in this population and may be associated with impaired muscle health; however, the magnitude and clinical characteristics of this association remain uncertain. This systematic review and meta-analysis aimed to quantify the association between pain and sarcopenia-related outcomes in middle-aged and older adults.

PubMed, Embase, Web of Science, and the Cochrane Library were searched from database inception to April 10, 2026. Observational studies involving adults aged ≥50 years, or populations with a mean age of ≥50 years, that reported the association between pain and sarcopenia-related outcomes were included. Adjusted odds ratios (ORs) and 95% confidence intervals (CIs) were pooled using random-effects models, with between-study variance estimated by the restricted maximum likelihood method. Subgroup and secondary meta-analyses were conducted according to consensus-based sarcopenia criteria, pain severity, and anatomical pain site. Studies using SARC-F were excluded from the corresponding main analyses and were considered only in separate sensitivity analyses. Leave-one-out sensitivity analyses, funnel-plot inspection, and Egger's regression test were also performed. The review was registered in PROSPERO (CRD420261406169).

Nine observational studies were included in the systematic review, of which six studies using consensus-based sarcopenia criteria contributed to the primary meta-analysis. Pain was significantly associated with higher odds of sarcopenia (pooled OR = 1.26, 95% CI: 1.16-1.38; p < 0.001), with low between-study heterogeneity (I² = 1.43%). No significant difference was observed between studies using the AWGS 2019 and EWGSOP2 criteria (p for subgroup difference = 0.83). The pooled ORs were 1.33 (95% CI: 1.07-1.65) for mild pain, 1.49 (95% CI: 1.17-1.89) for moderate pain, and 2.17 (95% CI: 1.32-3.57) for severe pain. Back or low-back pain and joint or knee pain were also positively associated with sarcopenia, with pooled ORs of 1.72 (95% CI: 1.28-2.31) and 1.78 (95% CI: 1.12-2.83), respectively. In a sensitivity analysis of the overall pain association, inclusion of PPB 2022, which used SARC-F, increased the pooled OR to 1.56 (95% CI: 1.06-2.31), markedly increased heterogeneity (I² = 94.24%), and reduced result stability. In a separate site-specific sensitivity analysis, inclusion of CLC 2025 yielded a pooled OR of 1.95 (95% CI: 1.30-2.91) for joint or knee pain, and the positive direction of the association was maintained in the corresponding leave-one-out analysis. Egger's test did not indicate statistically significant small-study effects (p = 0.533), although its power was limited by the small number of studies.

Pain was associated with higher odds of sarcopenia and sarcopenia-related outcomes in middle-aged and older adults. Positive associations were also observed for severe pain and for site-specific back or low-back pain and joint or knee pain in analyses restricted to studies using consensus-based sarcopenia criteria, although substantial heterogeneity in several secondary analyses warrants cautious interpretation. Sensitivity analyses incorporating SARC-F-based studies yielded positive pooled estimates; however, screening-defined risk of sarcopenia should not be considered equivalent to sarcopenia confirmed using consensus-based criteria. Given the observational nature of the evidence, causal conclusions cannot be drawn. These findings support consideration of sarcopenia screening and physical-function assessment among middle-aged and older adults with persistent or clinically significant pain.

https://www.crd.york.ac.uk/PROSPERO/view/CRD420261406169, identifier [CRD420261406169].