Musculoskeletal (MSK) disorders are among the leading causes of morbidity and long-term disability worldwide (1). Common characteristics of MSK disorders involve chronic pain, reduced flexibility, impaired function, and diminished work capacity, posing a great potential to compromise quality of life and placing significant economic burdens on individuals and healthcare systems (2, 3).

Findings from Global Burden of Diseases, Injuries, and Risk Factors Study (GBD) indicated that MSK disorders largely affect older adults, with the peak age of onset being 50 and 54 years (3–5). Additionally, MSK disorders share several risk factors common to other non-communicable diseases, including aging, obesity, poor nutrition, and a sedentary lifestyle (2, 6, 7). The co-occurrence with serious chronic conditions can worsen health outcomes and intensify financial strains on healthcare, especially in an aging global population (6). As such, understanding both the individual and contextual determinants that contribute to the MSK disease burden should be a critical public health priority.

Globally, the prevalence and associated health burden of MSK disorders vary substantially by geographic region, and diagnostic category, with high-income countries experiencing a disproportionately greater impact (7–9). A female-biased trend in the overall burden of MSK was also documented, suggesting that sex/gender may play a role in MSK development (1, 3, 4, 9). For example, females experience more low back pain, whereas gout is typically seen more often in males (10, 11).

Beyond these sociodemographic contributors, a growing body of research has highlighted potential links between meteorological factors, such as temperature, barometric pressure, humidity and precipitation, and MSK symptoms (12–15). Notably, gout stands out for its sensitivity to environmental triggers: temperature and humidity can alter physiological regulation of serum urate levels (12, 16, 17). In other MSK conditions, shifts in weather coinciding with variations in joint pain and stiffness is supported by theories that barometric pressure could affect joint spaces, temperature might modulate inflammatory mediators, and behavioral or emotional changes linked to seasonality could exacerbate pain (16, 18, 19). Nevertheless, more recent findings question the consistency of these weather-pain links (17, 20), citing limitations including restricted disease coverage, short study durations, wide geographic variability, or reliance on self-reported meteorological exposures. As a result, epidemiological evidence regarding direct meteorological influences on MSK disorders remains inconclusive. It is noteworthy that these reported associations may not necessarily reflect direct biological effects of specific atmospheric variables alone. At the population level, meteorological indicators may also function as contextual proxies for broader behavioral, environmental, and infrastructural conditions, such as seasonal changes of physical activity, indoor heating and cooling practices, air pollution, and access to healthcare (21–26), which themselves are socially patterned and often exhibit gendered distributions.

In the present study, with a focus on the 55-and-older age group, we are trying to address the research gap by leveraging three high-quality, nationally representative data sources. First, GBD 2021 estimates to evaluate the MSK disorder burden across the United States. Second, inter-annual meteorological data were obtained from the Global Historical Climatology Network-Daily (GHCN-D) Version 3 to characterize annual variations of temperature, humidity, barometric pressure and wind speed. Third, state-level behavioral risk and healthcare access indicators were derived from the Behavioral Risk Factor Surveillance System (BRFSS), providing standardized estimates of obesity prevalence, smoking rate, and healthcare access patterns. The GBD data offer a comprehensive, standardized methodology for comparing disease metrics over time and across geographic regions (27). To facilitate systematic evaluation and comparison of the worldwide burden, GBD 2021 classified MSK disorders into six major categories: rheumatoid arthritis, osteoarthritis, low back pain, neck pain, gout, and other musculoskeletal diseases.

We chose to study the United States (U.S.) for several reasons. First, MSK disorders increasingly strain the country's healthcare system and economy, with one of the highest age-standardized prevalence rates worldwide (9, 28). Second, the Global Historical Climatology Network (GHCN), which is supported by U.S. National Centers for Environmental Information, provides detailed meteorological indicators that are uniquely available for U.S. territories. Third, the broad geographic expanse of contiguous U.S. captures substantial meteorological variation while relatively narrowing confounding factors associated with economic development, demographics, and healthcare resources. We specifically limit our modeling analysis to the contiguous 48 states and the District of Columbia (hereafter referred to as the “49 continental states”), excluding Alaska, Hawaii, Fed States of Micronesia, and Puerto Rico, to further minimize the effects of extreme outlier weather conditions or socioeconomic contexts, thus allowing a more reliable assessment of potential meteorology-health associations. Moreover, we adjusted for key sociodemographic and structural factors, including the Socio-demographic Index (SDI), age-specific population estimates, and state-level behavioral indicators, to account for potential confounding and effect modification in observed associations between inter-annual meteorological variability and MSK burden.

To elucidate these relationships, we employ two complementary statistical approaches. First, we use Generalized Linear Models (GLMs) to identify broad associations between meteorological conditions and MSK burden. Then, we apply penalized Generalized Additive Models (GAMs) to detect non-linear patterns and complex interactions. By integrating population-level disease estimates from GBD 2021, systematically curated meteorology observations from GHCN-D, and state-level behavioral indicators from BRFSS, together with sophisticated analytic techniques, this research aims to explore how weather variability influences MSK disorders among older adults. Rather than inferring direct causality, our findings are intended to enhance understanding of population-level meteorology-MSK associations and to support context-sensitive public health planning and preventive strategies in aging societies.

In 2021, older adults in the United States experienced considerably higher burdens from six musculoskeletal disorders compared to global averages, with gout among males and other musculoskeletal diseases among females showing the most substantial disparities. Over the study period, the burden for most MSK disorders increased, except rheumatoid arthritis and low back pain, which exhibited a declining trend. Correlation analyses revealed significant bivariate associations between specific meteorological variables and disease burdens. Subsequent modeling using GAMs, allowing for non-linear meteorology-health relationships, jointly accounted for behavioral risk factors and residual temporal trends, significantly improved model performance relative to baseline models, uncovering nuanced and disorder-specific effects of ambient meteorological conditions with potential common thresholds across MSK conditions. Notably, beyond the impact of annual average conditions, inter-annual fluctuations in temperature and humidity consistently exhibited significant associations with MSK burdens. Furthermore, absolute levels of wind speed and barometric pressure was significantly correlated with nearly all disorders studied, underscoring their broad population-level relevance. Sex-based differences in meteorology-disease associations were also evident, particularly for gout and rheumatoid arthritis. Rather than implying direct causality, our findings primarily aim to advance understanding of population-level meteorology-MSK associations and to inform context-sensitive public health planning and preventive strategies in aging societies.

Previous research has long suggested an association between meteorological factors and MSK conditions (20, 36, 37), yet findings remain inconclusive. Notably, gout is supported by the strongest evidence implicating weather conditions among the MSKs examined (17). Many studies report seasonal peaks in gout attacks driven by changes in air temperature, barometric pressure, humidity, and wind speed (12, 16, 21, 38). Several biological mechanisms have been proposed to explain these associations, including disrupted physiological homeostasis, enhanced renal reabsorption of urate, and dysregulation of innate immune responses (12, 21). Additionally, a meta-analysis of case-crossover studies indicated that the combination of high temperature and low humidity significantly increased the risk of gout flares (17). Consistent with this, our study found that gout burden reached a lowest level within moderate ranges of the annual average temperatures (MEAN_TAVG) but rose markedly at the higher end (most pronounced among males). Apart from the absolute temperatures, there is also evidence highlighting that greater temperature variability may induce acute gout episodes (12, 17). In contrast, our study revealed a moderate and negative association between annual maximum temperature range (TRAN_ANN) and gout burden, and this effect was again more pronounced among males. In particular, this inverse association was estimated after adjustment for mean annual temperature, suggesting that the effect of intra-annual temperature variability may be independent of average thermal exposure.

Similar regulatory effects of temperature have been previously explored for other MSK subtypes. For example, a retrospective longitudinal analysis from Morocco reported that increased daily minimum temperatures during summer were associated with reduced pain intensity in patients with rheumatoid arthritis (14). Similarly, a 14-year primary care study conducted in Spain observed fewer referrals for shoulder or arm pain in years when annual minimum temperatures were higher (39). In Australia, a web-based longitudinal study found associations between sudden temperature fluctuations and increased hip osteoarthritis pain (40). Moreover, nationwide big-data research from South Korea reported a stronger association between monthly temperature differences and the temporomandibular disorder prevalence compared to absolute temperatures alone (41).

In our current study, although we did not observe a consistent pattern of temperature effects across the six MSK subtypes, some common “breakpoints” were identified across six MSK subtypes in terms of annual average temperatures (MEAN_TAVG) or maximum temperature range (TRAN_ANN). These threshold points corresponded closely to local minima or maxima, indicating critical changes in the temperature-burden relationships. It is biologically plausible that extreme environmental conditions trigger adaptive physiological responses, thereby influencing the pathology of MSK disorders. For example, prolonged exposure to high temperatures can induce heat stress, altering immune function through changes in cytokine production and inflammatory signaling pathways (42). By contrast, cold exposure might exacerbate joint stiffness and pain in inflammatory arthritis, likely through transient reductions in peripheral blood flow and neuromuscular function (43, 44).

More importantly, the outcome of interest in this study was disease burden measured by DALYs, which reflects the chronic accumulation of disability and premature mortality rather than acute disease incidence or short-term symptom fluctuations. As such, the observed associations with the inter-annual meteorological variability are unlikely to represent direct biological triggers of acute pain episodes. Instead, long-term weather patterns, particularly those characterizing regions with greater seasonal temperature contrast, may serve as proxies for broader contextual influences, including habitual physical activity, occupational exposure, healthcare access, and meteorology-related adaptive behaviors, all of which can shape cumulative MSK burdens over time. Consistent with this interpretation, elevated summer temperatures can contribute to increased consumption of beer, sugary beverages, and high-purine foods, thereby raising uric acid levels and exacerbating gout risk (21). In parallel, extended periods of extreme heat or cold may discourage regular outdoor physical activity (22), while reduced physical activity levels can lead to weight gain, loss of muscle strength, diminished joint support, and ultimately increased burden of conditions such as osteoarthritis or low back pain (23). Recent evidence further suggests that meteorological conditions may influence musculoskeletal health primarily by shaping physical activity patterns, activity constraints, and the utilization of rehabilitation and physical therapy resources, rather than through isolated direct biomechanical or inflammatory effects alone (24–26). In addition, substantial individual variability, shaped by genetic predisposition, lifestyle factors, psychological resilience, pain perception, coping mechanisms, or baseline disease severity, can further explain heterogeneous vulnerability to meteorological exposures (45–48).

Humidity has previously been implicated in gout flare-ups, with Neogi et al. reporting a reverse J-shaped association between average relative humidity and recurrent gout attacks, characterized by increased risk at higher humidity extremes (16). Our analyses revealed predictive potential of both humidity-related metrics (annual average and range) for gout and rheumatoid arthritis. Given previous research primarily emphasized short-term humidity exposure, our findings highlight the inter-annual humidity variability may also influence MSK burden through cumulative, indirect pathways, offering new avenues for future research.

Compared to temperature, humidity, wind speed, and barometric pressure are less consistently documented in relation to MSK aggravation. Nonetheless, some research has suggested a mitigating role of lower barometric pressure and stronger winds in chronic MSK pain (14, 49, 50). Under GAM specifications in our study, the population-level associations of most MSK disorders and annual average barometric pressure (MEAN_ASTP) demonstrated a similar U-shaped pattern. Conversely, annual average wind speed (MEAN_AWND) exhibited more distinct, disease-specific trends despite sharing common turning points. In this context, unlike temperature and humidity, which were characterized using both annual mean and annual range metrics to better capture physiologically relevant exposure patterns, MEAN_ASTP and MEAN_AWND were represented solely by annual mean values. Thus, their associations with MSK burden are more plausibly interpreted as population-level statistical correlations that likely arise from complex environmental and structural pathways.

Despite meaningful insights emerging from various study designs so far (51, 52), systematic reviews and bigdata-based epidemiological studies have often questioned the assumption that meteorological factors directly trigger MSK pain onset or exacerbation (17, 36, 45, 46). These conflicting findings possibly stem from methodological limitations commonly encountered in environmental-health research, including small sample sizes, short follow-up periods, misclassification of meteorological exposure, heterogeneity in outcome measurements, and insufficient adjustment for potential confounding factors (17, 20). The case-crossover design is frequently employed to assess the effects of transient environmental exposures on the risk of acute MSK pain events whose validity depends on appropriate selection of control time windows (pain-free periods). Besides, due to the self-reported nature of symptom exacerbations, participants may recall or report environmental conditions differently during episodes of pain compared to pain-free intervals, introducing recall bias. Another substantial concern is the inconsistent treatment of environmental variables across studies, complicating comparisons and synthesis of results. For instance, some studies utilize daily averages or maximum values, whereas others incorporate more precise hourly or instantaneous records. Furthermore, relatively few studies have adequately accounted for lagged effects (delayed weather impact on pain) or lead effects (pain preceding weather changes), potentially overlooking long-term or cumulative meteorological impacts on MSK symptoms (20). Addressing these methodological limitations through standardized exposure assessments, clearly defined referent periods, rigorous design choices, and long-term prospective studies will be critical to advancing the understanding of meteorological effects on MSK health outcomes.

Globally, MSK conditions rank prominently among the top contributors to the loss of healthy years, with burdens that accumulate with advancing age, and disproportionately affect older adults. The rapidly aging global population amplifies their importance as a public health priority. Our study identified distinct, occasionally contrasting patterns of meteorology-disease associations across the six included MSK conditions. Notably, we also observed sex-based disparities, particularly evident in gout and rheumatoid arthritis. The use of GAMs and derivative analyses revealed that both the direction and magnitude of meteorological effects varied across certain thresholds, characterized by some common breakpoints located around the central portion of the exposure distribution (i.e., near the mean or median on the standardized scale). These breakpoints likely represent transition zones in relative exposure intensity experienced by a large proportion of the population, where modest shifts may interact with behavioral adaptation, physiological tolerance, and healthcare-system buffering capacity, thereby exerting a disproportionate influence on the long-term accumulation of MSK disease burden at the regional level. Based on these insights, observed non-linear and sex-specific patterns are more plausibly interpreted as reflecting the integrated influence of environmental conditions, behavioral adaptations, psychosocial vulnerability, and healthcare utilization over prolonged periods, rather than direct short-term physiological triggering alone. To move beyond ecologic inference, future research should prioritize longitudinal and individual-level study designs that integrate repeated symptom assessment with detailed psychosocial, behavioral, and social-contextual data. Such approaches will be essential for clarifying how meteorological variability interacts with aging, lifestyle, healthcare access, and broader structural determinants of health in shaping the long-term population burden of MSK disorders. Ultimately, this integrated perspective may inform context-sensitive prevention strategies and resource planning for MSK disorders in an era of demographic aging and increasing environmental variability.

Several limitations should be noted when interpreting our findings. First, because we conducted a secondary analysis of GBD study data, the results may be influenced by biases inherent in GBD modeling, and our scope may exclude certain MSK conditions not captured by that study. Second, meteorological elements are usually highly correlated, and multicollinearity challenges the robustness of studies on environment-health associations. In our design, we improved numerical stability by rescaling predictor variables and mitigated multicollinearity by employing GAMs with penalized cubic regression splines, using restricted maximum likelihood and automatic smoothness selection. Additionally, VIFs were assessed to confirm minimal residual collinearity (VIF < 5) among predictors.

Third, meteorological exposures were generated by IDW over the continental domain and then averaged within state polygons, whose precision depends on station density. Coverage is limited for extended elements, and some state estimates necessarily borrow information from neighboring states. As a result, values are spatially smoothed and more uncertain in sparsely monitored areas, although IDW still recovers broad, physically plausible continental gradients. Fourth, this study is based on state-level aggregation of both meteorological exposures and MSK burden outcomes, which inevitably introduces exposure misclassification, particularly in meteorologically heterogeneous states. This aggregation also implies an inherent risk of ecological fallacy, whereby population-averaged associations cannot be directly translated into individual-level exposure–outcome relationships. This form of misclassification is expected to be largely non-differential with respect to DALYs and would therefore predominantly bias associations toward the null rather than generate systematic false-positive findings. To partially address this limitation, we conducted multiple sensitivity analyses incorporating alternative demographic and healthcare-access adjustments as well as sex-specific models, and the overall patterns of the main associations remained generally consistent. Fifth, although we adjusted for key sociodemographic, behavioral, and healthcare-access factors across the main and sensitivity model specifications, residual confounding by unmeasured individual-level factors such as comorbidities, detailed lifestyle behaviors, and individual healthcare utilization patterns may still confound or modify the observed meteorological-MSK relationship. Sixth, our analysis is explicitly burden-oriented and population-based, so there is a potential for ecological fallacy. The annual meteorological summaries used in this study capture regional environmental contexts under which MSK burden accumulates over time, rather than individual-level acute physiological exposures. Accordingly, the observed associations should be not interpreted as evidence of short-term weather-triggered symptom dynamics. Finally, our findings are specific to individuals aged 55 and older in the United States, and the results may therefore not generalize to younger populations or low- or middle-income regions with markedly different meteorological contexts, healthcare systems, or lifestyle factors.

By integrating data from the Global Historical Climatology Network-Daily (GHCN-D), the Behavioral Risk Factor Surveillance System (BRFSS) and Global Burden of Disease (GBD) 2021, this study adopted an ecological design to explore condition-specific associations between inter-annual meteorological variability and musculoskeletal (MSK) disorders in older adults in the United States. Apart from the yearly mean summaries, annual temperature and humidity variations were consistently associated with MSK burdens at the population level. Additionally, annual average wind speed and barometric pressure were also associated with disease burdens across most disorders. Notably, sex-based differences were shown in meteorology-disease relationships, especially for gout and rheumatoid. Furthermore, General Additive Model (GAM) analyses highlighted common non-linear breakpoints across several MSK conditions. Given that Disability-Adjusted Life Years (DALYs) capture the cumulative impact of disability and premature mortality rather than acute symptom triggers, the observed associations should be interpreted as context-sensitive correlates of chronic disease burden operating through complex behavioral, psychosocial, and structural pathways. Collectively, our findings offer population-level support for the associations between inter-annual meteorological variability and MSK disorder burdens, reinforcing the importance of incorporating environmental variability into population-level MSK surveillance and burden forecasting, particularly in aging societies. Future research should prioritize longitudinal, individual-level studies that incorporate physiological, psychological, and behavioral data and social-contextual data. Such work will be critical for disentangling potential biological mechanisms from perceptual biases, behavioral and structural influences, and for clarifying how social resources, cultural beliefs, and healthcare access interact with meteorological variability in shaping long-term MSK disease burden. This integrated perspective is essential for informing population-based prevention and health-system planning for aging populations under ongoing environmental change.