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Posts Tagged ‘cortisone injection’

It’s been six weeks since right shoulder surgery was performed in order to resect the acronomim and clavicle joint (AC joint) and remove rotator cuff tissue that was damaged by bone spurs. At a follow-up with the surgeon today, he indicated that patients tend to talk about still having pain but of a different quality. This is true for me in that the joint pain is much diminished but dull aches remain. He said this is primarily from healing bone and surrounding soft tissues. He cleared me for stepping physical therapy up from gentle stretches to strengthening exercises. Given my battle with RA, he said that recovery is likely to be longer than normal.

We then turned attention to my left shoulder as it’s been bothersome for quite some time as well. The surgeon gave a steroid injection into it about 8 weeks ago but there was only about a week of relief. He got an x-ray during the visit and discovered that there was acronomim bone rubbing on clavicle bone with no joint space visible. He attributed this to inflammatory arthritis (RA) and said that the cartilage between the bones was damaged but there were no large bone spurs visible. Like with the right shoulder, surgery would be needed to repair this joint and he suggested waiting at least three months after the other surgery. This would be good timing as my insurance out of pocket costs are met and will be until the end of June. We will schedule surgery at another follow-up appointment in six weeks.

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So much for a new year’s resolution to avoid surgery in 2015. Surgery on my right elbow is now scheduled for February 6th – we’re waiting until after my son’s wedding at the end of the month. This will be my 6th RA-related surgery. Both elbows give fits including persistent pain and tenderness but the right one has been the bigger beast probably because I’m right handed. In August 2013, first symptoms were noted. An MRI in October 2013 showed a 50% tear in a tendon. Enthesitis is the term for damage in an area where a tendon connects muscle to bone and such soft tissue damage is common in rheumatoid arthritis in general an in my case specifically. The orthopedic surgeon gave a cortisone steroid injection in November 2013. Occupational therapy was done from December 2013 to February 2014 but it was stopped as progress was not realized. Finally, in November 2014 a novel platelet-rich plasma injection was tried to no avail. The orthopedic surgeon, who specializes in hands and elbows, said that all conservative treatments failed to help and surgery would be required. He indicated that the surgery would include an incision across the elbow, removal of the damaged tendon, shaving off damaged bone tissue, and using anchor sutures to reattach healthy tendon to the bone. Anchor sutures involve drilling holes in the bone and inserting anchors which hold special permanent suture material. The arm and wrist will be immobilized for a few weeks. Occupational therapy is already scheduled starting two weeks after the procedure. My rheumatologist wanted to add a new DMARD, CellCept, to help with Rituxamab infusions. But now we’ll wait until after surgery to help avoid any infection complications.

While surgery is always a last effort, it’s time to take care of this ongoing issue as the pain is non-stop and use of the arm is limited. Updates will be posted as the process unfolds.

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My right elbow has been giving me troubles for over a year now and my rheumatologist referred me to an orthopedic surgeon who specializes in hands and elbows. An MRI revealed a 50% tear in a tendon. Other parts of the elbow exhibit pain. In fact, the left elbow also displays the same symptoms but to a lesser extent probably due to the fact that I am right handed. The orthopedic doctor knows about my struggles with RA and my history with soft tissue damage. In fact, he works in the same clinic with the surgeon who conducted three surgeries on my ankles.

A bevy of conservative treatments were prescribed starting with rest and immobilization with splints designed to prevent movement of the tendon. After that failed to help, a cortisone injection was done. The doctor also used the needle to aggravate the tissue in the joint in order to stimulate a healing process by increasing blood flow to the region. Needless to say, excruciating pain was experienced for the next 24 hours but after that, the steroid provided some relief…for about 1 month after which time the pain returned. Occupational therapy was then prescribed. Occupational therapists (OT) tend to focus on the arm from the elbow down to the hand and they engage in treatments similar to physical therapists. Treatments included heat and transcutaneous electrical nerve stimulation (TENS), gentle stretching exercises, and continued use of immobilization with splints. The goal was to move into more rigorous strength building exercises. But this goal was never met as the pain only became worse. After several months of OT, the therapist made the decision that things were getting worse and indicated that I need to return to the surgeon to determine next steps. At about this time, severe neck problems were popping up and the orthopedic surgeon and I both agreed that priority needed to be given to the neck. The past six months were devoted to recovering from neck surgery.

The elbow continued to cause problems and it came to the point where use was difficult and pain was constant so I returned to the orthopedic surgeon. He said that surgery to repair the torn tendon and its attachment point to the bone would be the next option. But before doing that, he wanted to try one more, last ditch strategy – a platelet-rich plasma injection or PRP. He admitted that the research was sketchy and that it was not an FDA or insurance approved treatment. I would be required to pay for it out of pocket and the cost will be about $300. His argument is that in spite of the lack of experimental research on its effectiveness, there is clinic evidence, it is relatively inexpensive, and it is not as invasive as surgery. He did give me a choice between PRP and surgery but his comments were, “If it were me, I would do this first before having surgery.”

In PRP, a patient’s blood is drawn, platelets are separated from other blood components, and the concentrated solution is injected into a joint that has tissue damage in an effort to jump-start a healing process.[1] The theory is that growth factors contained in the platelets are able to help damaged tissue heal. It has been applied to tendon areas like the Achilles and elbow where there is a lack of blood low and healing is difficult. This approach is quite popular with professional athletes but clinical trails show mixed results (Harmon & Rao, 2013).[2]

In medical practice, there is a range of possible qualities of treatments. Balshem et al (2010) categorizes the ranges from very low quality to high quality evidence.[3] The approval of drugs would rate as high quality evidence. At the lowest end of the evidence quality continuum would be treatments that have little or conflicting evidence. Platelet-rich plasma would rank at the lowest end. This is why the FDA and insurance companies won’t approve it. There is even less research about PRP and rheumatoid arthritis. A search of research studies specific to RA revealed one study conducted on pigs[4] and another conducted in 1989 on knees of RA patients.[5] Never provided sufficient evidence documenting the effectiveness of PRP for rheumatoid arthritis.

Given the lack of evidence, I remain quite skeptical about PRP but am willing to give it a shot (pun intended) in order to avoid surgery.

[1] http://orthoinfo.aaos.org/topic.cfm?topic=A00648

[2] http://www.ncbi.nlm.nih.gov/pubmed/24319241

[3] http://www.jclinepi.com/article/S0895-4356(10)00332-X/abstract

[4] http://onlinelibrary.wiley.com/doi/10.1002/art.30547/full

[5] http://link.springer.com/article/10.1007/BF00270285#page-1

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Rheumatoid_arthritis_jointBone erosion is one of the hallmark symptoms of RA and the biological processes involved in RA often result in the breakdown of bony tissue primarily in joints which are surrounded by a sac called the synovium (see diagram). I have this telltale bone erosion in my fingers documented via x-ray and a dime-sized erosion was found in my heel bone several years ago which caused a sharp bone spur. A surgeon removed the damaged tissue and a pathology report confirmed that it was caused by the erosive processes associated with RA.

But RA can impact other parts of the joint including the surrounding soft tissue – tendons, ligaments, and cartilage. Chronic tenosynovitis, inflammation of the sheath of a tendon is common in rheumatoid arthritis and can result in the permanent damage and tearing of the involved tendons. Such tendon problems caused by RA are well known by the scientific community and are linked to joint deformities (see Sivakumar, et al, 2008; Wakefield, et al, 2007). Tendon problems have even been posited as being one of the most powerful predictors of early RA (Eshed, et al, 2009). Sophisticated imaging techniques developed in the last few decades, such as MRIs and ultrasound, can reveal connective tissue damage in joints caused from RA including tenosynovitis and bursitis (Boutry, et al, 2007). Bursitis, inflammation of the fluid-filled sacs that protect joints (see NIH site), often accompanies tenosynovitis. RA is also implicated as a cause of cartilage damage in knees (see the AAOS site). An MRI taken at the onset of my RA diagnosis revealed cartilage damage in one knee.

Soft tissue damage became apparent after dealing with a persistently cranky elbow that was only getting worse to the point that major pain killers were needed one evening. I learned from an orthopedic doctor this week that I now have tendon tears in my elbow. The good news is that the bones and joint spaces are in good shape and appear to be undamaged from RA. While in non-RA patients the tendons commonly tear due to overuse, the doctor was unsure about the relative contributions of RA and overuse to the tearing. But since I don’t tend to overuse my elbow, except when fishing a couple of times this summer, I can’t help but think that RA is the major contributor – especially in light of previous history. Tendon problems have been a hallmark of my struggles with RA. One of the first symptoms I experienced, even before official diagnosis, was Achilles tendon tearing in both ankles which resulted in two surgeries. This bilateral problem, coupled with other symptoms, ultimately led to seeing a rheumatologist and receiving a diagnosis of RA. Several years later the tendon tearing continued and a third surgery was needed on the right ankle to repair the tendon, remove a bursa sac, and remove damaged bone tissue. Even after those procedures, my Achilles tendons continue to speak rather loudly everyday.

At this point, conservative treatments to the elbow will begin and include use of braces, topical NSAIDs (Voltaren gel), and physical therapy. Cortisone injections may be used if conservative treatments don’t work with surgical repair being the last line of treatment. So we wait and see if the most recent RA treatment (Rituxan) and the newly prescribed elbow treatments can slow down soft tissue damage enough to allow the tendons to heal on their own.

Photo attribution: By Wouterstomp at en.wikipedia [Public domain], from Wikimedia Commons

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