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Posts Tagged ‘joint’

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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Given the fact that there are a slew of RA medications laying on the failure heap, I’m willing to move outside the box and so is my doctor. The latest drug to be tried will be secukinumab – brand name Cosentyx by Norvartis. This biologic is currently approved by the United States Food and Drug Administration (FDA) for the autoimmune diseases psoriasis, psoriatic arthritis (PSA), and ankylosing spondylitis (AS). Cosentyx is an interleukin 17 (IL-17) inhibitor. IL-17 is a cytokine produced by T cell lymphocytes and is connected with autoimmune inflammatory responses. I reported on clinical trials with secukinumab for RA back in 2012. In a recently reported clinical trial being conducted for RA, patients demonstrated improvement over a one year treatment period. Safety and side effect profiles match other biologics with increased risk of infections, allergic reactions, changes in liver and blood tests, and cases of inflammatory bowel disease.

My official diagnosis has been seropositive rheumatoid arthritis due to positive rheumatoid factor (RF) tests, classic RA symptoms like symmetrical bilateral presentation, and bone erosions. But I’ve also shown symptoms more associated with AS like tendon insertion tearing, large joint involvement, and uveitis but without a positive genetic marker for AS (HLA-B27). In addition, my grandmother dealt with psoriasis and her brother had a debilitating case of ankylosing spondylitis. My insurance approved this drug for my use and I will begin the weekly loading dose self-injections as soon as they are shipped. We’ll see how I respond to this newest option.

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It’s been a little over two weeks since I had arthroscopic shoulder surgery. At the post-op followup visit with the physician assistant (PA), an x-ray was done and the steri-strips placed across the small incisions were removed. The incision scars are quite small FullSizeRender (3)compared to other surgeries (see photo). There remains a large area of bruising around the front incision where fluids pooled up after the surgery. I was told that the sling was not necessary except to provide relief and to send a message to others not to grab my hand or hug me!

The PA showed me 24 photos of the procedure and explained what was going on in each one. One showed a grinding tool right above the rotator cuff which had some damage from a bone spur right above the tool. The tool was

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bone spur above and rotator cuff below

used to remove both the damaged rotator cuff tendon tissue and the bone spur. In the next photo, the tool is shown working on removing some bone tissue on the end of the clavicle. Finally, a space between the acromium and clavicle is visible after removing about 1/2 – 3/4 inch of the clavicle. The x-ray shows an that there is an open space where the AC joint used to exist. Bone will no longer grind on each other. The x-ray technician asked who did my neck surgery as she “sees all” on the image. The screws and plates are visible on the image.

I was cleared to start physical therapy and was given a prescription. I went upstairs to the PT clinic run by the surgery group and scheduled PT starting February 17 with two sessions each week for six weeks. The goal is the begin stretching and moving to strengthening.

For the present, I’m careful with the shoulder and avoid moving it too much as any movement can cause it the tire easily and become painful. But without being immobilized, I find myself going into usual movements and paying for it later. Overall, recovery from arthroscopic surgery has been much easier compared to open incision surgeries and I’m thankful for this technology.

In the meantime, I still can’t start my new RA treatment, daily Kineret injections, as I’m battling a thrush fungal infection. I see an ear, nose, and throat doctor tomorrow to address the ongoing cough and the thrush infection.

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grinding tool removing bone tissue on clavicle

 

 

 

 

 

 

 

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opening between acromium and clavicle after removing bone tissue

 

 

 

 

 

 

 

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X-ray showing end of clavicle removed. Screws and plates are visible in neck from previous surgery

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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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Corticosteroids or glucocorticoids are powerful anti-inflammatory drugs commonly used to treat a variety of medical conditions. They are not to be confused with anabolic steroids that are notoriously abused by athletes.1 Anabolic steroids are associated with muscle mass gain and corticosteroids are connected with metabolism and immunity.

Most every RA patient has probably taken oral steroids in the form of pills or a dose pack that tapers down the dose over a period of time. Oral steroids are effective at providing quick reduction of RAsymptoms although long-term use is generally discouraged and even short-term use is being questioned.2 When taking an oral steroid, the drug goes throughout the entire body systemically. But there are other forms of steroids that are directly injected into a specific area of the body in an effort to treat RA related symptoms. Since being diagnosed with RA, I’ve had one steroid injection into my right knee, four into my left hip, one into my neck, and one into my right elbow.

Read the rest of the post at http://rheumatoidarthritis.net/living/steroid-injections-treating-ra-symptoms/

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I’m still in the midst of recovering from cervical fusion surgery on May 15 and am currently completing physical therapy. The process seems to be going well, pain and numbness is almost completely gone, and I’m slowly regaining muscle strength. After dealing with it for over 8 months, the neck and associated parts finally feels much better. But RA is never silent and has a way of rearing its ugly head just when you think things are calm. Sure, there is always the ongoing “background noise” of RA – fatigue, joint and muscle pain, finger swelling and pain, joint locking, and the persistent ankle pain after having three surgeries. But now the left hip is begging – no screaming – for attention.

Hip problems became apparent almost two years ago when I began getting steroid injections for trochanteric bursitis from my rheumatologist. Bursae are sac-like structures that are found in some joints and aid in providing friction reduction.[1] I had a bursa removed as part of an ankle surgery. The trochanteric bursa is on the outside of the hip and is commonly involved in RA.[2]

While my neck was healing, the left hip progressively grew worse. Sitting for any length of time was impossible, getting in and out of a chair and car was difficult, sleeping on the left side was not feasible, and the left side was favored while walking. At a recent rheumatology appointment, a fourth cortisone steroid injection was given into the trochanteric bursa. But the injection brought no relief. My rheumatologist referred me to an orthopedic specialist.

The orthopedic surgeon examined x-rays and noted that the space in the ball and socket joint, while somewhat reduced, looked fine. There was no bone erosion perceived. We spent some time discussing my earlier problems with the trochanteric bursa, the multiple steroid injections, and my current symptoms of groin and buttock pain. He then laid me down on my back and began to examine my hip movement through a series of tests. I couldn’t lift my leg off the table and extreme pain was felt when he manipulated it in various ways. After the physical exam his entire line of inquiry changed from the more external trochanteric bursa to focusing on tissues around the joint itself. He immediately began to suspect a labral tear. The labrum is cartilage that surrounds the hip joint.[3] But a physical exam and x-ray cannot directly pinpoint what’s really going on so an MRI is needed. A traditional MRI can’t always detect soft tissue in the complex hip joint so an arthrogram is added. Before the MRI, a radiologist injects a combination of fluid, steroid, and a contrast into the hip joint under the guidance of an x-ray. After the injection, you go directly to the MRI machine. The steroid can also provide a therapeutic purpose in reducing inflammation and pain. I am scheduled for an MR arthrogram tomorrow and hopefully it will help solve the mystery.

In addition to the more traditional bone erosion, I have a history of developing soft tissue damage to the musculoskeletal system from RA. This episode with the hip seems to be following that story.

[1] http://orthoinfo.aaos.org/topic.cfm?topic=a00409

[2] https://www.rheumatology.org/Practice/Clinical/Patients/Diseases_And_Conditions/Tendinitis_and_Bursitis/

[3] http://www.hss.edu/condition-list_labral-tears-hip.asp#.U_zH9WRDvA4

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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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