Posts Tagged ‘swelling’

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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I had a follow-up appointment with my rheumatologist to see how the Rituxan/Methotrexate combination is working. Since the time I started Rituxan, an MRI of my right elbow revealed a 50% tear in a tendon and active inflammation in the joint space. A cortisone shot from the orthopedic surgeon seems to have calmed things down for the time being. My right ankle displays regular sharp pain feeling much like it did a couple of years ago when I had surgery to remove bone erosion and repair soft tissue damage. Under examination from the rheumatologist, my toes were tender and painful – something I never noticed since I don’t regularly inspect my toes. I still experience considerable overall stiffness, joint pain, and fatigue. But the good news was that my rheumatologist noticed that I had less tenderness and swelling in my finger joints (it amazes me how she distinctly remembers such things). I agreed as I had noticed the same thing. My wife, one of the best and objective observers, also noticed some improvement over the past few weeks.

When I started other biological treatments, it was pretty clear whether or not it was working within the first few weeks. But that is not the case with Rixutan. Unlike anti-TNF drugs like Enbrel and Humira that can work more quickly, the full effect of Rituximab may not be seen for 16-24 weeks (National Rheumatoid Arthritis Society). My first Rituxan infusion was on September 23rd and I’m sitting at about 11 weeks since I started. According to the Rituxan frequently asked questions (FAQ) website,

At the time of their first checkup—8 weeks after starting treatment—many of those people had seen an improvement in their symptoms. And 6 months later, many were still experiencing improvement.”

The hope remains that this combination will continue to cause an improvement in symptoms. My rheumatologist believes that with the RA out of control for so long, it may take some time for a treatment to catch up and put out the inflammatory fire.

Rituxima Binding to CD20 on a B Cell Surface

Rituxima Binding to CD20 on a B Cell Surface (Photo credit: NIAID)

In this fast-paced, electronic society, we demand everything instantly. It’s difficult to wait for a treatment to take effect. But with the complex biological processes involved with rheumatoid arthritis, the immune system, and Rituxan, we must be patient. While scientists aren’t completely sure about the exact details, it is believed that Rituxan works by depleting the production of B cell lymphocytes by targeting an antigen called CD20 (see graphic) (Pescovitz, 2006). Since B cell production takes time and Rituxan only works on a portion of the production line (see graphic below from the Rituxan website), it stands to reason that it will take time for the therapeutic action to take hold. Slow and steady, hold the course, wait and see…these are all operative words at this time.


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The last four days have been a grand time of celebrating our oldest son’s college graduation. It’s been a whirlwind of events including his senior engineering project presentation, three formal ceremonies of various sizes and durations, dinners, and a large party hosted at our house. This meant much physical activity around the yard and house the principal of which was 10 hours of smoking five large pork shoulders for 50 people (it was tasty and you should check out the website http://www.amazingribs.com/).

Tired_brown_bear_050701_01Going into this set of events, a nagging thought persisted…”I’m going to pay for this later.” Sure enough, by Sunday evening I could barely walk, my fingers were swollen and throbbing in pain, and sheer exhaustion washed over my body causing me to collapse. I knew that going to work Monday morning would not be possible.

Many argue that movement and exercise is critical medicine for arthritic joints stating that it relieves pain and stiffness (see these websites – Mayo Clinic, NCHPAD). In addition to potential positive impact on joints and muscles, exercise is obviously important for other reasons include cardiovascular and mental health. But my experience over the years has been that exercise and movement causes rebound pain and stiffness. Yet, I know that I’m missing out on the benefits of exercise.

It’s interesting to read some of the recommendations from medical websites. From WedMD…“Regular exercise can actually reduce overall pain from rheumatoid arthritis.” In my experience with RA, exercise always causes more pain. There are many times when I’ve had to stop movement because the pain got worse. WebMD also makes this statement, “Regular exercise improves functional ability and lets you do more for yourself.” This may be true for some but the functional ability of my ankles and Achilles tendons actually got worse after exercising. The tendons tore at a quicker rate and my orthopedic surgeon and physical therapist both recommended that I avoid any activity that puts stress on the tendons.

Can exercise actually be contraindicated for RA? Kelly Young at RA Warrior has an excellent series of posts about this topic. She concludes, “If you can, you should; if you can’t, you shouldn’t.” At the Health Central RA website, Dr. Borogini wrote a balanced article about the topic and makes an excellent suggestion which is in alignment with Kelly Young’s statement, Rest More When RA Is Active, Exercise More When It Is Not. The Johns Hopkins Arthritis Center website makes a great observation about movement and RA.

Acutely, resting of involved joints can assist with pain management and decrease the inflammation of the involved joint. However, the potential side effects of inactivity include decrease range of motion, loss of strength, altered joint-loading response, and decrease aerobic capacity.

This leaves those with active disease in a real quandary.

The conclusion that must be drawn from the recent set of weekend experiences is that my RA is not under control and I should probably avoid strenuous physical activity. But of course, I already knew that going into the weekend. The difficulty lies in the fact that life must go on and I was not about to miss this once-in-a-lifetime celebration. I just have to be ready to pay the consequences afterwards.

Creative Commons Photo Credit: http://commons.wikimedia.org/wiki/File:Tired_brown_bear_050701_01.JPG

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5195232402_d7914561e0_nThe past few weeks have been a real pain in the neck literally. The lymph nodes under my jaws and neck are swollen and quite painful. This is not uncommon when fighting a cold or flu but I have no symptoms of any such infection. The pain was bad enough that it woke me up early this morning. I’m not too concerned as I’ve been down this road before.

About a year and a half ago, while taking Humira, a series of lymph nodes from under the jaw, down the neck, across the chest, and under the armpits were swollen and at times, quite painful. My rheumatologist called it lymphadenopathy which simply means “disease of the lymph nodes.”[i] This rather general definition doesn’t get at the cause of the changes in the lymph nodes. After a physical exam, my rheumatologist said that I probably had some sort of infection caused by the immune-suppressing medications used to treat RA. This made sense at the time since the lymph system is part of the immune system and includes liquid containing white blood cells that attack foreign invaders like bacteria and viruses.[ii]He called for a chest x-ray to rule out sarcoidosis[iii] which is an autoimmune disease of the lymph system and commonly shows up as many swollen lymph nodes deep in the chest. The x-rays were negative and he told me to keep an eye on the nodes. After a few months, I returned to the rheumatologist and told him that the nodes were the same. He found some nodes that were rather large including one being 3 centimeters. He called for an ultrasound to image the culprit. The ultrasound technician could not find it and she called in the radiologist on staff that day. She poked and prodded and moved the ultrasound wand all over the place without finding anything. She mentioned that a 3 centimeter node was rather large and wanted to be sure that she didn’t miss it. I went away not thinking about it much anymore. After another 6 months, I mentioned them again to my rheumatologist and this time he recommended that I see a hematologist since they are experts on blood and lymph system disorders. Little did I know that hematologists are also oncologists…doctors who treat cancers. That sent the stress level up a bit since I knew that Humira and other immune-suppressing treatments for RA were linked to higher levels of lymphoma. The oncologist was wonderful and very reassuring stating this is was likely not lymphoma but he wanted to rule it out. He ordered a CT scan with contrast and ran a large amount of blood tests…9 vials in all! At the follow-up, he told me the good news that he could not find anything and didn’t want to do a biopsy of the nodes. He did find an increased level of rheumatoid factor (RF) in my blood and said that I was probably experiencing an increase of disease activity and that lymph nodes can be impacted like this in RA patients. According to rheumatology researchers,

“Lymph node enlargement is
an important physical finding associated with RA and SLE
[lupus] disease activity. Atypical locations and unusually
large lymph nodes should raise clinical suspicion of another
underlying disease.”

So it seems that lymphadenopathy is common with autoimmune diseases and that makes sense given the fact that the lymph nodes are part of the immune system. I’ve been down this road before and won’t think too much about it. But I’ll keep an eye on things since starting a new combination of Actemra and Imuran both of which impact the immune system. I just wish it wasn’t such a pain in the neck!

Creative Commons Photo Credit: http://www.bartleby.com/107/illus602.html

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It hurts to sit. It hurts to walk. It hurts to lie down. It hurts when awake. It hurts when asleep (or trying to sleep). It hurts even when not moving. The pain radiates down the leg and into the buttocks. Such is my recent experience with the left hip. An inflamed bump on the trochanteric bursa which lies on the outside of the top of the femur bone is quite noticeable by simple observation. I observed the swelling today while comparing it to the right side. My rheumatologist drew attention to it during my last visit in August. She gently pushed on the outer most part of the hip where the bursa lies and a sharp pain immediately became apparent. She mentioned that such inflammation of this bursa is common with RA. According to an article published in the Annals of Rheumatic Diseases,

“Trochanteric bursitis is an underdiagnosed, easily remediable cause of pain in RA. Specific examination for in presence should be a routine in all patients with RA, especially those with hip pain.”[i]

I do wonder about the “easily remediable” part of the quote as nothing related to RA ever seems to be easy or permanent. Over the past few months, the pain has gotten increasingly worse to the point where it’s impacting daily routines. My rheumatologist mentioned that the first line of treatment will likely be a cortisone injection. This will be the first topic of discussion at next week’s appointment. I’ve never had a cortisone injection so this will be a new experience.

Off for my monthly Orencia infusion tomorrow morning…

[i] http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1000992/

Photo Credit Creative Commons public domain image: http://commons.wikimedia.org/wiki/File:Kugelgelenk.jpg

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About two years ago was the first time I began to notice swelling and pain in my proximal interphalangeal (PIP) joints in both hands. The PIP joints are the middle knuckle in each finger (not including the thumb). Although I had other symptoms, this was really the reason for seeing my primary care physician ultimately leading to a visit to a rheumatologist and a RA diagnosis. Early on, my rheumy ordered x-rays and the radiology report indicated some bone erosion in these joints. In spite of being seronegative for RA factor, this finding was enough for my rheumy to quickly begin disease modifying medications eventually leading to the use of TNF blockers (Enbrel, Cimzia, now Humira). Since then, inflammation has spread to the some of my metacarpophalangeal joints (MCP) at the bottom of each finger and to the wrist (and elbow, and knees, and feet…).

Inflammation of the PIP joints is typical in RA patients and can lead to permanent deformities in the fingers.[i] Joint damage can come on rapidly if RA is not treated. I vividly recall my first encounter with RA about 20 years ago. In the days before major disease modifying medicines, my neighbor had severe RA and his hands, fingers, and feet were deformed beyond use. He was such a gentleman and upon shaking my hand, quickly explained why his fingers were so deformed. Surgery scars were prominent on each finger. Surgeons went in and clipped the ligaments in a futile attempt to slow the deformity.

Because of this, I’ve kept an eye on my fingers. A few months back, my rheumy ordered another round of x-rays and the good news was that the radiologist noticed no additional bone erosion. But since I live with my fingers every day, it’s easy for me to notice slight changes. Several fingers began to bend towards the outside (called ulnar drift) and some are no longer straight but are twisting/rotating (see photos).

I can certainly rejoice in the fact that bone erosion in my fingers seems halted at this time. And I can’t complain because many RA patients have dramatic joint damage and deformity. I suspect that the use of TNF blockers has something to do with my case. Never the less, I can see the changes over time.

[i] http://www.hopkins-arthritis.org/arthritis-info/rheumatoid-arthritis/rheum_clin_pres.html

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I’m at a loss about how to describe the various types of pain I’ve experienced with RA. As I prepare this post, all of my PIP finger joints (middle joint) are swollen and tender to the touch. The DIP joint (tip) on my left pinky smarts. The MCP joint (base of finger) on my left middle finger lets me know when I grab the steering wheel. Both wrists hurt when I flex them. My right elbow displays a sharp pain right above the joint. Both knees ache and crunch when moved. My calf muscles feel stretchy and stiff. Both Achilles tendons sting…the right one is bad enough that it was difficult to drive home from work today. The sides of my feet hurt when I press on them. While this day may not typical, one thing is certain…some sort of pain is always present with RA.

Sometimes I find it hard to pinpoint the source or cause of the pain. Yet my analytical mind wants to understand the underlying reasons. Perhaps knowledge can lead to pursuit of the right treatment. But it’s probably more curiosity than anything since my stomach can’t handle oral NSAIDs, I try to avoid taking inflammation-reducing prednisone as much as possible, and I tend to shun narcotic pain relievers for their side effects.

Pain is the body’s way to telling you something is wrong. According to one source,

“[Pain is] an unpleasant sensory and emotional experience associated with actual or potential tissue damage, or described in terms of such damage. While it is unquestionably a sensation in part or parts of the body, it is always unpleasant and, therefore, an emotional experience.”[i]

Pain can be classified as either acute – short term, or chronic – long term.[ii] While some RA induced pain may be acute, it can come and go depending on what joint is being affected, much of it is chronic. Pain sources can be nociceptive – caused from the stimulation of local nerve receptors, or non-nociceptive – caused by problems with the central nervous system.[iii] RA pain is nociceptive since it tends to be localized to various inflamed or damaged tissues. Nociceptive pain can be further divided into somatic – localized to an area resulting from damage to the musculoskeletal system, and visceral – non localized pain.[iv] With somatic pain,

“Patients may describe this as sharp, aching, and/or throbbing pain that is easily localized.” [v]

Pain associated with RA is typically chronic, nociceptive, and somatic. Management for this type of pain is facilitated through the use of analgesics like acetaminophen (Tylenol), non-steroidal anti-inflammatory drugs (NSAIDs) such as ibuprofen, or narcotics.[vi]

Another type of pain caused when the nervous system is damaged, called neuropathic pain, may also be associated with RA. [vii] For example, the tingling sensation associated with carpal tunnel syndrome I’ve experienced lately is caused by pressure on, or damage to the median nerve that enters the hand.

With RA, the first and foremost goal is to treat the cause of the pain – inflammation. In this regard, my thought is, “Humira, do your thing so inflammation and pain is reduced.” If not, I’ll be forced to take more drastic actions such as treating the pain symptoms directly. That’s where my treatment options become less available. I guess I’m left with Tylenol, the hottub, topical Voltaren gel (an NSAID), and rest! If that doesn’t work, perhaps I’ll pull out the prednisone tomorrow. I’d prefer to treat the cause directly and not the pain symptoms. In the meantime, I’ll try “taking” some of those peanut M&Ms my daughter brought home for me from back-to-school shopping! 🙂

Photo credit: Creative Commons License http://www.flickr.com/photos/azariusrex/

[i] American Pain Society. Principles of Analgesic Use in the Treatment of Acute Pain and Cancer Pain. 5th ed. Glenview, IL: American Pain Society; 2003.

[ii] http://www.texmed.org/Template.aspx?id=1462

[iii] http://www.ehow.com/about_5393798_somatic-pain-vs-visceral-pain.html

[iv] http://www.painbalance.org/nociceptive-pain-overview-1956304245

[v] http://endoflife.northwestern.edu/pain_management/part_one.cfm

[vi] http://www.medterms.com/script/main/art.asp?articlekey=10933

[vii] http://www.painbalance.org/neuropathic-pain-overview-2772791

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