Shoulder Pain

Tags

deltoid, Generalized DJD, glenohumerl joint, infraspinatus, pmr, radiculopathy, rotator cuff, shoulder, subacromial, subdeltoid, supraspinatus, tendonitis

Shoulder is a complicated joint as it involves three bones and four articulations. It is also not a usual place for arthritis and therefore cause of shoulder pain requires prompt investigation. 

Shoulder pain can be either inflammatory or it could be structural. Shoulder inflammation often causes pain at night and is better with activity during the day. These include: 
– Polymyalgia Rheumatica 
– Rheumatoid Arthritis 
– Seronegative Arthritis 

Structural shoulder problems on the other hand cause pain mostly during the day and also at night. These include: 
– Bursitis 
– Tendonitis 
– Rotator Cuff tear 
– Shoulder impingement 
– Frozen shoulder 
– Osteoarthritis
– Scapulothoracic syndrome
– Neck pain radiating into the shoulder

Evaluation usually involves
– physical examination
– X-rays
– MRI exam
– Local injection with Marcaine to determine the cause of pain in selected cases

Treatment depends on the specific cause and can range from exercise to medication and at time surgery.
– Polymyalgia Rheumatica: Diagnosed by a short trial of steroids. It is treated by Methotrexate or long term low dose prednisone with gradual taper.
– Rheumatoid Arthritis: Diagnosed by a short trial of steroids as well. It is treated by Methotrexate as well as other drugs listed.
– Seronegative Arthritis. These may not respond to steroids. They would usually do respond to NSAIDs.

Structural shoulder problems on the other hand cause pain mostly during the day and also at night. These include:
– Bursitis
– Tendonitis
– Rotator Cuff tear
– Shoulder impingement
– Frozen shoulder
– Osteoarthritis
– Scapulothoracic syndrome
– Neck pain radiating into the shoulder

Temporomandibular problems or TMJ

Tags

bruxism, dentist, jaw, mandible, Neck pain, oral surgeon, physical therapy, rheumatologist, splint, teeth, TMJ

1. TMJ problems are not uncommon. The first step here, once you rule out obvious causes, is to see a general dentist and not an oral surgeon. If the general dentist indicate that this is not a dental issue, then I will proceed with further evaluation.

2. MRI I believe is the best imaging modality to look at TMJ. X-rays may show arthritis or dental issues but MRI will give you the best detail.

3. TMJ problems often can be solved once the cause is identified and treated. Treatment include self care activities such as eating soft food, avoiding chewing gum, exercise, relaxation, use of splint, and medications. I have not found physical therapy to be helpful with treatment of TMJ.

4. Surgery should be avoided if possible. Always ask for MRI first especially if surgery is being considered. No one I believe should be operated on without having an MRI first. Also, find another independent oral surgeon yourself in another town or preferably at a university setting to get a second opinion if surgery is being considered.

5. If still not sure, see a rheumatologist who can do the work-up for you and make a proper referral if needed.

Arthritis, and Rheumatic Diseases

Tags

ankylosing spondylitis, Anti-phospholipid antibody syndrome, Arthritis, Autoimmune Disease, biphosphonates, colitis, connective tissue disease, Crohn's disease, Enthesopathy, Granulomatous disease, Infectious Disease, inflammation, Monoclonal antibody, osteoarthritis, Osteonecrosis, osteoporosis, Psoriasis, Rheumatic diseases, rheumatoid arthritis, Rheumatology, Sarcoidosis, Scleroderma, Sjogren's Syndrome, Systemic Lupus, Systemic Sclerosis, ulcerative colitis

Regional problems

Temporomandibular joint disorders
Shoulder pain
Elbow pain
Wrist pain
Hand pain
Neck pain
Mid-Back pain
Back pain
Hip pain
Knee pain
Ankle pain
Foot pain
Fibromyalgia
Chronic Fatigue Syndrome
Reflex Sympathetic Dystrophy (RSD)
Neuropathy

Spondyloarthritis
Psoriatic arthritis
Colitis associated arthritis
Ankylosing Spondylitis
Reactive arthritis (Reiter’s Syndrome)

Infections and Arthritis
Viral Arthritis
Lyme disease
Rheumatic fever
Bacterial arthritis
Fungal arthritis
Gonococcal arthritis
Tuberculosis arthritis
Osteomyelitis

Bone diseases
Osteoporosis
Osteomalacia
Paget’s disease
Osteopetrosis
Osteogenesis Imperfecta
Ehlers-Danlos Syndrome
Parathyroid disorders
Osteonecrosis
Osteochondritis
Marfan Syndrome
Hypermobility

Crystal Induced Arthritis
Gout
Pseudo gout
Crystal arthritis

Systemic Diseases
Rheumatoid arthritis
Seronegative Arthritis
Palindromic Rheumatism
Sjögren’s syndrome
Undifferentiated connective tissue disease
Mixed connective tissue disease
Systemic Lupus
Drug Induced Lupus
Scleroderma (Systemic Sclerosis)
CREST Syndrome
Eosinophilic fasciitis
Adult-onset Still’s Disease
Anti phospholipid antibody syndrome

Vasculitis
Temporal arteritis
Polymyalgia Rheumatica
Takayasu’s arteritis
Polyarteritis Nodosa
Wegener’s granulomatosis
ANCA associated vasculitis
Microscopic polyangiitis
Allergic angiitis
Churg-Strauss syndrome
Henoch-Schönlein purpura
Urticarial Vaculitis
Leukocytoclastic Vasculitis
Cryoglobulinemia

Inflammatory Muscle Diseases
Polymyositis
Dermatomyositis
Inclusion-body myositis
Drug induced myopathy
Infectious myositis

Rheumatic diseases
Relapsing Polychondritis
Behçet’s Syndrome
Amyloidosis
Whipple’s disease
Sarcoidosis
Diabetic arthropathy
Immunodeficiency syndromes
Raynaud’s phenomenon

Pediatric Rheumatic Diseases
Juvenile Idiopathic Arthritis
Juvenile Spondyloarthritis
Juvenile connective tissue diseases
Dermatomyositis
Vasculitis
Scleroderma

Anti-Rheumatic Medications

Nonsteroidal Anti-inflammatory Drugs (NSAIDs)
Aspirin (Ecotrin, Salicylic Acid) Bufferin
Celecoxib (Celebrex)
Diclofenac (Voltaren, Cataflam, Voltaren-XR)
Diflunisal (Dolobid)
Etodolac (Lodine)
Fenoprofen (Fenopron, Nalfron)
Flurbiprofen (Ansaid)
Ibuprofen (Advil, Motrin)
Indomethacin (Indocin)
Ketoprofen (Orudis, Oruvail)
Ketorolac (Toradol)
Meclofenamic acid (Meclomen)
Mefenamic acid (Ponstel)
Meloxicam (Mobic)
Nabumetone (Relafen)
Naproxen (Aleve, Anaprox, Naprosyn, Naprelan)
Oxaporozin (Daypro)
Piroxicam (Feldene)
Salsalate (Salflex, Disalcid, Trilisate)
Sulindac (Clinoril)

Steroids
Prednisone
Methylprednisolone
Hydrocortisone
Solumedrol
Celestone
Kenalog
Decadron
Aristospan
Depomedrol

Disease Modifying Drugs (DMARDs)
abatacept
adalimumab
azathioprine
Certolizumab pegol
chloroquine
Cyclosporin
Cyclophosphamide
D-penicillamine
etanercept
golimumab
gold salts
hydroxychloroquine
infliximab
leflunomide
methotrexate
minocycline
rituximab
sulfasalazine
Tocilizumab
Tofacitinib
Ustekinumab

Hypouricemic Drugs
Allopurinol
Colchicine
Uloric
Probenecid
Sulfinpyrazone

Osteoporosis Drugs
alendronate
risedronate
ibandronate
Pamidronate
zoledronic acid
raloxifene
denosumab
teriparatide

Rheumatology in pictures
Sternoclavicular joint swelling

Rheumatoid Arthritis

Tags

anti-ccp, arava, cimzia, CRP, ESR, humira, JIA, JRA, Methotrexaate, orencia, Plaquinel, ra, remicade, rheumatoid factor, rituxan, simponi, sulfasalazine, synovitis, Xeljanz

Description:
This is an inflammatory arthritis involving upper and lower extremity joints.

Presentation:
– Pain
– Stiffness
– Swelling in multiple joints including hands, wrists, elbow, shoulders, hips, knees, ankles, and feet
– Night pain
– Morning as well as rest stiffness
– Fatigue
– Insomnia because of pain

Evaluation:
– History and physical examination
– Tests are then ordered for confirmation of the diagnosis.

Testing:
– Blood tests: Rheumatoid Factor, Anti-CCP, ANA, HLA-B27, Lyme titers, ESR, CRP, Hepatitis C Antibody
– X-rays: Hands, wrists, ankles, feet and other involved joints

Diagnosis: This is based on the following criteria listed below:
– Type and number of joints involved
– Positive Rheumatoid factor or Anti-CCP
– Elevated CRP or ESR
– Duration of joint involvement more or less than six weeks
– The criteria might be fulfilled over time

Treatment:
– Sulfasalazine. I do not use this a whole lot and when I do it is mostly along with Plaquinel and Methotrexate in combination. I use a lot more of Sulfasalazine overseas along with Plaquinel, Methotrexate, and low dose prednisone 5 mg daily for lack of better or cheaper treatment.
– Plaquinel. This can be effective by itself in mild cases and in combination with moderate involvement. I have seen studies claiming the combination therapy of Plaquinel, Methotrexate, and Sulfasalazine work as good as biologic therapy. But in real life patients, I have not seen this to be true. I have seen heavy use of these drug combination along with Prednisone 5 mg daily overseas. Unfortunately, this only works for a number of years and most of these patients end up with severe deformity, terrible osteoporosis, obesity, diabetes, very difficlut ending and I can even say that their life span is shortened by at least 10 if not 20 years.
– Methotrexate. This is the first treatment I use in most patients with moderate to severe disease. It often requires use of biologic in combination to achieve desired effect.
– Arava. This I use if Methotrexate is not effective by itself or I use it in combination with Low dose Methotrexate or Humira.
– Enbrel. This works very well and brings this terrible disease under excellent control especially along with Methotrexate.
– Humira. This is also an excellent choice along with Methotrexate as well. Humira has the advantage of treating Psoriasis and colitis as well as uveitis over the Enbrel.
– Remicade. This works very well with Methotrexate especially in medicare patients who can not afford the self injectables such as Humira. I also use this as a first choice in severe cases when you need rapid control of the rheumatoid arthritis. It is also very useful when Enbrel or Humira are only partially effective.
– Simponi. This is also an excellent choice but most insurances do not want to cover it and they all insist that the patient be on Methotrexate at the same time.
– Cimzia. This can be very effective but being a late comer, it has not gotten the attention it deserves.
– Orencia. This can also be a great choice. I do not see many infections with Orencia but this could be because I do not use it as much as Enbrel and Humira.
– Xeljanz. My initial use of this drug was disappointing as I was using it in those who have failed previous DMARDs listed above. But using it as a first line drug along with Methotrexate has been very promising with rapid and excellent results.
– Rituxan. This is undoubtedly the best treatment for Rheumatoid Arthritis. It takes time to work but once it starts working, it does very well. I have seen the benefits last for as long as 2 1/2 years after one or two treatments. This also help one distinguish the true
– Actemra. This I believe is a very good drug but it is a late comer. It was also mismanaged by the drug company keep emphasizing liver enzyme elevation with this drug early with its release. I yet to see any problem with this drug. It does need a more closer monitoring because of potential for interactions with other drugs. I believe I will be using more of this drug in the future.

Newest drug for treatment of osteoporosis!

Tags

alendronate, ostecoclast, osteoblast, romosozumab, sclerostin, teriparatide

Romosozumab is the newest agent for treatment of osteoporosis that appears to be far more effective than FOSAMAX (alendronate) and even more effective than Forteo (teriparatide) based on a recent study. It was not compared to the other monoclonal antibody on the market PROLIA possibly because they are both made by the same company.

This medication was given by injection every month and also every three months. A newer drug for osteoporosis has been long overdue and being an injectable given every month or every three months should improve compliance.

Hopefully this drug is priced similar to Prolia and not Forteo which is five times more expensive.

Most effective drug on the market today is still Forteo.

Prolia effective up to eight years for treatment of Osteoporosis!

Tags

Actonel, and Reclast, biphosphonates, bone loss, Boniva, DEXA, Fosamax, fracture, osteopenia, Prolia, t score

Prolia, an injectable drug used for treatment of osteoporosis, was shown to remain effective for up to eight years based on recent data presented.

This is certainly better than the current recommendations limiting the use of treatments with biphosphonatesg such as Fosamax, Actonel, Boniva, and Reclast to five years for lack of data.

In other words you could lose almost a third of your bone density and still have normal looking x-rays.!

Tags

Actonel, alendronate, bone loss, Boniva, denosumab, DEXA, Dual-Energy X-ray Absorptiometry, estrogen, Evista, Fosamax, Fosamax D) risedronate, ibandronate, osteoporosis, Prolia, raloxifene, Reclast, Zoledronic acid

Osteoporosis or Bone Loss can not be detected on routine X-rays unless you have lost 40 percent of your bone density.

In other words you could lose almost a third of your bone density and still have normal looking x-rays.

Therefore, if you want to know if you indeed have lost bone, you should obtain a DEXA examination.

DEXA or Dual-Energy X-ray Absorptiometry is a scanning technique using extremely low radiation exposure to determine bone density with Significant precision.

Sulfasalazine

Tags

anti-ccp, arava, cimzia, enbrel, humira, methotrexate, remicade, rheumatoid arthritis, rheumatoid factor, sulfasalazine, synovitis, Xeljanz

Points to remember about Sulfasalazine are:

– This is seventy year old medication.
– It was developed as a combination of an anti-inflammatory and a sulfa antibiotic to treat Rheumatoid Arthritis.
– It is the first disease modifying drug (DMARD) that was actually developed to treat Rheumatoid Arthritis.
– Enteric coated form of Sulfasalazine would minimize stomach side-effects.
– It can be used by itself or along with other DMARDs such as Methotrexate, Plaquinel.
– Periodic blood testing is needed to look for possible toxicity specifically affecting liver and Neutrophils.
– Although never approved by FDA, it is used to treat variety of inflammatory conditions including:
– Rheumatoid Arthritis
– Psoriatic Arthritis
– Spondyloarthropathy
– Ankylosing Spondylitis
– Juvenile Rheumatoid Arthritis
– Ulcerative Colitis
– It can help both bowel and joint symptoms in patients with inflammatory bowel disease who also have associated arthritis.
– It may take up to three months to see an effect.
– At times the improvement is so slow that Sulfasalazine has to be stopped to see if the patient actually becomes worse off of it. Becoming worse off of this treatment would be indication of a response and treatment with Sulfasalazine can thus be resumed.

TMJ or Temporomandibular Joint Pain

Tags

Arthritis, disc, displacement, jaw, JCA, JRA, osteoarthritis, psoriatic, rheumatoid arthritis

Key points to remember here are:

1. The first step here is to make sure there is no dental issues causing the TMJ such as the mandible not lining up with maxilla. It is not unusual for this to develop after dental work.

2. MRI often provide the details needed to make proper diagnosis as to what is causing the pain in TMJ.

3. The causes here vary from trauma with damage to the joint structures to various forms of arthritis including:

– Disc displacement
– Meniscal tear
– Juvenile Idiopathic Arthritis (Juvenile rheumatoid arthritis)
– Rheumatoid arthritis
– Psoriatic arthritis
– Traumatic arthropathy
– Gout

4. Treatment obviously depends on the cause. Early treatment of the underlying disease is the key to avoid damage to TMJ.

5. Aggressive and early treatment of Rheumatoid, Psoriatic, and JIA with new biologics treatments such as Enbrel and Humira has resulted in significant decline of TMJ problems in these patients.

6. Oral Surgeons often deal with TMJ when medical therapy is exhausted.

Metal-on-metal hip implants

Tags

chromium, cobalt, Diabetes, Hip replacement, immune suppression, metal ion, nickel, obesity, steroids

The seven points to remember about metal-on-metal implants:

1. There are now FDA guidelines regarding these implants.

2. MoM hip systems should not be implanted in those with kidney failure, metal sensitivity to cobalt, chromium, nickel, immune suppressed patients, those on high dose steroids, and women of childbearing age.

3. Potential risks with with metal-on-metal hip implants according to FDA include:
Infection
Loosening
Dislocation
Osteolysis
Bone or device fracture
Elevated metal ion levels in the joint and blood
Transplacental transport of metal ions
Development of local inflammatory reactions and lesions including soft tissue masses and tissue necrosis
Development of potential systemic events related to elevated metal ion levels
Revision surgery
Femoral neck fracture (for hip resurfacing)

4. Those patients at risk for problems with metal-on-metal hip implants according to FDA
include:
Patients with bilateral implants
Patients with resurfacing systems with small femoral heads (44mm or smaller)
Female patients
Patients receiving high doses of corticosteroids
Patients with evidence of renal insufficiency
Patients with suppressed immune systems
Patients with suboptimal alignment of device components
Patients with suspected metal sensitivity (e.g. cobalt, chromium, nickel)
Patients who are severely overweight
Patients with high levels of physical activity.

5. Local symptoms related to MoM implants is as a result of metal particles being released to tissue surrounding the hip implant causing pain, bone and soft tissue damage. As a result patients may develop pain or swelling at or near the hip, a change in walking ability, or a noise from the hip. Other local reaction include:
Hypersensitivity (allergic type reaction)
Loosening
Infection
Osteolysis (bone loss)
Aseptic lymphocytic vasculitis-associated lesions (ALVAL) (histologic reaction in surrounding tissue)
Soft tissue mass (fluid-filled or solid soft tissue mass around the replaced joint that is diagnosed radiologically)
Femoral neck fracture (for resurfacing systems)

6. Systemic reactions to MoM implants has to do with metal ions that were release are moving via blood stream to other organs causing systemic symptoms. These systemic symptoms include:

General hypersensitivity reaction (skin rash)
Cardiomyopathy
Neurological changes including sensory changes (auditory, or visual impairments)
Psychological status change (including depression or cognitive impairment)
Renal function impairment
Thyroid dysfunction (including neck discomfort, fatigue, weight gain or feeling cold).

7. Proper patient selection, correct placement, and implantation are most important in order to avoid problems with metal-on-metal implants.

M. Rezaian, MD