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How can I manage constant pain in the right knee?

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How can I manage constant pain in the right knee?

The following is an actual conversation between an iCliniq user and a doctor that has been reviewed and published as a Premium Q&A.

Answered by

Dr. Srinivasa C.

Medically reviewed by

iCliniq medical review team

Published At April 19, 2018
Reviewed AtMarch 18, 2024

Patient's Query

Hello doctor,

I am a 38-year-old male. After a twist, I had a sudden pain in the right knee while cleaning the house. Initially, it was diagnosed as a ligament tear, but later, no tear was detected on repeated MRIs. The pain is not resolving with Methotrexate 20 mg, Prednisolone 10 mg, and Etoricoxib 120 mg. I have seronegative spondyloarthropathy and have been on Methotrexate for the past nine years.

Kindly help.

Answered by Dr. Srinivasa C.

Hi,

Welcome to icliniq.com.

I understand your concern.

Please send the MRI (magnetic resonance imaging) reports of the knee. Who diagnosed the tear on MRI?

I hope this information will help you.

Thanks.

Patient's Query

Hi doctor,

Thank you for the reply.

I have attached the report (attachments removed to protect patient identity). The knee MRI (magnetic resonance imaging) before the blank slide is when the radiologist diagnosed the medial meniscal and anterior cruciate ligament tear. But, subsequent MRI ruled it out.

Thank you.

Answered by Dr. Srinivasa C.

Hi,

Welcome back to icliniq.com.

I understand your concern.

With Etoricoxib (pain killer) of 120 mg, your inflammatory pain should resolve. Otherwise, it might have a different cause. The other option is considering an intra-articular injection into the knee. However, I need to discuss both MRIs with the radiologist to determine the problem. You can undergo hemorrhoid surgery, and plan biologics later. Prednisolone needs to be decreased before surgery as infection risk will be high. Regarding the knee, inflammation versus tear is the primary concern. You can discuss this with a musculoskeletal radiologist.

I hope this information will help you.

Thanks.

Patient's Query

Hi doctor,

Thanks for the reply.

As suggested, I took opinion from suggested doctor.

Thanks.

Answered by Dr. Srinivasa C.

Hi,

Welcome back to icliniq.com.

I understand your concern.

Please wait for at least two weeks before planning for intraarticular injection, and after two weeks, get CBC (complete blood count), ESR (erythrocyte sedimentation rate), C- reactive protein, RBS (random blood sugar), and creatinine. After the reports, we can plan.

I hope this information will help you.

Thanks.

Patient's Query

Hi doctor,

Thank you for your reply.

My knee pain is persisting. Now I have it in both my knees as well as my fingers. I am currently on Tablet Methotrexate 20 mg/week, Tablet Folic acid 5 mg/week, Tablet Sazo 2 gm/day, and Tablet Etoricoxib 90 mg SOS (3-5 days/week). There is a month for my hemorrhoid surgery. The proctologist has given clearance for an increase in immunosuppression if needed.

My recent blood workup including SGOT (serum glutamic-oxaloacetic transaminase), SGPT (Serum glutamic pyruvic transaminase), creatinine, urea, ESR (erythrocyte sedimentation rate), CRP (C-reactive protein), HIV (human immunodeficiency virus), TPHA (Treponema pallidum hemagglutination assay), HLA B 27, Sr ACE (Serum angiotensin-converting enzyme), RA factor (Rheumatoid factor) are normal. I got my MRI repeated. It still shows fluid in joint space. Please take a look at the MRIs, and history and suggest further treatment plans.

Thank you.

Answered by Dr. Srinivasa C.

Hi,

Glad to have you back!

I am here to help you get the best medical advice.

Please share the MRI (magnetic resonance imaging) report. It is difficult to assess using the film. I suggest taking an intra-articular injection of steroids and continuing the medication given before. Otherwise, you would require biological drugs like Etanercept or Adalilimab.

I hope this information helps provide some insight into your symptoms.

Please do not hesitate to reach out if you have any further questions or concerns.

Thank you.

Patient's Query

Hi doctor,

Thank you for the advice.

I have attached the report of my last MRI knee. Will there be still a need for an intra-articular injection if I go for Adalimumab? Can Methotrexate be immediately discontinued after starting the injections, or should it be tapered off or continued in the same dose? What is the pre-injection screening and post-injection laboratory workup required? Can these injections be discontinued abruptly after two to three months and resume Methotrexate therapy as before if feeling better? Please help.

Thank you.

Answered by Dr. Srinivasa C.

Hi,

Glad to have you back!

I am here to help you get the best medical advice.

Please meet your rheumatologist and decide on the injection. You can try intra-articular articular injections, and then go for Adalilimab (biological medicine). Sometimes Adalilimab might be enough to control the pain and swelling in the knee. I suggest a minimum of three months of injections, and then reverting to your old doses. Methotrexate can be kept at 10 to 15 mg per week during the period of Adalilimab. In addition, I recommend screening tests like chest X-ray, Montoux test (screening for tuberculosis), TB quanteferon gold (screening for tuberculosis), viral markers, and a physical examination to be done by your doctor.

I hope this information helps provide some insight into your symptoms.

Please do not hesitate to reach out if you have any further questions or concerns.

Thank you.

Patient's Query

Hi doctor,

I visited a rheumatologist, who suggested I discontinue Methotrexate, start Exemptia 40 mg subcutaneously every 15 days, and continue tablet Saaz 1 gm twice daily. He also advised me to get a fibro-scan for the liver and to decide on AKT prophylaxis. I re-investigated as advised, except for fibro-scan. My CBC, LFT, RFT, HBsAg, HCV, HIV, chest and abdomen CT, Mantoux, Quantiferon TB Gold are normal. I do not have any other TB symptoms. I need a second opinion on:

1. AKT prophylaxis before Exemptia.

2. Stopping Methotrexate at once or tapering (also can both Methotrexate and Exemptia be taken together on the same day?)

3. Need of fibro-scan if LFT and abdomen CT are normal.

4. Dosing of Exeptia. Can the interval be stretched 1 month after the initial few biweekly injections? Any specific investigations during Exeptia injections? Also when to repeat MRI? Please advise.

Thank you.

Answered by Dr. Srinivasa C.

Hi,

Glad to have you back!

I am here to help you get the best medical advice.

AKT prophylaxis is to be decided by the treating rheumatologist. If the Montoux TB test and CT scan are normal, we normally do not give prophylaxis. I suggest doing a Fibroscan. Exemptia (antirheumatic) can be tapered, but not recommended by guidelines. Methotrexate can be stopped as advised.

I hope this information helps provide some insight into your symptoms.

Please do not hesitate to reach out if you have any further questions or concerns.

Thank you.

Patient's Query

Hi,

Glad to have you back!

I am here to help you get the best medical advice.

I have started Exemptia. I am done with two injections over. However, I do not see any improvement in the symptoms. Now I also have neck pain. I have also reduced the dosage of Methotrexate and stopped Etoricoxib. Within a few days, I had to restart Etoricoxib. I was back on Methotrexate 20 mg the next week. Again after the second injection, when I tried to step down Etoricoxib keeping Methotrexate 20 mg, I had knee pain and neck pain the very next day. I see no relief with Exeptia in three weeks. Currently, I am on Methotrexate 20 mg, Etoricoxib 60 mg, Saaz DS 2 gm, and biweekly Exeptia. The only medication that gave results was Etoricoxib. Not able to get off Etoricoxib. How long do I have to wait for Exemptia to kick in?

Is there any possibility of isolated metastatic knee infection on a background of A.S., provided no other known infectious foci elsewhere in the body? The knee pain is bilateral (mainly left) along with minor neck and finger involvement. Is intra-articular injection for the left knee recommended? Is any prior workup needed? Please help.

Thank you.

Answered by Dr. Srinivasa C.

Hi,

Glad to have you back!

I am here to help you get the best medical advice.

Very strange that Exemptia is not working, should have acted by now. I suggest trying intra-articular injection. If possible, if the joint is swollen, you can aspirate the synovial fluid and send for an infection work-up.

I hope this information helps provide some insight into your symptoms.

Please do not hesitate to reach out if you have any further questions or concerns.

Thank you.

Patient's Query

Hi doctor,

I got the follow-up MRI and blood workup done:

Hemoglobin: 12.7, ESR (Erythrocyte sedimentation rate): 11, total count: 5460 (N 46.9%, 40.5%), platelets, CRP, SGOT, SGPT, Urea, Creatinine, and bilirubin are normal. Peripheral smear shows mild normocytic normochromic anemia. My hemoglobin is low and my ESR is raised for the first time. My lymphocytes used to be between 25 to 30 percent, now raised and neutrophils, which used to be in 60's have dropped. Are those changes due to Exeptia?

I do not have any rectal bleeding after the hemorrhoidectomy, nor do I have any melena. Can Exeptia cause anemia?

Although the MRI report says "significant reduction in intra-substance signal changes in the meniscus", it also says the presence of a mild fluid in the joint space, (which is as before). Moreover, I do not feel improvement subjectively, and now my left knee is also getting involved. Is fluid tap and investigations possible with this amount of fluid in the joint? Shall I wait and watch for a week more after the third injection of Exemptia (due in 10 days)? Or intra-articular steroid injection is immediately recommended?

Thank you.

Answered by Dr. Srinivasa C.

Hi,

Glad to have you back!

I am here to help you get the best medical advice.

Hemoglobin is not so low to worry about. Yes, some changes in the neutrophil count can be attributed to Exemtia, and so need not worry.. You can wait for one or more more weeks before you plan for an intra-articular injection.

I hope this information helps provide some insight into your symptoms.

Please do not hesitate to reach out if you have any further questions or concerns.

Thank you.

Patient's Query

Hi doctor,

I got my MRI repeated. It showed a grade three complex tear of the meniscus, with mild joint effusion. My ortho-surgeon has advised arthroscopy and trimming. I am on Exemptia monotherapy only and Etoricoxib as required now. I also have back pain and neck pain. I have pain in my other knee on and off, and is mild. The pain on my right knee is also mild, and more on extreme flexion. I do not have any joint swelling, nor is warm. My injection is due the next day. After how many days of the Exeptia injection I can undergo arthroscopy? Are any other precautions to be taken? When can I resume Exemptia injection after the arthroscopy (if the surgery goes uneventful)? It is recommended to re-start Methotrexate, steroids, or Sulfasalazine (which I discontinued in the past month) or shall I be on Etoricoxib only?

Thank you.

Answered by Dr. Srinivasa C.

Hi,

Glad to have you back!

I am here to help you get the best medical advice.

I suggest planning surgery such that at least two weeks before and two weeks after the surgery, Excemtia be avoided to prevent infection post-operatively. Tablet Saaz and Methotrexate are not required when you are on injection Excemtia. When planning to stop the Exceptia injection, I recommend overlapping at least a month before with Saaz and Methotrexate. Please help.

Thank you.

Patient's Query

Hi doctor,

Thank you for the advice.

So I will be one month off on any immunosuppressives. What if the spondylitis relapses during this period? I am already experiencing mild backache in the mornings. How about inflammation caused by the surgery? Will the surgical intervention exacerbate arthritis? Do you advise intra-articular steroids to prevent postoperative recurrence of arthritis, considering there is already a small amount of effusion in the joint as documented on 3T MRI? Is oral NSAID (Nucoxia) prophylaxis recommended before the surgery?

Thank you.

Answered by Dr. Srinivasa C.

Hi,

Glad to have you back!

I am here to help you get the best medical advice.

Mild flares are common. You can use NSAIDs intermittently while planning for the surgery. If you are not taking steroids, the risk of infection will be high. Yes, the chances of recurrence of arthritis is always there.

I hope this information helps provide some insight into your symptoms.

Please do not hesitate to reach out if you have any further questions or concerns.

Thank you.

Patient's Query

Hi doctor,

Thanks for the reply.

I underwent the surgery successfully and have recovered well. I have been on Exemptia monotherapy for a few months. I can do routine activities. The surgery has been done prophylactically for the bucket handle tear. I got my MRI repeated for both knees, and it showed similar medial meniscus tears in the left knee, also with mild effusion. Ortho said no intervention. The pain in both knees is the same as before the surgery. I am still not able to squat. Back pain is on and off, along with minor neck pain. There are no side effects with Exemptia other than mild hair fall. Recent blood counts, LFT, and KFT are normal.

The post-hemorrhoid ligation proctologist's examination said mild non-specific inflammation. IBD symptoms are slightly better with Exemptia. Would you recommend:

1. Adding Saaz to Exemptia?

2. Should I restart Methotrexate?

Thanks.

Answered by Dr. Srinivasa C.

Hi,

Welcome back to icliniq.com.

I understand your concern.

Adding Saaz (Sulfasalazine) to Exemptia is not rational. It is better to add a low dose of Methotrexate, around 10 mg per week. As Exemptia is better than the combination of Methotrexate and Saaz, continue Exemptia with low-dose Methotrexate and Folic acid. Meet your rheumatologist for further discussion. You can go for Infliximab. Consult your specialist, and take medications with their consent.

I hope this information will help you.

Thanks.

Patient's Query

Hi doctor,

Thanks for the reply.

I am developing unusual side effects of Exemptia. After I started Exemptia, I had a few episodes of nasal boils, which subsided to oral and local antibiotics. For the past three weeks, I have been experiencing a lot of dryness in my nose and throat. Nasal dirt becomes very hard and large. Upon picking it up, it bleeds. The endoscopy was normal. They advised avoiding nose pick and had given an isotonic nasal spray. I purposefully skip one dose of Exemptia. Now I am feeling better. One nostril is clear, and the other will get clear soon. Blood tests done one mon back before this thing started were normal. I want to know about nasal mucosal dryness or dryness in the throat. Are there any other things to be checked?

Thanks.

Answered by Dr. Srinivasa C.

Hi,

Welcome back to icliniq.com.

I understand your concern.

It is very unusual to get side effects, but infections are common. If you get it again after starting Exemptia, you would better consult your doctor.

I hope this information will help you.

Thanks.

Patient's Query

Hi doctor,

Thanks for the reply.

After six months of exemption, I developed a skin rash and a dry nose. After consulting my rheumatologist, he suggested discontinuing the exemption and starting Scaphoid (Secukinumab), but another rheumatologist advised me to restart Methotrexate if the pain was not significant. I re-started Methotrexate 10 mg. Joint pain is mild, and routine activity is not restricted, but I sacrificed physical activities like long walks and climbing more than five floors. Skin rashes were suspected to be psoriasis by one rheumatologist, while another said it was dryness. The dermatologist disagreed with psoriasis. Now that issue is resolved after winter. I also had an episode of proctitis which lasted for two to three weeks. Colonoscopy was normal. My dry nose has been diagnosed as rhinitis sicca. ENT people were advised to use Mupirocin ointment, although they said it was not an infection. It does help, but symptoms recur once I stop it, as reported by them. I have not been able to discontinue it for the past four months. I need other treatment options to work for me. My CBC, ESR, CRP, SGOT, SGPT, creatinine, HIV, HBsAg, and HCV are all normal. Can I increase the dose of Methotrexate for my persisting rhinitis sicca for four months?

Thanks.

Answered by Dr. Srinivasa C.

Hi,

Welcome back to icliniq.com.

I understand your concern.

If there is no infection, you can increase Methotrexate to 15 mg weekly. However, discuss with your ENT (ear-nose-throat) doctor whether immunosuppression worsens the rhinitis.

I hope this information will help you.

Thanks.

Same symptoms don't mean you have the same problem. Consult a doctor now!

Dr. Srinivasa C.
Dr. Srinivasa C.

Rheumatology

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