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Q. I have knee problem with hand and shoulder stiffness. Could this be RA?

Answered by
Dr. Naval Mendiratta
and medically reviewed by Dr. Vinodhini. J
This is a premium question & answer published on Mar 30, 2020

Hello doctor,

I am a 28-year-old female currently under investigation for RA and have been for a while now. I began having knee problems at the age of 15 (my mother’s problems began in her knees at the age of 13) and the problems remained there for a few years. In the last three to four years my symptoms have massively progressed to my hands, fingers, shoulders, hips, toes, and ankles making daily chores quite painful.

It sounds silly but when the blood tests came back and did show inflammation I was bizarre, pleased. I had been made to feel like I was over-exaggerating a lot so to have it proven was one step in the right direction. The private doctor I saw was the one that recommended medication.

I take Celebrex 200 mg in the morning with 15 mg Lansoprazole as previous medication has upset my stomach. This medication seemed to be working until eight months ago. My blood tests showed my inflammation levels rising again. Recent stressful situations have, I think caused quite a bad flare and I am taking Paracetamol more religiously than I would usually. Small tasks like doing a jigsaw were causing my shoulder to ache. I recently got a new set of blood tests done and the results, along with results from the last 1.5 years have been included. I would appreciate any advice you can give me.

I also hand scans of my knees and hips done. The scans came back showing effusion in my knees, I was told it is nothing to worry about at the moment as the fluid buildup is at a level that could be absorbed back in by the body. If it were to get worse though, I was told I would need it drained manually. My hip scans came back normal but at the time of the scan my hips had only been part of the problem for maybe a year whereas my knees had been bad for the best part of 10 years.

I am getting frustrated with myself because of my inability to do simple tasks some days. I know it is no fault of my own but that does not help when your only 28 and cannot wash the dishes or mop the floor because something will start hurting and I will have to stop. I have also progressed quite badly with hand issues. I have had occasions where my left wrist and hand will start shaking. I have also regularly found myself dropping things like pans, cups, my cell phone, my medication among other things. My left side of my body has always been worse than my right side although my right side is slowly catching up. I am unsure whether to mention my condition while looking for future work. At the moment it is not preventing me from working. I have had to occasionally, wear braces on my knees or wrists and my current job is aware that if I am sitting down in class it is medically necessary.

I am aware that compared to some people my inflammation levels, when looking purely at bloodwork are very low but the actual pain I am in is very real and I would very much like some advice on how to proceed. Primarily, I am looking for a more effective way to manage my pain levels so I can get back to doing more things typical of a 28-year-old rather that sit with a hot water bottle on my back and Paracetamol at the ready. I have attached a blood tets.

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#

Hi,

Welcome to icliniq.com.

I have gone through your query and blood reports. (attachment removed to protect patient identity).

I do have a few queries to help you reach the correct diagnosis. I want to be really sure we are dealing with inflammatory arthritis and so we can modify your medicines accordingly as Celebrex 200 would not be a solution for a long term.

Do you experience early morning stiffness and swelling? If yes for how long? Are these pains intermittent in nature or persistent? How is the sleep pattern? Do you have early morning fatigue as if you did not sleep well? Any recent complaints of irritability and forgetfulness? Any persistent headaches? Any bowel upsets like increased frequency of stools? Do let me know these answers. Because for pain there are many reasons. If inflammation is one we should act early.

Thank you doctor,

I have tried to answer all the information you have asked for and some that could be relevant.

Visible swelling - There is some visible swelling in my knuckles and around my thumb joint. When holding things like plates and pans, even holding a pile of paperwork at work will cause my thumb joint to become painful. I have close friends that I mentioned it to when I was visiting them and when they saw my hands they became rather concerned which made me realize it was probably time to get back in touch with a doctor.

Stiffness in hands - I have not noticed any stiffness in my hands in the morning although I do wake with the typical aches through my joints. It also sometimes feels like my finger joints are swollen and it can stop me from bending my fingers properly, this can happen any time of day though. Once I am up and moving some pains calm down, some go away and some just get worse as the day goes on.

Pain - My pains are persistent. Some areas are intermittent as they have only recently begun causing problems whereas pains in my knees for example, have been ongoing for 13 years now. Of course, some days are worse than others and different areas can be painful different days depending on what I am doing. As I am a teacher and this requires a lot of walking around the classroom and things I did inform my colleagues. Now I rest my knee. Primarily, my knee and my left wrist have the main problem areas as these are the areas where I have to occasionally wear supports. Although issues with my hands and shoulders prevent me from doing simple household chores which is frustrating.

Sleep - My sleep is fine, however, I have found myself very tired recently. Even if I sleep well I still find myself tired throughout the day. It has been a hectic few months so that could be part of it.

Fatigue - I have been finding it difficult to wake up properly in the morning. It is like my eyes just do not want to open. I have been trying to get into more of a routine as I am due to start back at work soon. I have found myself falling asleep on the sofa, it has only ever happened once in a day but I do fall asleep very quickly.

Interaction with doctors - I saw a rheumatologist. Both he and my other doctor are considering the possibility that maybe I do not have RA. The rheumatologist mentioned that I could end up with a diagnosis of undifferentiated arthritis if a specific diagnosis cannot be found. When I first saw my doctor he said seronegative RA was a possibility as I have a lot of the typical signs and symptoms but my blood do not necessarily corroborate an RA diagnosis.

I have not been put on medication other than NSAIDs. I was first on Naproxen, then Etodolac, both of which upset my stomach and I could not get Etodolac. Then my doctor suggested Celebrex. He initially suggested 100 mg twice a day but where I am living I could only get access to 200 mg tablets which is why I take one dose in the morning. The rheumatologist suggested to get a scan of my hands and feet, this is yet to be done as I did not have the insurance coverage. I do now. I do intend to get these scans done whenever I am able to get access to the local hospital again.

Other issues and general history which I have discussed before. I do not have any known medical issues with my lungs although I am prone to chest infections. Whenever I get a cold which is usually two to three times a year, paticularly, spring and autumn as the temperatures change, I nearly always end up with a chest infection afterward. Last year, after recovering from a chest infection which proceeded a cold I had about two weeks later I then developed acute bronchitis. I have also had viral ear infections and sinus infections that nearly always proceed a cold. When I was young I did suffer from asthma and was on inhalers for it. Because of the levels of pollution whenever I get a cold or infection it does take longer to clear as well even when I am on antibiotics.

Irritability and forgetfulness - Forgetfulness no, nothing more than I would say would be typical of any person. Irritability, yes. I have found myself to be on a bit of a short fuse lately. Again, with everything hectic schedule over the last three months and being indoors a lot more than usual could be the simplest explanation for it.

Headaches - I had a bad headache recently that lasted for about a week and a half. I started to wonder if it was a migraine. My mother gets migraines when she gets issues with her neck and shoulder due to her RA and my shoulders and neck do get stiff occasionally. Again, though recent stresses could have been the cause of that headache too. I do not want to sound like I am making excuses for this I am just trying to think of logical explanations.

Bowels - I have quite a lot of issues with my bowels for a while now. Sometimes, I physically have to fun to get to the bathroom on time which is quite embarrassing. Especially when this results in having to run out of my classroom. Thankfully, I do have a very supportive work environment. I also have another issue that is connected to this. I tend to get itchy spells in and around my anus and I have noticed it is primairily around the time I am due a bowel movement. The itching can get very intense and I have sometimes scratched so hard I have made myself bleed.

#

Hi,

Welcome back to icliniq.com.

Thanks for the detailed reply.

Well, I would agree with your rheumatologists that it does not seem to be like rheumatoid arthritis (RA). Your symptoms do not really match the disease of rheumatoid arthritis. Next on my list was Sjogren's syndrome, which could resemble rheumatoid with a lot of pains, fatigue, and no evidence of swelling as such. But for that our ANA (antinuclear antibodies) is negative and your sicca symptoms are absent.

As for undifferentiated arthritis (UDIA), there still has to be inflammation present to label you as one. We only call it UDIA, when there are asymmetrical swellings but does not fit into any disease. So, yes I would suggest a whole body bone scan or ultrasound of the hands and feet should give us a clue, which I would suggest you can plan as and when needed.

But saying all that, we have to reach a conclusion for you and work on the medications and lifestyle modifications as well. Because for pains, there are many reasons. We normally classify them as inflammatory and non inflammatory. For you, I feel it is more of non-inflammatory pain. Non-inflammatory pains are usually disturbance of the pain chemicals. Associated symptoms which come with it are headaches, irritable bowel, fatigue, tendon pains and poor quality of life. If you ask me, it is more difficult to manage then the inflammatory ones. We normally label it as fibromyalgia or chronic pain Syndrome. You can once read up on it and see if your symptoms match. Because the medications will differ. But sadly, there is no diagnostic test for it. It is more of a diagnosis of exclusion.

Either way, I do not want you to be on Celebrex. If you need something for pain management, go with Tylenol or Ultracet.

So the step forward would be, we try some medications for fibromyalgia like Pregabalin. At least we can give it a two-week trial. Or else if you want to wait for the scans to be done we can plan it that way. My suggestion would be to try the medicine. If there is improvement, you do not need any further scans. We can then work on your graded aerobic exercises and stress management.

I hope this helps.

Thank you doctor,

This information is very helpful. If I were to try the medication usually used to treat fibromyalgia how would you suggest I stop taking the Celebrex? How long should I wait between stopping Celebrex and starting the other medicine? Should I continue taking 15 mg Lansoprazole? Does Ultracet have any other name? Is the chemical composition Tramadol hydrochloride and Acetaminophen? Any idea of how one should get in UK, China? Does Pregabalin have any other name? Does it seems that is the chemical composition itself? I appreciate your help.

#

Hello,

Welcome back to icliniq.com.

Well, Celebrex you can stop immediately. Normally, we need tapering with steroids only, so if you think you have trouble removing it you can reduce it to half a day first and then alternate day for the next one week and then go off it. Pain killers can get habitual and eventually it is harmful for the stomach and kidneys. Lansoprazole is just given as a protection along with Celebrex for stomach. So that can go with it too.

Yes, Ultracet is the same composition as you mentioned. It is an international product. You may need a prescription for it, but Acetaminophen you can avail it online.

As for Pregabalin, you can try with Lyrica. That is an international product too but you will need a prescription for it. Either you can request your GP for the same or you need a specialist prescription for it. It would be difficult to get it without it.

I am not sure when you can schedule your next appointment considering the chaos the world is in.

I hope I could provide you with a near about diagnosis and the treatment helps you and you are back to what a 28-year-old needs to be.


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