Online Health Chat with Bijal Jayakar, MD, & John Donohue, MD
May 5, 2014
Joint pain can be associated with more than 50 kinds of arthritis — but it also can be caused by conditions that are not arthritis at all. So when a joint aches, how do you know whether you have arthritis or something else? And if you have arthritis, how do you know which kind you have?
Getting the right diagnosis is critical. Treatment for joint pain differs widely, depending on the cause. The right diagnosis and early treatment can arrest joint damage and return you to your previous level of activity. The wrong treatment — or avoiding treatment — may mean joint deterioration, poor function and compromised mobility.
Arthritis literally means “joint inflammation” — redness and warmth within the joint. Because inflammation is painful, arthritis limits movement. The three most common types of arthritis are:
- Rheumatoid arthritis
The causes, symptoms and risk factors for each of these forms of arthritis may differ. You may suffer from more than one type of arthritis — for example, gout and osteoarthritis.
Our expert will discuss the symptoms and treatments and explain how to better communicate with your doctor so together you can arrive at the right diagnosis and treatment sooner.
About the Speakers
Bijal Jayakar, MD, is a rheumatologist in the Orthopaedic & Rheumatologic Institute. She specializes in rheumatoid arthritis, osteoarthritis, psoriatic arthritis, osteoporosis, lupus, and myositis. Dr. Jayakar graduated from Topiwala National Medical College and went on to Good Samaritan Hospital of Maryland for her residency in internal medicine. She completed her rheumatology fellowship at Cleveland Clinic.
John Donohue, MD, is a rheumatologist in the Orthopaedic & Rheumatologic Institute. He specializes in rheumatoid arthritis, osteoarthritis, lupus, spondylitis and connective tissue disorders. Dr. Donohue graduated from the Georgetown University School of Medicine and went on to complete his internal medicine internship and residency at Columbia-Presbyterian Medical Center. He completed his fellowship at Brigham and Women’s Hospital.
Let’s Chat About Arthritis Pain
Moderator: Let's get started with our questions.
Diagnosis of Joint Pain
Capw: How can I determine if my joint pain is due to my osteoarthritis, my rheumatoid arthritis or my lupus?
Bijal_Jayakar,_MD_: Some joints like the hips and top row of knuckles are usually always due to osteoarthritis. Rheumatoid arthritis and lupus affect some joints more than the others. It is usually your rheumatologist who will be best able to tell you how to manage this better.
Homer: How can I tell if I have rheumatoid arthritis or osteoarthritis (OA) in my wrists? Also, if I chose to have carpal bone fusion to relieve the wrist pain, will that prevent the further development of arthritis? Thirdly, how can I tell if my wrist pain is due to arthritis or carpal tunnel syndrome?
Bijal_Jayakar,_MD_: The location for wrist OA is specific and your doctor will be able to tell. The fusion of one joint will not prevent arthritis in other joints. The location is different for pain from arthritis vs. carpal tunnel. There are tests which show that you have carpal tunnel clinically. Your rheumatologist or orthopedic doctor will be the best judge of this.
Rheumatoid Arthritis Diagnosis and Treatment
grammol: My husband is a carpenter. He can get through the day, but nights are horrible. Any little bump to his hands causes great pain, and he is up often walking the floor. He takes medication, and recently was fitted for a brace that actually exacerbated the pain at night. What more can be done? The area involved is the index and middle finger knuckles of both hands.
Bijal_Jayakar,_MD_: He could have rheumatoid arthritis. He will need an evaluation by a rheumatologist who will perform an examination and detailed blood work before considering further treatment decision. The medications to treat rheumatoid arthritis are strong. Hence, we need a thorough work-up before starting treatment
Sastruga: I am a 58-year-old female, and have been challenged with arthritis for many years now (in my large joints as well as my hands and feet). My hands and fingers are starting to get deformed and even more painful. Can anything be done for that condition?
Bijal_Jayakar,_MD_: You need an evaluation for rheumatoid arthritis, especially if there is deformity now. If the evaluation is negative, it could be due to osteoarthritis as well. There are lots of treatments available to treat both, but first a decision needs to be made whether the disease is due to degeneration or inflammation—as the treatment is different for both
lasimon: What is seronegative rheumatoid arthritis (RA)? Is it treated the same as other arthritis?
John_Donohue,_MD: Seronegative RA is rheumatoid arthritis where the blood test, rheumatoid factor and the CCP (cyclic citrullinated peptide) antibody are negative. Around 20 percent of patients with RA will be seronegative or blood test negative. The treatments are typically similar.
oldgolferguy: I am 75-years-old, and my hands are my problem. Like my father, I am losing the ability to make a fist. I am having trouble gripping things like a golf club. Can anything be done to arrest or reverse this?
John_Donohue,_MD: This sounds like osteoarthritis. I would again suggest splinting, occupational therapy and injections.
Gail Ann: At some point in their lives will everyone be affected with some type of arthritis?
John_Donohue,_MD: Most of us will experience some form of arthritis as we age. Osteoarthritis is far more common.
meue01: Is it possible to have arthritis in one knee only? I have a Baker cyst, and cortisone does not work for more than three to five days. I finally had it scoped and there was minimal frayed tissue that the doctor cleaned out. The swelling is not as bad or as often now four weeks later, but it still gets stiff and sore some days. I was tested for rheumatoid arthritis (RA) and I am not positive for that. I am only 47 years old, and this knee is my only problem area.
John_Donohue,_MD: Yes, it is possible to have arthritis in one knee. Typically, RA involves more than one joint on both sides where it would be more symmetric.
morsch2: Can osteoarthritis turn into rheumatoid arthritis?
John_Donohue,_MD: No, osteoarthritis cannot turn into rheumatoid arthritis. However, they can coexist.
DMWachholz: If you have osteoarthritis in the knees, can you have leg pain with it also, or would that be an indication something else may be going on?
John_Donohue,_MD: You can have some leg pain. However, it should be evaluated to look for other causes such as referred pain from the spine.
Spine and Neck Arthritis
lmartin: Is arthritis of the spine associated with degenerative disc disease and spinal stenosis usually osteoarthritis?
John_Donohue,_MD: Yes, it is a form of degenerative arthritis. Rheumatoid arthritis does not typically affect the lower spine.
Lucyinthe Skies: Can you have osteoarthritis and rheumatoid arthritis (RA) in your hands at the same time? I know I have degenerative issues in both thumb joints, but I am wondering if the painful nodule at the base of the index finger could be RA?
John_Donohue,_MD: Yes, you can have both. An evaluation by a rheumatologist will determine if the nodule on your finger is in fact a rheumatoid nodule.
JonCas: What conditions does a rheumatologist address as compared to an orthopedist and neurologist when symptoms are severe? I have lumbar, sacral and hip pain and the inability to walk with a history of laminectomy with instrumentation and fusion twice. Who should be consulted first?
John_Donohue,_MD: If you have had previous surgical intervention, I recommend starting with a neurosurgeon.
Gail Ann: How would you treat mild arthritis of the neck?
John_Donohue,_MD: Mild arthritis of the neck can be treated with physical therapy to improve the strength of the neck muscles. Tylenol® (acetaminophen) would be first-line therapy.
NOGRITS: Does pain and weakness in my groin area indicate a hip disorder?
John_Donohue,_MD: Typically, pain in the groin does suggest hip pathology. However, it can also be referred pain from other areas such as the spine or abdomen. I would recommend an evaluation by a rheumatologist and imaging.
SLE2014: I have degenerative disc disease (DDD) in my cervical spine at C5-C6 and to a lesser extent at C6-C7. This is a recent diagnosis. I experience numbness, tingling, thigh, knee, and moderate foot pain as well as pain in my bilateral hips, buttocks and sacral spine. Two years ago I was told that I have an 8 mm perineural cyst at S1. I was told at that time that there was nothing that could be done. I suffer from daily pain that is usually at least a 7. I have recently gotten a pain management doctor who prescribed Vicodin® (hydroxycodone). However, I would much rather have an epidural injection. I suffer from lupus. I have many joint pains and problems standing and walking because of this. Is there anything you can suggest? I have a rheumatologist and I am on methotrexate 18 mg, Plaquenil® (hydroxychloroquine) 200 twice per day, Neurontin® (gabapentin) 600 three times per day, and Vicodin® and Lidoderm® (lidocaine patches) as needed.
Bijal_Jayakar,_MD_: Methotrexate is used to treat rheumatoid arthritis and not lupus. So, a better diagnosis needs to be made. I agree with the Neurontin® if you have symptoms of chronic pain. I do not advocate narcotic pain medications. Plaquenil® is a good treatment for lupus.
Chest and Shoulder Pain
lilpuu: My daughter has an arteriovenous malformation (AVM) in her brain and has right hand and arm weakness. She has developed muscle pains in her shoulder and the right half of her chest area. Being 50 years old, does this sound like arthritis? If so, how does one deal with relieving the pain?
Bijal_Jayakar,_MD_: A thorough physical evaluation would be necessary to determine the root cause of the pain.
Hand Arthritis Diagnosis and Treatment
Sastruga: How do you deal with arthritis that is causing your hands to be deformed (in addition to pain)?
John_Donohue,_MD: The most important first step is to determine what type of arthritis it is. An evaluation with a rheumatologist to pinpoint whether this is rheumatoid arthritis or osteoarthritis with appropriate treatments is recommended.
04montycarlo: I have arthritis pain in both hands. I am taking 50 mg of Ultram® (tramadol) twice a day for pain and there is no difference. I am also on Tenormin® (atenolol) 50 mg and Lipitor® (atorvastatin calcium) 10 mg. What do you recommend that I do
Bijal_Jayakar,_MD_: I recommend a rheumatology evaluation. You may need to consider hand X-rays. If only a few joints are involved and painful, you can do cortisone shots. If the hand X-rays show erosions, you need to consider Plaquenil® (hydroxychloroquine)
ldsuz: I seem to have arthritis in the fingers of my left hand, which results in difficulty gripping and holding on to items. Exercise seems to help a little bit with range of motion, but within a few minutes after exercising the joints are right back to being stiff. Is there really anything that can be done and/or medicine that can provide relief for longer than just a few minutes?
John_Donohue,_MD: I suggest that you be evaluated by a rheumatologist to determine whether this is rheumatoid arthritis or osteoarthritis.
Treatment of Osteoarthritis
rosalie: I am a 57-year-old woman with arthritis in my hands. I especially feel it in my thumb joint. Other than keeping my hands mobile, if there anything else I can do to prevent progression?
John_Donohue,_MD: Assuming this is osteoarthritis, you may consider splinting, occupational therapy and injections.
Nonsteroidal Anti-inflammatory Drugs
rls1953: What are the best over-the-counter anti-inflammatory products?
Bijal_Jayakar,_MD_: I never recommend daily use of pain medications like Advil® (ibuprofen), Aleve® (naproxen sodium), etc. It is o.k. to take these infrequently—as needed only? I usually advise my patients to take Tylenol® Arthritis (acetaminophen) 650 mg one to two times a day, as needed only and not on a daily basis. Long-term use of pain medications like Advil® and Aleve® can cause liver and kidney problems. They also may raise your blood pressure.
lasimon: Is short-term use of Lyrica® (pregabalin) for disc herniation causing radicular pain dangerous? With all of the precautions with this medication, it is disturbing.
Bijal_Jayakar,_MD_: Lyrica® takes eight to 12 weeks to work effectively. So, taking it for less than this time is not useful. Please talk to your pain management doctor for further details.
lepton197: What role do neuron receptors and ligands play in osteoarthritis (OA)? Can one exploit this circuitry for pain reduction?
Bijal_Jayakar,_MD_: Medications like Neurontin® (gabapentin) work through the nerves to alleviate the pain. But, this is nerve-related pain in patients with diabetes or fibromyalgia. Usually Neurontin® does not help OA pain that is caused as the cartilage is worn out.
writer53: The back of my left knee has been swollen for several years. I swim and walk regularly and stick to a largely plant-based diet. The swelling can be better or worse, but never goes away. Should I get a cortisone shot to reduce the swelling? Will the effect last and for how long?
Bijal_Jayakar,_MD_: A cortisone shot may help, but first I recommend an ultrasound of the leg to evaluate for a Baker cyst. If present, it will need to be drained under ultrasound guidance and this will help you with your pain.
Grannyscott: I am an 85-year-old senior with arthritis in my back, shoulder, and now in both of my thumbs. This is according to my spine health physician. What, if anything, can be done to help with the thumbs? I have tried wearing stretch splints. They do help to keep them from being pulled painfully, but I can't wear them all the time.
Bijal_Jayakar,_MD_: I recommend cortisone shots for the thumbs as this is most likely due to degenerative joint disease. You will need to make an orthopedic surgeon or a rheumatologist.
Rheumatoid Arthritis Treatment
RAprogression: I have been diagnosed with rheumatoid arthritis (RA). I am a 51-year-old female. I have been taking glucosamine with chondroitin for five weeks now and it seems to be working. I am also taking a tapering dose of prednisone. (I have been off of it for five days.) I have had Hashimoto thyroiditis for five years. I am taking 125 mcg Synthroid® (levothyroxine) daily. My rheumatologist has prescribed methotrexate, prednisone, folic acid, and flu and pneumonia vaccines. I am concerned about side effects, but don't want the disease to progress. At this point it is affecting my fingers and wrists. I am trying to rule out the cause. I have been tested for parvovirus and Lyme disease, but I haven’t received the results yet. I am checking into bioidentical hormones and mercury toxicity. (I have had six silver fillings removed.) I can’t wrap my mind around this of not understanding a cause and with no cure. I quit smoking, but have a wood-burning stove. I have no family history of RA. Any advice would be appreciated.
Bijal_Jayakar,_MD_: If you have been diagnosed with RA, I recommend treatment for this before more damage and deformities develop. If you would like to have a second opinion before starting these medications like methotrexate, that should be o.k. too. Glucosamine usually does not help RA. If at all, it is meant for osteoarthritis.
writer53: My daughter was 21 years old when she developed a rare autoimmune disease (granulomatosis with polyangiitis). Her symptoms included severe arthritis joint pain and swelling throughout her body. Although she is now in remission, she still suffers monthly joint pain associated with her monthly cycle. For the rest of the month she is pain free. For 10 years preceding she developed this autoimmune disease, she suffered symptoms of hormonal imbalance (infrequent periods, hot flashes, facial flushing, mysterious rashes, sweaty palms, etc.). With autoimmune disease disproportionately occurring in women (75 percent and on the rise)—especially in adolescent girls and young women—can you discuss the connection between hormones and immunity and the implications for hormonal imbalance (estrogen dominance, progesterone deficiency) to predispose females to developing autoimmune disease? How can and should hormonal imbalance, especially in adolescent girls, be addressed? How is it best diagnosed and treated?
Bijal_Jayakar,_MD_: Diseases like rheumatoid arthritis are nine times more common in women than men due to hormonal factors. It is entirely unclear as to which hormones play a role in this though.
chickbull: Are hip replacements done 12 to 13 years ago subject to requiring a replacement?
John_Donohue,_MD: Periodic evaluations by an orthopedic surgeon to assess the integrity of the joint replacement should be done.
Capw: Do you have any information regarding the success of biologic medications—specifically, Orencia® (abatacept) to treat rheumatoid arthritis?
Bijal_Jayakar,_MD_: These are very good medications and help if indication. But first you should be on an oral medication like Arava® (leflunomide) or methotrexate. If these do not help, then Orencia® can be added if indicated. We have a lot of success with biologic therapy in treating rheumatoid arthritis.
Knee Pain Treatment
NOGRITS: What would be corrective action for a bone spur resultant from knee (medial meniscus) surgery 40 years ago? I am experiencing pain when taking long walks.
Bijal_Jayakar,_MD_: Surgery probably would be the best. I would recommend an orthopedic evaluation.
Summertime: What is the best way to eliminate arthritis pain? Does physical activity help or does it need to be addressed with medications?
Bijal_Jayakar,_MD_: If it is osteoarthritis, then pain medications should help. However, I always recommend physical therapy to prevent joint loss and mobility. If it is inflammatory arthritis—like rheumatoid arthritis, then stronger immunosuppressive medications are needed.
chickbull: I am 80 years old of normal weight with osteoarthritis. I have had two hip replacements about 12 years ago, cervical spondylosis and some lower back pain. I find most exercise too difficult and painful. I do not take pain medication except for Advil® (ibuprofen) occasionally. I try walking when possible. Other than that, can you suggest anything?
John_Donohue,_MD: After an appropriate evaluation by a spine doctor or rheumatologist, you may consider a course of physical therapy with aquatherapy.
DMWachholz: I have osteoarthritis in both knees. I have had a Synvisc® (hylan G-F 20) shots in one knee that were very painful, so I hesitate to have them in the other knee. I have been going to a chiropractor who is doing cold laser therapy and the knee pain is almost gone. The only problem I am still having is the throbbing at night. Is there anything that can relieve that? Also, what type of exercise would you recommend? I used to walk at least three miles per day, and now I just can't do it.
Bijal_Jayakar,_MD_: Walking is a great exercise. The longer you walk the farther you will be able to go. Do not stop walking. I recommend quadriceps strengthening exercises for the knee pain to strengthen the quadriceps. I think you may try Euflexxa® which is once a week for 3 weeks. if this does not help, the knee replacement will be the next step, because the arthritis may be way advanced
chickbull: Is tai chi helpful and safe to use as an exercise when pain exists in lower side of back?
John_Donohue,_MD: Yes, it can be helpful. A good rule of thumb with any exercise is not to push through pain. Some positions can be modified for those with specific conditions.
Nutrition and Arthritis
NOGRITS: I have arthritis in my hands (at the joints at the base of my thumbs) as well as a frozen "trigger-finger" thumb. I anticipate surgical correction of this on May 12. I am concerned that the pain seems to be getting worse as time goes by. My question is should I try to initiate a "sugar-free” lifestyle. Would that help my arthritis and overall health at my age of 74 years old?
Bijal_Jayakar,_MD_: Trigger fingers may improve with cortisone shots. I am not aware whether a sugar-free diet that might help, but there is no harm in trying.
Capw: Is a gluten-free and sugar-free diet useful to counter the inflammation in the gut to help immune issues such as lupus and arthritis?
Bijal_Jayakar,_MD_: I am not sure if this helps, but there is no harm in trying this and seeing if this benefits you. Each individual is different and may help some more than others.
rls1953: In addition to sugar, what foods contribute to inflammation and arthritis pain?
Bijal_Jayakar,_MD_: There is no study to show which foods are related. However, people both doctors who practice alternative medicine and some patients believe a gluten-free diet helps. Additionally, there believe citrus foods can worsen arthritic pain. I do not have any specific recommendations regarding this
Supplements and Alternative Therapy
Gail Ann: Is there any total natural treatment for osteoarthritis?
Bijal_Jayakar,_MD_: If it is hand osteoarthritis, I recommend daily hand exercises, soaking hands in warm water, and you may try paraffin baths. For knee osteoarthritis, daily walking and weight loss help. Quadriceps strengthening exercises also help. Water aerobics is good because if does not put pressure on the knees.
rls1953: What foods and natural supplements are effective in mitigating pain and reducing joint inflammation?
Bijal_Jayakar,_MD_: Usually ginger and turmeric are beneficial. We always recommend 1500 mg of calcium daily in divided doses and 2000 units of vitamin D for bone health and to prevent osteoporosis.
Gail Ann: What dosage of turmeric and ginger do you recommend daily?
Bijal_Jayakar,_MD_: There is no specific dose, just buy either turmeric pills over the counter or in powder form. One tablespoon full in milk or water is good daily. You may also take this with honey. You can use ginger in cooking with no specific amount.
circusman: I am 74 years old, and have pain in both shoulders from arthritis. My orthopedic surgeon says MSM (methylsulfonylmethane) is worthless; but I read a physician-written book that says it's wonderful for relieving pain. What's the current thinking on MSM.
John_Donohue,_MD: MSM has not been studied at any large-scale controlled trial. However, there is little downside to a trial of several weeks to see if the pain has improved.
Sastruga: My doctor recommended glucosamine for large joint pain. Do you also recommend that?
Bijal_Jayakar,_MD_: There is no harm in taking this, but studies have shown that it helps only early mild to moderate arthritis. usually Rheumatologists do not recommend it. No definitive data is available to prove it is useful.
chickbull: I have heard that acupuncture has been helpful. Is that something that is recommended?
John_Donohue,_MD: Acupuncture can be complementary to traditional treatments. We do recommend it in some instances.
Capw: Are there any Cleveland Clinic rheumatologists that also use alternative method treatments in conjunction with conventional medications?
Bijal_Jayakar,_MD_: There is a Department of Integrative Medicine that uses alternative treatment methods. However, I am not aware of any rheumatologists who do this.
Moderator: To learn more about alternative treatments to treat arthritis such as by acupuncture, Chinese Herbal Therapy and nutrition consultations visit the Center for Integrative Medicine website: http://my.clevelandclinic.org/wellness/integrative-medicine/default.aspx or by visiting www.clevelandclinic.org/cim or call toll-free 877.311.WELL(9355)
Cleveland Clinic Evaluation
Sastruga: Do Cleveland Clinic rheumatologists require a referral from a primary care doctor?
Bijal_Jayakar,_MD_: Not necessarily. You may also call and make an appointment yourself. It depends if your insurance will cover the visit if you make the appointment yourself. So please check with your insurance first.
Bijal_Jayakar,_MD_: Thank you very much for joining us today!
John_Donohue,_MD: Thank you for your very interesting questions!
To make an appointment with Bijal Jayakar, MD or any of the other specialists in our Department of Rheumatic and Immunologic Diseases at Cleveland Clinic, please call toll-free at 866.275.7496. You can also visit us online at clevelandclinic.org//orthopaedics-rheumatology/departments-centers/rheumatic-immunologic-diseases/
To make an appointment with John Donohue, MD or any of the other specialists in our Department of Rheumatic and Immunologic Diseases at Cleveland Clinic Florida, please call toll-free at 877.463.2010. You can also visit us online at clevelandclinicflorida.org.
For Health Information on Arthritis
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On Cleveland Clinic
The Orthopaedic & Rheumatologic Institute at Cleveland Clinic offers expert diagnosis, treatment and rehabilitation for adults and children for bone, joint or connective tissue disorders. The Institute blends the strengths of Cleveland Clinic’s Orthopaedic and Rheumatologic Programs, both ranked first in Ohio and among the top three nationally byU.S.News & World Report.
Cleveland Clinic’s Arthritis & Musculoskeletal Center within the institute is a multidisciplinary clinic combining the expertise of nonoperative orthopaedists and rheumatologists in one location. Our evaluation and treatment center brings together experts so the cause of your joint pain can be quickly and appropriately diagnosed. Our team includes rheumatologists, nonoperative orthopaedic physicians, musculoskeletal radiologists, physical and occupational therapists, brace technicians and musculoskeletal patient educators.
Cleveland Clinic’s Department of Rheumatic & Immunological Diseases provides state-of-the-art diagnosis, treatment and rehabilitation for adults and children for diseases ran including rheumatoid arthritis, osteoarthritis, bursitis/tendonitis, osteoporosis, gout, pseudogout and multiple other forms of arthritis, systemic lupus, vasculitis, fibromyalgia and other diseases.
To learn more about alternative treatments to treat arthritis such as by acupuncture, Chinese Herbal Therapy and nutrition consultations visit the Center for Integrative Medicine website: http://my.clevelandclinic.org/wellness/integrative-medicine/default.aspx or by visiting clevelandclinic.org/cim or call toll-free 877.311.WELL(9355)
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