Online Health Chat with Mathilde Pioro, MD & Kim L. Stearns MD

May 26, 2017


Description

If you are concerned you might have arthritis because of pain in your knees, elbows, hips, shoulders or other joints, join us for answers. Your questions will be answered by a rheumatologist and an orthopaedic surgeon who will discuss different types of arthritis, other possible causes for pain, diagnosis and treatment options.

  • Did you know the risk of arthritis increases with age?
  • Did you know arthritis is more common among women than men?

Arthritis is the inflammation of a joint or joints. Inflamed joints are often red, hot, swollen and tender. It describes more than 100 conditions that affect the joints or tissues around the joints. Specific symptoms vary depending on the type of arthritis.
Arthritis symptoms may include pain or aching, stiffness, swelling, redness and less range of motion.

There are many types of arthritis such as osteoarthritis (OA), rheumatoid arthritis (RA), lupus and gout. Hip and knee pain can have many causes including osteoarthritis, bursitis, tendonitis in the knee and hip fractures.

At Cleveland Clinic’s Orthopaedic & Rheumatologic Institute, we have designed our services so that all the specialists you need – including orthopaedic physicians and surgeons,  rheumatologists and physical therapists – work together to help you return to an active lifestyle.

Using state-of-the-art diagnostics and decades of experience, we evaluate the cause of your joint pain and then tailor the most appropriate treatment for your individual needs. Cleveland Clinic’s orthopaedic and rheumatology programs have a long history of excellence and innovation, and are consistently ranked among the top five programs in the nation by U.S. News & World Report.


About the Speaker

Mathilde Pioro, MD, is a rheumatologist in the Orthopaedic & Rheumatologic Institute. She specializes in rheumatoid arthritis, osteoarthritis, lupus, spondylitis, gout and connective tissue disorders. Dr. Pioro graduated from McGill University in Montreal. She completed her rheumatology fellowship at Cleveland Clinic and graduate work at Case Western Reserve University. She is an associate professor of medicine at Case Western Reserve University, and is board certified in internal medicine and rheumatology.

Kim L. Stearns MD, is a board-certified orthopaedic surgeon. He specializes in sports medicine and adult reconstruction. Dr. Stearns is a 1985 graduate of Northeast Ohio Medical University. He has been employed by the Cleveland Clinic Foundation since 2006. He is board certified by the American Board of Orthopedic Surgery.
 
Dr. Stearns is a team orthopaedic surgeon for the Cleveland Indians and head team physician for the Lake County Captains. He is a consultant for the World Wrestling Entertainment, Cleveland Playhouse, Live Nation Entertainment and the Rockettes. He is a clinical assistant professor of anatomy at Northeast Ohio Medical University as well as an assistant professor of surgery at Cleveland Clinic Lerner College of Medicine.


Let’s Chat About Joint Pain and Arthritis

 

Referrals and Recommendations

Rhebuck: What type of doctor can diagnose my entire body as to what is causing my arthritis? I am a 65-year-old, active female. I am 5 feet 2.5 inches tall and weigh 125 pounds. Outdoor activity is my life, but with pain in my lower back, hip region, both knees, posterior tibialis tendonitis, shoulder and something new frequently, my life is miserable with pain, including at night. I do yoga, stretch, ice, roller foam, occasional NSAIDS, prescription inserts, knee braces and rest, but nothing seems to help for very long.

Kim_Stearns,_MD: A physician who can diagnose the entire body is either a rheumatologist or a physical medicine and rehabilitation specialist. You do not need a referral to see either one.

bohill: I currently suffer from arthritic trapezium joints in both hands. I have taken injections every three months for two and a half years. I was told that I can no longer receive these injections. Which surgical procedure is the better option?

Kim_L._Stearns,_M.D.: There are several different types of surgical procedures that can successfully treat this condition. A hand surgeon would be able to discuss which procedure would be best for your particular arthritis.

Lhoc: Hello. I am 51 years old with tendonitis in both upper arms/shoulders. I have had many shots of cortisone that have not been successful. It is very difficult to do daily chores, and I have difficulty sleeping. Do you have any suggestions to help?

Kim_L._Stearns,_M.D.: If you have not had MRI's, that would be your next step to confirm that tendonitis is the issue to be treated. The next step would be a course of physical therapy, which needs a referral from a physician. Surgery would be a last resort depending on your response to therapy and what the MRI shows.

sinaihospital: I have arthritis in my right knee, and also in my right ankle and right foot. I also have carpal tunnel syndrome in both hands. I tried shots, medicines and physical therapy for my right knee and right. It helped very little. Doctors, is there a surgery I can try for this problem? Thank you, doctors.

Kim_L._Stearns,_M.D.: I do not have enough information to make a diagnosis to say whether or not surgery would be helpful. X-rays and an MRI can determine if something can be done arthroscopically or if some type of arthroplasty is indicated.

Tova: I had a botched microdiscectomy a year ago. I also have degenerative disc disease of the cervical spine. I live in constant pain from osteoarthritis, but my concern is that I have had a very salty taste in my mouth since the surgery and wonder if I could possibly have a spinal fluid leak someplace and my neurosurgeon is missing it? I'm dizzy with both legs in pain and tingling with low back pain, not to mention the agony of my cervical spine issues. Is a fluid leak possible, and how to I get a doctor to listen about this? All I get from doctors is "I dunno." Do you have any suggestions?
 
Mathilde_Pioro,_MD: Spinal fluid leaks are rare and would not typically result in a salty taste. Given your symptoms of dizziness and tingling and your concerns, I recommend that you be seen by a neurologist. It is very important for you to gather your medical/surgical records including clinical notes, lab tests, imaging test results and imaging pictures (the CD of the actual MRI/CT) to bring with you or send ahead for review prior to the consultation.


Conditions and Complications

YG: For about three years, I have had chronic lower back pain that is present at rest but worsens with exertion, but with no particular morning stiffness. An x ray taken recently showed some evidence of a little amount of calcification of the anterior longitudinal ligaments and mild sacroiliatis, but it was reported as within normal limits. I have mild pain in my left knee on exertion as well. In addition, I have a neck pain with tenderness in the lower neck region. I had an episode of severe tendinitis in my hand a while back, but was told it could possibly be attributable to hypermobility in the joints. However, I also get frequent episodes of tenderness on tendon insertion points in the elbows on minimal exertion. Should I be tested for ankylosing spondilitis, or can there be another course of action?

Mathilde_Pioro,_MD: The symptoms you describe may be representative of an early inflammatory arthritis or may simply be due to degenerative arthritis (osteoarthritis) and soft tissue tendinitis, particularly if you are hypermobile. X-rays need to be interpreted in the context of your medical history and physical examination. There is no single test for ankylosing spondylitis. It is a clinical diagnosis, meaning that the information from your history, physical examination, laboratory tests and imaging studies needs to be pulled together to determine a diagnosis and recommend a treatment plan.

gm3: Is trigger finger related to arthritis? If so, what type of treatment is available to help the problem?
 
Kim_L._Stearns,_M.D.: It can be, but it can also be a separate condition unrelated to arthritis. It is treated initially with a steroid injection and if the triggering returns a simple outpatient surgery.

loveitaly: I have had flat foot since I was a child. I used orthopedic boots with the metal inserts at 7 years old. In my teen years, I had no pain. In my adult years, I am always wearing the right shoes, inserts inside sneakers and small wedges. Two times in my 40s, I had severe plantar fascitis that resolved with good PT. I have two spurs in my left ankle. Since February 2016, I have had severe pain and swelling in my left ankle. My foot and ankle surgeon prescribed the walking boot for eight weeks, another brace, custom-made orthotics and PT for five months, with no big relief. I have posterior tibial tendon dysfunction. Now, I have the Ritchie Brace and am still in pain. My doctor says to have the surgery, which requires fusing some bones and repairing the tendon. I use low doses of prednisone and diazepam 5mg for the pain. I do icing and elevate my feet. A second doctor told me to avoid that surgery; there’s no warranty I will be fine afterward. A third told me to do it. It is very complicated and has a long-term recovery. What is your input about plasma or stem cell for pain and inflammation? Thank you.

Kim_L._Stearns,_M.D.: There is also no guarantee that plasma or stem cell injections will make your pain go away. In fact, for this condition they are not likely to help at all. I agree that surgery is a last resort. It sounds like you have done all of the proper treatments that are currently available. The surgery is major with a very long recovery. However, if you cannot tolerate the pain, and the braces and inserts aren't working, surgery is the next step.

chickbull: I am an 83-year-old male with arthritis and Paget's but no special treatment. Many years ago, I had Dr. Deal review my Paget's x-ray data, and he indicated it showed some in my lower back, but my alkaline phosphatase was not high enough to do anything for it. That was about 17 years ago. My most recent test was in 2012 at 276. Dr. Deal had said unless it is over 300, we don't have to do anything. I have needed treatment for cervical spondylosis and lower back pain. I have taken turmeric and curcumin capsules for almost five years and it has helped. Do you have any suggestions for self help? I have been to PT on occasion.

Mathilde_Pioro,_MD: Given your age, it is most likely that your neck and low back pain are related to osteoarthritis. The pain from Paget's can, however, be difficult to differentiate from osteoarthritis. It would be reasonable to request repeat testing of your alkaline phosphatase since your most recent result dates from 2012. I agree with Dr Deal that there is nothing to do if your alkaline phosphatase is less than 300. If it is above 300, I would recommend repeat evaluation for the Paget's. In terms of self help for spine osteoarthritis, I would recommend regular back exercises as you have been instructed by your physical therapist; regular physical activity (e.g., tai chi, yoga, aquatic exercises, walking, gentle stationary cycling); maintenance of/striving for a healthy body weight; eating a sensible diet; evaluating your sleep habits and if these are poor/you have poor sleep, discussing this with your PCP.


Asking About Osteoarthritis
 

eatveggies: Other than a two times per week yoga class and doing daily back and core exercises followed by ice packs, is there any new treatment for severe osteoarthritis ("bone on bone") of the lower back? Also, which is better for long-term use for osteoarthritic pain: ibuprofen (several per day) or 12-hour Aleve (naproxen)? Thank you.

Mathilde_Pioro,_MD: Both ibuprofen and naproxen are NSAIDS (nonsteroidal anti-inflammatories) and can cause similar long-term complications. One is not better than the other. Acetaminophen (Tylenol) is another option you can consider. You should be under medical care if you are taking any of these medications long term. There are no new treatments for severe osteoarthritis; however, osteoarthritis of the low back can also be addressed with medications that may help nerve-related pain such as amitriptyline and gabapentin.

msugal: I had bilateral knee replacements and one hip replacement. I have osteoarthritis throughout and was taken off arthritis medications because of renal problems. Other than taking extra-strength Tylenol for arthritis, what can I do for the pain. Changing weather fronts cause more pain now that I'm much older. I am an 81-year-old female.

Kim_L._Stearns,_M.D.: I recognize that is a difficult problem because anti-inflammatory medicines do effect your kidneys. Use of topical anti-inflammatory gels and patches can be effective and not affect your kidney function. These are prescription medications.


Frustrations Following Surgery

painFree: I had my right knee replaced on January 12, 2017. My recovery was remarkably pain free and ahead of schedule, re: flexibility, etc. I did therapy religiously and was close to abandoning the cane by March. In early March, I began having sharp pains in my right hip. I had bursitis in that hip prior to surgery and thought it had returned. It turns out it is the IT band. The surgeon says nothing other than physical therapy can help because medications (cortisone, etc.) may cause infection in the new knee. It is now May, and I have only occasional periods of relief from pain. (That’s mostly due to 2/3 Aleve/day.) Although I think my surgeon is great, I feel somewhat abandoned since answers to questions have been slow, and I feel the surgeon’s attitude has been “we can't help you, so you're on your own.” Perhaps because of the pain, I am over sensitive. Is IT band pain something that needs to go away in its own good time? I continue assigned PT. Visits to a chiropractor give some relief. The situation is depressing and frustrating.
 
Kim_Stearns,_MD: Generally, the treatment of an IT band issue is physical therapy. Unfortunately, you are trying to recover from a major knee operation at the same time. That can make treatment of the IT band issue a longer process. Once your three months out from knee replacement, the risk of infection from a steroid injection into the IT band should go down, and that would be an option now. There are some topical anti-inflammatories such as Voltaren Gel and Pennsaid that are also very good for IT band issues. These are both prescriptions.
 
fiat127: Five months ago, I had a knee procedure to reduce pain after Aleve and physical therapy did not help. An MRI indicated I had a lateral meniscus tear. My surgeon did knee arthroscopy, partial lateral meniscectomy and chondroplasty of the patella. I did physical therapy since the surgery. The recovery estimate was four to six weeks. Twenty weeks later, the knee pain is still higher than before surgery. After two months, we tried Mobic but had NO success. After three months, we tried a steroid shot, which failed to help. An MRI done four weeks ago did not reveal any issues (except a popliteal cyst). The surgeon claims that the pain is a result of inflammation/arthritis, and recovery with that takes longer than usual. I got a second opinion, and the other surgeon told me he does not see any inflammation, and my knee is just weak and I need to strengthen it. Is there any way to rule out the inflammation theory considering the fact that traditional treatments (steroid shot, Mobic and Voltaren Gel) have failed? In your opinion, what causes the increased pain?

Kim_L._Stearns,_M.D.: If you are worried about continued inflammation, you can get another MRI. If steroid injections didn't help you, then a gel injection with something like a series of Euflexxa injections would be the next step.

tejpal: I had a total knee replacement (TKR) four years ago, and although there is no pain like before TKR, the knee now feels as if there is a 20-pound weight tied to it. It is like having a tight clamp around the joint. The knee otherwise is quite flexible. My question is whether there is any cure for this besides going for a corrective surgery?

Kim_L._Stearns,_M.D.: There really is no corrective surgery. Sometimes, a feeling like this can be a sign of quadriceps muscle weakness, which can be treated with a refresher course of physical therapy.

Babydoll0115: My husband had two knee replacements and a hip replacement. He just now had another knee surgery for a revision because something broke in the former knee replacement. He states that he has pain in his knees all the time even though they have been replaced. Is there a reason for that? I have bad knees, too, and have been putting off any knee replacement surgery because of what he has told me. I was diagnosed a year ago with breast cancer, and after radiation, I was put on anastrazole. This medication is a nightmare for me because it causes extreme pain in all of my joints. I would go for injections every six months for my knees to eliminate my knee pain, but since I am on this medication the pain comes back much sooner than the allotted six month cycle. Is there something I can do that would help alleviate some of this joint pain?

Kim_L._Stearns,_M.D.: For your husband, the results after repeated total knee operations unfortunately are not as satisfying as most people would like. A knee replacement doesn't make your knee new or normal, or perfect. Most people still have occasional aching pain even after successful knee surgeries. After a revision it can take up to two years to reach maximum medical improvement. In the meantime, continue therapy exercises. For you, the recommendation is steroid injections, hyaluronic injections, topical gels, oral NSAIDS, physical therapy and surgery when you cannot tolerate the pain any longer.


Mentioning Medications

lilred67: I was diagnosed with MCTD: scleroderma, lupus (SLE), fibromyalgia, a severe spine diagnosis and a whole host of other diagnoses. I am a very complex case. I have A LOT of joint pain, swelling, redness, etc. I've tried many medications, and as I progress, I need stronger anti-inflammatory medications. I’m currently on meloxicam. My rheumatologist has suggested rituxin, but also left Xeljanz and Areva as options. It's my decision as to which medication to try. My question is: Which would you recommend? Or would you recommend something else entirely? My joint pain is intolerable.

Mathilde_Pioro,_MD: Yours appears to be a very complex case. The medications that have been suggested to you are immunosuppressants, which lower the immune system and can have many adverse effects. It is very important to clarify your diagnosis because this will determine the best treatment for you. A full medical history and examination is also necessary because this will also need to be taken into account to determine your treatment. I recommend you obtain your past medical records including clinical visits, lab work and imaging studies and see a rheumatologist for a complete evaluation.

Jasmin: What is the daily effective dose for an adult male for sulfasalazine?

Mathilde_Pioro,_MD: The dose depends on the disease being treated, your kidney function/liver function/blood counts, your weight and other medications being used. In general, the dose for an adult male is between 1000mg twice daily and 2000mg twice daily. You should be getting regular monitoring blood tests if you are taking sulfasalazine.
 
february1940: I have been receiving monthly infusions of Orencia for more than five years for rheumatoid arthritis. Would you advise ceasing those infusions and trying an oral treatment? I take 200 mg of Plaquenil Sulfate twice daily. I have had very few flare-ups. I would like to avoid the threat of side effects from Orencia. I am a 77-year-old male. I had prostate cancer, which was successfully treated with radiation in 2016. I have frequent episodes of skin infections.

Mathilde_Pioro,_MD: Whether to try another medication depends on the details of your rheumatoid arthritis (including whether there has been evidence of inflammation in organs other than the joints) and on your past RA medication use. There is one new oral medication for RA (tofacitinib/Xeljanz) and several older, but still effective, oral medications (methotrexate, leflunomide, azathioprine, sulfasalazine). All of these medications are immunosuppressants and have potential adverse effects similar to those associated with Orencia. I would recommend seeking a second opinion from a rheumatologist in order to best answer your question. It is important for you to gather together your past medical information to bring with you (or send in advance for review) if you do so.

EMG: About 10 years ago, I was told I had osteoarthritis. At first, over-the-counter NSAIDS worked well with no side effects I could tell. It became necessary to take more than my doctor liked, and my doctor put me on meloxicam 15 mg, which has worked well. The label said to stay out of the sun and heat, and it may cause dizziness. I am a gardener and lived in North Carolina the last two summers. I have experienced dizziness when out in the sun/heat. Could the meloxicam be causing the dizziness, which lingers until winter, or is it something else developing? I am 75 years old.

Mathilde_Pioro,_MD: Dizziness is a nonspecific symptom that is on the side effect list of most medications, including meloxicam. That being said, if your dizziness was due to meloxicam, I would expect this to be present year-round and not just in the warm months. It is important to stay well-hydrated when taking meloxicam and all other NSAIDS because this is beneficial for the kidneys. Dizziness can also be a result of cardiac or neurologic disease, so I would encourage you to discuss this with your PCP.

bifa: Will Arthrotec help osteoarthritis pain?

Mathilde_Pioro,_MD: Arthrotec is a combination anti-inflammatory (NSAID) and stomach protectant medication. It can be helpful for osteoarthritis especially if the arthritis is mild to moderate, somewhat less if the arthritis is severe. You should check with your PCP before using Arthrotec long term (i.e., more than four to six weeks of continuous use) because NSAIDS can have significant adverse effects, and their use should be monitored with regular blood work.


Non-Surgical Treatments

bifa: What is the best over-the-counter topical pain cream, spray for knees and joints?

Kim_L._Stearns,_M.D.: IcyHot and BioFreeze are the most common readily available products.
 
bifa: Do compression socks help leg pain and swelling?

Kim_L._Stearns,_M.D.: Yes. These can work for pain and swelling, and can be purchased at a drug store.

Roger: I am right handed. The finger tip in the most joint on my left hand exhibits a slight pain when bent. Can one have "arthritis" in just one finger and joint? I have noticed this condition for about three to six months now. If so, what is the treatment?

Kim_L._Stearns,_M.D.: Yes. You can have arthritis in one finger. These are very small joints and generally do best with topical ointments and gels, some of which can be obtained over-the-counter such as Aspercream, IcyHot, etc. You can also take ibuprofen for pain relief.

geewhiz82: My question: Is there a natural way to control joint pain without prescription medicine? How about arthritis pain?
 
Mathilde_Pioro,_MD: There are many different types of joint pain and not all are treated the same way. However in general, it is a good idea to: 1) Maintain or aim for a normal body weight through sensible eating, portion control and daily physical activity. This is especially important for weight-bearing joints including the hips, knees and low back. You can determine your optimal body weight by calculating your BMI (body mass index) using your height and weight. This can easily be done online. 2) Eating a sensible diet low in processed and refined foods and high in fiber and vegetables can help decrease inflammation. 3) Evaluate your sleep habits, and if you are not sleeping well (six to eight hours of solid sleep), discuss this with your PCP. 4) Topical medications e.g., IcyHot, Biofreeze, can provide temporary relief. 5) Consider an evaluation by a rheumatologist or pain management and rehabilitation specialist.

Barbs312: Are platelet-rich plasma and stem cell therapies effective in relieving knee pain? Does Medicare cover them?

Kim_L._Stearns,_M.D.: The technology is still new and evolving. PRP is further along than stem cell treatment at this point. Medicare doesn't pay for either. They are very promising technologies. At some point in the future, they will become more mainstream treatment options, but at this time, they are still considered experimental and very expensive.

Skio_17: What are your thoughts on a gluten-free diet to aid in the treatment of RA? I have heard many things about it to help with flare-ups, but I was recently switched to Remicade infusions and am tapering off all other medications (except for methotrexate). Could this help the taper? Would it be beneficial to go gluten free?

Mathilde_Pioro,_MD: There is no medical evidence that a gluten-free diet helps in the treatment of RA or in tapering off RA medications. It is a good idea to follow a sensible diet based on moderation and minimizing processed and refined foods.
 
TomP: What is the best over-the-counter pain medicine?

Kim_L._Stearns,_M.D.: Tylenol is always a good choice. If you have pain from inflammation and are not on any blood thinners or have any stomach issues, any of the OTC ibuprofen or naproxen sodium medications are effective as well.

bpgbg247: Great information listed in this chat. Thank you.


Closing
That is all the time we have for questions today. Thank you, Dr. Pioro and Dr. Stearns, for taking time to educate us about Joint Pain and Arthritis.

On behalf of Cleveland Clinic, we want to thank you for attending our online health chat. We hope you found it to be helpful and informative. If you would like to learn more about the benefits of choosing Cleveland Clinic for your health concerns, please visit us online at http://my.clevelandclinic.org.


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To make an appointment with Drs. Pioro, Stearns or any of the other specialists in Cleveland Clinic’s Orthopaedic & Rheumatologic Institute, please call 216.444.5632, toll-free at 800.223.2273 or visit us at clevelandclinic.org/orthorheum for more information.


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About Cleveland Clinic
Cleveland Clinic's Orthopaedic & Rheumatologic Institute offers expert diagnosis, treatment and rehabilitation for adults and children with bone, joint or connective tissue disorders. The institute blends the strengths of Cleveland Clinic's Orthopaedic Program and Rheumatology Program, both ranked among the top three nationally by U.S. News & World Report (the top rankings in Ohio).

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