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Psoriatic Arthritis

What is psoriatic arthritis? Psoriatic arthritis is

What is psoriatic arthritis?Labelled plaque

Psoriatic arthritis is a type of arthritis that can be seen in people with psoriasis. Psoriasis is a chronic skin condition that can cause patches of inflamed, red or scaly skin. In most cases of psoriatic arthritis, psoriasis was present before the arthritis. However in a minority of people, arthritis occurs at the same time or even before the skin rash appears.

What causes psoriatic arthritis?

The exact cause of psoriatic arthritis is unknown. Genetic, immunologic and environmental factors seem to play a role in its development.

Symptoms of psoriatic arthritis

Psoriatic arthritis is an inflammatory type of arthritis. This means there is not only pain but also swelling and stiffness in the joint. Pain and stiffness are usually worse in the morning and improve throughout the day or with activity.

In addition, psoriatic arthritis has a few unique features:

  • It is essentially the only inflammatory arthritis that can involve the distal part of the fingers also known as DIPs. The other type of arthritis that commonly affects these joints is osteoarthritis, which is not an inflammatory arthritis.
  • It is one of the few types of inflammatory arthritis that can involve the spine (the other ones in this family, known as seronegative spondyloarthropathies, are ankylosing spondylitis, inflammatory bowel-disease associated arthritis, and reactive arthritis).
  • Nail abnormalities like pitting or crusting can be a harbinger of arthritis in the distal part of fingers
  • Unlike rheumatoid arthritis, which is usually symmetrical, psoriatic arthritis can be asymmetric. For example, it can affect the left knee and the right wrist only.
  • Psoriatic arthritis can sometimes cause swelling of an entire finger or toe, making a digit look like a sausage. This is known as “dactylitis” or “sausage digit”.
  • Psoriatic arthritis can be associated with inflammation of the area where tendons attach to bones. This is known as “enthesitis”. Some of the commonly affected tendons include the Achilles tendon (back of the heel) and plantar fascia (sole of the foot)

Besides the joints, People with psoriatic arthritis can sometimes experience iritis, which is inflammation and redness in the eye. People with psoriatic arthritis may also be at higher risk of heart disease and stroke.

Psoriatic_arthritis labelnail pitting label



Iritis PSADactylitis-6


How is psoriatic arthritis diagnosed?

Psoriatic arthritis is diagnosed by a combination of medical history, physical examination, labs and x-rays.

Medical history:

A personal history of psoriasis makes it more likely that your inflammatory arthritis is in fact psoriatic arthritis. Features of inflammatory arthritis may include pain that is worse in the morning, stiffness in the morning lasting more than 30 minutes, and improvement of pain and stiffness with activity.

Physical examination:

Presence of psoriasis, swelling in joints, joint tenderness in the distal part of fingers or toes, inflammation of the entire finger or toe, an asymmetric involvement of joints can be suggestive of psoriatic arthritis.

Laboratory studies:

There currently is no specific blood test to diagnose psoriatic arthritis. People with psoriatic arthritis usually have a negative rheumatoid factor and CCP antibody (both seen in rheumatoid arthritis). A small percentage may have a positive ANA, a nonspecific antibody which can be seen in a variety of diseases including lupus. Some people with psoriatic arthritis who also have involvement of their spine may have a positive HLA-B27.

X-rays:PsA xray

There are specific features that may clue a radiologist or rheumatologist to the presence of psoriatic arthritis. For example, the type of deformity that can be caused by psoriatic arthritis looks different from that of rheumatoid arthritis or osteoarthritis.

Psoriatic arthritis treatment:

Like all inflammatory arthritides, early treatment of psoriatic arthritis is associated with a greater chance of joint preservation and disease remission.

Treatment is usually selected based on severity of the disease, patient preference, and other medical conditions someone may have. Medications from each category may be used alone or in combination with a medication from another category to achieve maximum results if necessary.

    1. Nonsteroidal anti-inflammatory drugs (NSAIDs). In order for these drugs to be effective, it is usually recommended that they are taken regularly.
      • Examples include ibuprofen, naproxen, Celebrex, meloxicam, diclofenac
    2. Disease-modifying anti-rheumatic drugs (DMARDs). These oral medications decrease inflammation, reduce pain, and can prevent joint damage. Laboratory monitoring is required every 2-3 months.
      • Methotrexate
      • Sulfasalazine
      • Leflunomide
    3. Biologic drugs – these medications target a specific component of the immune system thereby decreasing inflammation and pain. They are administered either intravenously or subcutaneously.
      • TNF-inhibitors (Humira, Enbrel, Remicade, Simponi, Cimzia)
      • Stelara (Ustekinumab)
      • Cosentyx (Secukinumab)
      • Orencia (Abatacept) and Rituxan (Rituximab)- are currently being studied
    4. Otezla (Apremilast) – This oral drug suppresses multiple molecules that cause inflammation.



Ankylosing Spondylitis


Diagnosis and Treatment of Ankylosing Spondylitis

How is it diagnosed?

Ankylosing spondylitis is diagnosed starting with a thorough history, asking about symptoms and risk factors discussed in previous sections. A detailed exam is necessary to find any kind of inflammatory back signs, peripheral arthritis, or extra-articular manifestations. Certain maneuvers and measurements should be performed in the office. Below are just a few exam techniques that may be used to diagnose AS, such as:Patrick's_test

  • Occiput-to-wall test: to measure the cervical spine range of motion
  • Chest expansion test: to measure the thoracic spine range of motion
  • Schober test: to measure lumbar spine range of motion
  • Patrick’s test: Also known as FABER test, to test to sacroiliac joint inflammation



After exam, certain labs can be ordered to check for inflammation (ESR and CRP levels). An HLA-B27 can also be checked through blood work if there is a high suspicion for AS. However, imaging helps greatly in the diagnosis. X-rays can show changes in the SI joint and lumbar spine (such as Bamboo Spine). If it is early in the disease course, an MRI may be needed to catch subtle changes, such as erosions or inflammation.

Ankylosing-spondylitis labeledNormal Lumbar











How is it treated?

Treatment is aimed at maintaining mobility of the joints (especially the vertebrae), decreasing stiffness, and decreasing pain. Some modifiable risks include smoking cessation and increasing exercise. Home exercises and stretches can be beneficial, but a supervised physical therapy program usually provides greater benefit. Exercises usually focus on postural training, range of motion stretching, recreational activities, hydrotherapy, and local treatment with heat and cold.nr55552058

When medications are decided on, Nonsteroidal anti-inflammatory drugs (NSAIDs) are usually first line therapy. Examples of NSAIDs includes:

  • Ibuprofen (Advil, Motrin)
  • Naproxen (Aleve)
  • Meloxicam (Mobic)
  • Celecoxib (Celebrex)
  • Diclofenac (Voltaren)
  • and others…

NSAIDs are used to decrease pain and inflammation, and hopefully aim to control back pain and stiffness.

However, it the inflammation and symptoms are not controlled, the next step in therapy is biologic medications. The main-stay is Anti-TNF biologics, which work by blocking TNF-alpha, an important component of the immune system which causes inflammation and ultimately leads to joint damage. Examples include:

  • Adalimumab (Humira) – subcutaneous injection every 2 weeks
  • Etanercept (Enbrel) –  subcutaneous injection weekly
  • Infliximab (Remicade) – IV infusion every 2 – 8 weeks
  • Golimumab (Simponi) – subcutaneous injection monthly
  • Certolizumab (Cimzia) –  subcutaneous injection monthly

The newest FDA-approved medication for treatment is Secukinumab (Cosentyx), which works differently than the Anti- TNF medications. This medication inhibits an inflammatory protein known as IL-17, which is believed to play major role in other inflammatory diseases such as psoriatic arthritis, rheumatoid arthritis, and inflammatory bowel disease.

These medications are injectable or infusion based, and should be prescribed by a rheumatologist or trained physician. Steroids can be used, but show little long-term benefit. These medications all have possible side effects, and should be discussed with your rheumatologist prior to use.

Overall, if treated early and adequately, ankylosing spondylitis should not limit a patient’s daily life significantly, and patients can be expected to live a long, healthy life



What is Ankylosing Spondylitis?

Signs and Symptoms of Ankylosing Spondylitis



Psoriatic Arthritis








Signs and Symptoms of Ankylosing Spondylitis

What are the symptoms of Ankylosing Spondylitis?

AS is characterized mainly by inflammatory back pain (described below). Inflammation can occur in several areas, leading to pain and stiffness. These include:1280px-Sacroiliac_joint_svg

  • Sacroiliac and spinal joints
  • Hip and shoulder joints
  • “Peripheral” arthritis: smaller joint such as the hands, wrists, elbows, knees, and feet
  • Joints involving the ribs, clavicle, and sternum and there attachments

Inflammatory back pain is usually reported in almost all AS patients. The characteristics of “inflammatory” back pain include:

  • Pain at night (that improves with waking up and moving)
  • Insidious onset
  • Improves with exercise
  • Does not improve with rest
  • Age of onset < 40 years old

Other bony symptoms include:

  • Impaired spinal mobility: inability to fully bend at the waist or move the neck. Chronic, untreated disease can lead to fusion of the spine. Fusion at the cervical spine limits neck motion, fusion at the thoracic spine limits chest expansion (and breathing), and fusion of the lumbar spine limits the way a person sits and bends
  • Abnormalities in posture: Patients can experience “hunching” of the back (hyperkyphosis) with long term disease, leading to a stooped posture
  • Buttocks and hip pain: Which can alternate sides depending on the sacroiliac joint that is involved
  • Enthesitis: inflammation at the attachment site of tendons and ligaments to bones that presents as pain and sometimes swelling. These include areas such as the Achilles tendon, the plantar fascia, and costochondral joints (cartilage of the ribs), and the superior iliac crest (areas of the pelvic bone)
  • Dactylitis: Also known as “sausage digits”. This occurs in about 6% of patients with AS

Dactylitisankylosing spondylitis 2







Symptoms can also occur that are not related to the joints or bones, known as “extra-articular” symptoms. These can be related to the active disease or complications of AS, and include:Iritis

  • Uveitis: Also known as Iritis. It is inflammation of the anterior portion of the eye. It is a common manifestation in AS patients with up to 35% of patients experiencing this sometime in there disease course. It can occur in one or both eyes, and can “jump” from eye to eye. Can be a one-time phenomenon, or recurrent, and usually improves when the AS is treated effectively
  • Lung issues: fibrosis of the lungs can occur from the inflammation (scar tissue formation), as well as restrictive lung disease from the inability to expand the chest
  • Heart disease: There is an increased risk of heart disease and acute coronary syndromes due to the active inflammation of the disease. Other cardiac manifestations include aortitis (inflammation of the aorta), conduction abnormalities, and pericarditis (inflammation of the lining of the heart).
  • Discitis: Inflammation of the vertebral discs
  • Kidney disease: Nephropathy from antibody deposition (IgA) and secondary amyloidosis from chronic inflammation
  • Neurologic conditions: Chronic inflammation and damage in the spine can affect the adjacent nerve roots or even the spinal cord itself
    • Cauda equine syndrome: damage to the lumbar nerve roots leading to sensation changes in the legs, impotence, and bladder and bowel incontinence
    • Spinal cord injury: mostly related to fractures, and can lead to paralysis
    • Atlantoaxial subluxation: instability in the C1 and C2 vertebrae, leading to compression of the spinal cord, which can also lead to paralysis



What is Ankylosing Spondylitis?

Diagnosis and Treatment of Ankylosing Spondylitis



Psoriatic Arthritis








Ankylosing Spondylitis

What is Spondyloarthritis?

Spondyloarthropathies (or Spondyloarthritis) are a family of inflammatory disease that cause arthritis, and are different than other inflammatory arthritides because the can affect the spine and soft tissues such as tendons and ligaments (known as enthesitis). The 4 main spondyloarthropathies are ankylosing spondylitis, psoriatic arthritis, reactive arthritis, and enteropathic arthritis associated with inflammatory bowel diseases (ulcerative colitis and Crohn’s disease).

Ankylosing Spondylitis is the most common condition from this group. Also known as AS, this form of arthritis primarily affects the spine, and can cause chronic pain, discomfort, stiffness, and eventually fusing of the bones, leading to decreased mobility.Blausen_0037_AnkylosingSpondylitis

Who gets it?

There are several risk factors to be aware of for AS. These include:

Age: Unlike most other forms of arthritis, AS is usually seen in younger people. It usually begins in the teens or 20’s, with typical age of onset anywhere from age 17 – 45

Gender: It is likely to happen in 2 – 3 times more frequently in the males than females, unlike many other rheumatologic conditions

Genetics: Having a family member with AS puts a patient at higher risk of getting it, partly due to an inherited gene known as the HLA-B27 gene. The HLA-B27 gene is actually present in about 8% of healthy individuals in society. Of this 8% of people with a positive HLA-B27 gene, only 2% of them develop ankylosing spondylitis. If you have a first degree relative that is affected and you are HLA-B27 positive, your risk increases to 15 – 20%. Though infrequent, 90% of white AS patients and 50 – 80% of non-white AS patients have a positive HLA-B27.

Race: The highest frequency of this condition is in more northern populations, such as Scandinavians, Alaskans, Siberian Eskimos, and Native American tribes. These populations have a higher prevalence of the HLA B-27 genes, and the prevalence of the disease decreases from north to south as you near the equator. African Americans seem to be affected the least of all races.

What exactly happens in the disease?

It is not completely understood how the condition occurs, but it seems to start after some kind of triggering event in genetically susceptible individuals (HLA-B27 positive). The trigger has been hypothesized to be some type of infection, exposure to an unknown antigen, or molecular mimicry where your body confuses itself with an infecting organism.



Signs and Symptoms of Ankylosing Spondylitis

Diagnosis and Treatment of Ankylosing Spondylitis



Psoriatic Arthritis








Is Your Diet Causing Inflammation?

Is Your Diet Causing Inflammation?


You might not know it, but inflammation plays a big role in our daily lives. Inflammation is essentially your body’s protective response to a stressor or harmful stimulus. These include bacteria, viruses, toxins, irritants, and physical trauma that cause cell damage. Our body uses inflammation as a way to eliminate the cause of cell injury, clear out dead cells and tissue, and overall repair the damage. However, though inflammation has a good end result in our bodies, the process is not very enjoyable.

The signs of inflammation include pain, redness, swelling, heat, and loss of function. Though inflammation is a very complex process involving our immune system (mostly innate immunity and not adaptive immunity which is more specific), there is a delicate balance we must have to stay healthy. No inflammation can cause progressive cell death (such as if you have an infection that you can’t fight off), but too much inflammation can lead to conditions like heart disease, rheumatoid arthritis, inflammatory bowel disease, and allergies to name a few.

It is known that stress, weight, and even medications can change the levels of inflammation in the body. However, studies have shown that DIET can actually play a huge role in inflammation.

Though there is no exact diet to reduce inflammation (as everybody is different), here are just some foods that have been shown to decrease inflammation:

Fruits and Vegetables:Fruits And Vegetables, Image courtesy of Suat Eman at FreeDigitalPhotos.net

One of the best and easiest ways to decrease inflammation is increasing your fruit and vegetable intake. Not only do they help with weight loss, but also contain antioxidants, carotenoids, quercetin, and loads of vitamins that lower inflammation. Try all colors! Bright colored produce, leafy greens, and “purple” fruits help fight inflammation. These include:

  • Broccoli, Celery, Beets, Kale
  • Cabbage, Bok Choy, Swiss Chard
  • Cherries, Raspberries, Blackberries, Blueberries, Pineapple

Anti-inflammatory Fats:Bottles Of Olive Oil, Image courtesy of m_bartoschat FreeDigitalPhotos.net

While saturated fats cause inflammation, weight gain, heart disease, and a whole slew of conditions, mono-unsaturated and poly-unsaturated fats help control inflammation. Omega-3 and Omega-6 fatty acids are great examples of anti-inflammatory fats. These “good” fats also help lower LDL cholesterol and triglycerides, help with blood pressure, and decrease blood clotting and risk of heart attacks. Examples of good sources of anti-inflammatory fats include:

  • Virgin olive oil, Avocado oil, Flaxseed oil, Walnut oil, & Hempseed oil
  • Whole Avocados
  • Chia seeds, Flax seeds
  • Almonds, Cashews, Pistachios, Walnuts
    • Avoid candied, honey roasted, or heavy salted nuts
    • Keep in mind that nuts are high in calorie, so servings should be limited to a handful a day.
  • Mackerel, Lake trout, Herring, Sardines, Albacore, Tuna, Salmon
    • AVOID FRIED!!!

Ingredients And Condiment, Image courtesy of Khotcharak at FreeDigitalPhotos.netHerbs and spices:

They have several antioxidants and boost the body’s natural ability to reduce inflammation. These include:

  • – Turmeric, oregano, rosemary
  • – Ginger, green tea

Bowl Of Muesli For Breakfast, Image courtesy of Serge Bertasius Photography at FreeDigitalPhotos.netWhole grains:

Unrefined grains are usually higher in fiber, which can help with inflammation. Try replacing carbs with more whole grain alternatives. These include:

  • Oatmeal, brown rice
  • Whole grain bread, rice and pasta
  • Quinoa, yams, plantains

Foods To Avoid

While the above mentioned foods help fight inflammation, there are foods have been associated with increasing inflammation in the body. As a general rule, you should try to avoid highly processed foods, overly greasy foods, and super sweet foods. Some of these foods include:


Lump Sugar, Image courtesy of Suat Eman at FreeDigitalPhotos.netRefined starches and sugary foods:

Usually, they do not have many nutrients and can lead to cholesterol issues, changes in blood sugar, and weight gain (all increasing inflammation).

  • – Sugar (any added sugar)
  • – Soda and sweet drinks
  • – Refined flour, Gluten
  • – Foods with high glycemic index

Sausages, Image courtesy of savit keawtavee at FreeDigitalPhotos.netHigh-fat and processed red meat:

These foods are high in saturated fats, increasing inflammation:

  • – Sausage, bacon, hot dogs, etc
  • – Other high-fat meats


Butter Isolated On The White Background, Image courtesy of khumthong at FreeDigitalPhotos.netButter, whole milk, and cheese:

Again, the problem is saturated fat. Instead, eat low-fat dairy products.
Fried Chicken”, Image courtesy of piyato at FreeDigitalPhotos.netFried Food:

Cooking them in vegetable oil does not make them healthy. Even if you use oils high in Omega 6, too much affects the Omega 3/Omega 6 balance, leading to more inflammation.

Nightshade Vegetables:Fruits And Vegetables” by Suat Eman

Some people states that they experience pain and inflammation when eating nightshades. Nightshades continue glycoalkaloids, which has been shown in some studies to cause inflammation. However, these vegetables affect people differently, and not everyone that eats them will have inflammation. The nightshades include:

  • Tomatoes, Tomatillos
  • Eggplants
  • Potatoes
  • Tobacco
  • Peppers (bell peppers, chili peppers, paprika, tamales, tomatillos, pimentos, cayenne, etc.)

These are just general guidelines, and dietary changes may help some people with inflammation and not help others. You should discuss diet changes with a physician.


Esposito, K, & Giugliano, D 2006, ‘Diet and inflammation: a link to metabolic and cardiovascular diseases’, European Heart Journal, vol. 27, no. 1, http://www.onlinejacc.org/content/48/4/677
Aeberli, I, Gerber, PA, Hochuli, M, Kohler, S, Haile, SR, Gouni-Berthold, I, Berthold, HK, Spinas, GA, & Berneis, K 2011, ‘Low to moderate sugar-sweetened beverage consumption impairs glucose and lipid metabolism and promotes inflammation in healthy young men: a randomized controlled trial’, The American Journal Of Clinical Nutrition, vol. 94, no. 2, https://www.ncbi.nlm.nih.gov/pubmed/21677052
“Lump Sugar”, Image courtesy of Suat Eman at FreeDigitalPhotos.net
“Ingredients And Condiment”, Image courtesy of Khotcharak at FreeDigitalPhotos.net
“Fruits And Vegetables”, Image courtesy of Suat Eman at FreeDigitalPhotos.net
“Bottles Of Olive Oil”, Image courtesy of m_bartoschat at FreeDigitalPhotos.net
“Bowl Of Muesli For Breakfast”, Image courtesy of Serge Bertasius Photography at FreeDigitalPhotos.net
“Seeds On Wooden Spoon”, Image courtesy of adamr at FreeDigitalPhotos.net
Sausages, Image courtesy of savit keawtavee at FreeDigitalPhotos.net
“Butter Isolated On The White Background”, Image courtesy of khumthong at FreeDigitalPhotos.net
“Cheese”, Image courtesy of Suat Eman at FreeDigitalPhotos.net
“French Fries”, Image courtesy of artemisphoto at FreeDigitalPhotos.net
“Fried Chicken”, Image courtesy of piyato at FreeDigitalPhotos.net

Polymyalgia Rheumatica

Polymyalgia Rheumatica

What is it?

Polymyalgia Rheumatica (PMR) is a relatively common inflammatory condition that causes aching pain and stiffness in the shoulders, hips, neck, and back. The term “polymyalgia” means many muscle pains.


Who gets it?
There are certain risk factors that make PMR more likely

– This condition is almost only seen in people over the age of 50
– The Incidence of the condition increases with age
– The peak incidence is around 70 – 80 years of age

– Women are affected more than men (about 2-3 times more)

– People of Scandinavian and Northern European decent have a higher incidence of the condition

– The condition is associated with the HLA-DR4 haplotype
– A high level of IL-6 (a pro-inflammatory cytokine) has also been associated with this condition

What exactly happens in the disease?

The exact cause of the PMR is unknown, though it is believed to have a genetic factor to it. Environmental and infectious causes were studied, but have been inconclusive.

What are the symptoms?
Patients with this condition usually have symmetrical pain in the shoulders, hips, neck, back, and torso, described as an aching pain and stiffness. It has been shown that not only are the joints involved, but the bursa around the joints, making the pain in the arms and thighs a “referred pain”. The pain is usually abrupt onset, worse in the morning (with morning stiffness lasting > 1 hour), and usually limits normal daily activity, even simple activities such as putting on a shirt, getting to a standing position, and going up stairs, putting on shows or socks. The pain usually starts in the shoulders, and can be on one side, but usually becomes bilateral in a few weeks. Stiffness can occur after prolonged times of rest, known as the “gel phenomenon”. Patient can also have distal arthritis and even edema (swelling of the extremities)PMR

Main Areas of Pain in PMR

Systemic findings include:
– Weight loss
– Low-grade fevers
– Fatigue
– Malaise
– Depression
– Difficulty getting out of bed, out of a chair, or off the toilet
– Difficulty with daily activities (dressing, bathing, etc.)

Musculoskeletal findings include:
– Morning stiffness > 1 hour
– Muscle stiffness after prolonged inactivity (“gel phenomenon”)
– Arthritis in the distal joints (hands, feet, etc.)
– Joint swelling, particularly in the affected joints
– Carpal tunnel syndrome
– Swelling of the hands and feet
– Patients can also suffer from fatigue, decreased appetite, and sometimes low grade fevers.

In some cases (around 10% of patients with PMR), patients may experience a related condition known as Giant Cell (Temporal) Arteritis, also called GCA, in which patient get inflamed blood vessels and present with high fevers, headaches, blurry vision, and jaw complaints (GCA discussed here)

How is it diagnosed?
Unfortunately, there is not a specific test for PMR. The diagnosis is made based on the history, risk factors, symptoms, examination, and blood work. Blood work tends to show elevation in the markers of inflammation, specifically the Erythrocyte Sedimentation Rate (ESR) and the C – reactive protein (CRP). Though these labs are not specific, they are often elevated in PMR (though can be low in some cases). Imaging studies are usually not done as they tend to be unrevealing. MRI has been used before, and usually shows synovitis (inflammation) in the affected joints as well as bursitis. These findings are not specific, and hence why MRI is usually not used.

How is it treated?
The good news is that most cases are treated successfully with oral steroids (prednisone), and most patients notice an improvement within a few days. The bad news is that most patients must stay on prednisone for a prolonged period of time (anywhere from 6 months to 2 years +) as it is taper off slowly to prevent relapse. For more resistant cases or development of GCA, patients may need higher doses of steroids or the addition of stronger anti-inflammatory medications, such as Methotrexate or Tocilizumab. NSAIDs (Ibuprofen, Naproxen, etc.) can help with some of the pain, but do not address the underlying cause of symptoms. Physical therapy can help maintain activity, but again, will not resolve the underlying cause.

See Also
Giant Cell (Temporal) Arteritis

Thumb spica splint

Ways to decrease thumb pain

What causes thumb pain?

The most common causes of thumb pain are arthritis and tendonitis. De Quervain’s tendonitis is caused by the inflammation of the two tendons that extend the thumb (move the thumb up, as in hitchhiking). Arthritis of the base of the thumb joint is one of the most common and early forms of osteoarthritis and the number one cause of thumb pain.

How to distinguish between the two? First palpate the base of the thumb where it meets the wrist. Is this area tender or even swollen? This may indicate arthritis in this area. Next, put your thumb in a closed fist, extend your arm and lower the fist. This extends the tendons and can cause pain in the area if there is tendonitis.

Thumb osteoarthritis
Thumb osteoarthritis
DeQuervain tendonitis
DeQuervain’s tendonitis










Ways to decrease thumb pain:

Whether from arthritis or tendonitis, there are conservative, nonsurgical ways to decrease pain in this area:

1) Bracing

Using a hand-based thumb spica splint is known to help with thumb pain whether from arthritis or tendonitis. The splint stabilizes the base of the thumb but leaves  the thumb tip, fingers and wrist unrestricted. This way you will still have full function of your hand while protecting the base of the thumb.

Thumb spica splint
Thumb spica splint



Carpal tunnel braces, which have a hole where the thumb is, will not help stabilize the thumb and will not reduce thumb pain.


2) Topical analgesic creams

Creams like Voltaren gel can be applied to the area to reduce pain and inflammation without affecting the entire body.  Combination of diclofenac (active ingredient of Voltaren gel) with lidocaine can be made by some compounding pharmacies and may be available by a prescription.  Other topical creams, like Capsaicin and Aspercreme can also be used with caution as they can cause stinging if they touch the eye.

Voltaren gel
Voltaren gel


3) Strengthening exercises

Specific exercises to strengthen the muscles and tendons supporting the thumb can be recommended by an occupational therapist. The goal of these exercises is to strengthen the area without causing further pain and damage.


4) Thermal modalities

Application of heat or ice to the area may help with pain relief and even decrease inflammation.

Paraffin baths and heat wraps can also provide relief.


5) Joint preservation techniques

Arthritis and tendonitis both occur as a result of overuse. So techniques that reduce force to the area can help decrease thumb pain and heal symptoms. The basic principles of joint preservation are:

  • Using larger, more stable joints during activities
  • Providing appropriate rest or break periods
  • Decreasing muscle force
  • Using adaptive equipment if appropriate

For example, instead of lifting a bowl by pinching the rim with your thumb and forefinger, carry it using the palm of your hand. Use assistive devices to open water bottles and jars, use foam grips for pens and pencils, use electric can openers, etc.

Here are a few examples:

Foam grip
Foam grip
Self opening scissors
Self opening scissors
Jar opener
Jar opener
Vegetable peeler
Vegetable peeler














Osteoarthritis Treatment- From Diet to Surgery!

Osteoarthritis Treatment- One problem, many solutions

Osteoarthritis Treatment

There is no cure for osteoarthritis. Symptoms of arthritis can gradually worsen over time as we age. However, there are multiple treatment options that can reduce pain, increase mobility, and possibly slow the progression of the disease. There is no one osteoarthritis treatment regimen that works for everyone. Treatment of arthritis, much like any other condition, is tailored to the type and location of the arthritis as well as the individual.


1. Conservative Therapy

Weight loss

Extra weight on the joints- especially on the hips, knees, and lower back- is known to expedite development and progression of osteoarthritis. Losing those extra pounds can significantly reduce the load on the joint and not only decrease pain, but also slow down the progression of arthritis.


Physical Therapy

Regular exercise not only improves flexibility of the joints and their surrounding tissues, it also helps strengthen the muscles that support the joints. The stronger the muscles, and the less we rely on the joint alone to do the work, the less arthritis pain we’ll have.


Cold/Heat Therapy

  • Heat (ie heating pads, packs, etc) helps reduce muscle spasm and decrease stiffness in the joint.
  • Cold (ie cold pads, ice packs, etc) helps decrease inflammation and irritation around the joint



  • There are many patches that can be used for topical pain control.
    There are many patches that can be used for topical pain control.

    Glucosamine/chondroitin sulfate- Although lacking in convincing evidence from controlled trials, this combination may provide pain relief in some people with osteoarthritis

  • Turmeric- this spice has mild anti-inflammatory properties and may provide mild pain relief in people with arthritis.
  • Creams- creams like Capsaicin, Bengay, Aspercreme, Tiger Balm, Arnica, and other over-the-counter pain relieving creams can be used for arthritis pain.
  • Patches- One of my favorites is Salonpas, but other pain-relieving patches may be found over the counter.


Assistive devices

  • Shoe inserts that provide cushioning to the feet may help alleviate pain from foot arthritis.
  • Bracing the joint (like the knee or ankle) can help provide stability
  • Canes and walkers can be used to increase stability when walking and prevent falls
  • Use of devices to open jars, button up shirts, hold a pen, etc. can help decrease arthritis pain


TENS unit

A TENS unit delivers a mild electrical current to the skin and stimulates the nerve fibers in the skin. These nerve fibers may interfere with the transmission of pain signals from the arthritic joint.



In a few recent controlled studies, acupuncture has shown some benefit in reducing pain from arthritis.


Osteoarthritis treatment modalities with unproven or questionable benefit:

  • Dimethylsulfoxide (DMSO)
  • Copper bracelets
  •  Transcutaneous electrical nerve stimulation (TENS)
  • Chiropractic manipulation



2. Medications


Acetaminophen (Tylenol)

Tylenol can help relieve mild to moderate arthritis pain. The maximum dose of Tylenol recommended in 24 hours is 3 grams for people without significant liver disease. This recommendation is a recent reduction from the previous allowed 4 grams, to reduce risk of liver toxicity.

This is what the recommendation translates to in number of allowed daily Tylenol tablets:

  • Regular Tylenol (325mg each): 2 tablets, 4 times per day – total of 8 tablets in 24 hours
  • Extra strength Tylenol (500mg each): 2 tablets, 3 times per day – total of 6 tablets in 24 hours
  • Tylenol arthritis (650mg each): 2 tablets, 2 times per day – total of 4 tablets in 24 hours


 Pain medications

The pain of sudden, severe arthritis exacerbations may require treatment with narcotic analgesics such as codeine. Narcotics should be taken for only short periods of time because they can be addictive. They are often most effective when taken together with nonsteroidal antiinflammatory drugs (NSAIDs). Narcotics can also be combined with acetaminophen (eg, Tylenol 3 contains acetaminophen-codeine).


Nonsteroidal anti-inflammatory drugs (NSAIDS)

Examples of this class include ibuprofen (Advil, Motrin), Naproxen (Aleve), Meloxicam (Mobic), Celebrex, Diclofenac (Voltaren), etc. These drugs can reduce pain and inflammation of arthritis.


Hydroxychloroquine (Plaquenil)

This drug can sometimes be used in people with severe inflammatory osteoarthritis.


3. Joint injections

Corticosteroid injections

Injection of a small dose of steroids into the arthritic joint can help reduce the pain. Pain relief can last anywhere from a few days to several months. The benefit of this treatment is that it is delivered locally to the affected joint and has little effect on the rest of the body.  These injections can be safely repeated about 3-4 times per year in each joint.


Hyaluronic acid injections

SynvisHyaluronate, or hyaluronic acid, is the naturally occurring substance present in the joint fluid which lubricates the joint. Synthetic forms of hyaluronic acid can be injected into some joints to provide cushioning and lubrication that has been lost from the arthritic joint. Pain relief from these injections may last an average of 6 months; although they are not effective in everyone. Currently the only joint that has been FDA-approved for these injections is the knee; but injection of other joints like the hip or elbow may be done off-label.

HyalganThe hyaluronic acid formulations currently available in the United States are Synvisc, Synvisc One, Hyalgan, Orthovisc, Supartz, and Euflexxa.


4. Surgery

Arthroscopic joint surgery-

Some arthritis patients may benefit from arthroscopic surgery to “clean out” the joint, but this form of surgical intervention is actually controversial. It is not generally recommended in people with severe osteoarthritis who may benefit more from a joint replacement.


Joint fusion

Fusion of two or more bones may sometimes be recommended for joints of the wrist and ankles or the small joints of the hands and toes. Eliminating the movement in the joint reduces the pain from arthritis but also limits mobility.


Joint replacement surgery

When joint pain has not responded to the alternative treatment methods, and when it interferes with the person’s mobility and activities of daily living, joint replacement may be recommended. There may be a lengthy recovery period.

See also:

Osteoarthritis- The most common type of arthritis

Osteoarthritis- diagnosis









Sjögren’s syndrome


Sjögren’s syndrome is a chronic autoimmune disease where the immune system mistakenly attacks the moisture-producing glands of the eyes dry mouthand mouth causing dry eyes and dry mouth.

In addition to causing dry eyes and dry mouth, Sjögren’s syndrome can affect other organs like the skin, lung, heart, kidney, and nerves.

The exact cause of Sjögren’s syndrome is not known, but it is thought that genetic factors together with environmental triggers lead to disease in certain individuals.


Primary versus secondary Sjögren’s syndrome:

In ½ the cases, Sjögren’s syndrome occurs alone and is called primary Sjögren’s syndrome.

In the other half, known as secondary Sjögren’s syndrome, it is associated with another disease like rheumatoid arthritis, lupus, or scleroderma.


Sjögren’s syndrome symptoms

Sjögren’s syndrome is a systemic disease. In mild cases in can only cause dry eyes or dry mouth. In more severe cases it can affect other organs:

  • Eyes: dry eyes, eye infections, corneal ulcers
  • Mouth: dry mouth, mouth sores, cavities, difficulty with chewing, speech
  • Nose: dry nose, nosebleeds, chronic sinusitis
  • Esophagus: difficulty swallowing, heartburn, inflamed esophagus
  • Lungs: bronchitis, pneumonia, interstitial lung disease
  • Stomach: upset stomach, slowed digestion, autoimmune pancreatitis
  • Liver: abnormal liver tests, autoimmune hepatitis, primary biliary cirrhosis
  • Brain: problems with concentration and memory
  • Joints/muscle: arthritis, muscle pain
  • Skin: dry skin, vasculitis, Raynaud’s phenomenon
  • Genital: vaginal dryness, painful intercourse
  • Extremities: peripheral neuropathy


Diagnosing Sjögren’s syndrome

Since dryness of the eyes and mouth is fairly common and can be caused by a variety of different conditions or medications, definitive diagnosis of Sjögren’s syndrome can be tricky.

  1. First, other conditions that can cause these symptoms should be ruled out.
  2. Blood tests: Many people with Sjogren’s syndrome have a positive blood test for antinuclear antibodies (ANA), SSA, and/or SSB.
  3. Measuring dryness in the eyes by an ophthalmologist or a rheumatologist:
    • Schirmer test: a small piece of filter paper is placed on the corner of the eye. Decreased amount of wetting is a subjective way to measure eye dryness.
    • Rose-Bengal test: presence of scratches on the surface of the eye may be an indication of dry eyes causing damage to the eye membranes.
  4. A salivary gland biopsy may be needed to confirm the diagnosis.


Potential complications of Sjögren’s syndrome:

  • Damage to the surface of the eye from dryness
  • Increased incidence of dental cavities and mouth infections
  • Damage to the lung tissues
  • Damage to the kidney tissues
  • Abnormal thyroid function
  • Inflammation of the vessels (vasculitis)
  • Increased risk of lymphoma (cancer of the lymphatic system)


Treatment of Sjögren’s syndrome:

Although there is no cure for Sjögren’s syndrome, there are good treatments that can improve the symptoms and prevent complications:

Dry eyes– the goal is to increase tear production or decrease drainage of tears.

  • Lubricating drops- Artificial tears can be used throughout the day (ex. Refresh, Tears Naturale Free, etc.). Thicker eye gels that last longer but are difficult to see through may be used at night (ex. Refresh PM, viscotears, etc.).
  • Prescription drops- Cyclosporine ophthalmic drops (Restasis) and hydroxypropyl cellulose ophthalmic insert (Lacrisert).
  • Punctal plugs- this involves plugging the ducts in the eyes that drain the tears from the eyes to the nose.

Dry mouth– the goal is to increase salivation

  • Frequent sips of water
  • Sucking on sugarless candy, lozenges, dried fruits, or chewing gum
  • Medications to stimulate saliva production: Pilocarpine (Salagen), Cevimeline (Evoxac)
  • In addition, good dental hygiene and care such as brushing, flossing, fluoride supplementation via toothpaste, and regular dentist visits is important to prevent dental decay.

Dry skin– moisturizing creams, petroleum jelly.

Vaginal dryness– use of vaginal moisturizers, estrogen cream, vitamin E oil, and vaginal lubricants.

Acid reflux (heartburn)– this is treated the same as acid reflex in any other person: decrease intake of caffeine, spicy and greasy foods, eat smaller meals, do not lay down after eating, do not eat for 3 hours before going to bed, and elevate the head of your bed. Over the counter and prescription medications for acid reflux can also be used.

Joint and muscle pain– Tylenol, Nonsteroidal anti-inflammatory drugs (NSAIDs, like advil, ibuprofen, aleve) can be used as needed.

Systemic treatment– Plaquenil, Rituxan, and other immunosuppressive medications may be used in persistent cases.



UpToDate  – Sjögren’s syndrome (Beyond the Basics)

Sjögren’s Syndrome Foundation


Raynaud’s Phenomenon

What is Raynaud’s Phenomenon?

Raynaud’s phenomenon is a condition where the blood vessels in fingers and toes (and occasionally other areas) constrict upon exposure to cold, causing discoloration of the digits.

Disease vs. syndrome

There are 2 types of Raynaud’s phenomenon: primary Raynaud’s phenomenon or Raynaud’s disease, where symptoms are not associated with another disease, and secondary Raynaud’s phenomenon, or Raynaud’s syndrome, where symptoms are connected to another disease. Primary Raynaud’s phenomenon is not uncommon in young women.

  • Raynaud’s disease:
    • idiopathic. The cause is unknown
    • more common in young women
    • usually milder
  • Raynaud’s syndrome:
    • secondary to another disease
      • connective tissue diseases- systemic lupus erythematosus (SLE), scleroderma, rheumatoid arthritis, Sjogren’s syndrome, mixed connective tissue disease, etc.
      • Medications- beta-blockers, Bromocriptine, sulfasalazine, cyclosporine, some chemotherapies, others
      • Cryoglobulinemia
    • often more severe and may be more difficult to treat


What happens in Raynaud’s phenomenon:

The small blood vessels in the skin normally play a role in controlling the body’s temperature. They do this by constricting when it’s cold and reducing blood flow to the skin, therefore minimizing the loss of heat through the skin. They also dilate when it’s hot which increases the blood flow to the skin and helps lose some of the body heat. The blood vessels’ constriction and dilation is regulated by the sympathetic nervous system. Changes in the temperatures causes the sympathetic nervous system to fire signals to the blood vessels and direct them to either constrict or dilate. Interestingly, emotional stress can also cause a similar triggering of the sympathetic nervous system; which explains why people may have cold or sweaty hands when they are stressed.

In people with Raynaud’s phenomenon, the vessels have an abnormally exaggerated response to the sympathetic nervous system’s signals from cold weather.


Although Raynaud’s phenomenon most commonly affects the blood vessels supplying the fingers, it can also involve the feet as well as the ears, nose, face, and rarely, other areas. The classic Raynaud’s phenomenon attack resembles the colors of the United States flag: white, red, and blue. Initially, when the blood vessels constrict, the fingers may turn white from the lack of blood flow. The attack may involve one or more fingers and may happen in one or both hands
simultaneously. The most commonly involved fingers are index, middle and ring fingers. The white discoloration sometimes does not involve the entire finger, and one may see a distinct border between the areas of white and pink in the same finger. If the constriction is severe or prolonged and the oxygen supply in the blood is running low, the digit may turn blue/purple. When the fingers are warmed up and the vessels dilate again, the fingers may become red, indicating a rush of blood flow to the skin.

  • white: decreased blood flowRaynaud
  • blue: lack of oxygen
  • red: blood flow re-established



During an attack of Raynaud’s phenomenon, the fingers or toes usually feel cold and they may be painful or numb. If the attacks are severe and prolonged, lack of blood supply to the area can eventually lead to death of the tissue (ulcers, necrosis, and gangrene). In severe cases, usually in people with Raynaud’s syndrome, tissue injury may be irreversible leading to loss of the finger or toe.


Diagnosing Raynaud’s phenomenon

Raynaud’s phenomenon is diagnosed clinically, based on one’s description of the fingers’ color change upon exposure to cold. When I evaluate someone for Raynaud’s phenomenon, my primary goal is to determine if the disease is primary or secondary. Primary Raynaud’s tends to be milder and responds better to conservative treatments. Secondary Raynaud’s (or Raynaud’s syndrome) can be more severe and more difficult to control. In addition, it can have implications depending on the disease it is associated with. For example, Raynaud’s symptoms associated with scleroderma can be associated with pulmonary hypertension, a very serious lung disease.

Blood tests are done in evaluation of Raynaud’s to rule out possible secondary diseases (see above). A rheumatologist may also do a nailfold capillary test, which involves looking closely at the small blood vessels around the nails. Normal blood vessels are thin and straight, but in severe Raynaud’s then can get inflamed, dilated, and tortuous. Recent studies have shown a correlation between abnormal nailfold blood vessels and development of pulmonary hypertension in people with scleroderma.


Treatment of Raynaud’s phenomenon

In milder cases, simple lifestyle changes may be all that one needs to control the disease. The more severe cases are treated with medications to prevent necrosis of digits and gangrene.


Keep fingers and toes warm

This may mean wearing socks more often and carrying a pair of gloves in your purse and using gloves to reach into a cold freezer. Keeping the entire body warm will also help warm the extremities- jackets, hats, scarfs. Running warm (but not hot) water over the affected fingers.

Stop smoking

Nicotine causes the blood vessels to constrict therefore worsening Raynaud’s.

Beware of medication reactions

Some medications can cause blood vessels to constrict. Some of these medications include beta-blockers (that lower blood pressure), pseudoephedrine (decongestants), among others.

Medical treatment

These are usually used in more persistent cases of Raynaud’s phenomenon. These medications work by dilating the blood vessel, helping restore blood to the extremities.

  • Calcium channel blockers– ex. Amlodipine, Nifedipine, Diltiazem
  • Topical nitroglycerine– ex. Nitrobid, Nitropaste
  • Other blood pressure medications– ex. Prazosin, Losartan
  • Phosphadiesterase inhibitors– ex. Sildenafil (Viagra), Pentoxyfylline (Trental), Cilostazole
  • Prostaglandins– ex.Prostacyclin

Procedural/Surgical treatment

In severe cases that are refractory to medications, surgical procedures are used to minimize injury.

  • Sympathectomy– cutting the nerves of the sympathetic nervous system that supply the blood vessels of the fingertips can their constriction
  • Amputation– If the damage is not reversible and not responsive to treatment, surgical amputation may be necessary.

Alternative treatments

Some nutritional supplements and herbs may help control milder cases of Raynaud’s phenomenon.

  • Ginko biloba
  • Fish oil
  • Vitamin D