Is Knuckle Cracking Bad for Arthritis?

January 23, 2024

Is Knuckle Cracking Bad

The distinct pop and crack of knuckles being pulled and stretched is a familiar sound to many. You may not even realize how often you crack your knuckles until you consciously try to stop the habit. Up to 54% of people report regularly cracking their knuckles, whether for stress relief, simple habit, or just liking the sensation. But is this harmless fidgeting or is knuckle cracking bad for arthritis?

Anatomy of Knuckles

The knuckles are the joints that connect the bones of the fingers. Each finger has three joints called the distal interphalangeal (DIP), proximal interphalangeal (PIP), and metacarpophalangeal (MCP) joints ¹. The thumb only has an MCP and DIP joint.

The MCP joints are where the main part of your hand meets your fingers, letting your fingers bend and straighten. The PIP joints are in the middle of your fingers, helping them to move too. The DIP joints are at the very end of your fingers and they let you bend the tips of your fingers. 2

The knuckles are covered by a special pocket of filled with a fluid. This fluid is called synovial fluid and it helps them move without any friction. There are strong bands called ligaments on the sides of the knuckles that keep them in place, and there are also protective plates in front of them. The finger bones are connected to the muscles of the hand and forearm by tendons, which help you move your fingers.

What Creates the “Cracking” Sound

The cracking or popping sound when knuckles are cracked is not caused by the bones themselves cracking, but rather by the gases being released from the fluid inside the knuckle joints. The current theory is that it is caused by the gases rapidly coming out of solution from the synovial fluid inside the joint capsules.

As Dr. Robert Klapper, an orthopedic surgeon at Cedars-Sinai Medical Center explains, “The noise of cracking or popping in our joints is actually nitrogen bubbles bursting in our synovial fluid” (source).

Similarly, according to a Scientific American article, “The cracking or popping sound is thought to be caused by the gases rapidly coming out of solution, allowing the capsule to stretch a little and decompress the joint” (source).

So in summary, the cracking sound comes from the release of gases from the joint fluid, not from the actual bones cracking or breaking.

Short Term Effects

When you crack your knuckles, you may experience some short term effects in the minutes and hours afterwards. One common sensation is a feeling of relief or release after cracking knuckles. This is likely due to the stretching and loosening of ligaments surrounding the joint during the cracking process.

Some research has found that immediately after cracking knuckles, grip strength can increase by up to 25% for a brief period. Castellanos and Axelrod (1990) measured hand strength before and after knuckle cracking and observed this temporary boost in grip force.

However, other short term effects are less beneficial. There may be some mild swelling and inflammation around the joint capsule after cracking. One study using MRI scans found more joint swelling in the knuckles of habitual knuckle crackers compared to non-crackers. This suggests frequent knuckle cracking could irritate the joint tissue.

Long Term Effects

The main question around knuckle cracking is whether or not it increases your risk of developing arthritis over time. There have been several key studies that have looked into this.

One study published in the Journal of the American Board of Family Medicine looked at 215 people ages 45-89 who had cracked knuckles on one hand for many years. They did not find any increased signs of arthritis on x-rays in the hand they cracked vs the one they did not.¹

Another study followed 300 people over 50 years. Some were habitual knuckle crackers while others were not. But there was no difference in the incidence of arthritis between the two groups, leading the researchers to conclude knuckle cracking does not appear to increase arthritis risk.²

So the evidence indicates that knuckle cracking itself does not cause or worsen arthritis. However, a study in 1990 and 2018 did find that people who cracked knuckles frequently had more swollen hands and reduced grip strength compared to those who did not crack often. So while it may not directly lead to arthritis, habitual knuckle cracking can increase inflammation and impact hand strength and dexterity over time.

Other Risks

Although habitual knuckle cracking is generally harmless, there are risks with too forcefully or excessively cracking the knuckles. Cracking the knuckles with excessive force can potentially cause ligament or tendon injuries, though this is very rare. Sometimes it can it cause a finger to dislocate but this is very rare.

Additionally, the sound of knuckle cracking can be annoying or disruptive to those around you, especially if done frequently throughout the day. While not inherently dangerous, the noise and habit can be bothersome. According to a study cited by Harvard Health, knuckle cracking is associated with other habits like nail biting, smoking, and drinking alcohol ³.

Conclusion

Overall, research indicates knuckle cracking is not inherently dangerous or harmful when done in moderation. While the sound may be disconcerting, studies show it does not do damage to the joints or increase risk of arthritis. However, those who crack habitually and aggressively should exercise caution, as this can irritate the joints and tendons and lead to reduced grip strength.

Though not conclusively proven to be benign, cracking knuckles generally does not cause serious issues for most people. It appears to be more of an annoying personal habit than a major health concern. However, moderation is still advisable, as excessively forceful cracking could potentially injure joints and ligaments.

Medical Disclaimer

This information is offered to educate the general public. The information posted on this website does not replace professional medical advice, but for general information purposes only. There is no Doctor – Patient relationship established. We strongly advised you to speak with your medical professional if you have questions concerning your symptoms, diagnosis

Diseases and Conditions When to see a rheumatologist

Signs you may be at risk for psoriatic arthritis

January 16, 2024

Psoriatic arthritis is a type of inflammatory arthritis that occurs in people with psoriasis, an autoimmune condition affecting the skin. It causes swelling, stiffness and pain in the joints as well as nail changes and overall fatigue.

Psoriatic arthritis can be difficult to diagnose in its early stages but it’s important to identify and treat it quickly. Early treatment helps relieve symptoms, improve quality of life, and potentially slow down the progression of joint damage that can occur if the disease advances untreated.

Joint Pain

One of the most common early symptoms of psoriatic arthritis is persistent joint pain, swelling, and stiffness (Mayo Clinic). This pain often affects the large joints like the knees, ankles, elbows, and wrists, but can also impact smaller joints like those in the hands and feet.

The joint pain of psoriatic arthritis tends to be asymmetric, meaning it occurs on just one side of the body rather than symmetrically on both sides. The pain and stiffness tend to be worse when joints are at rest, and improves with movement. Psoriatic arthritis joint pain may also alternate between periods of flare ups and remission.

It’s important to note that psoriatic arthritis joint pain can occur even in people who do not have skin psoriasis. The joint symptoms may precede the skin lesions in some cases. Persistent joint pain, swelling, and stiffness, especially when asymmetric and alternating between flares and remission, can be an early sign of psoriatic arthritis.

Fatigue

Fatigue is a very common symptom of psoriatic arthritis, with studies showing that up to 80% of people with PsA experience some degree of fatigue (SOURCE). The chronic inflammation associated with PsA can contribute to feelings of tiredness and lack of energy (SOURCE). This type of fatigue is different than normal tiredness after a long day – it is often described as an overwhelming, debilitating exhaustion that affects your ability to perform daily activities.

Psoriatic arthritis fatigue can range from mild to severe. You may feel generally run down or constantly drained. Simple tasks like grocery shopping, cleaning or caring for your family may wipe you out. This fatigue can be mentally exhausting as well, making it hard to concentrate or be productive. Unlike normal tiredness which gets better with rest, psoriatic arthritis fatigue may persist even when you get adequate sleep.

If you are experiencing new, unexplained and persistent fatigue along with other psoriatic disease symptoms like joint pain, stiffness or skin changes, be sure to contact your doctor. Finding the right treatment can help manage inflammation and greatly improve psoriatic arthritis fatigue.

Joint Redness and Warmth

One early symptom that should prompt suspicion of psoriatic arthritis is redness and warmth over the joints, especially when it is confined to one side of the body. Unlike regular aches and pains, the joints affected by psoriatic arthritis often become noticeably red and feel warm to the touch. This occurs when the immune system mistakenly attacks the joints, causing inflammation. According to the Mayo Clinic [“results”][0][“url”]}>, this redness and warmth is a hallmark feature of inflammatory types arthritis like psoriatic arthritis.

Some people first notice the redness and warmth before feeling any arthritic pain or stiffness. The joints most likely to develop redness and warmth are those in the hands, wrists, elbows, knees, ankles and feet. If you notice persistent redness and warmth in these joints, particularly if it is asymmetric and predominately affecting one side, be sure to point this symptom out to your doctor during your appointment. Redness and warmth in your joints in combination with other psoriatic symptoms should prompt referral to a rheumatologist for further evaluation for psoriatic arthritis.

Swollen Fingers/Toes

One early sign of psoriatic arthritis is dactylitis, also known as “sausage digit.” This refers to swelling in the fingers or toes that causes them to appear sausage-like. Dactylitis is caused by inflammation of the tendons and soft tissues of the digits. According to the National Psoriasis Foundation, dactylitis affects roughly 40-50% of people with psoriatic arthritis^[1]. It often presents before any joint damage is apparent.

Dactylitis most commonly affects the middle joint of the fingers or toes, though it can occur in the wrist, ankles, and feet as well. The swelling and inflammation is often asymmetric, meaning it appears on just one finger or toe at a time, rather than symmetrically on both sides. Dactylitis causes stiffness, pain, and limited mobility in the affected digits. If you notice sausage-like swelling in your fingers or toes, it is important to see a doctor promptly, as it may be an early red flag for psoriatic arthritis^[2].

Nail Changes

Nail changes are a common early sign of psoriatic arthritis. The most frequent nail manifestations are pitting, grooves, and detachment of the nail from the nail bed (onycholysis).

Pitting appears as small depressions or holes in the nail surface and gives the nail a spotted look. These pits are caused by defects in nail growth. Pitting occurs in up to 50% of those with psoriatic arthritis^[1].

Nail grooves are furrows or channels that run vertically down the nail. They may be deep or superficial lines. Grooves are present in around 25% of psoriatic arthritis patients^[2].

Onycholysis refers to separation of the nail from the nail bed. The nail becomes detached from the skin underneath. This occurs when inflammation damages the nail matrix. Onycholysis is seen in approximately 10-15% of those with psoriatic arthritis^[3].

Getting early treatment for psoriatic arthritis can help prevent permanent nail deformities. See a doctor if nail changes accompany joint pains.

Lower Back Pain

Lower back pain is a common symptom of psoriatic arthritis. About 30-50% of people with psoriatic arthritis will experience pain and stiffness in their lower back caused by inflammation of the joints in the spine ¹. This is known as axial arthritis or spondylitis. The lower back is commonly affected before other areas of the spine.

Lower back pain from psoriatic arthritis often comes on slowly and worsens over time. It can range from mild to severe. The pain and stiffness tend to be worse in the morning and improve with movement and activity. However, prolonged sitting or standing can also aggravate the pain. Lower back pain from psoriatic arthritis may switch between sides or stay on one side consistently.

If you have lower back pain along with other symptoms of psoriatic arthritis like joint swelling and skin changes, be sure to see a rheumatologist. Getting an early and accurate diagnosis is key to preventing permanent spinal joint damage. Treatment for psoriatic spondylitis aims to relieve pain, improve function, and slow the progression of the disease.

Signs you may be at risk for psoriatic arthritis

If you experience any symptoms of psoriatic arthritis, it’s important to schedule an appointment with your doctor to get an evaluation. The earlier psoriatic arthritis is diagnosed, the better the outcome with treatment. You should see a doctor if you have:

Joint pain, swelling, or stiffness that persists for more than 2 weeks (https://www.mayoclinic.org/diseases-conditions/psoriatic-arthritis/symptoms-causes/syc-20354076)
Redness or warmth over joints
Swollen fingers or toes that look like sausages
Morning joint stiffness lasting over 30 minutes
New pitting, ridges, or separation of the nails (https://www.healthline.com/health/psoriatic-arthritis-early-signs)
Fatigue that is not relieved by rest
Lower back pain, especially with joints affected elsewhere

Don’t dismiss unexplained joint pain or wait and see if it goes away. The sooner psoriatic arthritis can be diagnosed, the better the outcome with early treatment to relieve symptoms and slow disease progression. See a doctor right away if you have psoriasis and develop any joint pain or swelling.

Medical Disclaimer

The information in this video is not intended nor implied to be a substitute for professional medical advice, diagnosis or treatment. All content, including text, graphics, images, and information, contained in this video is for general information purposes only and does not replace a consultation with your own doctor/health professional

Diseases and Conditions Journal Club

Osteoarthritis and the Weather: What the Research Shows

January 9, 2024

Does the Weather Affect Your Joint Pain?

We’ve all felt the pain of osteoarthritis before – that aching knee pain that flares up right before a big storm. Or those creaky hips that seem to get worse when the humidity is high. It’s a common belief that changes in the weather can influence joint pain, especially for people with arthritis and other joint conditions. But is this just a myth or is there real science behind the connection?

Researchers conducted a study and found that certain weather conditions can worsen joint pain. The study provides interesting insights into this common belief. It shows that there are connections between specific weather conditions and increased pain levels. This could have implications for managing joint symptoms.

Study Overview

Osteoarthritis is a common joint disease that causes pain and stiffness, especially in the knees, hips, hands, and spine. Many people with osteoarthritis feel that their pain gets worse depending on the weather. Researchers looked at previous studies to see if certain weather conditions like cold temperatures, rain, and humidity are really linked to worse osteoarthritis pain. The analysis combined data from quality studies that looked at connections between weather and osteoarthritis symptoms. By putting together information from these studies, the analysis was able to provide stronger statistical evidence about possible links between weather and osteoarthritis pain. Overall, they found evidence that lower temperatures and higher humidity are connected to worse osteoarthritis pain. The connections were small but still important statistically.

Study Methods

The researchers ultimately identified 14 eligible studies involving a total of 2,194 osteoarthritis patients from 5 different countries. Most studies relied on patient self-reports of osteoarthritis pain severity, often using standardized scales. Local meteorological agencies provided the weather data.

By looking at the data from these 14 studies altogether, the researchers could see general trends and patterns in how the weather is linked to osteoarthritis pain. This type of method allows for stronger conclusions by addressing the issues of smaller individual studies.

Key Findings

The meta-analysis found that there was a significant association between worse osteoarthritis pain and lower temperatures. Across the studies analyzed, each 10°C decrease in temperature was associated with patients reporting a 1.3 unit increase in joint pain on a 0-10 scale.

The research showed that when the air pressure drops, people with arthritis tend to feel more pain. For example, when the air pressure dropped by 10 hectopascals, the pain levels increased by 0.6. It’s like how you might feel more achy when a storm is about to hit.

Therefore, the findings indicate that colder temperatures and drops in atmospheric pressure tend to coincide with worsening osteoarthritis symptoms. Patients with osteoarthritis may be able to use local weather forecasts to anticipate bad pain days and plan accordingly.

Possible Explanations

Physiologically, there are several reasons why changes in weather may exacerbate osteoarthritis pain.

Barometric pressure changes – Drops in barometric pressure are associated with storms and rain which have been shown to increase joint pain. Some hypothesize that lower atmospheric pressure allows tissues to expand, putting pressure on joints.
Temperature changes – Cold weather causes blood vessels to constrict, likely decreasing blood flow and nutrient supply to joints. This may limit the joint’s ability to heal microtraumas. Heat and humidity can cause swelling and inflammation in joints.
Humidity – Higher humidity prevents joints from releasing heat as effectively. This heat buildup can increase inflammation and swelling.
Solar and geomagnetic activity – Some research indicates solar flares and geomagnetic storms may impact pain perception thresholds and inflammation. The exact mechanisms are unknown.
Vitamin D levels – Less sun exposure in winter can lower vitamin D levels which play a role in pain, inflammation and bone health.

The body’s complex response to weather changes likely involves multiple biological mechanisms that can influence osteoarthritis pain and inflammation.

Study Limitations

This systematic review was based on observational studies, which have inherent limitations compared to experimental studies like randomized controlled trials. The authors note some key limitations of the observational studies included:

Confounding factors – There may have been confounding variables that influenced the association between weather and osteoarthritis pain that were not measured or accounted for. Things like mood, activity levels, and use of pain medications could all impact pain levels.
Reporting/recall bias – Most studies relied on self-reported pain scores, which can be influenced by recall bias. People may not accurately remember and report their daily pain levels over time.
Small sample sizes – Many of the individual studies had relatively small sample sizes, limiting their statistical power to detect associations. Larger studies are needed to confirm findings.
Variability in methods – There was heterogeneity in the study designs, pain measurement tools, statistical analyses, and weather data collection. Standardized methods could improve consistency.
Limited weather data – Localized weather data may not fully reflect individuals’ actual exposure to weather conditions. More precise measurement tools could improve accuracy.
Population specificity – Most studies focused on patients in a single geographic area. Findings may not be generalizable to osteoarthritis patients worldwide exposed to different climates and weather patterns.

Additional Research Needed

This systematic review and meta-analysis provides important insights into the relationship between weather conditions and osteoarthritis pain. However, researchers need to conduct more studies to fully understand this connection.

Some key questions that require further investigation include:

What specific weather conditions have the biggest impact? This review looked broadly at temperature, precipitation, and barometric pressure. More studies on the effects of particular weather elements (heat, cold, humidity, etc.) could uncover more nuanced relationships.
How do weather changes trigger osteoarthritis pain? The mechanisms and pathways are still unclear. Understanding the biological processes involved could reveal potential treatment targets.
Can weather forecasts be used to predict and manage osteoarthritis pain? If robust predictive relationships can be established, weather-based pain forecasting models could help patients and doctors better manage symptoms.
What interventions can help? Beyond predicting pain, research should explore what coping methods or treatments could help osteoarthritis patients during weather changes known to worsen symptoms.
How do effects differ across demographics? More studies are needed on how factors like age, gender, ethnicity, and osteoarthritis subtype influence weather-pain connections.
Can location-specific research provide more insights? Larger studies across diverse geographic regions may uncover location-specific relationships and climate patterns that impact osteoarthritis pain.

Further research to address these key questions can lead to a more meaningful understanding of weather-osteoarthritis links, enabling better prediction, management and treatment for osteoarthritis joint pain during problematic weather conditions.

Takeaways for People

Many patients with osteoarthritis experience increased joint pain and stiffness when the weather changes. While the exact mechanisms behind this phenomenon are still unclear, here are some tips that may help ease discomfort during weather fluctuations:

Stay active and keep moving. Low-impact exercises like walking, swimming, or biking can help keep joints mobile. Avoid inactivity which can make stiffness worse.
Dress appropriately. Layer clothing and wear warm covers over painful joints to avoid getting chilled. Consider wearing compression sleeves or gloves.
Use heated pads or cold packs. Apply whichever one gives you relief – heat opens up blood vessels, while cold reduces inflammation.
Consider over-the-counter pain medication. Acetaminophen, NSAIDs, or topical creams/gels can provide some symptom relief. Consult your doctor first before starting any medication or supplement.
Adjust your environment. Increase humidity with a humidifier. Move painful joints closer to heat vents or fans.
Stay hydrated and eat a healthy diet. Drink plenty of water and consume anti-inflammatory foods like fatty fish, fruits, vegetables, and nuts.
Practice stress management. Pain can worsen with anxiety and tension. Try relaxation techniques like meditation, yoga, or deep breathing.
Get a massage or gentle stretch. This may loosen up tense muscles and decrease joint pain.
Communicate with your doctor. Report worsening pain and discuss treatment adjustments or assistive devices.

While it can be frustrating dealing with arthritis pain fluctuations, being proactive with self-care and talking to your provider can help you better manage symptoms

References

Wang L, Xu Q, Chen Y, Zhu Z, Cao Y. Associations between weather conditions and osteoarthritis pain: a systematic review and meta-analysis. Ann Med. 2023 Dec;55(1):2196439. doi: 10.1080/07853890.2023.2196439. PMID: 37078741; PMCID: PMC10120534.

Medical Disclaimer

Diseases and Conditions

Signs and symptoms of inflammatory myositis

March 19, 2019

Myositis is one of the rarer forms of autoimmune diseases having an annual incidence of 2 to 10 cases in a million. So yes, very rare! There are multiple forms of inflammatory myositis. In my adult rheumatology practice, I mainly see polymyositis and dermatomyositis, but there are other types.

Polymyositis
Dermatomyositis (DM)
PM/DM associated with cancer (12% of all myositis cases; 50% of myositis cases in people aged >65 years)
Juvenile dermatomyositis
Overlap syndrome (e.g., concurrent scleroderma and myositis, accounts for 11 to 40% of cases)
Inclusion body myositis
Giant cell myositis

Non-autoimmune forms of myositis are those caused by infections as well as drugs and toxins.

Who gets myositis?

That really depends on what form of myositis we are talking about. For example, the incidence of dermatomyositis is bimodal meaning that it has two peaks: 5-10 years of age and then 45-65 years of age. Polymyositis tends to occur later in life: 50-60 years of age. In general, like many other autoimmune diseases, women tend to be affected more than men: 2-3:1. Childhood cases are pretty much equal. Moreover, in the US African Americans are more commonly affected as compared to caucasians: 3-4:1.

What are the signs and symptoms of myositis?

Muscles

One would think that muscle pain would be the most prominent symptom seen in myositis. But actually it isn’t.

Muscle weakness involving the arms, shoulders, hips, and legs are the earliest signs of myositis.

Typically, symptoms progress over the course of 3 to 6 months. At times muscles used to speak, swallow, and breathe can be affected as well. People often experience low grade fevers, fatigue, and weight loss.

Sometimes, myositis can affect the heart causing myocarditis. This can then cause abnormal heart rhythms. This isn’t common though.

However, if there are symptoms involving the face or eyes, then we may be dealing with another form of myopathy. Not myositis.

Skin and nails

Many people with myositis develop Raynaud’s phenomenon. People who develop Raynaud’s experience a painful blanching of the fingers when exposed to the cold or in stressful situations. Your rheumatologist may use a special instrument to look at your blood vessels supplying your nail. I wrote about Raynaud’s in a previous article. Please follow the link to learn more.

People suffering from dermatomyositis may experience a host of different rashes. Please follow this link for pics.

Heliotrope rash
Gottron’s papules
V-sign
Shawl-sign
Holster-sign
Skin ulcers
Livedo reticularis

People with myositis, particularly those with what we call anti-synthetase antibodies can develop something called Mechanic’s hands.

Finally, people with dermatomyositis particularly in juvenile cases, can develop calcinosis. These are calcium deposits that form under the skin and in muscles and tendons. We also see these in scleroderma, lupus, and mixed connective tissue disease.

Lungs

Myositis can cause a host of different pulmonary manifestations. Because the diaphragm is a muscle, people often experience shortness of breath. They are also prone to develop aspiration pneumonia. This happens when someone inhales regurgitated food, which then causes pneumonia.

People suffering with myositis, particularly those with antisynthetase antibodies also can develop interstitial lung disease and pulmonary fibrosis. This occurs when there is inflammation within the lung. If left untreated, it can cause stiffness and hardening of the lung.

Pulmonary hypertension can also happen. This occurs when the pressure in the pulmonary artery increases, which in turn increases strain on the heart and can result in heart failure.

Gastrointestinal

Myositis affects the GI tract as follows:

Esophageal dysmotility
Reflux
Stool incontinence
Intestinal perforation (particularly in juvenile cases)

Musculoskeletal

Inflammatory arthritis can sometimes be seen: joint pain, swelling, and morning stiffness lasting more than one hour. This mainly occurs with antisynthetase antibodies, but also in overlap cases. e.g., polymyositis + rheumatoid arthritis.

How do we make a diagnosis of myositis?

Like most rheumatic diseases, a single lab test does not make or break a diagnosis. A rheumatologist may obtain any of the following to help establish the diagnosis but also help determine which organs are involved:

Identify clinical signs and symptoms: muscle fatigue, rash, etc.
Blood tests that detect muscle damage: CK, aldolase, LDH, elevated AST and ALT. Sometimes muscle enzymes can leak into urine.
Antibodies associated with myositis: Jo-1, Mi-2, anti-155/140 antibodies, Ro-52 etc.
Electromyogram: “nerve conduction tests”
Muscle biopsy
Skin biopsy if there’s a rash
MRI of an affected limb
Pulmonary function tests
Echocardiogram
Electrocardiogram (EKG or ECG depending on which side of the Pond you reside)
Right heart catheterization
Swallow test
CT of the chest, abdomen, and pelvis

If the presentation is classic and there is sufficient supporting data, at times a rheumatologist may skip the muscle biopsy. For example, if someone has muscle weakness, high muscle enzymes, a classic dermatomyositis rash, and positive antibodies.

Do steroids affect the results of a muscle biopsy?

No. Shinjo and colleagues studied the effects of prior steroid use in people undergoing a muscle biopsy. They found that if a person was experiencing active symptoms and their labs showed active disease, the muscle biopsy tended to to show active inflammation as well, despite prior use of steroids.

Can statins cause myositis?

Statins are a class of medications commonly prescribed to treat high cholesterol. About 1 in 10,000 people receiving low doses and 1% of people receiving high doses of statins can develop muscle pain and cramps. A very small percentage of these people can develop polymyositis. The muscle biopsy looks very different in these situation: necrosis without inflammation. These people also tend to have anti-200/100 antibodies also known as anti-HMG-CoA reductase antibodies.

Do people with myositis have a higher risk for cancer?

First, myositis is extremely heterogenous. There are certain forms of myositis that have a higher risk of cancer. About 12% of inflammatory myositis cases are associated with cancer, but about 50% of dermatomyositis cases occurring above the age of 65 year are.

There are also certain risk factors that increase the risk, such the presence of skin ulcerations and having anti-155/140 antibodies. However, people with a Mi-2 antibodies have less risk of developing a malignancy.

That being said, many rheumatologists will order a CT of the chest, abdomen, and pelvis at diagnosis to rule an occult malignancy. It’s also important to be up-to-date with routine cancer screening: colonoscopy, mammogram, etc.

How is myositis treated?

Typically the first medication we use are steroids. But these are just a band-aid and should not me used long-term. Like most autoimmune diseases, we use disease modifying anti-rheumatic drugs (DMARDs). There are many types of DMARDs. These can be used as monotherapy but also in combination with other DMARDs and also supportive treatments. For example, we can use mycophenolate mofetil, which is a DMARD, in combination with ambrisentan, which is a pulmonary hypertension medication. The specific type or regimen will depend on the manifestations, prior medical medications, and allergies.

The following are some the DMARDs used to treat myositis.

Methotrexate
Azathioprine
Mycophenolate mofetil
Hydroxychloroquine – for mild and mainly cutaneous cases
Cyclosporine
Tacrolimus
IVIG
Infliximab
Rituximab
Cyclophosphamide
Repository corticotropin injection (Acthar gel)

How does one differentiate between myositis and steroid induced myopathy?

Sometimes people develop weakness when receiving large doses or steroids for prolonged periods of time, which often happens in people suffering from myositis. It can be difficult to differentiate between the two.

Typically, people with steroid myopathy have normal muscle enzymes meaning their CKs and aldolase are normal. People with myositis tend to have high muscle enzymes when they are flaring. If for some reason, it’s still unclear an MRI with STIR images can help identify active inflammation. A muscle biopsy is rarely necessary. People with steroid myopathy will also improve with decreasing steroid doses.

Conclusion

I hope this article was helpful and if you are interested in learning more about myositis please check out these sites.

Medical Disclaimer

References

Rheumatology Secrets, 3rd edition
Shinjo SK, Nascimento JJ, Marie SK. The effect of prior corticosteroid use in muscle biopsies from patients with dermatomyositis. Clin Exp Rheumatol. 2015 May-Jun;33(3):336-40. Epub 2015 Jan 29.

Diseases and Conditions

What is pseudogout?

January 1, 2019

Pseudogout? What exactly is pseudogout? We typically divide inflammatory arthritis into the following categories: degenerative arthritis (i.e., osteoarthritis), autoimmune arthritis, arthritis caused by infections (septic arthritis), arthritis caused by cancer (neoplastic and paraneoplastic arthritis), and finally crystal arthopathy.

Pseudogout is a crystal arthropathy. Another common crystal arthropathy is gout. Like gout, pseudogout is very common, occurring in about 3.4% of adults. In fact, it’s the third most common cause of inflammatory arthritis.

What is pseudogout?

Pseudogout is a specific manifestation seen in calcium pyrophosphate deposition disease (CPPD). Basically, pseudogout is when CPPD flares up.

CPPD occurs when calcium pyrophosphate dihydrate deposits in cartilage and other parts of the joints. This leads to all sorts of possible symptoms. The following are just a few:

Asymptomatic: You see it on x-ray, but you don’t feel it. This is actually quite common.
Pseudogout: The joint is red, swollen, very tender, and sometimes people can have a fever. Often confused with gout or cellulitis. The knee and the wrists are commonly affected.
Chronic CPP crystal arthritis: Typically many joints are involved. It can almost look like rheumatoid arthritis or polymyalgia rheumatica.
Pyrophosphate arthropathy: This happens when people have severe osteoarthritis and then get superimposed pseudogout flares.

CPPD can also cause big deposits of crystals around the joints and bone. It can deposit on tendons, and can also involve the spine including the odontoid process. This is the part of the cervical spine that allows us to turn our neck from right to left and vice versa.

What’s the difference between pseudogout and gout?

Simply put, gout happens when monosodium urate crystals over-accumulate. Pseudogout is caused by calcium pyrophosphate crystals. This is why uric lowering medications like allopurinol or feboxustat, don’t work for pseudogout.

Who’s gets pseudogout or CPPD?

The vast majority of cases occur in people aged 55 years and above. In fact, if it occurs in someone aged less than 55 years, we need to look for other things:

Primary hyperparathyroidism
Hemochromatosis
Hypomagnesemia (from diseases and medications)
Hypophosphatasia

Other risk factors included dialysis-dependent renal failure and history of joint trauma or meniscus surgery. There are also familial forms. These genetic forms run in families and the first signs of the disease typically occurs in the person’s 20’s or 30’s. They also tend to affect the spine more.

What are the symptoms of pseudogout?

Pseudogout is an acute form of inflammatory arthritis. Look for warmth, redness, swelling, and pain. Sometimes, the joint and the skin looks infected. Sometimes people get a fever.

Usually pseudogout affects one joint at a time. But it can move around and affect more than one joint at a time. It likes the knees and wrists. However, if someone has “a bad” shoulder, pseudogout likes to go to “distressed” joints.

What triggers pseudogout?

Stress, infection, physical trauma, or a serious medical illness like a heart attack.

There are certain medications can cause a flare particularly those than decrease magnesium levels (e.g., certain forms of chemotherapy). Other medications include those that stimulate neutrophils as well as certain forms of intraarticular hyaluronic acid injections (e.g., Synvisc).

How do you diagnose CPPD?

The problem with CPPD is that it can cause arthritis without seeing it on x-ray. This happens in about 20% of cases. Consequently, the only way to 100% confirm CPPD is to pull fluid from the joint and test it for CPP crystals. Unfortunately, sometimes this isn’t possible. This is when the art of medicine really comes into play.

If possible, the joint should always be aspirated and tested. First, to confirm the diagnosis. Second, because the joint can also be infected at the same time. This happens in about 1% of cases. You don’t want to be the 1%!

Lab tests are not too helpful. There isn’t a specific test for CPPD or pseudogout. Inflammation levels are usually high including the CRP. Also about 10% of people have a positive rheumatoid factor. This is because advancing age is a risk factor for a positive rheumatoid factor. I encourage to read the article addressing this blood test in further detail. Please follow this link for further information.

How do you treat pseudogout?

If you do nothing, people typically get better on their own within 7 to 10 days. However, this is kind of brutal. Ice packs, rest, and removing the fluid from the joint may help. But, medications are often necessary. These include:

Nonsteroidal antiinflammatory drugs (NSAIDs): ibuprofen, naproxen, diclofenac, etc.
Steroid injection into the joint.
Steroid injection into the muscle
Oral steroid: typically tapered over 2 weeks.
Colchicine can help
In extreme situations we can use IL-1 blockers like anakinra or canakinumab. This is very expensive and not FDA-approved. I personally use this in rare and extreme circumstances.

The choice of treatment has to be tailored to each person’s medical conditions, allergies, medications, etc. No size fits all.

Can you prevent pseudogout flares?

Unlike gout, this is actually difficult to do. Sometimes colchicine or a very low dose of prednisone can help prevent attacks. You need to weigh the risks and benefits. Again, no size fits all.

If there is something that is predisposing someone to get flares… well address it if possible. For example, if a particular medication is decreasing your magnesium levels, see whether your doctor can replace the medication. If this is impossible, supplementing with magnesium could help. Remember to discuss this with your physician first. This is not medical advice.

Conclusion

I hope this information was helpful. If you would like to learn more about pseudogout, I invite you to follow this link.

References

Rheumatology Secrets, 3rd edition

Medical Disclaimer

Diseases and Conditions RheumDoctor Learning Center

What is the complement system?

October 2, 2018

The complement system complements or enhances the immune system. These proteins cause a series of chain events that induce inflammation that helps antibodies clear infection. There are three pathways by which complement helps the immune system:

The classical, alternative, and lectin pathways.

The complement system and disease

The complement system is a perfectly normal part of the immune system but sometimes it goes haywire. Systemic lupus erythematous is a famous example. But there are also some rare diseases such as Degos/malignant atrophic papulosis.

Here is an excellent YouTube video explained the complement system presented by MEDSimplified

References

https://www.ncbi.nlm.nih.gov/books/NBK27100/

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