[Music] good evening and welcome to Dr on call I'm Dr Peter nen professor and head of the Department of Family Medicine and biobehavioral health at the University of Minnesota medical school duth campus I'm your host for our program tonight on rheumatoid arthritis tendon and btis the success of this program is very dependent on you the viewer so please call in your questions tonight or send them in through email at ask pbsn north.org the telephone numbers can be found at the bottom of your screen our panelists this evening include Dr Anna Fernandez a rheumatologist with asentia health and Dr Paul Sanford an Internal Medicine specialist with Aspirus St Luke's our medical students answering the phones tonight are Carter andreon from Spicer Minnesota Brook Wilson from Mount Prospect Illinois and Wyatt windhorse from Alexandria Minnesota and now on to tonight's program rheumatoid arthritis tendinitis and btis and with that Dr Fernandez the first question is is what is btis well think of uh our joints for example a KN or a shoulder you have bones that are close together and they're they're kept together by ligaments and tendons and in order for things to move smoothly we have these fluid filled sacks um that allow things to move without friction but they can get irritated and so if they get irritated because of overactivity or an injury they can get inflamed and then they would be tender they would be swollen um and any would be localized pain so that would be one way that we would be able to identify that the patient has a btis you mentioned the shoulder what other joints might be involved in btis berstis are very common we have them all over our body so the shoulder is very uh a common area the knee the outer part of the hip also has a big Bersa that we tend to um recognize sometimes the feet uh behind the ankle so the elbow there's a big Bersa at the elbow so we really have these bursta sacks all over our bodies that allow us to have fluid motion uh and without a whole lot of friction and that thank you Dr Sanford aspirin was first synthesized about more than a hundred years ago and uh why is it still used because it works yeah aceta salicylic acid it's one of many different solic lates but you know in the old days the ojibway people used to use the LOM of the bark of the willow which had a high amount of solic lates as a pain controller there's still a basic Foundation aspirin and its cousins in treating arthritic pain and Dr Fernandez in treating some of these conditions that we'll be talking about this evening um what is the role of topical medicines and what are some examples so uh topical medicines are um substances that we have them over the counter now some of them used to be prescription and now are overthe counter volaran or diclofenac gel um they do allow um some minimal um uh penetration through the skin so it's less side effects compared to some of the oral anti-inflammatories that are available but they can uh cause a lot of relief they can be very helpful to some patients particularly with the small joints of the hands and feet they can offer a lot of relief there's several of them out there that have methyl cicil diclofenac there's even some uh lioc roll on so there's some things for minor um pain that can be pretty effective and even when in people with kidney problems which has always been a barrier or who are on blood thinners that's always been a barrier so the these are wonderful thank you Dr Sanford what are the features of rheumatoid arthritis in adults well you look for swelling and pain warmth and redness rubor calor doore and tumor usually in these joints the proximal interanal joints it'll start but it can extend through all of the finger joints and the feet too and and uh that means we got to start looking for an inflammatory process thank you and the pattern of arthritis for rumat arthritis um patients notice a lot of stiffness in the morning it's a lot of swelling in the morning uh they're going to notice that there's some visible swelling of the joints as opposed to for example the degenerative arthritis which may be a lot of pain at the end of the day after over activity after overdoing it and so there's a difference in the pattern and we want to make sure that people recognize rheumatoid arthritis just because we have so many um treatment options available now that we didn't have even a couple decades ago and how might those treatments be helpful if started early how do you advise patients it's wonderful that's a great question I think our patients who develop an inflammatory arthritis so swollen red very painful uh can have a lot of Destruction so for us we think of swelling as a destruction of a joint and so these are medications that are available as you work together with your doctors we want to quiet down that inflammation as quickly as possible because that means that we're preventing damage down the line thank you Dr Sanford under what conditions or criteria are joint Replacements considered for rheumatoid arthritis well pain disability inability to do activities of daily living like tying your shoes or but it's an orthopedic type question but really it's how much does the pain or deformity limit your ability to do even the most simple tasks and not just limited to the to the rheumatoid arthritis you know our patients with osteoarthritis and some of the other types of arthritis and we want to make sure that they are doing things on their own to prevent getting to that level so we want all conservative measures before if you are a little bit on the heavier side losing a little bit of weight can help stay active as best as you can so there's a handful of things that our patients can do to delay the need for a joint replacement thank you and Dr Fernandez a viewer from Wisconsin wants to know is joint injection for btis safe and is it worth it so cortisone injections uh can be very effective uh for btis and for their joints usually it's a steroid and we don't want to abuse it meaning we don't want people to do repeat injections more than every 3 to four months we want them to extend it and usually it's after you fail conservative measures so we want to make sure that you're taking advantage of the ice the topical arthritic grubs rest sometimes splinting uh so these are some of the things that can work but if it's really affecting the walking and and there's a lot of pain the cortisone injections could be very helpful thank you Dr San here's a question with a subtle difference what is tendinosis and how is it different from tendonitis well itis means inflammation pain osus can mean thickening um if you have a really inflamed tendon just moving a joint will be painful but not where the bone is meeting bone but in the tendons that are allowing you to flex and extend tendonosis can be any term for anything that's a derangement to the tendons whether it's trauma or medications um yeah it's a whole Spectrum Dr Fernandez a viewer asks what causes rheumato toid arthritis when we get there we're going to have a lot of solutions for our patients uh but there are some genetic predisposition to rheumatoid arthritis so first degree relatives of someone who has rheumatoid arthritis is maybe at higher risk um there's some environmental factors because even identical twins do not both get rheumatoid arthritis uh there are some things that you can do for example if you have a a genetic predisposition because you have a family member who has rumat arthritis make sure that you're not a smoker smoking has been associated with an increased risk of rheumatoid arthritis another one is make sure that you take good care of your teeth because gingivitis and inflammation of the gingiva and infection of the mouth has also been associated with a higher risk of rheumatoid arthritis but there's a lot of research going on trying to identify what can we do how can we modify and how can we recognize people that are at risk much sooner before the clinical findings are evident thank you Dr Sanford regarding these conditions of inflammation like btis and tendinitis what foods or drinks can make them worse or better well you know just remember what grandma said avoid sugar have the diet be primarily darker fruits and vegetables meat lean meats and fish as far as specific foods that cause inflammation the biggest answer is too much of them if we end up getting too heavy I should talk um you know then we're going to see degeneration in my Meniscus cartilage and the other structures of my weightbearing joints okay and a related question can turmeric help with tendinitis some people I don't know what do you think Dr F tumeric is a supplement that people are using to try to get some relief of pain uh remember that most of the supplements are not studied and we don't know how they interact with some of the medications that patients may be taking we do have a group of patients that do feel that the turmeric may help um buy the spice and cook with the spice that also could be um effective um so it's a trial and error but a lot of just remember that a lot of these supplements are not um studied with other medications that people may be taking Dr Sanford what can be done to make Achilles tendinitis better or what could the patient do to make it better well when people have inflammation of the big tendon of the back of the ankle the main thing is give it a rest if you're not having you know lots of redness swelling or a rupture of the tendon stay off the leg and just Elevate ice and if it's still bugging you then you know see your orthopedist or rheumatologist or internist but yeah any type of stress trauma can cause trouble with the Achilles from hermant toown a viewer asks when you have arthritis is neuropathy in your feet a side effect Dr Fernandez so neuropathy usually means that patients are noticing a burning type of sensation uh typically in the toes and it may progress um I don't think of neuropathy as one of the signs of rheumatoid arthritis unless they have very severe Advanced disease and there's Al entrapment of nerves I'm really thinking more diabetes I'm thinking more some of the vitamin deficiency so it's really important to make sure that patients are aware what kind of symptoms are they're noticing so if it's burning sensation uh numbness pins and needles that is triggering a completely different differential diagnosis than just a a rid arthritis picture or seratic arthritis a different workup and potentially different diagnosis including diabetes yes okay Dr Sanford uh what is the role of blood tests in the evaluation of arthritis well blood tests are the last thing that we tend to do the most important thing is talking to the person finding out the issues of timing quality characteristics Etc and then the physical exam and once you have a suspicion that this person has rheumatoid arthritis or lupus then you order the appropriate screening study rheumatoid factor or an anti-nuclear antibody but yeah I think that 90% of our diagnosis isn't in lab tests it's in talking to the person and examining them because there are some patients that may have a blood test that was done because they were not feeling well and they may have a marker for rheumatoid arthritis like for example we have the rheumatoid Factor we have CCP antibodies but if they don't have red hot swallen joints they don't have rheumatoid arthritis so we have to do the labs in the context of the history and the physical exam that makes sense thank you and speaking of physical exam what are key points of the physical exam for tendinitis so a lot of it is going to depend on the location um so if someone has a tendonitis in the shoulder for example the biceps tendon uh it's going to be painful with active motion meaning you're doing and you're reaching it's very painful if someone is doing the motion for you it may not be as painful also localized pain at the side of the uh the tendon can can cause a lot of a lot of pain and that's how we try to differentiate between vertis tendinitis and arthritis and Dr Sanford could you uh elaborate on tendinitis in the thumb or hand yeah well we have tendons that connect every muscle to every bone and so if you're busy hitchhiking and you're finding that it's causing discomfort quit hitchhiking but also you know you look for inflammation there's something called tenosinovitis which is involving any of the muscles and ligaments and tendons of the hand it's again a matter of talking to person examining them that's pretty much all you need for a diagnosis and some of the Maneuvers that you were showing that resisted when we put resistance against the tendon it will cause more pain and so that's one way that we can tell tendinitis versus abatis yep super spinatus tendon if you can't do this you know then you think about the rotator cuff thank you Dr Fernandez what are some uh Imaging tests that you might order um further in the evaluation of your patients with rheumatoid arthritis so that's important because we want to make sure that we are not seeing destructive changes or what we call erosions and so typically the location that we see rumat arthritis the most are small F uh joints of the fingers so hands and feet so we make get X-rays of the hands and feet to look for changes you know with the medications that we have nowadays I really do not want to see erosive or destructive changes because then we are too late we want to make sure that we're doing the x-rays to have us a baseline maybe see if there's any change in the bone structure around the joint we call it periarticular osteopenia but in reality we're doing it to make sure that we're not missing something else there's some hints in the x-rays whether it could be osteoarthritis versus rheumatoid arthritis versus other types of arthritis so it can help us uh but it doesn't give you the complete diagnosis you have to do the whole picture all right well Dr Sanford again about btis if a btis is injected what is injected into it usually a steroid a corticosteroid and uh it just helps it acts like a fire extinguisher reduces the inflammation liberates painless range of motion maybe not forever but you can get your bursta shot injection you know three times a year and it's safe thank you I'm looking over this question from Esco um a caller describes hip btis uh Awakening in the middle of the night uh feels uh like a fire so apparently hot and uncomfortable um what might be going on with that Hipp pertis that's one of the typical things that people notice is that they turn on their sides and it wakes them up because of pain so there's a lot of there's a lot of pressure and so um if you started an exercise routine and overdid it if you went up and down the steps or a ladder if you've been doing extra work trying to get the garden ready before winter and you're overdoing if you're going up and down a flight of steps it can irritate their Bersa which is on the outer aspect of the hips so we want to make sure that people are doing their stretches that they're using ice that they're using the topical RS that we've been talking about and if the physical therapy can be very helpful to make sure that you don't have a discrepancy in the legs that you have good shoes uh and then the last resort then we can do a cortisone injection if symptoms are not improving with conservative measures thank you Dr Sanford from a viewer in Ashland uh what else do you want to know about um the sensation of burning on the inside of the knee could this be arthritis and and what else are you wondering about well if they're wondering if it deep inside of the knee well there any type of inflammation of the the joints you know when you talk with people asking morning evening with activity without activity is there associated swelling or discoloration and then in your exam checking the cruciate ligaments the collateral ligaments feeling for fluid in the knee called an diffusion um you know then you get some answers remember there's a lot of Buras that's right and there's a lot of Buras in the knee and there's one that is just underneath the knee that can burn a lot so you know these could be possible sources of pain Dr Fernandez what are the connections between infections and arthritis so for example people may have a viral illness uh and they May develop influenza and we do get joint pain uh a lot of the viral diseases can cause uh joint pain some infections like for example Lyme disease if not treated appropriately can develop a type of arthritis if someone has a cut or a wound and it gets uh infected in the blood and it settles in the knee they can develop the a septic joint so so there could be a connection uh but most of the time we want to make sure that we're very attentive to address any infection in the joint right away oh boy otherwise it causes a lot of damage yes and uh what are some ways you might detect that so the signs of inflammation that Dr Sanford commented uh it's going to be very warm uh to the touch it's going to be visibly red it's going to be very painful with motion and a patient may have a fever because now you have a localized area of infection so there's going to be other symptoms they may not feel well an elderly patient may be confused um so those are the things but a fever and a joint that is red and hot uh it's really a warning signal for infection in that joint thank you Dr Sanford um what could contribute to an Achilles tendon tear well trauma the most common thing if you decide to jump off your garage roof after shoveling it you could hyper you know extend the joint and tear the tendon trauma is the most common one sometimes antibiotics in the flu quinin class like cicin can weaken the tendons and increase the risk of er rupture boy whole host do you know of any other in the past some people would do cortisone injections for the Achilles and we tend not to do that anymore because it it predisposes them uh to tear repetitive motion those are things that we would be attentive to yeah another vocabulary word question uh from Soul and springs we've mentioned tendonitis what is a tendonopathy just it's the same yeah same thing but it depends on pain itis you think pain like appendicitis pain or tendonopathy it usually tends to me that the tendon is not happy so the tendon is having pain it may not be torn uh but it may it may be irritated because an overa AC ity overuse a fall type of thing so we use the term sometimes interchangeably but the Idis component has a warmth and redness uh Associated to it Dr Fernandez could you describe a bit about juvenile arthritis so juvenile arthritis means that our kids can get arthritis uh not just as we get older and usually is arthritis that kids get under the age of 16 and so this we're talking sometimes four or five year olds that can develop joint pain they will have um a swollen knee typically and so it's a kid who would be running around and all of a sudden is not uh all of a sudden wants to be carried and lifted and so we tend to see a lot in the knees in the little ones and it same has the same presentation of a so and tender uh a joint thank you Dr Sanford uh why might ibuprofen be good for arthritis well it's an anti-inflammatory medicine like aspirin and there there a bunch of different medicines that are similar to ibuprofen or aoxin sodium a leave um that are over the counter and they they all help to reduce the inflammatory Cascade in a joint tendon Bersa but they have to be careful if people are on blood thinners don't use them if you're um have kidney trouble don't use them so every case is one at a time one thing doesn't fit everyone if you have a history of stomach ulcers you don't use them no no uh briefly Dr Fernandez can anything be done to prevent btis uh so usually he going to be be careful if you're doing repetitive motion so if you know that you have a job that you're doing a lot of repetition that you're alternating so that you're looking at your mechanics your body mechanics to prevent that that if you did go and did a very hard workout that maybe your ice um at the end of the day so it's really more prevention um thank you and uh another uh viewer from duth asks are there certain foods to avoid in arthritis oh boy well you know somebody's going to tell me to avoid a cheeseburger I can't do that but you want to avoid too much everything in moderation nothing in excess so the the trend now is that you are cautious with your carbs that you have uh no sugar that you're C cautious with processed foods uh that if you went out and you ate something and the next day you hurt a lot that you pay attention because your body may not like that all right and uh can there be uh pain in the in the shin associated with problems in the knee Dr Sanford yeah well you know you can you can get radiation of pain down into the shin the tibia they always want to make sure that people don't have something called the hypertrophic osteoarthropathy big Scrabble word but it can be a pain associated with other more malignant causes all right anything on that Dr Fernandez remember that in that Shen area there is no joint so those are two long bones that we have there there's some uh soft tissue that connect them so they can be irritated again it's going to be repetitive use or not use know being sedentary can aggravate some of these things and like Dr Sanford said making sure that we're not missing something else a stress fracture malignancies yes and uh Imaging might have a role in that workup just to make sure yeah okay well I uh want to thank our panelists Dr Anna fernandz and Dr Paul Sanford and our medical student volunteers Carter and Dre Brooke Wilson and Wyatt windhorst next next week please join Dr Ray Christensen for a program on diabetes and other endocrine topics including hyper and hypothyroidism when his panelists will be Dr Canan casturi Dr chrisa coyi and Dr Jason wall thank you for watching good night [Music] [Music] [Music] e e for