So you've been diagnosed with arthritis . . . now what?

You have started to notice pain in your hands and feet. A trip to your doctor leads to the diagnosis of "arthritis". Like many others, you have probably asked your doctor, what you should do about it and get a vague response to the effect of "take ibuprofen" or "you should see a specialist". Many times these referrals lead to a reiteration of the same information, leaving you frustrated and not knowing where to go next. If any part of this scenario resonates with your story, read on.

The most important first step is to get a concrete diagnosis. There are many types of arthritis. Some are the result of daily wear and tear (osteoarthritis) whereas others are the effect of an irregular immune response (such as rheumatoid arthritis, psoriatic arthritis, etc). To determine what type of arthritis is present, your doctor will likely need imaging and / or blood work. An X-ray will give information of the wear pattern, or any key findings to suggest one type of arthritis over the other. Sometimes an ultrasound or MRI can provide more information, however many insurance plans make it extremely difficult to get a MRI relegating you to imaging that is not considered "high tech". Certain forms of arthritis, like rheumatoid arthritis will have key findings such as erosion of the bone around the margin of the joint. This is usually present in 30% of individuals with early stage rheumatoid arthritis, and approximately 60% of individuals with a later stage of the disease. Blood work is very important for determining the type of arthritis. Certain tests such as Anti-CCP can determine the type of arthritis you have as well as the possible severity of the disease long term. This test is important as many pharmaceuticals are available to combat certain types of arthritis to limit and even prevent their progression in certain cases. There are many other types of lab tests that can be performed that we will go into in a later article for those individuals that are newly diagnosed.

If you have already been diagnosed with a form of arthritis, quickly determining the right treatment option is very important as early intervention can delay, and sometimes halt, the progression of disease. The best treatment is not the same for everyone. Large institutions are constantly attempting to "standardize" medicine, but unfortunately there is only so much standardization that can be done. As physicians, we go to school for many years because medicine is anything but simple. Our treatment options must be flexible to address the individual needs of our patients. Some patient's do well with immunomodulating drugs, others have side effects that are more severe than the condition being treated. Some patients do well with non-steroidal anti-inflammatory drugs (NSAIDS) whereas others cannot take them as a consequent of a gastrointestinal bleed (ulcer). We will not belabor the issue, but you get the point. Let's discuss some treatment options and suggestions for each type of arthritis. For sake of brevity, we have limited this review to the most common forms of arthritis. Should you possess a more rare variant, it is crucial you see a rheumatologist for specific management of your condition.

OSTEOARTHRITIS (OA)

Osteoarthritis, or OA, is the "wear and tear" arthritis. It is usually the consequent of aberrant anatomic alignment as well as environmental factors such as type of stress and strain that has been placed on the joints over the years. This is typically seen later in life. Like discussed above, if OA is diagnosed early, certain measures can be taken to prevent further progress. Forms of durable medical equipment (DME) such as custom or prefabricated orthotics can be used to limit the strain on certain joints. If you have already developed chronic symptoms of pain in the joint, conservative measures should be attempted prior to any form of surgical intervention such as steroid injections or physical therapy. A more recent, cutting edge technology for the management of arthritis pain, Class IV laser therapy, is available for patients wishing to pursue conservative measures only.

RHEUMATOID ARTHRITIS (RA)

Rheumatoid, or RA is very different from OA in that younger individuals can develop the disease as a consequent of the body's immune system (the system that protects you from bacteria, viruses, parasites and fungus) attacking your cartilage. In this particular condition, as well as other immune based arthritic conditions, the body's immune system gets confused, attacking your own body as though it is a pathogen (bacteria, fungus, virus, etc). Although some of the treatment methods for OA such as cortisone injections and Class IV laser therapy has been shown to improve and sometimes resolve the symptoms of RA, it is recommended that you see a rheumatologist to discuss medications that could control the progression of the disease.

PSORIATIC ARTHRITIS Psoriatic arthritis is a seronegative arthritis that affects approximately 329,000 Americans. It is recommended that individuals with psoriatic arthritis seek the counsel of a rheumatologist in the management of the condition. Numerous medications are available to manage psoriatic arthritis. Your rheumatologist will determine which medication is right for you, but a summary of the different classes of drugs are NSAIDs, corticosteroids, and disease modifying anti-rheumatic drugs (DMARDs). There are two arms of DMARDs, biologic and non-biologic. It is important to monitor how your body tolerates certain drugs. DMARDs are known for their side effects and they do not affect all individuals the same. Pay close attention to changes in your body when starting these drugs. Your rheumatologist will review the warnings as well as precautions prior to taking the medication.

Pain in the Ball of Your Foot

Do you sometimes develop pain in the ball of your foot? What if you have recently developed this pain and it has not improved? There can be many contributing factors to forefoot pain, but the most apparent is ill-fitting shoe gear or no shoe gear at all. It's important to first determine the exact point of pain. In medicine we refer to this as the point of maximum tenderness. Let's review some steps to determining the most likely cause of the pain based on the location.

Pain in the ball of the foot at the base of the second toe

This is one of the most common areas for pain in the ball of the foot. Patient's with this pain will many times describe the recent use of shoe gear with a heel or walking barefoot. The source of pain usually presents from inflammation of the capsule surrounding the 2nd metatarsal phalangeal joint and specifically a thickening of the bottom of the capsule called the plantar plate. Individuals suffering from this type of pain should see a foot and ankle specialist to rule out the presence of a tear in the plantar plate. Delayed treatment of this condition, many times referred to as Predislocation Syndrome, can result in a complete tear of the plantar plate, followed by subluxation of the joint and the second toe overlapping the big toe.

Pain in the ball of the foot and at the base of the big toe

Pain across the entire ball of the foot

All Color Changes to Nails Are Not Fungal

Do you have a nail that started to change shape or color? Did you notice that no matter what you do, the nail continues to grow back irregular? These could be signs of a fungal infection, or they could be signs of something far more serious.

Changes to our nails can be the first indicator of a deeper issue or problem. Whereas all nail changes do not suggest a severe medical condition, there are some nail changes that require seeing a doctor as soon as possible. It is important to know what to look for and when to seek medical attention. The first key finding requiring medical attention would be a color change to the nail, especially if that color change involves the skin surrounding the nail. Sometimes melanoma (a form of skin cancer) can occur at the base of the nail or involve the skin under the nails. This can only be definitively diagnosed with a nail biopsy by a doctor. If you have noticed color changes to the nail resulting in the presence of a dark brown or black pigment, you should schedule an appointment to see a doctor. Other color changes such as the presence of a thickened yellow nail may suggest a fungal infection. If you notice that the nails have changed to a yellow color, then check under the end of the nail. Do you notice any yellow or white debris coming from under the nail? If so this could be signs of a fungal infection.

It is very important to note when the nail change occurred and what was happening, if anything, at the time of the change. It is well-documented in the clinical literature that acute trauma to the nail bed or base of the nail called the eponychium, can result in nail changes. If you have noticed that the nail has become painful and black / blue after trauma to the nail, this could be signs of bleeding under the nail as well as a possible nail bed laceration. Nail bed lacerations, or tears in the skin under the nail, should be repaired as soon as possible. The blood that is pooling under the nail from the injury must also be removed. This condition, a subungual hematoma, can suggest a fracture of the distal phalanx (the bone at the end of the toe) requiring immediate medical attention.

Sometimes individuals do not recall a specific moment of trauma to the nail, but do note the presence of black and blue nail changes consistent with that of a bruise. This is notably common in patients with microtrauma from ill fitting shoe gear. Although these patients do not readily recall a moment of acute trauma, the repetitive insult to the nail complex leads to bleeding under the nail. It is best that any form of dark color change to a nail be thoroughly investigated by a medical professional.