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I am a healthy 35 year old male who has had a swollen knee for the past few years.  I have no other joint problems, only my right knee.  Some days it will almost be normal, while others it can be very swollen and difficult to walk.  After trying to deal with it on my own for 2 years, I scheduled several visits to the primary physician, who then referred me to an orthopaedist and a rheumatologist.  The Ortho did an MRI, which showed that the synovial fluid was thickened, as well as a baker's cyst and some other particles that shouldn't be there.  He gave me a steroid shot and took some of the fluid out of the knee to look at it.  The steroid shot started working immediately, and my knee was good for about 6 months!  I knew it probably would not last, but it was great to be able to exercise for a while.  The fluid did not show anything "abnormal".  I went to see the Rheumatologist next and he could not really do anything since I had the steroid shot and it wasn't swollen.  He did draw blood for a series of tests for RA, Lupus, etc, and those tests all came back normal.  He also gave me a prescrption for 75mg of Voltaren/Diclofenac per day, which works a little but not that great.

Recently, I went back to the Rheumatologist after my knee started getting bad again.  He drew some fluid and looked at it under a microscope to rule out Gout by looking for crystals.  He said he didn't see any crystals although his PA said she might have seen one.  So, he ruled out Gout.  Then, he left the room for a while and came back and sat down with a serious expression.  He said that he didn't know what was causing this, but was concerned it could be RA.  And, if I didn't take care of this knee that it would be in a crippled state eventually.  He said he wanted to put me on a drug called Methotrexate.  He explained that this drug had been around for 80 years and it was very safe and effective.  He explained that the drug would be given every week through shot form, and that I would need to take a test every 6 weeks.  He said the side effects included mouth sores, nausea, birth defects, and that it was hard on your liver.  He said I needed to pledge not to drink alcohol, also.  I asked him when he wanted me to start this, and he said "why not now".  Well, I was really apprehensive about starting a drug that I knew nothing about, especially one that sounded so hard-core.  So, I left the office without starting the treatment.

Once I got home and talked to my wife, and researched Methtrexate, I am now really thinking that the Doctor may have jumped ahead to a more serious treatment than I may need.  For one, the RA website has 7 characteristics for diagnosing RA, of which at least 4 should be present to diagnose RA.  I have zero of 7.  Secondly, I would think there are some other treatments that we could try before heading down the path of Methotrexate.  I don't understand why the knee isn't being scoped out to remove the cysts and material that the MRI showed.  That may not cure it, but who knows if that is causing the inflammation?  Maybe this is just hanging my hopes on something that isn't realistic.  Also, the steroid shot worked so well, why not try that again for a while (every 6 months or so), instead?

I am new to all of this since no one in my family has arthritis.  I guess I would like to get other people's views who are more experienced with this stuff.  What are your thoughts on what I should do?

Thanks for all your help and have a great Thanksgiving!

Ryan H

Ryan, because long term, steroid are more dangerous than Methatrexate (MTX). Steroid are one of the nasties drugs out there and although RA patients need to use the at times, they can have horrible, irepairable side effects like Osteoporosis.

Whereas DMARD's - Disease Modifying Anti Rheumatic Drugs, have side effects too but generally they are safer and less damaging to our bodies in the long run. I suspect this is why the Rheumatologist suggested it. I would bet that would be where you RD was going with thoughts about your treatment.

Unfortunately, RA is way to complex and variable disease to be able to diagnose in a simple 7 step process. So, you could still have RA. There is obviously something going on and a reason why your RD is thinking that Rheumatoid Arthritis may be a possibility of what's behind your knee problems. It might pay to follow through on tests and more discussion with your RD and see what happens.

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Cordelia2009-11-26 15:59:23Rhall97,

Some questions and comments:

1.    It was the orthopedic surgeon who aspirated fluid. Did he do this BEFORE or AFTER he gave the cortisone injection? [Hopefully BEFORE the cortisone injection.]

2.    Was the fluid that the orthopedic surgeon aspirated sent to a specialized lab?

3.    When you returned to the rheumatologist for the second visit, you said he aspirated fluid. It sounds as though the fluid was examined in the office [since the PA said she saw a crystal]. It would be highly unusual for doctors’ offices to have this specialized lab equipment. Of course, your physicians may have been in a large medical school with specialized research labs.

4.    My orth surgeon would have scoped the knee first.

5.    In the early stages of inflammatory rheumatoid diseases, few of us met the necessary ICD-10 criteria, I’m betting.

6.    Given that you are young and possibly starting a family AND that you meet none of the criteria, I might well be inclined to do the scoping [by the orth surgeon] first [rather than jump into MTX].

7.    Did your rheumatologist tell you what he expects your diagnosis might eventually be? If he believes it might be RA somewhere down the line then aggressive treatment is indeed indicated.

8.    Kenalog [cortisone] injections are indeed a godsend and I am an advocate of them during times of flares. My orth surgeon limits them to twice in the same joint in a given 12 month period. Any more frequently and some nasty tears could take place, creating more damage. In any case, Kenalog injections are not meant to be a mainstay of treatment, but rather an “ace up the sleeve” when the MTX and other NSAIDS haven’t worked.

I’ve used MTX for 15+ years, have had countless Kenalog injections in various joints over  the years [when all else has failed during the flare], and have had 3-4 scopes in one knee that seems to constantly need it. [And it always feels better after the scoping.]

Good luck!

I was started on plaquenil then 3 weeks later She added Methotrexate. I also get injections. I was getting them more frequently, my ortho allowed me to get as many as I needed as long as they helped. I went every 6 to 8 weeks last year, getting varies joints or sometimes just one joint injected...( odd thing is sometimes they worked better than others)...I have since reached a stable condition and have not required the injections. Although the last couple weeks I am starting get stiffnes and swelling with pain in several joints...seems to wax and wane.

Thanks for all of your responses!  I will try to answer all of the questions. 

1. When I had the knee aspirated, the orthopedic surgeon put a needle in the knee, then drained out fluid, then popped off that cartridge, and loaded a second one which was the steroid.  He then inserted the steroid in the knee. 
2. The fluid that was drained was analyzed by a lab, and I don't remember all of the things that they tested it for.  I need to get those records.  I am in the process of going back to consolidate all these tests.  At that stage I wasn't really concerned about having some sort of serious illness so I didn't track the tests closely.  I do know that I tested negative for Lupus and RA factor, as well as every other test that they gave me.
3. When I went to the RD on the second visit, the fluid was examined right there in the office in a matter of minutes.  They said they were looking for crystals "under the microscope".  This doctor is not at a highly specialized lab.  He is an internal medicine doctor, who also carries a title of Rheumatology.  Should that be a red flag?  He has many, many years of experience and very solid academic credentials, etc.
6. You are correct that we are just starting our family.  My wife is due with the first in December!  So, we were thinking about having one more, so the MTX is a huge concern to us.
7. The RD did not tell me what he expects the diagnosis to be.  He is clearly unsure what this is, except that he focuses in on the synovial thickening and the multi-year inflammation as the indicators of some type of systemic disease such as RA.  He seems highly surprised that I haven't had any other joint pain, or rashes, or fatigue, etc. 

Thanks, again, for all your help.  I think that I am going to hold off on everything until January, when I can go back to my PCP for a physical.  Then, I think I will ask for a second opinion/referral for another RD, and also go back to the Ortho to see if he can do another steroid shot to keep the inflammation down until we can figure out a long-term plan.  Hopefully, my insurance will pay to have it scoped too.

I also know there are some alternative things that I can try which probably won't help, but may be worth a try since they also can't make it worse. 
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Thank you
just an FYI...... originally.. my complaints were ONLY in my right knee..... it had gradually taken over every joint of my body including jaw ... 

1. This is the correct procedure. The lab will test for various crystals using special polarized microscope, looking to see if there were birefringent crystals or not,  which further differentiates calcium oxalate crystals or other types of  crystals, which speaks to Gout and Pseudogout and probably a few other disorders that I’m not aware of.

 

2. Many of us tested negative for RA in the beginning…..and continue testing negative….and yet it’s amazing how much like RA our symptoms are. Also, my knee was the ONLY abnormal joint for years.

3. Sounds like the testing protocol has improved over years and they can do it in the office nowadays???? And perhaps the cost of the equipment has come down over the years. [It’s been several years since I was tested.]

I did, however, find a link to a study of women who had MTX to “flush” ectopic pregnancies, and who got pregnant shortly after the MTX. See  http://www.ncbi.nlm.nih.gov/pubmed/19103279

Basically, based on 45 pregnancies, the chances of teratogenesis were nil. Again, that’s only 45 pregnancies AFTER MTX.  

However, you should know this:  If you were to decide to discontinue MTX before conception, just to be on the “safe side,” then you run the risk of having “rebound flares,” which essentially means that the RA may return with a vengeance. [Usually this can be brought under control in time.]

With all this in mind, if I were you, I’d go with your wife to her next ob/gyn visit and discuss this issue. The question to ask is:  “What is the likelihood of teratogenesis if I am taking [25] mg weekly of MTX at the time of conception?” And to be on the safe side, I’d question an oncologist who might have more experience in this situation.

Please don’t construe this negatively. I applaud you for wanting to get all your facts first. Let me throw in some advice:  holding off on treatment isn't a good idea. Having a baby is a HUGE lifestyle change, especially if it's your first, so better you should have your disease under control and feeling well rather than poorly.

I had something like17 joints effected at first and that was just in my hands...weird thing...you do not think about your joints until they swell, go stiff and scream in pain...I remember just a little bump or a jar would bring hot tears to me eyes... An update......I decided to hold off on Methotrexate for now and get a scope done on the knee, and a biopsy of the synovium.  That way we can rule out a bacterial infection, and the ortho can see what's going on better.  The surgery will be in March since we are having a baby any day now!   Sorry about the bakers cyst. Did they use contrast on the MRI? Some bakers cyst have an association with a tear in the ligament. They do not like to take out bakers cyst because they are often in the middle of some major arteries. I guess i missed your last post. Glad you are getting a biopsy. Milly, thanks for your input, and I am sure you mean well.  However, I have not been diagnosed with RA.  At least not yet.  At this point, the doctors are fairly certain that I have synovitis, and the cause of it COULD be RA, or some other condition.  I very well may develop the symptoms for them to diagnose it as RA, but so far the only symptom is the boggy effusion in the knee, which indeed is an early SIGN of RA. 

The bakers cyst is just synovial fluid that flowed to the back of the knee since it was so swollen.  It comes and goes with the amount of total fluid in the knee.  Hopefully, it won't do what yours did (OUCH).

I realize that steroid shots can be harmful over time, and I know they will not be a long-term solution.  However, I have now had only my second shot, almost one year apart.  And, the ability to do significant exercise while figuring out a treatment plan is very important to me. 

You mentioned that I may think that my "RA is cured" because the swelling has gone down.  Did I say that or infer that?  If I did, then my apologies.  I don't believe that I did, however.  Again, every doctor I have seen has not been able to diagnose exactly what this is, and I know that I am not "cured".

In terms of letting "RA destroy [my] knee"...I think you need to understand that I have had an MRI recently and just this week had an x-ray.  There appears to be very, very minimal changes in my knee compared to a healthy knee, so I don't think that I am irresponsible for looking at several possible causes first, before starting a drug treatment such as MTX.  This was confirmed by the Ortho that I saw this week.  The scope will further determine what exactly has happened to the joint. 

You may be right....I may get much, much worse in the coming months/years and regret not acting faster.  However, this knee problem is now going on 3 years and, yes, it sucks to have a bum knee.  But so far, I live a completely normal life, except I can't exercise vigorously.  I am not going to jump head-first into MTX treatment right now, like the Rheumy wanted to do, without some more information.  I don't think that is a poor choice given what I know at this point.

I am not trying to insult you. I am just worried. It was my ortho that sent me too a rheumatologist. I guess I was projecting my own experience on you. For me it took several years for the rheumatologist to listen. So it is not my decision to make but it took me a long time to get a doctor to offer me RA meds. Then it did not show up on my bloodwork and now it does.

I honestly hope that you do not have RA. I guess what I was trying to say is that few rheumotologist offer medicine to someone that does not need it. Most often it works the other way around. It would be wonderful news if you turned out to be the exception. I do wish you the best of luck.

Ryan,

Thanks for wishing me the best.  It could be a long road ahead. 

I will try to update but it may be a few months until anything new happens, as I stated before.  Good to luck to you all, too.

Ryan

I just got a call from the Ortho's PA, and she said he took a look at the actual MRI images (I had them delivered over to his office from the other Ortho's office).  He said that he suspects that I could have PVNS (Pigmented Villo Nodular Synovitis), a very rare benign tissue growth.  I haven't found much out about PVNS, but the symptoms are very similar to mine.  Apparently, blood in the knee's synovial fluid is a strong indicator of PVNS, and I have had blood-tinged fluid drained twice this year.   Is it common to have blood in your synovial fluid with RA?

Once I get the knee scope, then they will biopsy the tissue and know for sure.  Has anyone heard of this before?  I read it only affects 2 people per million!

Ryan
I've had my left knee scoped 3-4 times, plus have had aspirations from that knee. Always a lot of synovial fluid but never any tinge of blood. Sam, thanks for the additional reference info. I searched all over the Internet but didn't find those sites.  I do want to have this taken out ASAP, but the timing sucks.  Our baby is due any day now, so I want to be able to help with the first few weeks of that.  And, then I have a very important work trip in mid-February in Las Vegas that I need to attend.  It's possible to try and schedule it in between but I don't know if that's a good idea.  I am definitely thinking a lot about what to do.  I will keep you posted on what's next!

Ryan
Ryan, Just a thought, but have you had a Lyme disease test?  It might be worth inquiring about.  Good luck.Merry Christmas everyone!  Yes, I have had tests for Lyme disease and these other tests...they all came back as "normal":  Sedimentation Rate, IgG antibodies, RA Factor, C3, C4, Anti-Centromere B Antibodies, Schleroderma diagnostics, Systemic Lupus diagnostics, Smith antibodies, RNP antibodies, RA Latex Turbid, Sjogren's tests, and Anti-DNA tests. 

I have no other symptoms of Lyme disease either. It was a good guess though, and I did find a tick on me a year ago.  But, this all started almost 3 years ago now. 
Sam, thank you SO MUCH for the additional info on synovectomies.  The doctor said that I wouldn't be able to fly for about 3 weeks due to blood clot worries.  But, if I got the surgery in late January, then I might be OK to fly to the work trip in February.  I need to wait to see when the baby comes and that will determine how the timing works out.  Still waiting............  :-)

One question.....what is this CPM machine?  My ortho didn't mention it yet.
Interesting about the flying, but I understand. Sam12342009-12-23 16:33:16whatever you have, I hope all comes out well. Like the others, everything I had done was negative. I did finally get a positive (very weak) ANA reading that was sent off to another lab and came back neg for RA. Two years later, I am finally getting an RA dx. It sounds like you are doing all the right things, so all I can do is wish you the best of luck and welcome to fatherhood!!!Tried your website but couldnot find much info or cost or indeed anything other than minimel information. Advise please.Wowza, Hi, all.  I am back from a crazy schedule with work and with the birth of our baby girl.  She and mom are doing great!  So, now, I have to get back to this knee issue.  I have scheduled the surgery for April 15th!  I have a pre-op meeting with the PA on March 25th, so I will ask about the CPM machine at that time.  Even if insurance doesn't cover it, I will probably rent one for that first week of recovery.  We have a vacation scheduled for mid-May, so I hope to be long since healed by then!  I will update when I know more! Congrats on becoming a daddy. And a little girl - so glad to hear mom and baby are doing well. Anyone had a full night's sleep yet? Sam, believe it or not, our 2 month old is sleeping about 7 hours straight now.  I can't believe it!  Well, she's a well-behaved little girl.  like RA or PVNS, but he did send off some tissue for biopsy.  Pain is nonexistant right now which is great!  They prescribed Percoset and that seems to be doing the trick.  I will post more once I know more.   My follow up appointment is next Friday.   Told you the operation was a piece of cake. Although I don't understand why the Percocet.....usually they give you a little something in the joint before you leave the OR and you don't need to take anything once you get home. [QUOTE=Sam1234]Told you the operation was a piece of cake. Although I don't understand why the Percocet.....usually they give you a little something in the joint before you leave the OR and you don't need to take anything once you get home. Jasmine, Well I guess that just confirms that Jasmine's original comment to what I said was an insult. Pretty lame.Seems that many folks here thought it was rather appropriate, judging by all the PM's I got agreeing with my assessment and thanking me for saying it. Uh-huh. SURE they did.  [QUOTE=Sam1234]Uh-huh. SURE they did.  ok I did... I didn't feel there was a need to tell you to your face that you are sanctimonious and a "knoweverydamnthing"..... and frankly.. you don't.. but you think you do.. and it's irritating to say the least....

There?  happier now?

sheesh!
Gosh, Babs, you weren't even one of the people who PM'ed me! no.. I just thought about PMing you. 
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