Category Archives: Pain and swelling in my hands and feet

Many of the more than one hundred types of arthritis can lead to swelling and pain in the hands and feet. Find out more about this.

What’s a “sausage finger” or “sausage toe”?

Many types of arthritis can cause a sausage digit.  The technical term for this is “dactylitis.”sausage-toe

This is not the kind of sausage you would have with your eggs and pancakes.

Sausage digits are typically seen in conditions such as psoriatic arthritis (the arthritis that accompanies psoriasis), Reiter’s disease, inflammatory bowel disease, and occasionally ankylosing spondylitis.  Of these, psoriatic arthritis is probably the most common culprit. Dactylitis means inflammation of an entire finger or whole toe.

It is caused by inflammation involving the synovium (lining of the joint) as well as the lining of the tendon sheath.  Tendons are tough fibrous bands that connect muscles to bones.  Most tendons glide through a lubricated sheath lined with synovium. When the synovium in the joint and the tendon sheath becomes inflamed, the entire finger or toe will swell.

The tendons that are most often affected are the tendons that allow a person to bend or flex their fingers or toes.

If a patient has dactylitis, their prognosis is poorer in that the joints are more likely to sustain damage.  The presence of dactylitis indicates a greater chance for disease progression.

Early on, dactylitis may be extremely painful.  However, over time, as destructive changes occur, the inflamed tissue is replaced with bony deformity and the dactylitis no longer causes severe pain.  However, the swelling persists.

The presence of dactylitis should prompt a diagnostic workup.  Diagnosis can be substantiated by magnetic resonance imaging (MRI).  Recently, diagnostic ultrasound has also been found to be helpful.

The treatment of dactylitis depends on the number of digits affected.  If only a few fingers or toes are involved, ultrasound-guided steroid injection can be helpful for the acute situation.

However, the more important part of treatment is to initiate disease modifying therapy as soon as possible.

Generally, the dactylitis is often accompanied by enthesitis.  This is inflammation at tendon insertions such as the Achilles tendon, patellar tendon (the tendon that connects the kneecap to the tibia-lower leg bone, and the iliac crest.

Every disease that causes dactylitis is a systemic disease.  This is because the underlying pathology involves an abnormal immune response. So other organ systems can become affected.  An example is the eye where uveitis- inflammation of the middle layer of the eye- can occur.  Uveitis is a potentially serious complication that can lead to blindness.

Institution of drugs like methotrexate or sulfasalazine (Azulfidine) may be useful.

However, most patients will require the use of biologic therapies.

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Gout Old scourge/ New scourge

An old disease is making a comeback…120px-the_gout_james_gillray

Gout is a common inflammatory form of arthritis that affects approximately four million Americans and this number is increasing dramatically.  The major reason for this is the parallel epidemic of obesity that is partially fueled by the increased consumption of high-fructose containing soft drinks.  In fact, many experts feel that high-fructose containing beverages are the number one cause of the gout epidemic.

When these soft drinks are metabolized through the liver, they generate an increased amount of uric acid.  Accumulation of uric acid leads to an elevated level of uric acid in the blood, internal organs such as the kidneys, and in the joints.uric-acid-crystals

Gout is not a benign disease.  It is associated with many other medical conditions such as high blood pressure, elevated blood lipids, diabetes, chronic kidney disease, and coronary artery disease.  Gout patients are at increased risk for both heart attack as well as congestive heart failure. Gout is also associated with the development of osteoarthritis.

While high fructose containing beverages increase the risk of gout, dairy products such as milk appear to reduce the risk of gout.  This is accomplished through two mechanisms: the first is an anti-inflammatory effect; the second is through the lowering of serum uric acid.

It is clear from epidemiologic data that while the incidence of gout is increasing, the proper treatment of gout can have an enormous positive effect.  Studies have demonstrated that lowering serum uric acid reduces the risk of both heart attack as well as stroke.

Newer therapies designed to decrease serum uric acid through various mechanisms are under study at the present time. It is predicted that the incidence of gout will continue to rise as a result of dietary indiscretion but that newer approaches to gout will help reduce the negative health impact of the disease.

For more information on gouty arthritis treatments and other arthritis problems go to:

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Rheumatoid Arthritis: The scientific explanation of the new oral biologic therapies

rheumatoid-handRheumatoid arthritis is a chronic, systemic, autoimmune disease that is driven by inflammatory protein messengers, called cytokines.  Cytokines are produced by cells in the immune system including macrophages, dendritic cells, T cells and B cells. Abnormal regulation of cytokine production leads to the inflammation and tissue destruction that is characteristic of rheumatoid arthritis.

While much attention has been focused on what happens outside immune system cells, more recently, there has been interest in what happens inside these cells that might explain the abnormal regulation of cytokines.

Multiple pathways inside immune cells include pathways with such interesting alphabet soup names like the MAPK pathway, the JAK pathway, the Syk pathway, the NFK pathway, and the PI-3K pathway.

By way of background, if you’ve forgotten your biology, cells consist of an envelope called the cell wall, an inside soup called the cytoplasm, and a core called a nucleus.cell

Cytokines released by immune system cells bind to receptors located on the cell wall.  This binding then sends signals into the cytoplasm of the cell. In the example of the JAK pathway, the receptor on the cell wall, when activated by cytokine binding, sends a signal into the cytoplasm which activates the JAK pathway.

Activated JAKs do something weird then.  They phosphorylate (not an obscene word… just the action of adding a tag) other protein receptors found in the cytoplasm.  These protein receptors act as docking stations for another type of protein called STATs.  Once the STATs dock, they also become activated.  Yes… activation is contagious. These activated STATs then enter the nucleus of the cell and activate genes that lead to the production of more inflammatory cytokines. Pretty complicated, huh?

Why is this important?

It’s because these inflammatory cytokines activate, recruit, and attract more immune cells.  This leads to more inflammation and tissue damage… more or less an endless loop of destruction.

Understanding these mechanisms is what is now driving the pursuit of newer rheumatoid arthritis drugs, called small molecule drugs.  These are oral drugs that have a biologic action.

Clinical trial data has shown these drugs to be effective.  However, like other biologic therapies, they do have potential side effects including elevation of blood pressure, elevation of blood lipids, alterations in blood counts, decrease in kidney function and a few other issues.

Nonetheless, they will prove to be a helpful addition to our arsenal of rheumatoid arthritis treatments.

For more information on rheumatoid arthritis treatments and other arthritis problems go to:

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Psoriatic arthritis… an often-missed diagnosis

Psoriatic arthritis is a distinct disease, different from rheumatoid arthritis and ankylosing spondylitis- another common type of arthritis- but sharing similar features to each. The disability and functional impairment in psoriatic arthritis can be as severe as that occurring from rheumatoid arthritis.psoriatic-arthritis

psoriasis_0Typically, a patient will have had psoriasis for a number of years before the arthritis develops. A small proportion of patient will develop the arthritis concurrently with the skin disease and an even smaller percentage will develop the skin disease after the joint disease.

Psoriatic arthritis may affect most joints in an oligoarticular pattern, meaning a few scattered joints are affected and the joint inflammation does not have the symmetrical pattern seen in rheumatoid arthritis. Enthesitis, which is inflammation of the tendons that attach to bone, is common in psoriatic arthritis. “Sausage digits” – swelling of the fingers and toes so that they look like little sausages is frequent. Nail changes are also common. These include “pitting” nail-pitsand separation of the nail from the nailbed. Some patients will develop carpal tunnel syndrome because of inflammation in the wrist. Inflammation of the eyes is a serious complication, as is involvement of the uveitisaortic valve of the heart.

Joint deformity is frequent and affects 40% of patients with the disease. Psoriatic arthritis has a significant impact on quality of life. The skin disease is a tremendous burden and often leads to depression.

The inflammatory process that causes both the skin disease as well as the joint disease is driven by elevated levels of a substance called tumor necrosis factor, or TNF.

A patient with psoriasis who complains of joint pain, swelling, morning stiffness, and fatigue should raise a high level of suspicion for the diagnosis of psoriatic arthritis.

Laboratory testing will show evidence of inflammation and imaging procedures such as magnetic resonance imaging (MRI) can help confirm the diagnosis.

Treatments that improve the skin disease do not necessarily improve joint symptoms and vice versa.

Treatment goals include symptomatic relief and control of disease progression.

Non-steroidal anti-inflammatory drugs are helpful for relieving some symptoms. However the majority of patients with psoriatic arthritis will require a combination of methotrexate or sulfasalazine and anti-TNF biologic therapy. Anti-TNF therapies have provided a significant advance in the treatment of both the skin as well the joint disease in patients with psoriatic arthritis.

For more information on psoriatic arthritis treatments and other arthritis problems go to:

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Arthritis Treatment: New approaches to treating gouty arthritis

Gout is a common cause of arthritis affecting more than 8 million Americans.  Although it affects men more than women, there appears to be an increasing incidence of the disease in post-menopausal women. The incidence overall appears to be increasing as a result of the epidemic of obesity, hypertension, diabetes, and elevated lipids, all of which are associated with gout.

Gout, in 90 per cent of cases, is caused by the inability of the kidneys to get rid of urate.  In the other 10 per cent, there is an overproduction of urate.

Animals other than humans don’t get gout because they have an enzyme called uricase which breaks urate down and allows the animal to excrete it. Human beings, on the other hand, lack this enzyme and therefore are unable to excrete urate (uric acid) appropriately.  This leads to accumulation of uric acid crystalsuric-acid-crystals in the joints and other organ systems.

Gout typically occurs in three stages.  The first stage is what is called “asymptomatic hyperuricemia.”  Asymptomatic hyperuricemia is characterized by elevate blood uric acid levels without attacks of gout.  The higher the blood uric acid level is, though, the greater likelihood of an eventual attack.

The second phase or stage is termed “acute intermittent gout”.  During this stage, patients have attacks of gout but after the attack is over, they are relatively symptom free.  The danger here is that chronic inflammation persists despite the absence of symptoms.gouty-arthritis

The third stage is called “chronic tophaceous gout.”  In this phase, patients have chronic pain due to repeated attacks of gout with an increasing burden of urate accumulation in the joints, kidneys, and other organs systems.  Patients develop tophus“ tophi” which are deposits of inflammatory cells, uric acid crystals and fibrin. Gradual destruction of the joints occurs with the development of crippling deformity. Tophi can cause lumps on finger joints in addition to other areas.

The treatment of gouty arthritis consists of a two-fold approach with relief of the acute attack accompanied by attempts to lower the urate burden.

Acute attacks can be treated with colchicine, non-steroidal anti-inflammatory drugs, and steroids.  The latter can be given either orally or directly into the affected joint.

Drugs that lower uric acid need to be used for the chronic treatment of gout.  These drugs, when initiated, need to be accompanied by gout prophylaxis in the form of daily doses of either colchicine or non-steroidal anti-inflammatory drugs, for at least six months.  The reason is this: as urate shifts as a result of the effect of uric acid lowering drugs, there is a predisposition to acute attacks.

Drugs used to lower uric acid consist of medicines that make patients urinate out their uric acid (probenecid), medicines that suppress uric acid production ( allopurinol, febuxostat [Uloric]), and uricolytic drugs.  An example of the latter is pegloticase (Krystexxa), which converts uric acid to allantoin, an inert ingredient that is then excreted.

Counseling a patient in regards to lifestyle and diet also plays a role in the comprehensive approach to gout.

For more information on gouty arthritis treatments and other arthritis problems go to:

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Lump on finger joint

One of the most searched terms on the Internet is “lump on finger joint.”  This is obviously a problem that concerns many people.  Well… there’s good news and bad news about this.hand

Most lumps on finger joints are benign.  In people pas the age of thirty, lumps appearing on the middle row and last row of finger joints are called Bouchard’s and Heberden’s nodes.  These are bony swellings  due to osteoarthritis.

Osteoarthritis is the most common form of arthritis. That’s the bad news.  The good news is that while these lumps can be disturbing because of their presence as well as the fact they can be sore, these lumps usually do not cause crippling deformity.  Occasionally, particularly in the Heberden’s nodes, a gelatinous material can be expressed from the swollen joint.

Rheumatoid arthritis can also cause lumpy finger joints but here the swelling is much more evident in the joint rather than on the joint and is accompanied by significant generalized morning stiffness all over as well as fatigue. Longstanding rheumatoid arthritis causes rheumatoid nodules on the fingers.  These are collections of inflammatory cells and fibrous tissue.

Gout is another cause of lumps on the finger joints.  These lumps are called “tophi” and consist of collections of monosodium urate crystals, inflammatory cells, and fibrous tissue.

People with elevated blood lipids can develop lumps on the finger joints due to the accumulation of cholesterol.

Plant thorn synovitis is a condition caused by the puncture of a rose thron into the joint.  This leads to infection in the joint and is an unusual but dangerous cause of lumps on the finger joint.  This is considered a surgical emergency.

Unusual diseases like histiocytosis can also cause lumps.

Rarely, malignancy can do this.

For more information on lumps on the finger joints and other arthritis problems go to:

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Pain and Swelling in My Hands and Feet

Arthritis is probably the most common cause of swelling and pain in the hands and feet,.

It refers to more than 100 different diseases that can cause pain, swelling, and stiffness in the joints. Arthritis may also affect other supporting structures around joints such as the muscles, tendons, ligaments, and bones. Some serious forms of arthritis can affect internal organs.

The common symptoms of arthritis are due to inflammation (swelling, heat, redness, pain):

Diagnosing arthritis can be difficult because some symptoms are often common to many different diseases. The most common forms of arthritis that can cause swelling in the hands and feet are:

Osteoarthritis. This is the most common type of arthritis. When it affects the hands, it can cause painful swelling in the last row (Heberden’s nodes) and middle row (Bouchards nodes) of finger joints. In the feet it will affect the toe joints as well as the mid-foot. This disease affects cartilage, the tissue that cushions and protects the ends of bones in a joint. With osteoarthritis, the cartilage starts to wear away prematurely. The swelling of the fingers and toes may lead to bony deformity.

Rheumatoid arthritis is an autoimmune disease; the body’s immune system (defense mechanism against infection) attacks normal tissues. This autoimmune reaction causes inflammation of the synovium, the lining of the joint. RA symptoms include pain, stiffness, swelling, rapid loss of joint function, and crippling. When severe, rheumatoid arthritis can also affect internal organs. This is the type of arthritis that most commonly causes severe inflammation in the hands and feet.

Rheumatoid arthritis tends to be symmetric- one side of the body being affected just like the other.

Gout and pseudogout are inflammatory forms of arthritis due to deposits of crystals in joints and other body tissues. Uric acid is the culprit in gout and calcium pyrophosphate is the villain in pseudogout. Both diseases cause painful attacks of arthritis affecting the hands and feet.

Psoriatic arthritis. Some people who have psoriasis also have arthritis. This disease often affects the hands and feet. It is usually asymmetric. It also causes deformity of the fingernails and toenails (onycholysis) that is often misdiagnosed as a fungal problem. Sometimes the spine- neck and low back-can be affected. As with Reiter’s disease, dactylitis often occurs.

Serum sickness. This is an allergic reaction that can occur most commonly with antibiotics but can also be due to other medicines as certain antibiotics.

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