My hand hurts at night!

Carpal Tunnel Syndrome

If pain runs up the palm of your hand and into all of your fingers except the little finger, especially at night or when using your hand in certain positions, there is a good chance that you have carpal tunnel syndrome. Tapping on the middle of the undersurface of the wrist may cause pain to shoot into your fingers or forearm.

carpal_tunnel_syndromeThe pain may be felt in your palm, and extend into the thumb, index, middle and ring fingers. It may feel like an aching, burning, numbness or tingling. Most of the pain may be in the index and middle fingers where the large PainSpot is located in the picture. By clicking on a hand image at, and answering several questions, you may find out whether your pain is typical of carpal tunnel syndrome. Holding your wrist in a flexed down position may increase the pain. Carpal tunnel syndrome often is painful at night or driving a car. Pain may also go from your wrist up the forearm.

Why is it called the carpal tunnel anyway?

The palm surface where your wrist and hand connect together contains the ‘carpal tunnel’. Usually nine tendons and one nerve go through this tunnel-like area. It is bordered by the wrist bones on the back of your wrist, and a strap-like ligament on the undersurface of your wrist.

If these tendons swell up around the nerve, it can pinch the nerve and cause carpal tunnel syndrome. Injuries, tendonitis, tumors or some unusual diseases cause buildup of other fluid or tissue in the area and also cause carpal tunnel syndrome.

What causes carpal tunnel syndrome?

Any condition which puts unusual pressure on the nerve in the carpal tunnel may cause carpal tunnel syndrome. Usually this is due to swelling in the tendons, or swollen arthritic tissue in the area. Excessive or unusual use of your fingers may cause tendinitis and swelling resulting in compression of the nerve. Inflammation and swelling from arthritic diseases such as rheumatoid arthritis also will pinch or crowd the nerve. Sometimes conditions causing fluid to build up in the carpal tunnel such as injuries or pregnancy will compress the nerve.

How do you know for sure you have carpal tunnel syndrome?

Specialized nerve conduction velocity testing (NCV) may confirm the diagnosis. At the same time, electromyography (EMG) testing will determine if the muscles of the hand have been affected.

What kinds of treatment gives the best relief?

Treatment depends upon the cause and severity of your symptoms. If your hand is weak as well as painful, surgery may be considered. If left untreated, permanent weakness may result. Before that point, physical therapy and a change in activities or work conditions are important. Often a brace to keep your wrist straight, especially at night is recommended. Sometimes injections of a cortisone-like medication are used to reduce inflammation and swelling. If rheumatoid arthritis is causing carpal tunnel syndrome, specific treatment prescribed by a rheumatologist will reduce swelling in the wrist area and reduce the - Deal of the Month Medical Supply Depot

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Screen Yourself for Rheumatoid Arthritis

Is your hand pain from Rheumatoid Arthritis?

Pain Locator pain locator. First click on a painful area, such as a hand, then pick a knuckle

You can check for the possibility that you might have rheumatoid arthritis (RA).  Usually one or more finger knuckle joints is swollen. This swelling may be in the middle or large knuckles of your hands – not the knuckles next to your fingernails. The swelling does not feel ‘bony’, but feels tender and slightly soft.

Screen yourself to see if you are at risk of having RA.

Take the PainSpot quiz. Clicking here will take you to the Pain Locator (above) where you click on a painful  hand and then locate a tender knuckle shown on the zoomed picture (below).

Swelling in the knuckles where the fingers attach to the hand is often seen in RA.

How can Rheumatoid Arthritis be diagnosed in the early stages?

If you have at least one swollen, tender middle or large finger knuckle and if you have abnormal blood tests.

If at least one middle or large knuckle has been swollen and painful for more than six weeks, for no other reason, certain blood tests may help to confirm if you have RA.  Large joints may be swollen also, but at least two (wrists, knees, elbows etc.) are necessary. The balls of your feet are also targets for rheumatoid arthritis. The base of your thumbs and the big toes don’t count because more often pain there is from ‘wear and tear’ arthritis (osteoarthritis), and not rheumatoid arthritis.

Which blood tests do you need to have done?

Rheumatoid arthritis is very likely if you also have abnormalities in certain blood tests. If you or your doctor simply order an ‘arthritis panel’ there are four important tests usually included. Two measure antibodies (Rf and CCP).  The other two measure inflammation (ESR and CRP). High levels Rf or CCP, along with abnormal ESR or CRP levels are very useful in confirming the diagnosis of RA. Other tests often will included in the arthritis panel, and any abnormalities in those should be checked out at well.

To explain further, you have a higher risk of RA if you have increased levels of either of the following: Rheumatoid factor (Rf) or anti-Cyclic Citrullinated Peptide (CCP) antibodies.  If the levels are more than three times the normal limit, the risk of having RA is higher.

Abnormal results of ESR (Erythrocyte Sedimentation Rate) or CRP (C-reactive protein) also are risk factors and hint that the arthritis is causing inflammation in your system.

It is very important to understand that abnormal test results are not enough to give you a diagnosis of rheumatoid arthritis. Your health care provider may order these tests, or there are companies (such as Walk-In Lab) which allow you to order these tests yourself for a fee. If you order them yourself and they are abnormal make sure you see a doctor! If the blood tests are normal there are many other reasons you might have joint pain, and you should review your symptoms with your doctor. Sometimes even these four tests are normal with rheumatoid arthritis. A list of arthritis specialists in your area can be found at the American College of Rheumatology website.

Rheumatoid arthritis is treatable!

Although rheumatoid arthritis is a severe disease, which may not only severely damage your joints, it can affect other organs and can reduce your life expectancy. Newer treatments are very successful in reducing joint pain and damage. Remission of this disease now is a real possibility, but early treatment is very important to reduce permanent damage and disability (see other articles in this blog about the newest treatments and side effects of the medicines). - Deal of the Month Medical Supply Depot

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Why does my knee feel stiff after I sit for a while?

Your knee feels stiff and aches after you’ve been to a movie or resting for more than twenty or thirty minutes – why? In the past, this has been affectionately called ‘theater knee’, as you’ll see people who have been in the theater stand up slowly, maybe rub their knee, and walk – very slowly at first – until their knee loosens up. This knee stiffness is a symptom often experienced if you have osteoarthritis in your knee joint.



What is osteoarthritis of the knee?

Osteoarthritis is sometimes called ‘wear and tear’ arthritis. Nobody is sure exactly why, but we know in some people it may be caused by previous overuse or abnormal use, or due to an injury in the past which damaged the cartilage. Over months or years damage to the cartilage cushions in the knee worsens, and symptoms start. In the case of knee osteoarthritis, the smooth cartilage covering the bones of the joint becomes damaged, rough, torn or thin. Injury or abnormal pressure on the joint compartments over time may lead to osteoarthritis. If the kneecap is not in alignment osteoarthritis in the front of the knee can develop. The muscles around the knee support and protect the joint, and injuries or weakness in these may increase the chance of osteoarthritis developing.

What do knees with osteoarthritis feel like?

The increasing pain and stiffness of osteoarthritis is usually a gradual process. Usually your pain is worse with standing and walking, but can be reduced after several steps if it is in the early stages. When your knee is at rest there is less pain, but it usually will feel stiffer after a period of rest or inactivity. When moved again, it is more painful. In advanced knee osteoarthritis you may feel (or hear) grinding or creaking noises when your knee is moved. It may lock or give way if the ligaments are not intact, or if there is a tear in your meniscus. You may be able to find out if you are at high risk for knee osteoarthritis or other knee conditions by going to and taking the knee pain quiz.

How does a doctor know you have osteoarthritis?

Along with a history about knee symptoms, a thorough knee examination often suggests osteoarthritis is the diagnosis when pain is felt as the knee is moved and rotated. Your normal knee range of motion may be reduced. X-rays are helpful in showing osteoarthritis, and an MRI usually is not needed. The x-ray often shows narrowing of the space between the bones.

How is the knee joint put together?

The knee joint is a hinge-type of a joint. The thigh bone (femur) attaches to the shin bone (tibia) with the oval kneecap in the front. The joint may be thought of has having three compartments; the inner, outer and front compartments. There also normally is a thin, smooth covering of cartilage over the bones in the joint that allows normal, smooth and painless motion. There are two larger cushion-like oval cartilages in the knee, which help to stabilize the knee joint; each is called a meniscus; the one on the inside is the medial meniscus, and the one on the outside is the lateral meniscus. In addition to these meniscus cartilages, four strap-like ligaments also support and stabilize the knee joint. The ACL and PCL ligaments stabilize the knee against forward and backward pressures. On each side of the joint (medial and lateral) are the collateral ligaments and provide side-to-side stability. The kneecap protects the front of the joint, and also acts as a pulley for the large thigh muscles (quadriceps) which straighten the leg at the knee joint.

What kinds of treatment can help your knee pain?

The treatment of knee osteoarthritis depends upon the severity of your pain as well as how dependable the joint is when you walk on it. Efforts to rebuild joint cartilage are still in the early research stages. Initial treatment to reduce pain often consists of weight loss (if necessary) and exercises to strengthen the knee muscles and reduce the stiffness in the joint. Water exercise classes may be especially helpful. For more severe pain, medications may be recommended. These may include over the counter medications such as Tylenol (generic = acetaminophen) Aleve (generic = naproxen), Motrin (generic = ibuprofen) or aspirin. Various prescription medications which belong to a group of medications called ‘non-steroidal anti-inflammatory medications (or ‘NSAIDs’ for short) are commonly recommended. Some of the more commonly prescribed of these include medications such as Celebrex, Motrin, Naprosyn, Mobic, Voltaren, Relafen and Lodine. (a complete list is available at the reference below). More recently, a medication of a different class called Cymbalta has been approved to treat the pain from osteoarthritis.

How about knee injections or knee joint replacement?

More severe pain may be treated with injections of either cortisone-like medications, or lubricating fluids called ‘viscosupplements’ (such as Hyalgan, Orthovisc, Supartz, or Synvisc) into the joint. If the arthritis is severe, the knee joint may be partially or entirely replaced with surgery.

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Infection Rates with Rheumatoid Arthritis Medications – TNF Drugs

What are TNF Blockers?

The five medications below are often called called ‘TNF-blockers’ and are used for rheumatoid arthritis and certain other arthritic diseases (TNF stands for tumor necrosis factor, a protein – we all have naturally in our systems, but if you have rheumatoid arthritis, it makes things worse). These medicines may be used if another medicine, such as methotrexate alone fails to control the arthritic inflammation. Although generally very safe when they are used correctly, they slightly lower the immune defense system. Infections are one of the most frequent side effects of these medicines.

hope 2

They are Cimzia, Enbrel, Humira, Remicade, and Simponi. (Simponi is called ‘Simponi Aria‘ when given in the vein).

What types of infections?

The serious types of infections are usually pneumonia, sinusitis, bronchitis, sore throat, cellulitis (skin infection), kidney or bladder infections, and sepsis (blood infection).

Infection rates below are simplified for clarity, and are taken from the manufacturers’ official published drug information (prescribing information). As you can see, each company reports infections differently, making it difficult to exactly compare apples to apples, but the numbers below will provide a general feeling for how risky (or not) these medications are for the development of infections. As a group, it seems the risk is about 5 out of 100 treated patients each year will develop a serious infection; usually these are infections which could be life or limb threatening if not treated aggressively with antibiotics – often in the hospital.

Five Main TNFs – for now!

Cimzia – In all patient in study populations combined before the drug was approved, the most common reported infections were upper respiratory infections (18%) and urinary tract infections (8%). (For some reason they only reported infections that happened in more than 8% of people being studied). When compared with patients not taking Cimzia, infection of the nose and throat (nasopharyngitis) 5%, placebo 1%, upper respiratory infection Cimzia 6%, placebo 2%, and acute bronchitis Cimzia 3%, placebo 1%. (I’m not certain I know the difference between upper respiratory infection and nasopharyngitis however – they refer to the same area.)

Enbrel – serious infections overall 1.4% in treated groups using Enbrel (with or without methotrexate).

Humira – In their studies, if 100 patients took Humira for a year, there were 4.6 serious infections, versus 3.1 infections in patients not receiving the medication (placebo), for any condition that Humira is approved.

Remicade – 5.3% of patients who received Remicade serious infections as compared to 3.4% of placebo patients

Simponi – Using patient years,  if 100 patients took Simponi for a year for rheumatoid arthritis, there would be predicted 5.7 serious infections, versus 4.2 infections in patients not receiving the medication.

High Risk Infections

In all the the ‘TNF blockers’ patients at higher risk (elderly or those with diminished immune systems or a tendency for infections) are at higher risk for infections as they normally would not have to worry as much about due to bacterial, tuberculosis or other tuberculosis-like bacteria, invasive fungus, virus, parasite, valley fever or other opportunistic pathogens including certain mold-like and yeast-like diseases. These are usually less than 0.1% however, and low risk.

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Neck pain in the morning – no laughing matter

If you sit in a position where the head is held forward of the shoulders, such as reading or computer use, makes the upper back and shoulder muscles constantly work to hold the head up. Tension in the muscles builds up and causes tightness to build up in the upper shoulder and neck muscles, and results in neck pain and stiffness. Bad night posture leads to pain in the morning.

The spine in the neck is called the cervical spine and is made of a stack of seven block-like bones called vertebrae. These bones are separated by oval cushions called discs. The top vertebra, connects to the base of the skull, and the seventh attaches to the middle (thoracic) spine where the ribs are attached.

In the event of an unexpected sudden twisting movement, a car accident, or unaccustomed repetitive use of the neck, the neck muscles may become sprained or strained. Your neck feels stiff as result of the muscles tightening up and sometimes even going into muscle spasm. If the ligaments that attach to the vertebrae together become injured it is called a cervical sprain.

Both neck strain and neck sprain injuries are treated the same and are hard to tell apart. For the first 24-48 hours, home care with limited activity rest, gentle massage, and a heating pad may provide relief along with over the counter pain medications such as Tylenol, naproxen (Aleve) or ibuprofen (Motrin). Temporary use for short periods of a foam neck collar may be helpful if lying down to rest is not convenient. (Neck rings and other uncomfortable jewelry should be removed.)

neck rings Continue reading

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Newest Arthritis Medicines

The list below provides links to information about the newest and standard FDA approved medicines which have been shown in scientific studies to slow down the damage caused by rheumatoid arthritis.


This alphabetical list contains links to information about both standard and biologic DMARDs (which stands for disease modifying anti-rheumatic drugs) used to treat rheumatoid arthritis. Some are pills, such as Xeljanz, Plaquenil and Arava. Others are given by injections into the skin (subcutaneous) or into a vein (infusions). The injectable medicines are made from synthesized proteins, and are often called ‘biologics’. (photo credit

Arava, Plaquenil, and Xeljanz are taken daily. Most of the newer medicines given by injection are given  at intervals ranging from once weekly to once every two months. Methotrexate usually is taken in pill form once weekly, although it may be given as an injection instead to improve absorption.

Rituxan is an infusion often given every six months if necessary. Some can be given either as infusions or by self injection into the skin (Actemra, Simponi, Simponi Aria and Orencia are examples). Many new medicines are now being tested as well.

Actemra –

Arava (generic = leflunomide)-

Cimzia –

Enbrel –

Humira –

Kineret –

Methotrexate –,_Trexall)/

Orencia –

Otrexup – (methotrexate injectable) –

Plaquenil (generic = hydroxychloroquine) –

Remicade –

Rituxan –

Simponi –

Simponi Aria –

Sulfasalazine –

Xeljanz –

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Your spine can fuse solid.

“My spine fused itself, before they figured out why.” The pain and stiffness from ankylosing spondylitis is treatable, so your symptoms of severe back stiffness should not be ignored as ‘just routine back pain’. It could be due to severe inflammation in the connective tissues of the spine.

The symptoms of low back pain due to inflammation are different in several important ways from more common lower back pain, but especially in how long the stiffness lasts, several hours to all day. Also, the stiffness tends to worsen after a period of rest or sleep. The worst stiffness is usually in the morning, and also may be in the middle back and neck. This is different than other more common causes of back pain where the extra morning stiffness is usually no more than thirty to sixty minutes. It may be difficult to expand your chest when taking a deep breath, as your rib joints to the spine may be involved. In advanced cases, X-rays of the spine have a bamboo appearance, as the vertebrae are fused together.

In order to see if you are at high risk for having this disease based on your symptoms, go to , choose your painspot and take the quiz. If you are found to be at high risk, print out your results and take them or email them to your doctor. (Photo credit of bamboo forest – commons

Your lower backbone is called the lumbar spine is made of a stack of 5 block-like bones called vertebrae with a triangular bone attached underneath. These bones are separated by oval cushions called discs. The tip of the triangular bone is your tailbone, or coccyx. The large hip bones on each side under the buttocks attach to the sides of the lowest triangular bone and are called the sacroiliac joints, near the ‘dimples’ in your low back area.

If ankylosing spondylitis is present there may be damage to your sacroiliac joints or your spine. This leads to stiffness and in severe cases the spinal bones fuse together. The entire spine and sometimes other joints in the arms and legs are involved. There may be inflammation in your eyes, called iritis. Inflammation in your sacroiliac joints is called sacroiliitis.

In many cases a blood test for a gene named HLA-B27 is positive, especially in ankylosing spondylitis.

A physical examination and x-rays by an arthritis specialist called a rheumatologist may confirm ankylosing spondylitis is present.

Very successful treatment now is available for patients with ankylosing spondylitis. Newer medications reduce inflammation and improve pain, stiffness, function, and quality of life when the disease is treated.

The FDA has approved several medications called “TNF inhibitors” for the treatment of ankylosing spondylitis (Enbrel, Humira, Remicade, Simponi, Simponi Aria). Usually rheumatologists are asked to help provide care for this form of arthritis.

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Gout – it’s like pounding a nail into my big toe

“My big toe won’t even fit into my shoe!” I remember a 300 pound Hawaiian football player on crutches, tears in his eyes, with the toe of his tennis shoe cut out so it wouldn’t touch his foot.  The typical gout attack with a swollen, hot red big toe is very dramatic – and painful. Bedsheets feel like hot pokers.

Gout Gout,  by James Gillray 1799

Not all gout is in the big toe – it can (and often does) affect any joint, and often several at the same time. It is caused when uric acid crystalizes in or around the joint, forming microscopic needles  which are attacked by our own white blood cells. This causes intense inflammation and pain with joint and tissue damage. After a gout attack, the skin may peel almost like a sunburn.

Uric acid is normally produced when our bodies use food proteins for energy. The only mammals who make uric acid besides humans are Dalmation dogs and the great apes – although I remember a professor telling me he once treated gout in an elephant’s ankle.

In severe cases of gouty arthritis, the uric acid levels are so high it forms deposits of uric acid,  whitish lumps in the skin filled with chalky material made of pure uric acid.

finger tophus

These lumps are called tophi. The word tophus is a Latin term that refers to a porous type of volcanic rock called tufa. If your fingertip looks like this, you have tophitic gout (photo from

Gout also can cause an ongoing (chronic) arthritis, which is not as intensely painful as a gout attack but may cause severe joint damage.

The reason you may have high uric acid levels is not known, but heredity seems to play a role. Other conditions may cause an increase in uric acid. Foods high in a certain class of protein called purines can increase uric acid in some people (such as foods containing organ meats – such as sausage made using animal liver, hearts or kidneys). Fatty fish (anchovies, tuna, mackerel) and shellfish (shrimp, lobster), dark beers and heavy red wines also contain high purine levels. The uric acid level goes up with dehydration and obesity. Medications used to treat high blood pressure called diuretics (“water pills”) may increase uric acid. It now is known that sugary drinks containing high fructose corn syrup can also increase your uric acid level.

The diagnosis of gout is certain when uric acid crystals are seen in fluid removed from the joint or from a tophus.


Sometimes it is not possible to see the crystals, and gout may be presumed to be present if other typical gout signs and symptoms are present. These include a typically red painful and swollen big toe joint, attacks painful arthritis starting abruptly in other joints, along with high uric acid levels (uric acid crystals – photo wikipedia).

Treatment for a gout attack is usually very effective, if done correctly. Several different approaches are used, and should be tailored based on your individual circumstances. Situations such as diabetes, stomach ulcers, high blood pressure or kidney disease may require a specialist in arthritis called a rheumatologist to get involved.

If you think you might have gout or want to learn about the latest treatment advances, visit and take the quiz, or go to the gout information page.

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She just wanted to rock the drug babies.

She lived to rock the drug babies,  a patient I’ll never forget from years ago. Then she was 88 and has since passed on. I’ll always remember her as an example of the many people who are patients and friends, and also angels to others.

She had nobody left in her family, and her husband was long gone. Her life’s work was walking two blocks to the hospital every day, going to the nursery, and asking the nurses who needed rocking. Most days a newborn from a mother who was addicted to drugs would need comforting, and she would sit for hours, rocking and comforting the baby who was going through withdrawl.

The day she came in to my office she was thinner than I remembered, walking slowly and down in the dumps. I asked what was wrong, and small tears started flowing down her hollow cheeks. Her feet hurt too much to walk the two blocks to the hospital, and she hadn’t been in over three weeks. She was in worried and in despair, not for herself, but for the babies who needed rocking.

“I can’t afford a cab, and I can’t drive anymore”. It was heartbreaking. But after looking at her feet, I told her she had plantar fasciitis. Her shoes were worn out and too flat with no arch support. Her achilles tendons and skinny calf muscles were tight as a drum.

The hospital social worker found her some new shoes, and the physical therapist came to her house for a month. She worked tirelessly to stretch her leg muscles. A more motivated patient I have never had.

One beautiful Spring afternoon she returned to my clinic – walked in beaming from ear to ear. That morning she had walked to the hospital and rocked ‘her’ babies for the first time in two months.

rocking chair

She was able to do that for a couple more years until she quietly passed away one night.

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Heel pain in the morning

“I can’t even stand on my heel in the morning!”

Heel pain on the bottom of your heel often is due to a condition called plantar fasciitis (‘fash-ee-itis’). Pain from plantar fasciitis is a sharp or stabbing pain felt on the bottom of your heel. In severe cases the entire sole of your foot can be painful. Usually your pain is worst first thing when stepping on the floor in the morning, especially in bare feet. There may be tenderness with pressing on the heel, and a tight tender cord may be felt on the bottom of your foot.


The plantar fascia is flat fibrous band of tissue on the sole of your foot. It runs along the bottom of your foot, attaching to your toes in front, and your heel in the back.

If the arch of your foot is thought of as a bow, then the plantar fascia may be considered the bowstring. It supports your arch and provides stability and protection to the foot.

Plantar fasciitis may be due to shoes with poor arch support, flat feet, overuse or new vigorous running or jumping sports. Weight gain from pregnancy or other causes may lead to heel pain from plantar fasciitis. If the calf muscles and Achilles tendon are too tight, it is easier to develop plantar fasciitis pain.

The diagnosis of plantar fasciitis is made from the type of pain, its location and an examination of the foot and lower leg. X-rays may be done to exclude any bone or joint abnormalities, but they will not show the plantar fascia itself.

The pain from plantar fasciitis may take weeks or months to resolve completely. Physical therapy with specific stretching exercises is very important in the treatment of plantar fasciitis. Arch support in shoes helps to take tension off the plantar fascia, and weight reduction may be useful. A rest from sporting activities may be recommended, or the condition may become chronic and much more difficult to treat. Although in the past, cortisone shots frequently were used, these are less popular now due to concerns about weakening the plantar fascia and the possibility that a tear could occur. Local use of ice and medications called non-steroidal anti-inflammatory medications (NSAIDs for short) are used to stop the pain and inflammation. Some of the more commonly prescribed of these include medications such as Ibuprofen, Naprosyn, Indocin and Celebrex. Plantar fasciitis splints which keep the foot in a flexed position are worn at night and often provide excellent results. In resistant cases, and as a last resort, various surgical procedures may be necessary. For more information about other common causes of foot pain, please visit, and take the foot pain quiz.

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