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Dr. Andrew Rynne

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Suggest treatment for severe muscle atrophy and swelling on the legs

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Dr. Aashish Raghu

Orthopaedic Surgeon

Practicing since :2011

Answered : 5163 Questions

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Posted on Thu, 23 Mar 2017 in Lupus
Question: Good evening Dr. ,
I'm 37 years old and last year (July 16) I have been submitted to a left knee surgery due to previouys dislocations and instability of the patella which consisted in the advancement of the VMO which brought a huge muscle atrophy, swelling and hot on the leg involved for 1 month and a half.
In August 16, I have started to feel a pop each time I raise my leg up one at a time with my knee bend while standing or when doing sit-ups. I couldn't determined where the popping was coming from, if it was from the lower back or from the groin.
In September 16, I started to feel aching pain from the hips (lateral, buttock and groin) and I started to feel lot of popping from both shoulders too but no pain.
In October 16 did a new dislocation of the operated knee patella and with it, knee continued hot but with this episode came a lot of grinding and swelling in that knee.
In November 16 started to feel aching and burning pain from the shoulders with more intense cracking.
In December 16 started to feel popping and grinding in the wrists and hands and intense aching/burning pain in the lower back.
In January 17 started to feel aching pain from hands and wrists , grinding and cracking from the neck followed a few days later by aching pain and the feeling of tendons snapping each time I turned my head to the sides and when turning up and down I would feel a electrical shock in my hands. Felt too a lot of popping from the sides of the right knee that I haven't had any issues so far. The ankles ankles also started to pop with some aching pain on and off.
Actually I have all the mentioned symptoms and the feeling that all my joints are loose, aching, popping, grinding and unstable. Left knee (operated continues hot and little swollen with lot of grinding. Right knee is also a little warmer. I am being followed by a rheumathologist which prescribed me a NSAID (naproxen) and a lots of exams this month: Bone scan (which have shown high concentration of t-99 in the operated knee only), X-rays (knee,shoulders, cervical,lumbar, thorax, pelvis, ankles, hands) all came normal, Ultra-sound(hands/wrists/shoulders) all normal even tough the Dr. notice the presence of "crystals" in the tendon of the right wrist where I feel some pain, but said probably nothing related, Blood samples: RA came negative, HBL27 negative, FAN negative, only things not normal were: Vitamin D25 deficiency, Vitamin B12 Elevated, Inorganic Phosphorus low, Globulin Alpha 1 low, Creatine quinase Elevated .
What could be causing all this symptoms and so fast? And why it is not evident on the exams? What can I do? I have always been healthy and athlectic without excesses.
doctor
Answered by Dr. Aashish Raghu 40 minutes later
Brief Answer:
Ehlers-Danlos syndrome?

Detailed Answer:
Hi there

Thanks for the query

I have read your query and understood your problem.

I have also gone through all your reports and films in detail.

It always to me that you suffer from ligament laxity that is causing hupermobile joints. This can make you prone for early arthritis of the joints causing pain, cracking sound or sensation, back pain especially in sedentary lifestyle.

Floaters in the eye with Hupermobile joints could indicate Ehlers-Danlos syndrome. Do consult a Physician to look for other clinical signs to confirm.

The crystals found in the tendon could be due to Gout. I suggest you get a joint aspiration from the most painful or 'hot' joint, done to look for Negatively birefringent crystals that defects Gout. Also get Serum Uric aid levels done. Avoid all kinds of meat, fish, avocado and their gravies. Drink 2 litres of water daily. Gout can also coexist with your preexisting condition of hypermobility.

Antiinflammatory medication like Ibuprofen can be taken. Better to avoid Nimesulide as it is banned for common use.

Do consult with Healthcare Magic team to send the rest of the investigations to me or you can send a 'Direct' query addressed to me with the rest of the exams.

I hope I have answered your query.

I will be available to answer your follow up queries.

Regards,

Dr. Aashish Raghu
Above answer was peer-reviewed by : Dr. Raju A.T
doctor
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Follow up: Dr. Aashish Raghu 1 hour later
Good evening Dr,
Regarding the EDS, taking into account the Beighton criteria, I am not able to extend neither of my joints beyond normal range, don’t even remember ever being able to touch my feet with my fingers when the knees are straight and about my kneecap dislocations, were not that frequent and are due to my bone anatomy since I have throclea dysplasia and patella alta. Regarding Brighton criteria, I fulfil 1 major criteria: More than 3 months with arthralgia in more than 4 joints and 1 minor criteria: More than 1 dislocation in my knees. Therefore, I don’t satisfy the requirements to be diagnosed with EDS. And about floaters, I don't have myopia.
Basically has I said before, all started to happen gradually right after surgery, and my symptoms now are mainly characterized by:

-     Burning pain in all joints, but actually only the knees feel hot when this happens;
-     My muscles and tendons are gradually becoming loose and weakened like my joints are going to desintegrate, creating a sense of instability;
-     Clicking joints with every move I make, adding to this, my knees also grinding specially the operated one and my neck;
-     No apparent signs of joint swelling with the exception of small swelling in the operated knee;
-      When symptoms gradually appeared, they affected joints symmetrically, or in other words, in both sides;
-     Stiffness after being immobilized for sometime that fastly disappears;
-     Waking up at night when covered with blanket due to burning sensation in the joints specially in the knees;
-     Fatigue;
Another point that I have been noticing is that my wife shoulders are starting to pop and crack the same way mine started, and she has been complaining with some pain in the joints, adding to this, my kid which is 8 years old, has his joints popping a lot. Neither in mine or my wife family we have or had members with OA or RA. Could this be only coincidence?
I believe this symptoms are certainly not wear and tear symptoms due to the rapid onset.
What could this be? What should I do to stop this?
P.S: In attachment, I’m sending you all my latest x- rays, bone scan, my blood samples from January and February, be advised that in January I have been tested also for different stuff, so they are not all equal.
doctor
Answered by Dr. Aashish Raghu 15 hours later
Brief Answer:
Seronegative spondyloarthropathy

Detailed Answer:
I have gone through your detailed reply and all your reports.

You do have a Joint hypermobility syndrome. It may or may not qualify for EDS. Either way, the treatment stays at investing the strength of the muscles of the unstable joints.

You can take Tablet Sulfasalazine 500mg once a day to take care of the inflammatory arthritis which is part of the Seronegative spondyloarthropathy that you have.

Take high protein diet to increase the collagen content in the joints in yourself and your family members.

Do get an ANA, CRP and Anti-dsDNA test for yourself and your wife and holiest it for my review.
Above answer was peer-reviewed by : Dr. Vaishalee Punj
doctor
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Follow up: Dr. Aashish Raghu 12 hours later
Hello Dr.

After checking your answer I have to ask you some questions:

1.     Have you seen the x-rays I sent you (ankles, knees, pélvis, lumbar, thorax, cervical, shoulders, wrists and hands or bone scan? If so, where can you detect arthritis to say I have inflammatory arthritis or arthritis?
2.     My joints were never hypermobile or unstable, only in the kneecaps I felt instability and as I told you before it was a question of bone anatomy (throclea dysplasia) rather than joint laxity. Since the onset of this symptoms after surgery, which started with probably the operated knee, I notice that the joint was very laxed which I considered normal due to the inflammatory process related to surgery, but then happen the same with hips, followed by pélvis/hips, then by shoulders, then by wrists and hands, ribs cervical, and the other knee also now, like my joints are being “attacked” in a sectorial way and I’m talking of only 7 months. In other words, the process could be described in steps like this in joint from both sides: 1. Muscle becoming loose 2. Followed by cracking/clicking 3. Pain and weakness (like inflammed but without swelling. This loose joints feeling only came gradually after surgery, I never had it before. I don’t even remember my body cracking before!!!!I feel like my muscle weakness is due to inflammatory processes since the burning feeling in muscles and joints. After this description, do you continue to think I suffer from Joint hypermobility?
3.     Could this be a muscle disease? If so, could it be triggered by the VMO advancement? I can it be diagnosed?
4.     Have you seen my blood samples (Jan17 and FEB17)? If so, You will notice I have already done ANA and CRP in both and came negative for ANA and CRP in normal range. I have been submitted to very throughout blood examinations that you can see there.
5.     What about the parameters that were out of range in my blood samples like for instance: Vitamin D25 deficiency, Vitamin B12 Elevated, Inorganic Phosphorus low, Globulin Alpha 1 low, Creatine quinase Elevated, couldn’t this indicators reveal or suggest something?
6.     Taking a sample of the joint synovial fluid would help in something?
7.     Even my TMJ is cracking now. Could it be related with the overall symptoms?
8.     Everytime I do physical activity (very light after all this symptoms), posteriorly I feel my body very sore and aching. What should I do?
9.     Could a infectious or bacterial disease be responsible for this symptoms even tough my blood tests are quite normal?
10.     Regarding Seronegative Spondyloarthropathy, don’t forget that the main common feature is HLA 27 positive and I’m negative. Do you continue to think this is the cause?
11.     Could an MRI show something more helpful for providing a diagnose? And therefore a solid treatment plan to at least halt this?
12.     I also notice that my skin hands are looking wrinkled all of the sudden. Could it be related?
13.     Will have my wife doing the exams you requested, because she is also starting to have similar complaints of pai non her joints but in a lower degree.

Waiting for your reply
doctor
Answered by Dr. Aashish Raghu 24 minutes later
Brief Answer:
Answers

Detailed Answer:
I have gone through all your reports. Yes, there are inflammatory signs in your sacroiliac joints and lumbosacral spine in the bone scan.

Usually when the muscles are weak, the joint becomes unstable and leads to Osteoarthritis. Since you have pain and swelling, it could be Seronegative arthritis instead.

Not all Seronegative arthritis have HLAB27 positively. It's only in the Ankylosing spondylitis disease that it is usually positive. It's not positive in Reiter's arthritis, SLE, Inflammatory bowel disease arthritis etc.

The VMO has not caused increase in your symptoms. It was done to treat your patellar instability.

There are no signs of bacterial or any other kind of infection.

High creatinine kinase indicates muscle damage. This can be demonstrated in weak muscles affected by inflammation. You can do a test to find out which makes are involved CKMB, CKBB, CKMM. The CKMM points to skeletal muscle creatinine kinase and may be important in your diagnosis.

You need to strengthen all your makes with physiotherapy to prevent early joint degeneration due to instability.
Above answer was peer-reviewed by : Dr. Yogesh D
doctor
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Follow up: Dr. Aashish Raghu 7 days later
Hello Dr.,

First of all I would like you to kindly answer point by point the questions I’ve asked on the previous question. All the questions I made are important as well as the questions that I will send now also numbered so that you can answer them individually.
14. I’ve been to my rheumathologist and after she checked my exams that I’ve sent to you, she said that nothing was wrong with the SI Joints, and all the blood samples are good even the ones out of the parameters. She was only concerned by the CK being a bit above the normal range, so she asked me to do an Electromyogram to rule out any muscle disorder. She doesn’t think I’m hypermobile. She also passed me magnesium , vitamin D, glucosamine chondroitin, vitamin C suplements and prescribed me a NSAID diclofenac and a muscle relaxant to take (don’t know why since I reported that I’m feeling my muscles loose!). She also asked me to do a Lumbosacral MRI to check for my lower back aching pain. How Can I convince her that this is an inflammatory disease because according to her nothing is wrong with my samples?
15. According to the Drs in my country nothing is wrong with my SI Joints, so how can I prove that I have my SI Joints inflamed even tough I feel pain and also popping from there?
16. Last year I had some extra marriage affairs before this symptoms and surgery, but always with protection. Since my wife as started to develope some similar symptoms in her shoulders could this be some kind of STD causing this symptoms? I have been tested for chlamidia, syphilis, AIDS, Hepatitis B and C and all came negative.
17. Attached I send you a left shoulder x-ray taken in last november and one taken this month for comparison. They are different,looks like the AC joint is now separating again?!? Can you explain what’s happening?
18. I also send you the pelvic xray for you to analyse the SI Joint better so I can argue with my rheumatologist about a diagnoses. What do you see precisely
19. From my neck I also feel the same symptoms than from the other joints, pain, warm, muscle weakness, cracking and grinding. Do you think I have arthritis? Can you detect it on the xray I sent? If so, where?
20. From hips?
21. Take a closer look to the left knee x-ray and check the shadow on the external side, can’t you notice that the external facet of the patella is too close to the external condyle?
22. I notice that I feel some bumps above the knee that hurts and also on the side of the hips. I can’t see them but when I pass my fingers I feel and the pain I feel there, it’s equal to the pain I feel in the other joints. What could it be?
23. You mentioned that I have swelling?!? I never mentioned swelling on other joints besides the operated knee and only became swollen after surgery, even tough now it’s barely noticible.
24. I’m taking naproxen but the effect I feel it’s only in reducing the pain I feel on the external side of the operated knee when I bend , nevertheless, the aching on the other joints remains and seems to be increasing and I feel them warm but not swollen (hips, shoulders, Sacrum). What can I do?
Please answer point by point, they are 24 total.
doctor
Answered by Dr. Aashish Raghu 12 minutes later
Brief Answer:
More tests available to check for autoimmune inflammation

Detailed Answer:
Thanks for your reply.

I think you can get Anti-Smith antibody and Anti-DNA antibody detection done to look for more sensitive makers of autoimmune inflammation.

The popping sensation you feel is not typical of Sacroiliac arthritis but can be felt in low back paraspinal muscle spasms as seen in slip disc.

The shoulder xrays have been taken with different rotation angles of your body at the time of taking the Xray. This is why they are different. There are no appreciable abnormal findings in the xrays.

Sacroiliac joints appear normal in the Xray. If there was sacroilitis, the MRI would catch it.

The bumps and muscle weakness need to be quantified by EMG and muscle charting to look for myopathy.

I believe you need to strengthen your muscles with exercise and balanced diet if there are no abnormal changes in the EMG.

Do discuss with the Rheumatologist about starting you on a trial of DMARD medication to see if that helps, as well as steroids.
Above answer was peer-reviewed by : Dr. Vaishalee Punj
doctor
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Follow up: Dr. Aashish Raghu 9 hours later
Dr.,

I want you to answer my doubts. MY DOUBTS ARE WRITTEN IN 24 POINTS, ANSWER PLS POINT BY POINT i.e: 1. answer; 2. answer, and so on. Otherwise I will be oblige to complain.

So here they go again:

1. Have you seen the x-rays I sent you (ankles, knees, pélvis, lumbar, thorax, cervical, shoulders, wrists and hands or bone scan? If so, where can you detect arthritis to say I have inflammatory arthritis or arthritis?

2. My joints were never hypermobile or unstable, only in the kneecaps I felt instability and as I told you before it was a question of bone anatomy (throclea dysplasia) rather than joint laxity. Since the onset of this symptoms after surgery, which started with probably the operated knee, I notice that the joint was very laxed which I considered normal due to the inflammatory process related to surgery, but then happen the same with hips, followed by pélvis/hips, then by shoulders, then by wrists and hands, ribs cervical and on the other knee also now, like my joints are being “attacked” in a sectorial way and I’m talking of only 7 months. In other words, the process could be described in steps like this in joint from both sides: 1. Muscle becoming loose 2. Followed by cracking/clicking 3. Pain and weakness (like inflammed but without swelling. This loose joints feeling only came gradually after surgery, I never had it before. I don’t even remember my body cracking before!!!!I feel like my muscle weakness is due to inflammatory processes because of the burning feeling in muscles and joints. After this description, do you continue to think I suffer from Joint hypermobility?
3. Could this be a muscle disease? If so, could it be triggered by the VMO advancement?How can it be diagnosed?
4. Have you seen my blood samples (Jan17 and FEB17)? If so, You will notice I have already done ANA and CRP in both and came negative for ANA and CRP in normal range. I have been submitted to very throughout blood examinations that you can see there.
5. What about the parameters that were out of range in my blood samples like for instance: Vitamin D25 deficiency, Vitamin B12 Elevated, Inorganic Phosphorus low, Globulin Alpha 1 low, Creatine quinase Elevated, couldn’t this indicators reveal or suggest something?
6. Taking a sample of the joint synovial fluid would help in something?
7. Even my TMJ is cracking now. Could it be related with the overall symptoms?
8. Everytime I do physical activity (very light after all this symptoms), posteriorly I feel my body very sore and aching. What should I do?
9. Could a infectious or bacterial disease be responsible for this symptoms even tough my blood tests are quite normal?
10. Regarding Seronegative Spondyloarthropathy, don’t forget that the main common feature is HLA 27 positive and I’m negative. Do you continue to think this is the cause?
11. Could an MRI show something more helpful for providing a diagnose? And therefore a solid treatment plan to at least halt this?
12. I also notice that my skin hands are looking wrinkled all of the sudden. Could it be related?
13. Will have my wife doing the exams you requested, because she is also starting to have similar complaints of pain on her joints but in a lower degree.
14. I’ve been to my rheumathologist and after she checked my exams that I’ve sent to you, she said that nothing was wrong with the SI Joints, and all the blood samples are good even the ones out of the parameters. She was only concerned by the CK being a bit above the normal range, so she asked me to do an Electromyogram to rule out any muscle disorder. She doesn’t think I’m hypermobile. She also passed me magnesium , vitamin D, glucosamine chondroitin, vitamin C suplements and prescribed me a NSAID diclofenac and a muscle relaxant to take (don’t know why since I reported that I’m feeling my muscles loose!). She also asked me to do a Lumbosacral MRI to check for my lower back aching pain. How can I convince her that this is an inflammatory disease because according to her nothing is wrong with my samples?
15. According to the Drs in my country nothing is wrong with my SI Joints, so how can I prove that I have my SI Joints inflammed even tough I feel pain and also popping from there?
16. Last year I had some extra marriage affairs before this symptoms and surgery, but always with protection. Since my wife as started to develope some similar symptoms in her shoulders could this be some kind of STD causing this symptoms? I have been tested for chlamidia, syphilis, AIDS, Hepatitis B and C and all came negative.
17. Attached I send you a left shoulder x-ray taken in last november and one taken this month for comparison. They are different,looks like the AC joint is now separating again?!? Can you explain what’s happening?
18. I also send you the pelvic xray for you to analyse the SI Joint better so I can argue with my rheumatologist about a diagnoses. What do you see precisely?
19. From my neck I also feel the same symptoms than from the other joints, pain, warm, muscle weakness, cracking and grinding. Do you think I have arthritis there? Can you detect it on the xray I sent? If so, where?
20. From hips?
21. Take a closer look to the left knee x-ray and check the shadow on the external side, can’t you notice that the external facet of the patella is too close to the external condyle?
22. I notice that I feel some bumps above the knee that hurts and also on the side of the hips. I can’t see them but when I pass my fingers I feel and the pain I feel there, it’s equal to the pain I feel in the other joints. What could it be?
23. You mentioned that I have swelling?!? I never mentioned swelling on other joints besides the operated knee and only became swollen after surgery, even tough now it’s barely noticible.
24. I’m taking naproxen but the effect I feel it’s only in reducing the pain I feel on the external side of the operated knee when I bend , nevertheless, the aching on the other joints remains and seems to be increasing and I feel them warm but not swollen (hips, shoulders, Sacrum). What can I do?

Pls DR., answer point by point like I asked and check all the info I sent til now.
doctor
Answered by Dr. Aashish Raghu 31 hours later
Brief Answer:
Answers

Detailed Answer:
Hi XXXX

Here are your answers

1. I have seen the xrays. There are no signs of any kind of arthritis, especially inflammatory arthritis.

2. If you have symptoms of instability like excessive joint mobility as well as arthritic symptoms as a result, then yes, you do have joint hypermobility.

3. VMO advancement cannot cause myopathies. I have seen your ANA and CRP reports. You need to get an EMG and if needed, muscle biopsy to rule out myopathies.

4 and 5. Elevated Vitamin D and B12 could be due to excessive intake due to long term administration. High Creatinine kinase could indicate muscle disease. Do get a differentual test to find out CKMB or CKBB or CKMM to find out which component is causing rise in Creatinine kinase, such as muscle-bone, bone only or muscle only respectively. Low phosphorus and globulin 6 could be due to inadequate dietary intake.

6. and 7.Synovial fluid analysis can show infections or inflammatory pathology. You may get it done. TMJ cracking could be due to arthritis. Do get an arthrogram or MRI to confirm.

8. Limit yourself to doing physical activity within comfortable limits. Have a healthy balanced diet and perform regular physiotherapy and warm up first.

9. Since tests are normal, there is less chance for bacterial infection.

10. HLAB27 only is sourdough to detect Ankylosing spondylitis which is a type of Seronegative spondyloarthropathy. There are dozens of other types that need not be HLAB27 positive.

11. MRI will show sites of inflammation or arthritis but not reveal the pathology per se.

12. Excessive lax skin can cause the appearance of wrinkled skin.

13. Okay. Do follow up with me on that.

14. Do discuss with your Rheumatologist about the possibility of myophathies which may need special molecular markers and muscle biopsy to diagnose.

15. Pain and popping is not a typical feature of Sacroiliac joint arthritis. It could be muscle spasm for which you have been prescribed muscle relaxant. Do give it a try and see if it's gets better.

16. STDs have been ruled out by the tests. Do get tested again after a month because some STDs become positive later after a window period when they are usually undetectable.

17. I have seen the xrays. There is change in your position while taking the xrays which is why it looks different. Your AC joint appearance normal.

18. There are no positive findings of any disease of your sacroiliac joints in your xrays. You seem to have reduced disc space of the L5-S1 region. It could indicate early disc degeneration of slip disc.

19. Cervical spine xrays show osteophytic lopping suggestive of early arthritis or spondylosis.

20. Not the hips. But in the cervical spine.

21. You are looking at a wrong kind of Xray to evaluate facet morphology and relationships with the femur. Do get Skyline views.

22. They could be signs of Osteoarthritis. You can get them biopsied and tested for pathology confirmation.

23. Swelling usually accommodates arthritic joints since you claim you have arthritis, which is why I commented on it.

24. You may need further investigations like a synovial fluid analysis, ultrasound of the soft tissues in the painful region, muscle strength charting, Gout testing.


Above answer was peer-reviewed by : Dr. Kampana
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