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Differential Diagnosis

Posted , 8 users are following.

gail2910-US-MI
gail2910-US-MI

Still trying to discern if my pain is flare of PMR or tendonitis, bursitis/ or both due to overuse injury in May. My rheumy believes it is not PMR flare because my sed rate etc. is normal. (and also cuz going up to 10 didn't help at all) I am on 5 of Pred and 15 Meloxicam split into two doses q.d.(yes, I know these are contraindicated together)

Pain is pretty bad and often feels like PMR--no shoulder involvement this time--thank god-- but hip flexors, groins, sometimes glutes, often trocanter......I have a pelvis and hip MRI scheduled for next week. My question is: could it be PMR even if labs are normal (if so, why would rheumy think that test is diagnostic?) I guess if MRI shows NOTHING, then we know and I will have to up the dose of Pred. If it shows some polytendonitis then how the heck will we treat this? Eek. I have done everything I've been told to do and then some. I am on an anti inflammatory diet-- no grains, no dairy, no etoh, no sugar-- which is certainly not hurting me but I also don't see an improvement. Prednisone is causing some depression at this point too which feels both biological and also obviously the effect of chronic pain and immobility. I am trying to be resourceful so that I can ask the right questions when I see rheumy 9/6. What would you guys do?

0 likes, 5 replies

5 Replies

  • EileenH
    EileenH gail2910-US-MI

    Posted

    What would I do? I'd book myself 3 sessions of Bowen therapy and see what that achieves! This sort of pain you are describing can be due to several things including myofascial pain syndrome and piriformis syndrome, both of which seem to appear more often alongside PMR and both can respond quite well to Bowen - the advantage being it has no side effects and you don't need a referral from a doctor, you just have to pay for it. Trochanteric bursitis is another possibility - and it and the other 2 options tend to respond well to local cortisone injection whereas oral pred doesn't achieve a high enough  level of pred where it is needed.

    It COULD be PMR even with normal labs - 1 in 5 patients with PMR/GCA do not develop the acute phase response, as it is called. Their ESR and CRP remain "within normal limits" - but that doesn't mean they are normal for them. Normal is considered to be up to about 20 - my normal is 4 so 20 would be pretty high relatively speaking. You say "PMR flare" - does that mean you have previously had a diagnosis of PMR? If so, and your ESR/CRP were raised then it is less likely that they will remain normal now but it does happen. They also quite often lag behind in PMR.

    Our general experience is that diet doesn't make a shed-load of difference. Some people find ADDING things to their diet helps - such as oily fish, garlic and turmeric - but removing so many dietary groups from your diet just makes life boring and complicated (eating out is bad enough just trying to avoid wheat as I know from experience) and does put you at risk of deficiencies if you are not very conscientious.

    I wouldn't be 100% convinced by MRI - as far as I know it won't show up myofascial pain or piriformis syndromes though it may do. As I say - there are things I'd try first and Bowen therapy (or Bowtech) comes at the top of the list. If it hasn't made a difference in 3 sessions it probably won't so it isn't an open-ended black hole to swallow your cash! There are a lot of people on all 3 forums who have found it has improved their pain a lot - maybe not all gone but improved enough to manage on a lower dose of pred and no painkillers.

    • gail2910-US-MI
      gail2910-US-MI EileenH

      Posted

      Thank you! and yes, Totally open to Bowen! With the forum's suggestions, I finally found a Bowen therapist close by-- two days before her wedding. I'm in touch with her, waiting for her to return from her honeymoon.

      And yes, I had PMR dx in fall of 2013. Had sed rate of 58 at that time. It was 14 2 weeks ago. It was lower in FEb 2014 (1.4) but I was on higher dose of Pred. Does that make sense?

      and yes, I had the injection in bursa--it helped briefly. (Remember the run through the airport then overuse story that started this whole tale??) I was doing well managing the PMR until then.  I'm still in here pitching but trying to get clear about what the heck it is. I so appreciate all of your responses. I have a lot to ponder. Thank you thank you!

    • EileenH
      EileenH gail2910-US-MI

      Posted

      Makes perfect sense.

      All that does sound as if what is going on may not be the PMR - but some other thing with muscular involvement. Mind you - it is possible that your ESR is on its way up, it does lag behind. You need to have it checked again and if it has risen again it is a sign it could be the PMR flaring.

      I think that when you are on a higher dose of pred you achieve YOUR normal level of ESR and that is what you should be aiming for at later stages. Even if the "normal range" is 1-20 (or whatever your local lab quotes) that is what will be found across the entire population. It says nothing at all about what your normal level is. Mine is 4, yours sounds as if it is about 2 - so for either of us a reading of 14 is raised. Get it checked again and see if it rising - it is always the trend that is important. If it is going up then there is some inflammation somewhere. A single raised ESR could be due to a cold or injury - but if it continues to increase there is something active. You can't just say "it's normal" just because it is under 20 - you have to consider where it started.

  • pauline36422
    pauline36422 gail2910-US-MI

    Posted

    gail i have booked  bowens.   first appointment  is wed.   looking  forward to see  how  it goes for me,     for what it costs   its worth giving it a  go.  good luck x
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