Finger joint pain - what's the prognosis?

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I'm 71, and I developed PMR three years ago and tapered steroids over a year's time for the shoulder pain, but after that time I seemed to gradually develop morning stiffness/pain in my fingers such that I couldn't make a fist until mid-morning. This settled into a managable level but for the next year, but, two months ago I had a flare of PMR with elbow, shoulder, and hip pain and I went back on prednisone (now needing 20 mg/day to control those symptoms - vs 10 mg the first time).  The finger joint pain however has gotten worse, and now I don't have full painless motion until mid-late afternoon!  There is no visible swelling or reddness in these joints like I'd expect if I had RA.

Supposedly, in PMR, the joint pain is from tendon sheath edema as well as joint inflammation but apparently there are no erosive changes like those seen in RA.

My questions are:

a)  is this finger pain/stiffness typically seen in PMR? Seems weird to me, especially with other symptoms controlled.

b) what's the natural history of this finger joint pain - will there be any long term residual?

c) should I be upping the prednisone dose to see if I can get more relief?

d) should I be considsering methyltrexate?

My doc doesn't know the answers to these questions.

 

0 likes, 14 replies

14 Replies

  • Posted

    Hi ouzel – I’m your age and I have been working on PMR reduction with prednisone and methotrexate for about 2 years. I have been on a slow ‘taper’ from 20 mg pred using a 5-10% reduction of the medication monthly over that period and now I’m down to 4 mg.

    Generally all the thigh, shoulder, hip and shoulder girdles pain and ache levels seem to be maintaining a fairly uniform and bearable background level that has allowed me to keep the taper going at this rate but like you  – one big issue that is really bothering me, and hasn’t followed the overall body pain reduction, are my HANDS.

    The pain in the hands is not like carpel tunnel – it is in all joints of both hands from the wrist to the furthest finger joint. Both hands are almost locked up in the morning and need constant flexing (which is painful) to allow me to open the marmalade jar ! The flexibility and pain level does improve slightly toward the evening but is never gone completely.

    I have researched and been informed that PMR has an influence on synovial fluid loss in the hand joints. Most info regarding synovial fluid irregularities is from patients with joint disease related to knee effusions and most medical research is largely limited to findings in the knee joint, but there is evidence that it can occur with PMR.

    Regarding methotrexate (MTX) - my rheumatologist started me with MTX as well as pred after my first 'flare' and apart from this hand issue, I seem to be 'tapering' the pred quite well from 20mg to currently 4mg without any major issues. MTX (a DMARD) works as an addition ‘cover’ – OK for me but some others do not agree.

    Hope all goes well for you and you make a good decision.

    Dave

    • Posted

      Thanks for the response.  I keep the caps off my meds because I can't close my hands around them ... maybe I could do the marmalade jar if the lid was big enough. LOL. I was hoping to hear that the hands eventually returned to normal!
  • Posted

    When my PMR started it was in my hands. I would wake up with them in fists. I thought it was arthritis since i had broken most of my fingures due to spirts, over the next few months it moved to the rest of my body. Once on prednisone it was relieved.

    In looking back though it originally started in my back, I had back and shoulder pain at work.

    Hope this helps.

  • Posted

    I am 75 and I have this kind of pain early in the morning, but it goes away during the day.  I think it might be arthritis to some degree.  If it is painful and really tight ---- which has happened to me as well ---- it can be part of the RA factor I have to deal with in additon with PMR. 

    It could also be late onset of RA in your case.  I have refused to take MTX.  I was on Plaquenil for a while, but did not make any difference because of PMR later on, and the prescribed dosage of Prednisone.would help both.

    I like to take magnesium at night which helps the stiffness.

     

    • Posted

      "I like to take magnesium at night which helps the stiffness."

      Interesting -  I might try that once things get sorted out some.  

      You're right about the "arthritis to some degree" confusing things - in older folks there is usually some degenerative arthritis in finger joints, but more frequently it's the "distal" finger joints or the base of the thumb joint rather than the middle joints and big knuckle joints of the fingers.

      Thanks for your help!

    • Posted

      I also take magnesium and also potassium. They do seem to help with the excess symptoms, especially in the hands. I have actually stopped taking prednisolone for a month now and am just about managing. I had a bad fall about ten days ago which made me think I had encountered a flare or relaps into full blown PMR again but was relieved to find I had just pulled a few muscles and the symptoms have subsided. I could not put my arm up again for a few days but I can now and the pain is where the bruise is and getting less daily. I think our bodies get a bit wrecked and depleted of things like minerals whilst on Prednisolone for a long time. Also they can make ourselves feel well enough to continuously overdo things causing even more damage and stress . Adjusting is a matter of trial and error and docs are rarely supportive unless your bloods show significant deficiency. As we all know even a small deficiency can make you feel like hell.
  • Posted

    "Supposedly, in PMR, the joint pain is from tendon sheath edema as well as joint inflammation but apparently there are no erosive changes like those seen in RA."

    This is what I thought, and that this was called bursitis.  It seems to explain the exact nature of my range-of-motion issues in my hips and shoulders in particular, and extends to my ribcage area.

    I have no problems with sustaining force using my muscles, other than when changing position, which to me distinguishes this bursitis from any sort of bone joint irritation.

    There are other manifestations of pmr though.  I can't explain my thumb-joint flare-up as bursitis, but it does respond very well to small increases in pred dosage thankfully.  And the vasculitis which I believe causes headach during sleep seems to have no obvious connection to bursitis, unless perhaps vasculitis causes bursitis(???).

    I keep my pred dosage at the absolute tolerable minimum, to where I can get a full night's sleep and to where my thumb can grasp things, and to where my localized hip bursitis doesn't flare abruptly. So I am constantly having to make small adjustments to my pred dosage, to keep each sort of symptom from causing real grief.

    When I can get generous daily exercise (morning exercise seems to work best) is when I have consistently been able to make downward adjustments to my dosage and get away with it.

    Your joint stiffness reminds me of my severe finger/wrist/elbow stiffness that resulted from wrist injury-induced CRPS (complex regional pain syndrome). I didn't have any prednisone around at the time to try, but my doctor suggested a nervous system drug call Lyrica, which I chose to do without, and I did manage to recover almost entirely after about six months.

    • Posted

      dan38655, a couple of things:

      The bursae (sort of lubricant sacs) around major joints like hips and shoulders seem to be inflammed in PMR but there aren't any bursal areas that I know of in fingers and so the inflammation seen on MRI scans in fingers involves the capsule and the tendon sheaths that surround the tendons that span the joints.  

      In contrast, the inflammation in RA (in both small as well as large joints) involves the actual joint linings (synovial linings) and NOT the bursae, so you will see actual erosions of the cartilage on the ends of the bone ends in time.  That's also why reddness and moderate swelling is seen in more in RA vs PMR patients.  And that's why joint deterioration is seen so much in RA and isn't prevalent in PMR.

      You mentioned thumb "bursitis" but I guess you know pain there  commonly involves degenerative ("wear and tear") arthritis, particularly at the basal joint (and which is located almost back at the wrist level). Arthritic pain there is usually treated with an occasional steroid shot, or in severe cases by surgery.  

      If you have degenerative arthritis of the basal thumb joint you will have some enlargement of the base of your thumb, along with some swelling, and grinding the joint and grasping is really painful. You wouldn't want to treat this with oral prednisone.

      Also, if you are truly having vasculitis that causes headaches you should make sure you are not dealing with GCA and you should quickly see your doctor. 

      Thanks for your response!

       

  • Posted

    If your doctor doesn't know the answers to these questions maybe he should seek another opinion? Is this a GP or a specialist? Either way, they seem out of their depth.

    Finger pain like this can and does happen in PMR but usually at the outset and fades eventually with the pred as the inflammation is managed. It is synovitis and tendonitis - not bursitis: inflammation of synovial tissue and tendons and not bursae. Semantics to some extent, it's all inflammation!  Mine took several months of pred at above 10mg to fade but has never returned other than the odd painful stab when I bend a finger "wrong" which I think everyone gets at some point in advancing age!

    If 20mg isn't managing it, if it is getting worse, then you need some other investigations and possibly other forms of treatment. I hear the discussion about "Is this OA, is this RA" over and over on the forums - there are many forms of arthritis and connective tissue disorders and while the primary difference between, say, PMR and RA is the erosion or not of the joints, other forms of arthritis manifest in different ways and erosion may not be seen for some considerable time of non-management.

    So without knowing what this finger pain is due to it is impossible to answer any of those questions. It depends what it is as to whether there will be long term damage. It depends what it is as to whether methotrexate will help - even in RA it doesn't work for everyone or it works for a while and then the effect fades, requiring a switch to another medication. Should you be upping the pred dose? Probably not - not without a far better idea of what is going on. It is possible that other therapeutic measures may help - warmth, support and physio for example.

    As I said to start with - what you should be doing is looking for another opinion. Otherwise whatever you do is a mere stab in the dark - which may or may not make a difference for better or worse.

    • Posted

      You're right ... I need more information.  My internest is supposed to be making me an appointment with a rheumatologist but it's going slow.

      And you're right about joint vs. bursitis pain in the shoulders and hips.  My hip pain is in the joint (groin pain) and not the bursa (on side of joint) and my elbow pain was in the joint rather than in the olecranon bursa (at elbow point) so joint pain in PMR is more than bursal pain. Here's a study that describes where the changes are seen in the skeleton using ultrasoud (US), MRI, and PET.  http://rheumatology.oxfordjournals.org/content/51/1/77.long ;

      My finger joint pain came on over about a six month period while I was slowly going off prednisone at the disease onset two years ago, and stayed at low grade morning stiffness for a year of being off it. Now, with the relapse six weeks ago, the prednisone response is not as good and the finger pain has gotten significantly worse.  I've been on 20 mg per day and it mostly controls the hip and shoulder pain but not the finger pain/stiffness.  The fingers won't close without soaks of hot water and hurt all day so I'm wondering what the future holds. This fourm has been helpful.  Thanks 

    • Posted

      You CAN have bursitis pain in the groin: iliopsoas bursitis.

      And having just checked the anatomy - I realise that I had significant problems with the ilipsoas muscle in early PMR. I'd forgotten but it was the muscle my first Bowen practiioner identified as causing me problems on a recurring basis.

      Remember though - in a relapse your response to pred may NOT be the same as it was the first time wound. The people I know who have had PMR twice say the two episodes were very different in almost every way you could think of.

    • Posted

      Interesting .... my two episodes have certainly been different.  And I'm not clear on how the rheumatologist is going to tell between seronegative RA and PMR.  Seems sketchy in some cases.  Hopefully an MRI of hands will provide some additional info.
  • Posted

    Same symptoms but only in my right hand. Was worse a couple of months ago - might be I'm getting used to it! I'm 75 and now on 3.5 mg after w9 months

     

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