MRI update on left knee

[Lochy]

Results of my MRI came in and show swelling and inflammation with a couple of small meniscus tears probably attributable to my squash playing and running years. Left knee has continued to be painful and I don’t feel my drug cocktail (pred, leflunomide and hydroxychloroquine ) is working. Saw my rheumatologist yesterday and she is confused by my symptoms. My liver functions continue to fluctuate quite dramatically at times but we tend to feel I respond to the inflammation but she’s requested a liver ultrasound just to check what’s going on. I had a liver biopsy before steroid treatment started and all was clear. She’s considering trying me on methotrexate but obviously my LFTs are not ideal.

I’ve no idea what to do now but wait and see and make a decision with her when I see her next in November. In the meantime I had fluid drained off my knee and another steroid injection yesterday. Feel brand new today with no pain.......anywhere. My knee pain is definitely curtailing my steroid taper. I get down a few mg after I’ve had a steroid injection then the pain creeps back and I have to go up and add paracetamol to my cocktail. This is oscillating can’t be good but what else do I do?

So the MRI has at least proven I don’t have significant mechanical damage but I have lots of swelling and inflammation but nobody can explain or understand why it is in only one joint. I’m unique in my rheumatologist’s experience but she is determined to get to the bottom of it. She mentioned trying to re diagnose me with some type of rheumatoid arthritis so she could present my case to her committee therefore allowing me to try some different drugs (Biologics?)

Of course I’d left the room before I got all my questions asked and forgot to ask what other drugs might she be talking about?

So that’s my update, frustratingly little progress, does anyone have any ideas?

It’s so cathartic being able to post, I feel that halves my problem in some way 😁

[PMRpro Ambassador]

Leflunomide isn't an innocent when it comes to liver damage - and it can be severe. And if it is having an effect - and you add paracetamol to the mix, that is far from ideal. Do you drink alcohol? (a question, not a criticism)

Put it this way - that would all be enough to make me question being on it.

Ad just one knee messing about? Injury works like that!

[Lochy in reply to PMRpro]

I started on leflunomide at 10mg in February and my LFTs improved significantly so we felt it was having some beneficial effect. LFTs have remained ok for a few months but as the knee pain returns so my LFTs rise.

My liver has played up ever since my third pregnancy with a pregnancy induced liver condition, the name escapes me. This has been investigated over the years with no conclusions. PMR arrived and LFTs went through the roof - as my doctors had never seen, hence the biopsy. Increased to 20mg leflunomide in June and still on that.

I feel between a rock and a hard place as although I have concerns about my liver I do see a correlation with how I feel, as in PMR pain, and a raise in the liver levels. This has been the case throughout my PMR journey.

I have suggested stopping all the drugs and just take steroids and see how I get on. I have never had any problems with my left knee through my active years so feel the inflammation pain and swelling are a combination of PMR and reduced muscle strength in the leg as it only appeared last summer (2018) The MRI showed no signs of OA but there is a Baker’s cyst and a lot of swelling. The fluid drained is being tested. I’m unsure what the options will be if they find anything.

It might be I just have a sore knee from age and activity wear and tear and perhaps the PMR has exacerbated it. The prednisolone may have masked the sudden deterioration. It’s hard to know how to progress as I feel one sore knee is preventing my steroid reduction.

I do like my glass of wine but I have been much more careful and aware since starting leflunomide. That might be another good reason to stop it 🍷

Thanks for your input.

[Ruadh]

Think you need to see this Lochy - This is just in from Aunt Minnie - the online American radiology journal - always useful for up-to-date rad. information. auntminnie.com/index.aspx?

I knew of this in reference to cortisone infiltrations to the shoulder - been a 'known' for years that cortisone destroys tendons and ligaments to the shoulder (the surgeon's nightmare !) It isn't new, but, in relation to knees and hips ? Ho-Hum. So therefore no doubt, also applicable to spines as well... (could say Osteoporosis in a syringe...as 't'were'.)

Do steroid injections into joints do more harm than good?

X-ray imaging shows that corticosteroid injections for osteoarthritis pain in the hip and knee may actually damage the joints, leading to more rapid progression of the disease and eventually joint collapse, according to a study published online October 15 in Radiology...

IF you have problems accessing the article, please advise and I will put it up - Aunt-Minnie does not have a pay-wall, but does have a sign-in subscription wall !

[Lochy in reply to Ruadh]

Hi Ruadh, I can’t access the article beyond the first paragraph as you say there is a sub wall.

I have discussed this with my rheumatologist but she herself has done some experiments on steroids on cartilage whilst she trained and found it made no difference. I was concerned as I had heard from others that it can cause more damage. If you can send me the article it would be very much appreciated as it is more current. It’s good to be armed with information.

I don’t believe I show signs of OA from X-rays or the MRI I had although I appreciate swelling can be as a result of OA. They don’t feel that is the case with me at present.

Thanks for your help.

[Billswife in reply to Ruadh]

I have just read this article with great interest as I have had increasing pain in my left knee over the past five years, originally diagnosed as bursitis following a small injury many years ago. During those years I continued to walk and exercise to the best of my ability but as I felt the pain had escalated somewhat at the beginning of this year I decided to ask my GP for an X-ray in January of this year. The result showed "small effusion, joint spaces preserved" which my GP interpreted as "minor wear and tear" and suggested a steroid injection into the knee. This was done on12 February this year and gave no relief at all. I became more and more unwell with muscular and joint pain all over until after numerous blood tests on 10 June I was diagnosed with PMR and started on prednisolone. Muscle and joint pain immediately improved and I am now on reducing dose and at the moment am doing well, apart from left knee which is definitely worse. I think when I see my GP again in a few weeks I will ask to have a further knee X-ray to try to ascertain if there has been worsening of the original condition. Thank you for posting this article.

[Baileyw06 in reply to Billswife]

I have a torn miniscus and had a steroid shot which helped . when I have pain I use a tens machines which really helps.

[Mary63]

I have had torn cartilage x 2 in my L knee since developing PMR. My doctors have never questioned it as being part of PMR picture. It caused, swelling, pain, limp. 2 arthroscopies and one total knee replacement later I am now nearly pain free. It was two different unrelated problems for me, (ie PMR and torn cartilage and subsequent bone on bone requiring TKR) and I expect also for you. Not every problem comes down to PMR. I wish you good luck.

[Ruadh]

For those who were unable to access the article -

Do steroid injections into joints do more harm than good?

By Kate Madden Yee, AuntMinnie.com staff writer

October 15, 2019 -- X-ray imaging shows that corticosteroid injections for osteoarthritis pain in the hip and knee may actually damage the joints, leading to more rapid progression of the disease and eventually joint collapse, according to a study published online October 15 in Radiology.

The findings suggest that patients and their doctors need to be more aware of the risk of corticosteroid treatment for osteoarthritis, senior author Dr. Ali Guermazi, PhD, of Boston University School of Medicine, noted in a statement released by the RSNA.

"We've been telling patients that even if these injections don't relieve your pain, they're not going to hurt you," he stated. "But now we suspect that this is not necessarily the case."

Hip and knee osteoarthritis are common joint disorders and are often treated with injections of anti-inflammatory corticosteroids, which have long been considered safe, according to the researchers. But they found that these injections may actually accelerate the destruction of the joint, thus speeding up the need for hip and knee replacements.

Guermazi's team conducted a literature review to assess complications after treatment with corticosteroid injections, identifying four:

Accelerated osteoarthritis progression

Stress fractures beneath the cartilage

Complications from death of bone tissue

Rapid joint destruction, including bone loss

61-year-old woman with hip pain

Left: Anteroposterior left hip x-ray of a 61-year-old woman who presented with hip pain shows joint space narrowing (arrowheads) and femoral and acetabular osteophytic changes (arrows) consistent with hip osteoarthritis. Middle: Four months after intra-articular corticosteroid injection, anteroposterior hip radiograph shows severe interval joint space narrowing (arrowheads) and enlarging subchondral cysts (arrows). Right: Coronal intermediate-weighted fat-suppressed MRI obtained at the same time as middle image shows complete loss of the acetabular and femoral cartilage (arrowheads), with subchondral cystic changes (black arrows). In addition, there is joint effusion and synovitis (*) and periarticular soft-tissue edema (white arrows). This patient underwent total joint replacement three months later. Images courtesy of the RSNA.

In light of these possible complications, the authors suggested that patients with mild or no osteoarthritis on x-ray who are referred for injections to treat joint pain be carefully tracked -- perhaps even with MRI.

"We believe that certain patient characteristics, including but not limited to acute change in pain not explained by using radiography and no or only mild osteoarthritis at radiography, should lead to careful reconsideration of a planned intra-articular corticosteroid injection," the group wrote. "In these circumstances, MRI may be helpful to further evaluate the actual cause of pain prior to a planned injection."

Since corticosteroids are so commonly used to treat joint pain, the repercussions of the study's findings could be huge -- and radiologists have a definite role in protecting the health of patients, according to the researchers.

"Given that intra-articular corticosteroid injections are increasingly performed to treat pain in patients with hip or knee osteoarthritis, we suggest that the radiologic community should actively engage in high-quality research on this topic to better understand potential at-risk conditions prior to intervention and to better understand potential adverse joint events after these procedures to avoid possible complications," the group wrote.

And even though patients may be willing to take the risk of joint damage from corticosteroid injections, they need to be informed, Dr. Richard Kijowski of the University of Wisconsin in Madison wrote in an accompanying commentary.

"Patients have the right to make this decision for themselves, and this requires radiologists to discuss all potential risks and benefits with the patient when obtaining written informed consent," he concluded.

If you like this content, please share it with a colleague!

Related Reading

3D MRI helps predict osteoarthritis risk after ACL tears

Virtual 3D models of the knee based on MRI scans of anterior cruciate ligament (ACL) tears revealed which regions in the knee were most likely to develop...

3 ways to reduce unnecessary MRI knee scans

How can clinicians reduce unnecessary MRI knee scans? Three elements are needed: a standardized reporting template, a grading system to determine injury...

6 ways AI will enhance musculoskeletal imaging

Artificial intelligence (AI) is poised to greatly improve all aspects of the musculoskeletal imaging chain, helping radiology practices be more efficient...

Many knee MRI scans may not be clinically indicated

For at least one healthcare system, there is plenty of room for improvement when it comes to following the American College of Radiology's Appropriateness...

New 3D CT technique tops x-ray for diagnosing arthritis

Researchers from the U.K. have developed an algorithm capable of detecting subtle changes in the spacing between arthritic joints on 3D-reconstructed...

[Lochy in reply to Ruadh]

Thanks Ruadh, makes interesting reading. At present I don’t show signs of OA but then again the swelling and inflammation I have may well be the beginnings of deterioration. Establishing cause and effect is the problem.

Will have to wait see how long this steroid injection lasts and then take it from there.