RA: Always Another Surprise

I’ve been jousting with my old rheuma-dragon for decades, now. You’d think he couldn’t surprise me anymore. But he has, many times, and that crafty, snaggle-toothed old wyrm recently did it again.

I’ve had a lot of foot pain recently. It’s not the familiar, deep aching pain in the balls of my feet that I’ve had since the onset of my rheumatoid disease. This is new. It overlays that old pain. It’s sharp, burning, sometimes stabbing. It runs across the tops and down the sides of both feet and along the backs of both ankles.

It’s like wearing socks full of gravelly sand and glass shards.

RA and nerve pain

And while it’s mostly a “moderate” pain(!), it’s constant, worsening, and getting harder to ignore all the time. So, not long ago I told my rheumatologist about it. She did a brief exam, shrugged, and moved on, saying the gabapentin (an anti-epileptic medication commonly used for its nerve-pain reducing qualities) she’d already prescribed for my RD pain should handle it. She also started me on yet another biologic (my fourth, so far). Give it some time, she said.

I did—and I am—but this new pain continued. Eventually, it started to make wearing anything on my feet extremely uncomfortable.

I figured I’d give my new PCP at shot at it. She also examined my feet. Then she checked my records, noted that there were no x-rays of my feet—recent or otherwise—and ordered them. Until she could get a look at what might be going on inside them, she explained, she couldn’t identify a culprit.

Less than a week later, we had one. The x-ray results showed that I had enthesitis in my feet, ankles, and Achilles tendons.

Inflammation of entheses: Another RA complication?

According to enthesitis.org, enthesitis is “an inflammation of entheses, the site where ligaments or tendons insert into the bones.” It may cause calcification and fibrosis, a thickening and scarring of connective tissue. The result is more pain and, over time, decreased flexibility.

And what causes enthesitis? Joint diseases like rheumatoid disease, psoriatic arthritis, and lupus, among others. Injury or overload conditions like plantar fasciitis may cause it, as well. Enthesitis in rheumatoid disease occurs mainly with the feet, ankles, hands, and fingers, though it can affect the larger joints, tendons, and ligaments. Tendinitis and bursitis commonly occur, too.

“It causes irritation and “soreness,” understates enthesitis.org. Well, I can attest to the “soreness,” for sure.

Rheumatoid disease presents its own array of issues. As an autoimmune disease, it makes the body’s immune system mistake its own synovial tissues for malicious, foreign outsiders (like bacteria and viruses) and attacks them with single-minded, determined ferocity. That it’s damaging and destroying its own joints and, possibly, the synovial linings of its heart, lungs, and veins, its kidneys, and even its eyes seems not to matter to the rheuma-dragon. And then there’s the collateral damage of this internal, bodily war: enthesitis, bursitis, and tendinitis—damage and destruction of the tendons, ligaments, cartilage, and muscles that support the joints.

I’m glad to know, finally, what’s going on in my feet. The first step to health is knowledge, after all. But I’m still frustrated. Treatments for enthesitis focus on NSAIDs (Non-Steroidal Anti-Inflammatory Drugs), over-the-counter pain relievers, and, surprisingly, methotrexate (MTX) and anti-TNF biologics. Unfortunately, my body won’t tolerate MTX, and I’m already tried the other options in the past without success.

So. My rheuma-dragon is, for now, winning the battle.

But there is hope. There is always hope! I achieved some relief when I finally got to see a pain management specialist recently. She upped my gabapentin dose even further and reinstated my prescription for an opioid analgesic. And it may be that the new biologic (not an anti-TNF) will knock my dragon—the progression of my RD and the other physical problems it—down once again.

Fingers crossed. I’m sharpening my jousting lance.

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