I have a rheumatologist for my PSA, but sometimes I wonder if I should be seeing an Orthopedic specialist for many of my joint issues. Even if just to do x-rays and baseline where my joints are at this point, to be able to document future damage. I asked my Primary docs and my Rheumy, and both offices said that if I am talking about joint issues that are clearly related to inflammation, then talk to my Rheumy about it, and if it is not then go to an Ortho. Well, it is not always that cut and dry. I am guessing there is no major danger in going to an Ortho doc and later finding out that the issue was related to my PSA. But I haven't noticed many people here mentioning visits to Ortho docs, so I am wondering if anyone does it?
Well believe it or not it is pretty cut and dry. The only thing an ortho can do for you is send you to PT, perform surgery and give you sympathy. Two out of the three can be done by someone else. Some will see you with out a referral from a PCP or Rheumy, the good ones will not (unless you have an acute traumatic injury.) Trust me on this no Ortho wants to provide "care" he is a mechanic who has a series of steps to go through before he can do any mechanics. He makes no money seeing patients in the office and will avoid it if at all possible. To overcome this lack of cash stream many have opened their own surgi centers, bought their own MRI machines, set up their own PT clinics (most ortho operated PT clinics stink, The good PTs are in private practice at three times the income.
Base line x-rays document nothing. A lot of unscrupulous practices will spend a ton of your money (insurance money) doing a ton of imaging that means nothing.Think about "it." If "it" is there they treat it, if "it" isn't, they don't (there is nothing to treat.) If "it" is there now and wasn't before, it doesn't matter because they can only treat what is there. All of us at some point have been in the position that "it" wasn't there and now "it" is. If your function is the same, pain the same, or still within the realm of "I can live with it"
Your rheumy may be a specialist, but understand he essentially a key part of your primary care team (Rheumatology is actually a sub-specialty of Internal medicine, you become a rheumatologist on fellowship after completing your residency in Internal Medicine.) If you wonder about seeing an ortho, ask him.
Funny this should come up now as I am seeing an ortho Thurs. My rheumy and I decided it was time. (Of course they decided it was time several years ago.) We'll be deciding on an other roto-rooter job or new joint. There is a 3 - 6 month wait to see my Ortho if you call about a "shoulder" My rheumy called on Monday, I'm in tomorrow. Thats pretty much the way it works.
I was just going to say more or less the same as Lamb. I don’t think there’s much point in seeing the orthopedic surgeon unless you need her/him to get out sharp instruments. The rheumatologist or your GP will know when it’s time for that. An example might be a joint replacement or other invasive treatments like injections or arthroscopic procedures.
That said, when I went to my orthopedic surgeon because it looked like it was time for a hip replacement (and he confirmed that it was the only alternative for me), he looked closely at the images and said he suspected the damage was not OA, but PsA, from the way it looked. He informed my rheumie of that. That was incidental to the fact I was there to see about surgery.
Thanks Lamb and Seenie. I have worked in the medical field for 20 years, so I do know some of this already. Lamb, you make an excellent point about the three things that an Ortho can do, and I see you both are reminding me that Orthos are basically just for surgery. I like the practicality of saying that baseline x-rays are useless. My rheumy took x-rays of my lungs and hands at diagnosis and called them baseline x-rays. I was dismayed that he left out all the other joints that give me problems. I have already had my first MTP joint replaced on my right foot, both feet give me a lot of trouble. When I asked him why he wasn't x-raying my feet, he said that my Podiatrist could handle foot problems. Well, I am not sure I trust my Podiatrist, he insisted that my foot changes that led to my joint implant were due to OA, even though I pointed out at every visit that I was dealing with systemic, overall inflammation and questioned whether I might have an inflammatory process going on, he said it was just "wear and tear arthritis". I am not sure I want him to handle my feet anymore.
I guess the issue is more that my rheumy doesn't ask me about my joints, he doesn't know exactly where I have pain or what each joint is doing. He is concerned with controlling the overall flare and does not discuss, or ask, or advise, on any particular joint complaint I have. One time I went in urgently when my hands had swollen up and he did give me a depomedrol injection. (I am not allowed to take NSAIDs because of my hypertension). Otherwise, he looks at my hands, looks at my lab tests and sees me every few months. Maybe my real issue is that my rheumy isn't the best?
Much as I hate to admit it, I see Lamb's point completely. For example, I mentioned my wrists hurting to my rheumy. I asked if there was any point in imaging, and she said no, it's safe to assume that it's from the PsA. Mind you, it's noted in my file to keep track of progression of the disease. But what can be done about it? It's nowhere near needing surgery.
Now my hips, I did go to the orthopedist. He didn't do much. He took x-rays, gave me a PT referral (which my rheumy would have done as well), and sent me on my way. He told me that hips are great candidates for replacement. Good to know. But he didn't treat me in any way. I'm already being treated w/ anti-inflammatories.
Shelley- You said, "He is concerned with controlling the overall flare and does not discuss, or ask, or advise, on any particular joint complaint I have." This actually makes sense to me. My rheumy will check for inflammation, and range of motion. If those are okay, then she tends to stick with the big picture. If not, then a steroid dose pack or a cortisone shot may be in order. Otherwise, all she can do is take note of changes over time.
Interesting comments, Shelly. My first rheumatologist only seemed to be interested in what was happening in my fingers and toes, which wasn’t much. Her conclusion was that my disease was mild, and she treated it as such. It was only when I ended up at the orthopedic surgeon needing serious hip work that it emerged that my disease was serious and aggressive. A second opinion confirmed that, and I was switched to more aggressive treatment. Maybe it is time for you to seek a second opinion on your PsA.
As for podiatry, I don’t expect him/her to diagnose or treat the disease, only to help me cope with the symptoms and problems that result from my PsA. Figuring out why bad things are happening to my feet, that’s my rheumatologist’s job, and I would think that an x-ray might be informative for that. Helping me to walk more comfortably on my deformed feet is my podiatrist’s specialty.
To be honest, if I were uncomfortable with how my disease is being monitored, I think I’d be seeking a second opinion from a rheumatologist. I wish I had done that sooner when I started having doubts.
I see what you are saying, Stoney, but if there is more damage than the rheumie thinks then maybe consideration needs to be given to changing or stepping up treatment. Severity of pain isn’t always an indicator of severity of this disease. For that matter, neither is blood work. Something like 50% of PsA patients have normal or near-normal inflammatory markers. I did, even as my hips were being devastated by the disease.
Shelly, how is your PsA being treated right now?
I'm guessing your Rheumy is 50+ or Mayo trained influenced???
It used to be pretty standard that just the hands and chest were x-rayed as they were the real windows to systemic inflammation. Just about every rheumy will palpatate your hands looking for crepitus or listen to your chest for it. If they find nothing there, and your blood work is normal, they have done just about all they can do.
That is until recently. We now have MRI's with stir sequences, more sophisticated ultrasound etc etc. They can find inflammation they couldn't before. Thats all fine but finding it and doing something about it are two different things. They still with the exception of a few injections are limited to systemic medications. They can up them or they can change them. The NSAIDS (which you can't take) are pretty easy to tweak and change. when it comes to the DMARDs and Biologicals, they are very hesitant. They can get better but they can get worse too. and it takes time. Mistakes are really hard to recover from. Its kind of a don't fix what ain't broke thing.
None of them are ever really concerned about a particular joint (although some cover it up better than others) unless it is getting worse over time with no let up in symptoms. They often take a body score these days measuring (from your reporting) some 24 or so points based on 0 - 5. They come up with a weighted average. So although your feet are killing you this appointment, your elbow is better and your total score is the same.
Its sometimes hard to tell whether your doc is "not the best" or is a good clinician and horrible people person. Remember these guys are scientists first.......... when all the other kids were at the dance they were in the lab. these guys become rheumys because its like solving puzzles. They tend to be awkward in real life (as opposed to the neurologists who are just plain wierd)
I have found that the pathologists are the weirdest clinicians I deal with at work :). I guess I have always understood the orthopedic side of things the best. Ortho and Vasc, those make the most sense to me. They are like carpenters, fixing things in a very black and white way. I guess I don't have a good feel on how rheumatology works yet.
Yes, my rheumy is probably in his 50s, and ESL. Not sure what country of origin we are dealing with, I think he is Turkish. He's clinical and not very personable, definitely.
My PSA is being treated with Humira and Ultram. I did a 3 -month trial of methotrexate first, and my liver functions went from normal to abnormal, and so after 3 months, although I personally felt it was doing some good, my rheumy said that it was not helping enough, and that I shouldn't take it with the direction my liver enzymes were going, and so he discontinued it. I DO think that he is being adequately aggressive although as I mentioned, he doesn't discuss my specific joint complaints, he has never recommended PT, but I didn't specifically ask for it either.
I guess the voice in my head is saying "what if there is permanent damage being done, what if my joint needs x-y-z to prevent further damage, who is watching that?" What if in five years I find out that there is too much damage to my ankle/hip/back/wrist to be able to effectively operate on them, but if they had considered it a few years earlier, they could have done this or that?
You are telling me you all don't wear your best underwear to the Doc???? I'm shocked.
Do you?
tntlamb said:
You are telling me you all don’t wear your best underwear to the Doc??? I’m shocked.
As you know my rheumy and I have some history going back to when she tried to burn my place down while smoking with my daughter in the 8th grade. I wear tiger striped speedos for her. (actually shes on leave right now so I have a rather droll locum who flys in from Minnesota)
hey there I have not been to see a ortho only my rheum he from the beginning did alot of blood work and a lot of xrays to see what my bones looked he has handled everything plus a short while ago he had a bone density done on me and that showed osteo I am not an expert at all but I figured why a ortho when he did all that even with a few things to help me on my bad days neck brace cane walker hopefully this helped
No, Lamb, please. TMI.
Seenie said:
No, Lamb, please. TMI.
LOL!
This offshoot of the conversation reminds me of when I was in college (90-94). I still had some of my underwear from the 80's, when everything was BRIGHT!! I threw my clothes on in the morning, not thinking, and had a rheumatologist appointment that afternoon. Now, at that time I saw a woman rheumy, and I wouldn't have minded, but there was a young male medical student on rotation (maybe a few years older than me). In those years, I would change into a paper gown thing for my full body exam. I looked down after I changed and realized I was wearing HOT pink bottoms and a black bra. It was practically a blinking neon sign through my gown.
I was so embarrassed. :)
Since then I always double check what I have on underneath in case of tests or needing to get in a gown for any dr. I see.