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had a c-section in April. The day after my tailbone hurt so bad every time I sat down or stood up. Excruciating. So I went to the dr and she sent me for an xray. She got the results and said it looks like it might be broken and she wants to get a better look with an MRI. When she got those results back she said it looks like I have rheumatoid arthritis and wants to put me on medication and send me to a rheumatologist. I'm only 29 years old! Plus, how can they tell I have RA just through an MRI? Isn't there a blood test or at least some questions I have to answer?? What is going on here?
Answer
Hello,
I agree that your doctor's degree of conviction is surprising. The natural and obvious thing to suspect would be to bruising to your tail-bone, caused by your being laid on the operating table, (or dropped off it!! - I cannot forbear to say. Only joking.). The time-proximity (immediately afterwards), seems compelling.
Instead we have an off-the-wall, (desultory, non-sequitur) diagnosis, which is difficult to link to your c-section in any way.
We don't know what part, exactly, of your tail-bone we are talking about? The "main" tailbone itself, - the sacrum, - doesn't contain any joints: it's a solid mass of 5 fused bones, with a small joint below it to the vestigial tail (in humans), called the coccyx, ... and at both sides a major joint, each to the pelvis-wings, right and left.
This picture may help with the anatomy, (click and return) http://www.raqs.co.nz/safedance/graphics/pelvis.jpg
Either the lower coccyx-joint, or one/both of the side pelvis-joints, might be affected by rheumatoid arthritis, - I am not saying they are, in your case, but they could be, because they are of the correct type of joint, (a "synovial" joint).
If we are talking about your vestigial tail, (coccyx), - there is also a separate condition called "coccydynia," which is a non-rheumatoid bruising or strain of the vestigial tail.
To make any medical diagnosis at all, there are 3 main sources of diagnostic data. It is helpful to think in terms of these, because none of them can safely be ignored, and together they constitute a logical progression.
These are, (1) the history, - I mean the patient's story, (2) the examination, - the feeling with the hands, and (3) the further tests, - the further investigations, blood tests and X-rays.
In your case the history, (the story), seems to connect your problem to the c-section. Unless you already have other dodgy joints? - like the fingers, hands, wrists, feet, ankles, (because rheumatoid arthritis in its early stages, tends to affect the peripheral, extremity joints), - then there is no suggestion of rheumatoid disease in your history.
Examination, - presumably whichever bit of your tail-bone it is, is tender, - but this is non specific. Presumably your doctor didn't remark, on looking at all your other joints?
Further investigations, - I didn't think that an MRI scan was specific enough to diagnose rheumatoid arthritis reliably, - so I have just investigated the (online) research.
This 2000 paper, (click and return) http://rheumatology.oxfordjournals.org/content/39/7/700.full says: << "Bony erosions are seen well using MRI in early rheumatoid arthritis and are frequently detected before they appear on plain radiographs." >>
And it goes on to say, << "MRI has a clear advantage over other imaging modalities, such as plain Xâray imaging and CT [scan], in its ability to image soft tissues and fluid within the joint." >> Fair enough, so far, -
But, << "... This often involves the use of a contrast agent, gadoliniumâdiethylenetriamine pentaacetic acid (GdâDTPA), given [by injection into a vein before the test]. " >> You don't seem to have had this added refinement?
And at the end it says, << "One of the concerns about the use of MRI to monitor ... R[heumatoid] A[rthritis] is that its high sensitivity for detecting erosions may be associated with low specificity, so that false positives could occur." >> A "false positive" is where they definitely diagnose rheumatoid arthritis, based on the MRI scan, but you don't in fact have it.
I think you should definitely still have the blood tests! I think your doctor has raised a degree of anxiety which is not matched, by a corresponding degree of certitude. That anxiety is still her baby, in my opinion, and not the Rheumatologist's in a few weeks' or months' time.
The most important blood test is probably the "Rheumatoid Factor" test. You should also be blood-tested routinely for Gout, (the serum uric acid) and also for SLE, (the anti- nuclear antibody or ANA). You should also have a full blood count, - FBC, - in my opinion, and we also need to know if you have a raised ESR or a raised CRP, - because these are both non-specific, but sensitive blood-markers of *any* inflammation taking place inside your body.
I think this Rheumatoid Arthritis diagnosis is perhaps a tad premature. My suggestion is that you insist on the the appropriate blood-tests, before any rheumatoid-specific medication (besides ordinary pain-killers), is started. There is no harm in having an appointment with a Rheumatologist, I guess.
I hope this is of some help.
Best wishes,
Belliger
retired uk gp
Hello,
I agree that your doctor's degree of conviction is surprising. The natural and obvious thing to suspect would be to bruising to your tail-bone, caused by your being laid on the operating table, (or dropped off it!! - I cannot forbear to say. Only joking.). The time-proximity (immediately afterwards), seems compelling.
Instead we have an off-the-wall, (desultory, non-sequitur) diagnosis, which is difficult to link to your c-section in any way.
We don't know what part, exactly, of your tail-bone we are talking about? The "main" tailbone itself, - the sacrum, - doesn't contain any joints: it's a solid mass of 5 fused bones, with a small joint below it to the vestigial tail (in humans), called the coccyx, ... and at both sides a major joint, each to the pelvis-wings, right and left.
This picture may help with the anatomy, (click and return) http://www.raqs.co.nz/safedance/graphics/pelvis.jpg
Either the lower coccyx-joint, or one/both of the side pelvis-joints, might be affected by rheumatoid arthritis, - I am not saying they are, in your case, but they could be, because they are of the correct type of joint, (a "synovial" joint).
If we are talking about your vestigial tail, (coccyx), - there is also a separate condition called "coccydynia," which is a non-rheumatoid bruising or strain of the vestigial tail.
To make any medical diagnosis at all, there are 3 main sources of diagnostic data. It is helpful to think in terms of these, because none of them can safely be ignored, and together they constitute a logical progression.
These are, (1) the history, - I mean the patient's story, (2) the examination, - the feeling with the hands, and (3) the further tests, - the further investigations, blood tests and X-rays.
In your case the history, (the story), seems to connect your problem to the c-section. Unless you already have other dodgy joints? - like the fingers, hands, wrists, feet, ankles, (because rheumatoid arthritis in its early stages, tends to affect the peripheral, extremity joints), - then there is no suggestion of rheumatoid disease in your history.
Examination, - presumably whichever bit of your tail-bone it is, is tender, - but this is non specific. Presumably your doctor didn't remark, on looking at all your other joints?
Further investigations, - I didn't think that an MRI scan was specific enough to diagnose rheumatoid arthritis reliably, - so I have just investigated the (online) research.
This 2000 paper, (click and return) http://rheumatology.oxfordjournals.org/content/39/7/700.full says: << "Bony erosions are seen well using MRI in early rheumatoid arthritis and are frequently detected before they appear on plain radiographs." >>
And it goes on to say, << "MRI has a clear advantage over other imaging modalities, such as plain Xâray imaging and CT [scan], in its ability to image soft tissues and fluid within the joint." >> Fair enough, so far, -
But, << "... This often involves the use of a contrast agent, gadoliniumâdiethylenetriamine pentaacetic acid (GdâDTPA), given [by injection into a vein before the test]. " >> You don't seem to have had this added refinement?
And at the end it says, << "One of the concerns about the use of MRI to monitor ... R[heumatoid] A[rthritis] is that its high sensitivity for detecting erosions may be associated with low specificity, so that false positives could occur." >> A "false positive" is where they definitely diagnose rheumatoid arthritis, based on the MRI scan, but you don't in fact have it.
I think you should definitely still have the blood tests! I think your doctor has raised a degree of anxiety which is not matched, by a corresponding degree of certitude. That anxiety is still her baby, in my opinion, and not the Rheumatologist's in a few weeks' or months' time.
The most important blood test is probably the "Rheumatoid Factor" test. You should also be blood-tested routinely for Gout, (the serum uric acid) and also for SLE, (the anti- nuclear antibody or ANA). You should also have a full blood count, - FBC, - in my opinion, and we also need to know if you have a raised ESR or a raised CRP, - because these are both non-specific, but sensitive blood-markers of *any* inflammation taking place inside your body.
I think this Rheumatoid Arthritis diagnosis is perhaps a tad premature. My suggestion is that you insist on the the appropriate blood-tests, before any rheumatoid-specific medication (besides ordinary pain-killers), is started. There is no harm in having an appointment with a Rheumatologist, I guess.
I hope this is of some help.
Best wishes,
Belliger
retired uk gp
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