Tag Archives: bad joints

Methotrexate madness

Wow, so my last post was almost a year ago… How has time gone so quickly?!

I’ve been seen in my Rheumatology clinic twice since last September and a lot has changed! I feel like it is time for an update.

Back in February I saw the rheumatology registrar who confirmed that I have a type of inflammatory arthritis, but was unable to determine the exact type of arthritis. Back then my arthritis was causing me a lot of problems. My SI joints had really started kicking off at the end of 2015, and I actually spent New Year’s Day unable to walk because I had gone on a night out for New Year’s Eve and over did it. Since then, my back hasn’t improved. By the time I saw the Rheumy reg, in Feb, my SI joints, costochondritis, fingers, toes, ankle, knee and my ligaments and tendons were all flaring. I wasn’t in a great way, thats for sure. We decided to step up my treatment plan by adding in Methotrexate (MTX) – an immunosuppressant.

As I had a chest infection and was on antibiotics at the time of my appointment meaning I couldn’t start MTX until I had been off antibiotics for at least a week. I didn’t start MTX until the start of March. I started on a really low dose of 7.5mg which equated to 3 tablets once a week. After 2 weeks I increased my dose to 10mg once a week, or 4 tablets. With MTX you always have to take folic acid to counteract some of the side effect of MTX so I was started on these too… But even with the folic acid the side effects were horrendous. I had nausea 4-5 days a week, I could only eat one meal a day and on top of that, I still had loads of joint pain, stiffness and inflammation.

MTX requires quite close monitoring as it can affect a lot of different organs, especially the liver and lungs. I have been having bloods about every 2-3 weeks since February to ensure my liver was functioning okay but also to check my kidney function and full blood count to make sure my white blood count did not drop too low and so far so good! Everything is just about in range, but there is nothing too out of range to worry about. A rare side effect of MTX is pulmonary fibrosis, which tends to present with a dry cough and shortness of breath. As a precaution, the reg decided it would be best to send me for a chest x-ray and pulmonary function tests to establish my baseline lung function for if there were any issues – but again everything looked fine!!

MTX can take about 12 weeks to kick in, and by week 14 or 15 on 10mg it was clear that my joints weren’t responding enough. I phoned the rheumatology helpline and explained what was happening to the nurses. They spoke to my consultant who increased my MTX to 15mg (6 tablets) but kept my folic acid the same as before. The nausea was way worse on 15mg: I dreaded MTX day, I dreaded eating, I lost more weight. Things were just not fun.

After being on 15mg tablets for about 8 weeks I made the decision to switch to injections. With injections you can sometimes reduce your dose by 30-40% because that is equivalent to how much absorb with the tablets so I switched to 10mg injections via the Metoject pen and so far things are a lot better in terms of side effects. I’ve had 2 doses of the injections so far and although I still have hardly any appetite, I can eat without nausea. I also got an intramuscular steroid injection because my SI joints and hip were making walking without an aid difficult, my costochondritis meant that taking a deep breath was virtually impossible and my shoulder (a new joint that kicked up a fuss from March onwards) was pure agony. The steroids took the edge off everything but my back and chest are still sore, just less sore.

I think that brings us up to speed to this week! Yesterday I saw my consultant rheumatologist who was amazing. My nurses had briefed my consultant on what had been going on before my appointment.When I was called in, before I had even said anything my consultant said this:

“Your arthritis is not controlled. We need to treat this more aggressively, but not over-treat at the same time. It’s a balance, but I would prefer to be more aggressive now because it’s easier to reduce meds than never get full control”

I am so glad that we are taking a more proactive approach, it’s scary that there are medications out there that I wouldn’t be able to access unless my rheumatologist was taking a more aggressive approach.

Once I had updated my consultant on things from my point of view, she suggested 3 options:

  1. Increase MTX
  2. Keep MTX the same but add a third DMARD
  3. Do both

We decided to just increase MTX since I had just had a steroid injection and we had’t given the last increase enough time to become effective, but at the same time we couldn’t do nothing. Starting tomorrow I will be on 15mg MTX injections and I will also be learning to self-inject. I also have open access to my consultant for the next 6 months when my next follow-up appointment will be, so if things don’t settle I can go back and see her with an emergency appointment.

My consultant also confirmed that my arthritis is seronegative because my rheumatoid factor is negative, and that spinal involvement is common with seronegative arthritis. We are now treating my condition aggressively rather than watchful waiting to see if lower doses will help. I feel like this is the turning point, where we will hopefully manage to get full control over my arthritis, or at least it gives us the best shot of getting full control!

#RABlog Week Day 3 – How my condition affects me

The third prompt for #RABlog Week is “Explain your RA”. Technically I do not have RA, I have another joint condition caused by my immune system attacking my joints that hasn’t yet been identified. I can’t explain what exactly is going on because I don’t know that myself but I can explain to you how my condition affects me, and how it makes me feel.

When I was diagnosed back in November I wasn’t ready for a diagnosis. I had gone for 7 and a half years with everyone telling me that they believed my pain but no one could tell me what was going on. I remember asking my Rheumatologist in despiration if she has ANY idea what was going on… her answer was “It might be autoimmune, it might not be. I do not know what is going on with you”. That was what I was told when I was 14. I wanted to cry, I was so frustrated at my body, at being sore all the time. I found it hard to explain what was going on to people because I didn’t have a diagnosis so I felt as if I was a fraud. Other people would go to the physiotherapist because of a sports injury and they knew how to treat it, I would go and they would say that they would try a treatment… but when it didn’t work I would get passed to a different physiotherapist. I saw 6 different physiotherapists in the space of 5 years. That is a lot of physiotherapy, and it is a lot of specialists who couldn’t help me, even though they truly believed I was telling the truth. They would all look at me with really sad eyes and tell me that they were sorry they couldn’t help, and that I should see my rheumatologist again. And every time that happened, any hope that I had built up was gone again and I felt really alone.

I felt that people would stop believing me because I didn’t have an answer for what was going on, and apparently no one else did either. So when my Rheumatologist turned around to me and said “I think you have an autoimmune condition, I want to start on you Hydroxychloroquine” I didn’t know whether to cry with happiness because I finally had an answer or to cry because I had found out that what I was hoping wasn’t true, was true.

As I said before, we haven’t quite narrowed down what condition I have. There is speculation that I could have Lupus or Mixed Connective Tissue Disease… or I could have Psoriatic Arthritis or Seronegative RA. We haven’t worked it out yet. I personally believe that I could have something similar to Psoriatic Arthritis or Seronegative RA due to my negative test results and the inflammation in my ligaments and tendons… and more recently, the whole finger that swelled up for 5/6 days for no reason [AKA dactylitis, although I need to get that confirmed by my rheumatologist]. I am lucky that I am studying physiotherapy so my lecturers understand what sort of problems I may have at uni but the problem with not having a name for my condition means that I can’t tell them straight out what I have and then have to explain the whole “I’ve been diagnosed but they haven’t said what it is yet… because I am a mystery to my rheumatologist”.

Of course all that emotional stuff stems from how my condition affects me physically, and also partly on how other people treat me because of my condition. If you look at me you cannot tell that I have a joint condition. If you had a line up and you had to choose someone who you thought was chronically ill, I very much doubt you would choose me. I look healthy… and to some extent I class myself as healthy but if you read my medical file you would probably picture someone who is unhealthy. I want to quote some things that my rheumatologist has written about our meeting and I want you to try to think about what a person with these ailments would look like.

“Lumbar sacral spine movements were grossly restricted”

“… restriction of plantar flexion subtalar movements and mid foot movements” [AKA restricted movements in my feet and ankles]

Morning stiffness remains a significant problem and can last between 1 and 3 hours”

“…feels extremely tired”

“… grossly restricted movements in neck and back”

If I saw a description of this written down I would expect to see someone who probably wouldn’t be very active, and probably wouldn’t be able to move very well because of all the stiffness. However, that is not the case. I am active, I can run, I can jump… Some of the time that is. And this is the thing with chronic invisible illnesses of an autoimmune nature, sometimes you can feel really good and the next day, or even the next hour, you can feel absolutely horrendous.

There have been times that I have used a disabled toilet because of the fear that I wouldn’t be able to get up off of a normal toilet without handrails. There have been times where I have sat in the disabled seat on buses because my joints couldn’t cope with me standing any longer. There have been times where I have been physically sick from pain. There are days where I can’t write, or when I find it hard to type. What I want people to learn from this is that living with an illness is very unpredictable and you have little control over which days you feel great and which days you don’t. I deal with pain, swelling, stiffness and inflammation every single day and yet some days I can still be “normal” whatever normal is. The point is that you cannot see my suffering so just because I don’t tell you that I am sore doesn’t mean that I am pain-free. Please remember that your sister, brother, parent, friend, relative, colleague… who ever you know with RA/Autoimmine arthritis, will most likely be sore every day and have symptoms every day. Just because you can’t see them, doesn’t mean that they aren’t having problems. If they are doing things slightly differently to normal then this is probably them compensating for said symptoms in a functional way… they might even ask you for help. Don’t make a big deal of it, just help them. Don’t treat them any different to normal, they are the same person they have always been. They do not need to feel more isolated by their illness because you feel the need to make a big song and dance about what they can/can’t do or what they may/may not need help with.

#RABlog Week Day 2 – Managing fatigue

The prompt for Day 2 of #RABlog Week is managing RA fatigue… In short I am rubbish at managing my fatigue. I have a very busy lifestyle which lends itself to late nights and early morning starts which little time to nap during the day. I tend to survive on coffee, much like other students BUT having said that, I know when my body has had enough and when I need to give my body time to rest and recuperate.

I try to stay as organised as possible. If you looked at my bedroom right now you would probably think “How the hell is that organised?” which is true because my room is a complete mess at the moment. But I am usually quite good at keeping my room tidy. If I keep my room tidy then it means that I don’t have to do a massive [potentially exhausting] clean out when it gets to the point where I can’t cope. The same goes for my uni work… I try to stay on top of my work load by going over lectures and doing homework when I get it rather than waiting till the last minute and staying up all night writing and assignment. When I first started Uni, I was more interested in socialising than going home and doing my work which lead to me becoming so exhausted that I had no energy to do anything else except work in the end… and I didn’t even have enough energy to do that a lot of the time.

I also try to keep to a healthy sleep pattern so I try to get to bed by 12am and I don’t sleep past 9am at the latest… I try to go for 8 hours of sleep every night although most nights I get somewhere between 4 and 6. Along with this [attempted] healthy sleep pattern, I try to keep my day structured… Not like an army bootcamp where everything is planned to the second, but I try to make sure that I do at least 2 hours of work in the evening so I don’t fall behind, I try to keep to a cleaning rota, I make lists of what I am going to eat and make lunches in the evening so I don’t have to get up early in the morning to make something for lunch. Making lunches the night before has become particularly important now that I am trying a gluten free diet, since I am still not sure what foods contains gluten and which don’t so it is just easier for me to make lunches rather than get something at uni.

Along with sticking to a structured day, I try not to nap during the day because I find it harder to fall asleep in the evening… Obviously if I am so exhausted that I need to sleep then I do, but I try to limit my naps to a couple of hours max. I am not ashamed to admit that there are days where I have been so tired that I haven’t bothered getting out of bed. These days usually occur during a flare, when getting out of bed is difficult enough anyway… so coupled with the fatigue, I don’t get out of bed.

So those are a few things that I do to try and manage my fatigue… Personally I don’t find that it helps very much but everyone is different and I know a few people that this sort of thing works wonders for. I have actually been looking forward to this topic since the prompts were released because I want to see what the other bloggers write and suggest. I’m always open to suggestions.

There are also a couple of other things that I want to point out/make you guys aware of. Fatigue has been linked to the level of inflammation in a person’s body, obviously with RA and other autoimmune conditions, this is higher than in other, more healthy people. It sounds simple but if you can control the inflammation then this is probably a good starting point for managing your fatigue. However, the difficult thing is working out how to control the inflammation in your body. If I had the answer to that, I would be a very happy person… but I don’t so the only thing I can suggest is taking your medications as you have been prescribed them, and to work with your doctors/rheumatologist to try and find the best medication/combination of medications that work best for you. You might want to explore alternative therapies for coping with fatigue, or herbal medicine. I can’t say if that works or doesn’t but if you do decide to go down those routes PLEASE CONSULT YOUR DOCTOR FIRST. I don’t understand how herbal things or alternative therapies work, and you never know some might cause weird side effects so it is best that your doctors know what you are going to do.

Fatigue can also be caused by some deficiencies [e.g. iron deficiency] so if you find that you are becoming more tired than usual, and you aren’t flaring then maybe it is worth getting checked to see if you have any deficiencies… Most deficiencies can be easily corrects and if that is the case then that is great.

My condition, my decision… or so it should be

I think on this blog I tend to brush over just how much my joints affect me. I am not one to make a big deal out of things, and I don’t tend to complain that much… unless I am really struggling. However, even when my joints are relatively quiet they still cause problems in my daily life. I am constantly worried about doing too much, for fear of causing a flare. I now automatically analyse every task that I have to do in a day and prioritise what I needs done, and what I can do if I have the energy.

It’s been 10 months exactly since months exactly since my diagnosis, and I have just experienced something which is probably the most heartbreaking encounter since my diagnosis. One thing that I am not, is a quitter. I try not to let my joints get in the way of things. I push through, sometimes a little too far, but I do everything I set out to do. So when my lecturer tells me that I can’t take part in a module of my course because of my joints, I literally felt like crying. As part of the physiotherapy course you learn about manual therapies and manipulations which are aimed mainly at mechanical problems… AKA injuries and Osteoarthritis etc. so they aren’t supposed to be used in inflammatory joint conditions. Since I have notified the Uni about my condition, the lecturer for this particular module informed me that I will not be allowed to be used as a model in this module, although I can practice on other people. This means I am a barrier to my fellow peers. I am a problem. And I really don’t want to be a problem. Even though me being a barrier is protecting my joints, I still feel like I should be contributing in some way to the class, but the fact people can’t touch me during this module means that it is going to be incredibly hard to give people advice on whether they are doing things right or wrong, and it is harder for me to be able to perform things correctly since I don’t know what it should feel like.

I asked the lecturer if it would be possible to participate in sessions on joints that aren’t affected but he is scared that it could cause joint involvement in other joints, so I can’t. Even though I am absolutely devastated that I can’t join in… when it comes to my knees, I am really glad that I can’t participate. Even the thought of someone touching my knees makes me cringe. My ligaments have been sore continuously for 2.5 years now and I still can’t bare it when someone touches the ligaments. It’s just so painful… But having said that, I want to be able to participate in the other joints. I want to be able to show my enthusiasm for my course, I want to show that my joints don’t hold me back, I don’t want people asking questions about why I can or cannot participate. Even though this is for my own safety, it makes me feel like an outsider.

My illness is invisible, and even those who know about it don’t know the extent to which it affects me, both mentally and physically. Things like this really make me question how confident I am in my abilities. The choice I usually have on whether I can participate has been taken away, and I really don’t like it. To my knowledge, my lecturers have never dealt with a chronic, inflammatory joint condition so it must be hard to fully understand how much of an impact not having a decision causes. There have been times that my joints have dictated what I can or can’t do, and now I have people telling me what I can or can’t do because of my joints. It feels like I have less freedom than I had. And it makes me hate my joints. I had grown to accept my condition, and now I feel like I am at a point where I cannot accept it any more, and I am tired of it.

I am scared of the future now too. My joints have only caused me to be scared of the future once before, during a flare, but now I feel quite ill when I think about it. I don’t know what is going to happen, I don’t want my joints to dictate what I do, and I don’t want people to dictate what I do based on my joints. The only real control I have over this condition is deciding what I can and can’t do so the fact that it can be taken away is scary.

I have 2 mottos in life… the first is to appreciate everything and enjoy everything you get, because you don’t know when it is going to be taken away… and once it’s gone, it might not come back. Right now, I am really appreciating the control I had… and I’m not sure whether I am going to get as much of it back as I want. And my second one is to experience as much as I can in life… I guess this would be classed as one of the more negative experiences but I am going to try and grow from it. I need to learn to let go of the negative things and focus on the positive things, and this is one negative thing that I am letting go of by writing this post.

My bizarre body

I haven’t posted in a while, I actually don’t think I’ve blogged since my last Rheumatology appointment in July… Sorry about that.

So what’s been happening? Well I think I am starting to flare but I am not 100% sure because it is early days. I woke up on Thursday far more fatigued that I usually am, it was an effort just getting out of bed… In fact it was an effort just having the energy to lift my arm! I am well acquainted with fatigue but this is one of the first times it has affected me so severely. I woke up feeling like I hadn’t slept in a week yet my SleepCycle app showed that I had slept the best I had in days.  

 
Earlier in the week I had started running again. I didn’t do much (6x 1 min running each followed by 90 seconds walking) but it really took it out of me. My costochondritis wouldn’t let me run for any longer than 1 minute without making me want to be physically sick… So I stopped running. My knees were also aching after the run and on examination I had found that they had both become puffy.  

 Although they weren’t pink/red they were warm to touch and so I iced them and put Voltarol (topical NSAID) on them but I saw very little improvement. They haven’t really gone down all that much since.

Yesterday the distal interphalangeal joint (aka the joint at the top of the toe) of my fourth toe also joined in the fun and decided to swell. I actually couldn’t decide if my toe did look swollen or not because I haven’t really examined my toes before so I recruited some of my expert friends who confirmed that my toe was in deed swollen. [I would post a picture but my nails are in desperate need of painting and I don’t really want to inflict that image upon everyone 😅]. My friend Elizabeth from The Girl With Arthritis suggested that my toe looked suspiciously similar to those of people with Psoriatic Arthritis, a condition that has been brought up as a diagnosis for me. Here is a link to a picture that looks very similar to what my toe looks like. [Note – the picture is about half way down the page, but the page is a good read to learn about PsA].

Apart from my knees and my toe my thumb and PIP (middle joint) on my index finger have been swollen on and off… This isn’t unusual but if you add in my other joints and the fatigue (and of course the increased stiffness and pain) it’s starting to look like a flare. And on top of all that I have a low grade fever which isn’t unusual to have during a flare, but this is the very first time I have noticed it. My temperature was 99.4 degrees Fahrenheit earlier and I haven’t checked it again but I feel much the same so I would assume that I still have a low grade temperature. 

As you can probably tell from what I have written, I am not feeling on top form but I am actually doing a whole lot better than I usually am during a flare so I am grateful for that. I have also been researching supplements that are supposed to be helpful in treating the symptoms of autoimmune diseases so I am going to bring these up with my GP next time I see him… I am not a great believer in holistic medicines but I am more than happy to give them a go as long as my GP/a qualified medical professions familiar with my case/symptoms/condition/me clears me to take them.

 Surprisingly despite this flare my ankle is feeling amazing… This is the same ankle that I have been having trouble with for years but for the last 2 weeks or so it hasn’t swelled up once! I also have very minimal pain from it although stiffness is still a problem. My body is bizarre and I don’t understand it but I am totally on board with my joints feeling better so I am not going to question it! I’m just extremely grateful that I don’t have to deal with a flaring ankle on top of all the other joints and the low grade fever! 

Time for a new Rheumatologist

A while back someone posted on one of the support groups I am a member of asked for people to take pictures of themselves holding a sign with a message they would like to give doctors so that they know how we feel. My sign had a message which said that just because my problem may seem small to you [i.e. the doctors], doesn’t mean it is small for me. When I wrote that I was thinking about my experience with my rheumatologist. She sees people who are really really sick and she also sees me. I am not that sick at all. My condition is not life threatening nor has it caused huge problems for me in the past. But the problems it does cause me feel like a big deal to me and when doctors do not take these things seriously it feels like you are being ignored. It feels like the problems you’ve come to them for are invalidated.

As a future medical professional myself I never compare people’s conditions. Just because one patient is sicker than another doesn’t mean that they can be made to feel that their condition isn’t a big deal. I also try to put myself in the patient’s position and think to myself, “if I was this patient, with this problem, what might I be feeling?” and based on that I try my best to treat them accordingly.

Yesterday I had my 3rd review since starting Plaquenil/Hydroxychloroquine in November 2014. I expected my rheumatologist to be engaged, to ask questions and to do a physical exam but instead I found her to be disinterested, unwilling to ask questions and unable and/or unwilling to answer my questions. The only examination that she did was on my ankles as these have been causing the most problems. I explained that my wrists were sore. Her response was to say “okay”, she didn’t look at my wrists or ask any more about them. I asked her about my hair falling out and all she could tell me was that it might be my autoimmune condition but she didn’t look at my hair. I came out of that appointment feeling totally invalidated, she knows I have pain and she doesn’t doubt that but by not examining me and not letting me know what she is thinking she makes me feel as if she doesn’t care.

I felt as if I couldn’t tell her everything that was going on because she didn’t care. I felt as if I was bugging her more than being her patient so I didn’t ask about things I was intending to ask about which was daft because I had waited four months for this appointment but when you are facing someone who you feel doesn’t care what you are saying or seems completely uninterested, it is hard to go into the things that you want to discuss. It’s easier to just leave them.

This appointment has had a few outcomes:

  1. My ANA is now negative where it was positive before… but we don’t know what this means or what has caused it [although I believe it was the Hydroxychloroquine]
  2. The MRI of my ankle came back clear but it is going to get reviewed by a specialist to double check, and if it is clear I will get referred to physiotherapy [which is what I requested]
  3. My Rheumatologist didn’t say anything about the Hydroxychloroquine so I am going to continue it at 400mg as I was prescribed until someone tells me otherwise
  4. I can try OTC topical NSAID gel to see if that helps on top of the Naproxen and paracetamol – I have since bought Voltarol
  5. I need to get a new Rheumatologist – as suggested by many, many people throughout social media

It has been a day since my appointment and I still feel quite upset about all of this. I have been with this rheumatologist since I was 14 or 15 and she has always believed me, though is never able to give me many answers. She doesn’t seem to care that much about my case and makes me feel invalidated. But if I go to another Rheumatologist [who will be an adult Rheumatologist, not an adolescent Rheumatologist] they might not take me seriously either or even worse, might not believe me. I have so many emotions flying around, my head feels like a bit of a mess but I have decided that it would be best to ask for a referral to another Rheumatologist. Hopefully this new Rheumatologist will be closer to my University than this one was.

Achilles tendonitis and podiatry 

People who have been following this blog for a while may remember that back in December I was diagnosed with Bilateral Achilles Tendonitis (a fancy way to say inflammation of both tendons at the back of the ankles). I got my Achilles Tendonitis diagnosis just 3 weeks after I had been diagnosed with an Autoimmune disease so the thought was that it could be my autoimmune disease causing the inflammation. Makes sense huh? Well it isn’t quite that simple. Achilles Tendonitis can be caused by an autoimmune disease BUT it can also be caused by mechanical problems such as flat feet etc. And I do have flat feet. So my Tendonitis could be caused by my flat feet or by my autoimmune disease or both. 

My Rheumatologist referred me to a podiatrist that specialises in Rheumatology for some exercises/insoles that in theory should help strengthen position my feet in a way that reduces the strain on my tendons therefore preventing them from becoming inflamed because of my flat feet. But a podiatrist can not do much for inflammation caused by my autoimmune disease. The first podiatrist I saw believed that my autoimmune condition was the cause of the Tendonitis and it had nothing to do with the fact that I have flat feet because I already had insoles. I have given exercises to do and told to come back in a few months.

Those few months passed quite slowly. Although the Tendonitis was resolving, it was taking a long time and so by the time I saw the second podiatrist, I was better but not 100%. This time they decided to have a look at my insoles. It turns out that the hard plastic material my insoles were made out of couldn’t even support the weight of my podiatrists hand and would flatten out. Meaning that my insoles were pretty much useless as they couldn’t hold their shape when I stood on them. The plan from there was to get molds of my feet (involing me standing in a shoe box full of foam) and to get custom insoles which I should be getting tomorrow.

It took over 6 months for my Achilles Tendonitis to resolve, or almost resolve because I still had a few days where they were sore. But since the start of this month my heels have been getting progressively more sore. Not a good sign. As a physiotherapy student I am able to do a mini assessment (I can’t do everything because it’s actually surprisingly hard to assess your own feet) which is telling me that it’s quite likely my Achilles Tendonitis is back, and based on the area of my tendon that hurts (the insertion site) it’s quite likely that it is because of my immune system rather than if a different area of my tendon hurt which would be more likely a result of strain or injury.

Something that we also found with my tendons is that one is thicker than the other. This is usually a result of inflammation, so the 6+ months of inflammation I had earlier this year have caused scarring at my Achilles tendon causing it to become thickened. There isn’t an awful lot I can do about that unless it becomes so bad that surgical intervention is needed, which is not necessary right now. But hopefully with the help of these insoles we can reduce any inflammation caused by my flat feet and that won’t become any worse. 

I see my rheumatologist next week, on the 29th, and this will be another thing we have to discuss. I am getting worried now that the combination of me having more inflammation at my tendons and already having one ankle that has lost a significant amount of movement is going to cause problems for me. Walking is hard mainly because of the pain so I am back to taking Naproxen 500mg twice a day and topping up on Paracetamol as needed but that is only doing so much. Walking is also hard because of the lack of movement in my right ankle which means that walking on uneven ground or up steps that aren’t level is quite difficult because of the lost flexibility. I don’t think I wrote about the problems my ankle has been causing me when I was on placement (part of the physiotherapy course is called placement, where you go out into a hospital and learn how to apply the skills learnt at Uni in a hospital setting with real patients). With most patients I was okay to treat them while I was standing up which is perfectly fine for me, but for a few patients their treatment involved me kneeling. My ankle is not flexible enough for me to kneel, and at one point the pain caused by my needing to kneel resulted in me nearly passing out and almost being physically sick. This is a major problem because if I can not kneel, working is going to be difficult. I am terrified that I won’t be able to work in the future because I won’t be able to sit in the positions that I need to, to treat patients. I’m terrified that the Plaquenil/Hydroxychloroquine medication I am on is not helping me sufficiently so that I know I will be able to work when I qualify, and I know I will be able to finish my course. And I am really angry that my joints have got this bad that I am terrified about my future. This should never have happened, I should have started physiotherapy as soon as it was apparent I was loosing range of movement instead of being in the position that I have lost the range of movement and I don’t know how easy it is going to be to get back. Physiotherapy is definitely one thing that I am going to ask my Rheumatologist for. Along with discussing whether the Plaquenil is working sufficiently to help reduce the inflammation in my joints even though I am still swelling and sore and stiff.