RheumaBlog

Same dragon, different day.

Physiatrist-type doctor to Wren: “Well, I’m stumped.”

He’s referring to the fact that steroid injections into both hips, twice, have provided no relief at all to Wren’s painful bursitis. In fact, it’s much worse now than it was.

Wren to Physiatrist: (gapes)

P to W: “In most cases, bursitis tends to resolve over time on its own in spite of our best efforts.” He grins in a self-deprecating manner.

W to herself: Oh, isn’t he cute? He’s “stumped,” so I just have to live with it. I hate him.

W to P: (a bit acidly) “So I just have to get used to it? I’ll always have this?”

P to W: “I know it hurts. I have a torn meniscus and I’m in training for a 100-mile marathon. It’s a matter of perseverance and balance. You just keep doing the stretches and, here, take this Vicodin for the pain. I don’t see any need for a follow-up.”

W: “Right. Well. Thanks anyway.” (thinks to herself as she presents her backside to this jerk: Next time you practice for that marathon I hope you trip and skin both knees.)

So, that’s where it stands. The pain/physical therapy physician/specialist my rheumatologist referred me to is out of ideas regarding my bursitis, except to give me another prescription for narcotic pain meds. I have an appointment with Joe, my PT, on Wednesday, so perhaps he’ll have more stretches, etc. I can do, and maybe, someday, they’ll help relieve the inflammation and the pain will finally go away. “Someday” is the operative word.

Since I was at the VA hospital anyway, I had my RA and routine blood tests done today. I also made an appointment with my primary care doc to see if she’ll prescribe me something to help me sleep through my bloody aching hips, since the fancy pain/whatever-he-is doc told me I’d have to discuss that with her when I asked him for something to help me sleep at night. Sleep aids, it seems, are not his thing.

Tomorrow  I’m going to see if I can get an appointment with my rheumatologist. He told me not to come back until May, but I think I need to see him sooner than that, if I can. See, I figure that my inflammation levels must be off the charts right now. The hip bursitis pain is 24-7. My hands ache constantly and I’m having intermittent flares of varying intensity in other joints all over my body. Shoulders. Elbows (!! Never had flares there before!!). Ankles. Even, I think, that funny little joint in the larynx, since I’m hoarse off and on these days for no good reason I can think of, except RA.

So it seems pretty obvious to me that the RA drugs I’m taking at the moment aren’t working very well. Perhaps if I can get the RA to calm down, the bursitis will too, since it’s most likely being triggered by the RA.

Man, I’d like to tie that smug doc’s shoelaces together.

Grrrr.

30 thoughts on “Stumped?!

  1. pollyannapenguin says:

    Oh Wren – how awful! What a jerk! You’re far too nice to only wish skinned knees on him! ‘A question of balance’ indeed. Idiot has NO idea what you’re going through, obviously. Grrrrrrrrrrr on your behalf!

    Polly

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    1. Wren says:

      What a terrific “grrrrrrr,” Polly! I heard it all the way across the ocean and the continent! THAT would sure make that doc shake in his fancy running shoes… 😉 Thanks for that, m’dear. 😀

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  2. Jules says:

    OH Wren- I am so sorry you aren’t getting any relief. Are they positive it’s bursitis? My hips are miserable and my rheumy believes mine are somewhere between my RA and my fibro. She did cortisone injections recently for the short term because I am heading on a trip today where I will be walking for hours on end but for the long term she has me on 3 flexeril and 2 neurontin a night so I can sleep. I hope they give you something that gives you some relief.

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    1. Wren says:

      It really IS bursitis, Jules. But your idea about taking flexeril (a muscle relaxer, right?) and neurontin (nerve pain reliever) is intriguing. I’ll ask my rheumy about them. My mother takes one capsule of neurontin each evening for her sciatica, and it makes her sleep like a baby, something she’s NEVER done before. So it’s definitely worth looking into.

      I hope your travel and time on your feet is going well, and that you’re feeling good. Thanks for your compassion, kindness and support. 🙂

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  3. Laurie says:

    I was going to say what Jules said: maybe it’s not bursitis but RA. My hips are arching somewhat now while I’m transitioning drugs and they haven’t ached in ages. I know it’s RA and nothing else. And since you’re aching in other areas, too, it seems logical. Are you on a biologic? Might be worth checking out…

    Hope you get some answers soon and feel better soon.

    🙂 L

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    1. Wren says:

      Thank you, Laurie. I hope I get some answers and relief soon, too. I’ve had awful RA flares over the years, so I’m familiar with coping with pain. But RA flares eventually fade away and you get some relief, even if it’s not for very long. This bursitis pain is 24/7, and it has really worn me down.

      Even so, I figure it can’t last forever, right? Right?? 😉

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  4. carlascorner says:

    I’m sorry. Having been a hip bursitis sufferer for years, I know exactly how frustrating this is. One thing that I’ve found that helps mine — rather than a steroid injection, you might ask your rheumy for a prednisone taper. If it is RA, that will help calm it down, and if it truly is “just” bursitis the systemic application of steroids will have a blanket/shotgun effect rather than the injection which might be targeting the wrong area. Hopefully they can give you something to help you sleep. Hang in there.

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    1. Wren says:

      Ah, Carla, you’re always so compassionate and encouraging. Thank you for that. I’ll ask my rheumy about the prednisone taper, though I’ve never really wanted to take that drug because of all the nasty side-effects I’ve read about. Still, if it can relieve the pain, it’ll be worth it. Unrelenting pain really does dampen joy and tromp hard on hope.

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  5. Lana says:

    If it makes you feel any better, I wish I could slap him for you. 🙂 I am sorry that you are having a difficult time. I hope that it gets better and soon. Take care my dear and I wish you pain-free days.

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    1. Wren says:

      Thanks, Lana. You’re absolutely welcome to give that doc a virtual slap for me. He needs to be startled out of his superiority, for sure. 😉

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  6. Mary says:

    Really sorry you continue to have so much pain in your hips. I agree with Laurie that perhaps this has something to do with your RA. It may be time to look into biologicals. Are your on Mtx? It just doesn’t sound like the plaquinil is enough. Hope you find a solution soon.

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    1. Wren says:

      Hi Mary! My rheumatologist told me a while back that the VA does have Humira on its formulary, but he only prescribes it when all other options have been exhausted, since it makes you so infection prone. I’ll ask him about it again, though. I really do think that my RA is ramping up again in spite of the cocktail of meds I’m already taking each day. Sigh. In a way, I guess I should be glad that my immune system is so danged tough, you know? I just wish it wouldn’t mistake my joints for enemies! 😉

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      1. Wren says:

        Oh–and I’m not on MTX, as it made me feel horrible. I’m taking leflunomide, sulfasalazine and plaquenil right now.

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  7. Squirrel says:

    What a jerk!!!!!! The nerve, going on about training for his marathon.. rubbing it in your face that he’s so fit and healthy. I would’ve punched him.

    The others have given good advice, maybe it is all the RA’s fault. I hope you can see your rheumy very soon. Thinking of you and keeping my fingers crossed something moves forward with this soon, you’ve suffered with these hips for too long!!

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    1. Wren says:

      It’s pretty clear that what I have going on in my hips is bursitis (the tender points prove it), but it’s true that my RA is probably what triggered the bursae to get inflamed. And, since that’s likely the case, then a change of meds might be effective for relief.

      Thanks for the encouragement and support, Squirrel. If you’d been there with me, I’d have stepped back and allowed you to punch the guy in the nose! Sure would have felt good!

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  8. RA Guy says:

    What a coincidence…I’m currently training for a 100-foot marathon myself.

    Hope your hips get some relief soon!

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    1. Wren says:

      LOLOLOL! Oh, Guy, you do have a way about you. Thanks for making me laugh!

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  9. Melissa says:

    I’ve had bursitis in my left hip for nearly 4 years. I’ve had several cortisone injections and my old doctor was just like, “Well, you have bursitis, get used to it”. But then I spoke to another doctor and I was informed that ultrasound therapy helps a lot of people with bursitis. I’m on a list to get in to get it. Might be something to ask about?

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    1. Wren says:

      My PT did use ultrasound on my left hip today, Melissa, and it (along with a TENS treatment, so I’m not sure which one worked… maybe both?) did relieve the pain somewhat in that hip for several hours. As you might imagine, I was delighted! Thanks for the suggestion. I’ll definitely ask for this again.

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  10. Wendy says:

    Wow, anyone that would compare pain they inflict on themselves to RA and bursitis is a moron! I’ve run 50 miles in a day for the American Cancer Society and it hurt like heck the last couple of hours, but nothing like an RA flare. With running I know I can quit and go home any time and the pain will stop, it is a choice, not inescapable pain with no relief like RA.

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    1. Wren says:

      Yep, running with an injury is a choice (not a real good one, I suspect), while RA and bursitis certainly aren’t. This smug doc absolutely lacks empathy. Sympathy I can do without, but empathy from a doctor or a caregiver boosts hope. Ah, well. Perhaps one day he’ll be in a position to need it himself, not get it, and learn a valuable lesson.

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  11. Eileen says:

    Yes he’s an idiot – but allow him one thing: despite his training that he is omniscient and (probably) omnipotent he DID actually admit the truth, which is that he is neither!

    I’ve been looking all over the place to see if I can find an answer but the most useful medical articles are all behind a pay-wall (Grrrr!) – ask your rheumy if it is possible for patients with RA to also develop PMR (polymyalgia rheumatica). It was the mention of your shoulders that makes me think about it: my worst symptoms with PMR were bursitis in both hip joints that was bad at night as well as when walking plus my hands hurt all over and my elbows were also bad with tendonitis causing pain running down diagonally towards my wrists. It is common for shoulder bursitis to be found by MRI in PMR patients (they don’t usually bother, it was a research thing). If you are not on steroids for your RA it could be – the other drugs don’t have an effect. At this stage of pain anything is worth considering! Do hope the rheumy can come up with something though. Pain is bad, non-stop pain is hell – especially when you can’t sleep.

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    1. Wren says:

      Hi, Eileen! I hadn’t even thought about this possibly being polymyalgia rheumatica, but wow, I suppose it could be. Since I’ve had RA flares in my shoulders many times in the past, I naturally figured that was what caused my shoulder to hurt. But… who knows? Another good question to put to my doc. Thank you!

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  12. Sabine says:

    How truly awful to have pain like that.
    I have had bursitis in my heel (yes, it’s possible and no, injections were simply too painful there) and it did take ages – one whole year to be precise – but it passed. Just like that, but also with reducing stress and strain to the affected area as much as possible.

    As for pain relief: There are many more options available today than the standard pain numbing medications which hit you like a brick and make you drowsy like hell. I have had my share of that and have been lucky with my pain doctor. She put me on a drug to stimulate serotonin production – which is what your body produces to counteract pain (amitriptylin). In fact, it’s a first generation antidepressant but it has long since found its way into analgetics. I just took it before night time and it usually put me to sleep gently and without the heavy knock out effect of sleeping pills. I also got Lyrica for a couple of months and it worked really well. Lyrica basically untangles the pain receptors when they have become messed up after lengthy or chronic pain episodes.
    Good luck, don’t stop looking for medical help.

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    1. Wren says:

      You know, Sabine, my rheumy prescribed Elavil to help me sleep about a year ago, back when this bursitis first started bothering me–and before I knew what it was. I’m not sure why I stopped taking it. So I’ll ask him for it again. It did help me sleep, though I suspect I’d need a larger dose of it now, since the pain is much more intense than it was back then.

      Thanks for the suggestion and reminding me about it. 🙂

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  13. Chelsea says:

    Agree you should try some oral prednisone if you haven’t already.

    I don’t know for sure if bursitis is or can be directly caused by RA, but I believe it at least predisposes you more to getting bursitis.

    Here’s some of what I found:

    J Orthop Sci. 2009 Jul;14(4):455-8. Epub 2009 Aug 7.
    Iliopectineal bursitis associated with rapid destruction of a rheumatoid hip joint.
    PMID: 19662482 [PubMed – indexed for MEDLINE]
    (no abstract)

    Mod Rheumatol. 2008;18(4):394-8. Epub 2008 Apr 18.
    Iliopsoas bursitis-associated femoral neuropathy exacerbated after internal fixation of an intertrochanteric hip fracture in rheumatoid arthritis: a case report.
    Abstract
    We present the case of a 63-year-old woman with a six-year history of rheumatoid arthritis (RA) and a left iliopsoas bursitis. Radiography had detected destructive changes in her hip joint associated with her bursitis, and she had reported some paresthesia along the left anterior distal thigh. Her pain and numbness remained tolerable, and her disease activity was well controlled until she accidentally fell on the floor, which resulted in an unstable intertrochanteric fracture of left femur with displacement of the proximal portion. The fracture was successfully treated with open reduction and internal fixation, but after the surgery, her femoral nerve palsy worsened. She subsequently underwent bursa excision after the failure of conservative treatment. Accordingly, after bursa excision, the postoperative course was uneventful, and her neurological symptoms gradually disappeared. We would recommend that bursa excision be considered even in cases of iliopsoas bursitis associated with mild femoral neuropathy when destructive changes in the hip joint are also present.
    PMID: 18421416 [PubMed – indexed for MEDLINE]

    Ann Rheum Dis. 1982 Dec;41(6):602-3.
    Trochanteric bursitis–a frequent cause of ‘hip’ pain in rheumatoid arthritis.
    Raman D, Haslock I.
    Abstract
    One hundred consecutive patients with rheumatoid arthritis (RA) were examined for the presence of trochanteric bursitis. This condition was found in 15. Ten patients responded to a single local injection of corticosteroid and the remaining 5 to a second injection. Trochanteric bursitis is an underdiagnosed, easily remediable cause of pain in RA. Specific examination for in presence should be a routine in all patients with RA, especially those with hip pain.
    PMID: 7149797 [PubMed – indexed for MEDLINE]PMCID: PMC1000992Free PMC Article

    Reumatismo. 1965 Jan-Feb;17:35-44.
    [SUBDELTOID RHEUMATOID BURSITIS WITH RICE-LIKE GRANULES].
    [Article in Italian]
    LUCHERINI T, BURATTI L.
    PMID: 14299217 [PubMed – indexed for MEDLINE]
    (no abstract)

    Ann Rheum Dis. 1982 Aug;41(4):360-70.
    Rheumatoid and other diseases of the cervical interspinous bursae, and changes in the spinous processes.
    Bywaters EG.
    Abstract
    Bursal spaces between the cervical interspinous processes were found at necropsy in 14 out of 27 “normal’ adult necks, especially when the spines were close together. In this random series they were the seat of crystallopathic disease in 2 instances out of 14 cases. In spines from 9 cases of adult-onset rheumatoid arthritis, rheumatoid bursitis was seen in 2 and banal bursitis in 2. In juvenile-onset chronic arthritis inflammatory bursal changes of rheumatoid nature were found in 2 out of 5 cases, and are compared with the “normal’. A third case showed crystallopathic destruction. In one instance of adult RA very severe changes were seen, with destruction of the spinous processes, and this was associated with hypermobile segments dependent on discal destruction starting in the oncovertebral joints. An association is described between discal lesions, spinous erosion, enthesopathy, and interspinous bursitis.
    PMID: 7114919 [PubMed – indexed for MEDLINE]PMCID: PMC1000952Free PMC Article

    Ann Rheum Dis. 1985 May;44(5):336-40.
    Rheumatoid bursitis extending into the clavicle and to the skin surface.
    Bassett LW, Gold RH, Mirra JM.
    Abstract
    A woman with rheumatoid arthritis developed persistent sterile drainage from a cutaneous fistula after biopsy of an inflamed supraclavicular mass. Radiographs showed several cavities in the underlying clavicle. Inability to culture a pathogen and failure of the fistula to heal despite empirical courses of antibiotic therapy led to surgical intervention. The final diagnosis, based on careful histological analysis by special staining techniques, was rheumatoid bursitis extending into the clavicle and to the skin surface.
    PMID: 4004363 [PubMed – indexed for MEDLINE]PMCID: PMC1001642Free PMC Article

    Clin Rheumatol. 2006 Sep;25(5):734-6. Epub 2005 Oct 13.
    MRI appearance of retrocalcaneal bursitis and rheumatoid nodule in a patient with rheumatoid arthritis.
    Mutlu H, Sildiroglu H, Pekkafali Z, Kizilkaya E, Cermik H.
    GATA HEH Radyoloji Servisi, Istanbul, 81327, Turkey. hakanmutlu1@yahoo.com
    Abstract
    Rheumatoid arthritis is an autoimmune disorder of unknown etiology characterized by symmetric, erosive synovitis and sometimes multisystem involvement. Rheumatoid nodules have been reported in as many as 20-30% of patients with rheumatoid arthritis; however, they are not commonly seen in the feet. We present magnetic resonance (MR) findings of a rarely seen case of rheumatoid bursitis in the retrocalcaneal bursa associated with a subcutaneous rheumatoid nodule inferior to the calcaneus which histologically confirmed the rheumatoid arthritis. To the best of our knowledge, this is the first case that rheumatoid bursitis in the retrocalcaneal bursa associated with the rheumatoid nodule in the foot was revealed by MR imaging.
    PMID: 16222409 [PubMed – indexed for MEDLINE]

    Rev Rhum Engl Ed. 1999 Jun;66(6):354-8.
    Multiple rheumatoid bursitis with migrating chylous cysts. Report of a case in a European woman and review of the literature.
    Berthelot JM, Huguet D, Gouin F, Letenneur J, Bertrand-Vasseur A, Moreau A, Lemaitre R, Maugars Y, Prost A.
    Rheumatology Department, Nantes Teaching Hospital, France.
    Abstract
    We report a case of recurrent multiple bursitis (19 episodes at nine sites) requiring seven surgical procedures in a European women with a 38-year history of severe, nodular, destructive seropositive rheumatoid arthritis unresponsive to second-line drugs. The episodes of bursitis were not correlated with activity of the joint disease. Some cysts migrated over a considerable distance. At least two cysts contained chylous fluid. The histologic study of one cyst demonstrated a cholesterol crystal granuloma. Potential relationships linking cholesterol crystals, chylous cysts, and migrating multiple bursitis are discussed. The relevant literature is reviewed.
    PMID: 10418067 [PubMed – indexed for MEDLINE]

    J Pediatr Surg. 2008 Nov;43(11):2087-90.
    Aspiration and triamcinolone acetonide injection of wrist synovial cysts in children.
    Colberg RE, Sánchez CF, Lugo-Vicente H.
    UPR School of Medicine, San Juan, Puerto Rico.
    Abstract
    PURPOSE: The aim of this case series report is to assess the effectiveness of aspiration and injection of triamcinolone acetonide for treatment of wrist synovial cysts in children.
    METHODS: Twenty-one records of pediatric patients with synovial cyst on the wrist treated with aspiration and triamcinolone acetonide injection were selected for analysis of their outcomes. All cases were aspirated and injected at the operating room under mask induction anesthesia. Three categories were used to classify the patients’ outcomes: (1) successful treatment with no recurrence, (2) successful treatment with residual sclerotic lump, and (3) recurrence of cyst.
    RESULTS: Fourteen females and 7 males with an average age of 7.2 years had a mean time with the cyst of 1 year. All children were asymptomatic. After aspiration, 13 (62%) of 21 patients experienced successful treatment of the synovial cyst with no recurrence after a single intervention. Five patients had a residual lump at the site of the cyst (24%), which disappeared after an average of 6 months. Three patients experienced true recurrence of the synovial cyst (14%). Average follow-up was 2.5 years.
    CONCLUSIONS: Aspiration and injection of triamcinolone accounted for a considerable reduction in recurrence. Aspiration and triamcinolone acetonide injection of wrist synovial cysts is an effective and safe treatment that may be considered as first-line treatment in the pediatric population if there is no resolution after 1 year of observation.
    PMID: 18970945 [PubMed – indexed for MEDLINE]

    Dermatol Surg. 2002 Dec;28(12):1177-9.
    Successful treatment of multiple bursal cysts in systemic sclerosis.
    Tanemura A, Yamaguchi Y, Kubo T, Yano K, Itami S.
    Department of Dermatology, Osaka University Graduate School of Medicine, Osaka, Japan.
    Abstract
    BACKGROUND: Bursitis frequently occurs in the various conditions of autoimmune disorders including rheumatoid arthritis, but there have been few cases of effusive bursitis in systemic sclerosis.
    OBJECTIVE: To present a case of systemic sclerosis with multiple bursitis on upper, lower extremities, and trunk with or without joint involvement.
    METHODS: Case report and review of the literature.
    RESULTS: Multiple asymptomatic cystic masses contained yellow and chalky sterile fluid, all of which were diagnosed as effusive bursitis. Most of them were treated with a surgical resection, a continuous drainage, and an injection of highly concentrated ethanol into their internal spaces. However, an intrabursal injection of emulsified triamcinolone acetonide was the only effective treatment for the giant mass that occurred on the right chest wall.
    CONCLUSION: Successful treatment of multiple bursal cysts with systemic sclerosis was presented.
    PMID: 12472502 [PubMed – indexed for MEDLINE]

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    1. Wren says:

      WOW, Chelsea! THANKS for taking the time to look all this up and post it, and the links, for me! I definitely WILL ask my rheumy about the oral prednisone. You’re so kind!

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  14. Terry says:

    Wren, I’, so sorry to hear this. I did get a good laugh out of “I hope you trip and skin both knees.” Thank you for the laugh and I hope you find some relief soon my friend. If you need me to, I’ll come out there and help tie his shoe laces together!

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    1. Wren says:

      Thanks, Terry. Between us, I bet we could come up with a terrific knot for those shoelaces! 😉

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  15. Eileen says:

    Go back to see him with the cane – and let it slip slightly if he gets up to pass you! Preferably between his legs – whether at foot level or higher!

    Just answered a forum post from a 47 year old who was told “PMR /GCA happens in 70 year olds, it never occurs at 47”. REALLY? 2 mins on google found a paper in a journal of general practice entitled “24 year old man with signs and symptoms of PMR”, mentioning 6 other cases at similar ages. When treated as a horse not a zebra he was back to running training after 2 days of oral pred at 50mg/day after being unable to get out of bed before.

    Now I know doctors have to know a lot about a lot – wouldn’t it be nice if on some occasions they didn’t show themselves to know a lot of nothing!

    Good luck Wren – I hope that’s a 10-fold appointment you’ve got with your poor rheumy!

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