A 55 year-old man with a history of RA is seen for pain in both knees with recurrent swelling of the right knee for the past 6 months. He has been seen twice at a walk-in clinic and has had the fluid drained. Each time the fluid has re-accumulated. He has tried increasing his oral prednisone from 5 mg to 20 mg a day without improvement in either the pain or the swelling. He is stiff for 10 minutes in the morning and is stiff when he arises from a chair. Walking is limited because of the pain. Because of the knee problems, he was not able to continue working and has been unemployed for the past 6 months. He denies any other joint pain on the 20 mg of prednisone.

He relates a 15 year history of RA. He was doing well on methotrexate 15 mg weekly, prednisone 5 mg a day and etanercept 50 mg weekly but had quit taking all but the prednisone roughly one year prior because he thought he was doing well.

His examination is notable for difficulty arising from the chair secondary to knee pain and stiffness. He walks with the aid of a cane. There are synovial effusions in both knees, larger on the right. No warmth is noted. Valgus deformity is present on the right. There is pain, stiffness and coarse crepitance with range of motion of both knees, more pronounced on the right. In the hands there is ulnar deviation and subluxation of the MCPs with swan-neck deformities in multiple fingers, but no synovitis. Both wrists demonstrate widening and subluxation with some loss of flexion and extension but no warmth, swelling or pain. There is a nodule at the left olecranon. The feet also show old deformities consistent with RA with subluxation of the metatarsal heads but no tenderness.