Yoko Kashiwagi is a successful 42-year-old media executive, a graduate of Keio University who now lives in Denenchofu, just outside Tokyo, and works in Tsukiji downtown. Ms. Kashiwagi was a marathon runner in her college days, and continued to run and exercise regularly well into her 30s. But for the last five years her business responsibilities have prevented her from getting much exercise, and over the last two years she has stopped exercising altogether, has taken up smoking cigarettes, and has gained 7 or 8 kilos. Over the same period, she has been finding it increasingly more difficult to move her left knee, the same knee she injured during her running practice when she was in college.

Ms. Kashiwagi wants your advice because she is afraid that she might have rheumatoid arthritis or some other kind of arthritis. (She is familiar with complications from arthritis since her father, who was also an athlete, underwent ACL reconstruction surgery last year.) Ms. Kashiwagi tells you that she's been feeling more and more fatigued lately, and the crackling and stiffness in her left knee sometimes is very painful. In addition, she has noticed that her left knee gets swollen and red, especially when she has to work late into the night. Ms. Kashiwagi would like you to help her relieve her pain, and she also wants to know what her prognosis might be for the future.

She tells you that she will not undergo ACL surgery under any circumstances, but she also admits that she is afraid of becoming sicker. "In my business, a youthful and vigorous appearance is most important, and I'm frankly afraid of looking older than I am -- I'm only in my early 40s, after all!" Since Ms. Kashiwagi is unmarried, she is fearful of becoming much more isolated if her knee causes her much more trouble.