Joint Pain

A few weeks ago I officially became old. After kneeling to place an IV in a patient’s arm I stood up and felt a shooting pain in my leg. I hobbled out of the room without the patient noticing. The next day my knee expanded to grapefruit size (not the knee pictured). Four weeks later I’m back to slow running with some twinges, but it seems my ultimate fighting days are coming to a close.

Patients land in ERs with new or recurrent joint pains all the time. Rarely are they emergencies that warrant $1000+ bills. However, exceptions do exist.

Red Flags:

• Fever
• Redness
• Previous joint infection
• Concurrent STDs
• IV drug use
• Direct trauma
• Multiple affected joints, esp in kids
• Associated rash
• Associated tick bites
• Suspected abuse
• “I can feel something crunching in there.”

Happy Words

• “This is gout and I just need a shot.”
• “Twisted wrong and felt a sudden pain.”
• “I just ran a marathon.”
• “My doc usually injects cortisone which makes it better.”

Quick fixes in the ER are few. Mainly we try to rule out the life threats, and then take the edge off. If we suspect fracture we’ll order an X-ray. If infection, maybe we’ll order “CBC, CRP, ESR” blood tests. Rarely are these particularly helpful, but they give future caregivers baseline numbers should the pains get worse. Plus they show we care.If we’re really concerned, maybe we’ll “tap the joint.” This means we’ll withdraw fluid using a needle and syringe to then send it for analysis and culture. Sometimes we’ll discover crystals to suggest gout, pus to suggest infection, or blood to suggest injury. Drainage itself can sometimes be extremely therapeutic as well. It’s actually one of my favorite services because of the immediate relief.

If no tap needed and we’re not so worried for infection or fracture, we’ll try to kill the pain with medicines, then recommend “RICE” for rest, ice, compression and elevation. Frequently we’ll offer crutches, splints or slings. Ibuprofen (always with food) is our go-to NSAID. Folks with gout may receive colchicine, though that’s getting fairly expensive now. We try to limit use of narcotics, but sadly, for some patients it’s their only relief.

For pains that persist or where we suspect serious ligamentous injury, then physical therapy and MRIs may be next in line. However, rarely are these organized through the ER. In general, if patients say it “hurts when I do that,” we counter with “then don’t do that.” This may sound snide, but it’s actually good advice. However, as in my case, more often than not, time is the best medicine.

Give Pre-R a call if you have joints giving you grief. Unless you’re suspecting deep underlying infection, I bet we can help. Even if infection is suspected, or if you may need an orthopedist or rheumatologist, PT or an MRI, we’ll do our best to point you the right way.

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