THE HOT RED SWOLLEN JOINT

© Copyright Philip Evans
CONTENTS

A PUZZLE AND A MYSTERY

These joints seem a mystery. There is the joint, looking for all the world as if it had been in an accident and got injured, - but it has not. The patient cannot think what has caused it, and supposes that it must be when she turned over in bed, or when opening a door, but surely that could not hurt a joint ?

The joint - indeed the whole region around the joint - is swollen and red, and feels much warmer than the other side. It is also painful, especially when moved, and cannot be used for day-to-day things like pouring a kettle (if a wrist) or going upstairs (if an ankle). After a day or two, when it seems it is not going to get better by itself, help is obviously needed.

By the way, the word 'arthritis', when it is used medically, does not mean 'a horrible disease that is going to cripple you'. It means 'a joint problem', or more accurately, 'inflammation in a joint or joints'. (Arthros Gk = joint, -itis = inflammation in, like appendicitis.

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ELIMINATING TRAUMA AS THE CAUSE

When a clinician is visited, the first thing she will do is to eliminate trauma, because the usual cause for a joint being like this is that it has been injured. Hence she will spend a considerable time trying to find if it got hurt without you realising it was.

When looking for a traumatic cause, questions will be asked to eliminate injury, over-use, or change of use. Thus, about any recent bangs or twists (gardening or sport? Falls in the pub car-park? - maybe at a time when your memory of such little things would be decidedly hazy !). Also about recent bouts of exercise (charity cycle rides ?, week-end seaside walks ?), or unusual activities (having to heave on a jib-sheet when crewing a dinghy ?).

A lady in her 50s developed a painful swelling over the forefoot over four weeks. Any recent change of walking, or activity? Well yes.... she had got a new dog, from a rescue centre; and she did have to exercise it. How far, for how long ? Well, say about one to two hours, depending on the weather. And that's twice a day, say about 4 to 5 miles a day. Any exercise before that ? Well, no, not really, none at all. This lady had developed a stress fracture of two metatarsal bones in her foot. This is nicknamed a March Fracture, as it was first described in raw army recruits unused to marching distances carrying full equipment.

A 42-yr old mother of four had swelling and pain at the back of her left wrist. It was only after a lot of inquisitive questions that she remembered that at the Christmas / New Year period, some days before she had had to make an emergency batch of six dozen mince pies for a surprise visit of her children and their friends - and make up the beds ! She was left-handed, and made pastry by hand. A good clinician may sometimes seem intrusively inquisitive!

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TENOSYNIVITIS AND BURSITIS

The mince pie mother had injured the tendons of her wrist by over-working them. The commonest causes for this type of injury are (i) painting and decorating the house over a bank holiday week-end, and (ii) taking on a new job that involves a lot of wrist work. Typical are factory assembly, chicken processing, and packing.

When we rest after work our bodies repair the small injuries that have occurred, ready for the next day. If the days work has been unusually hard, by the next day our body cannot yet not yet healed; It is unprepared to work again. If this occurs, a normal days work will cause further injuries. Without adequate rest, there is not enough time for healing to take place. The unhealed injuries lead to reflex inflammation [see Inflammation], a body reaction involving cells and blood vessels, and exhibiting the classic trio of Heat, Redness, and Pain (Calor, Rubor,and Dolor). And also Tumor (Swelling). Because the tendons cross the wrist the spread of Inflammation may appear to be from the wrist, so the joint and not the tendons may appear to be the cause.

The mince-pie Mum and the over-worked Factory Operatives or Home Decorators, all had symptoms from overworking the tendons to their wrist and fingers-and-thumbs. This is called Tenosynovitis. [See Tenosynovitis, in Injuries and Healing in Different Tissues.]

Then there is the home handyman, laying new carpets over a week-end; or the student, working through the nights of a week-end to make up for past term-times lost to drinking by day and frolicking by night. The former worker can find his knees become swollen and red over the knee-cap, due to inflammation in the lubricating bursa [Gk. = a purse] over the kneecap (Housemaid's Knee); the latter wastrel may find his elbow hurting two to three days later, with inflammation spreading from underneath the point. This is Students Elbow, or Olecranon Bursitis, inflammation in the little space that allows the skin to slide over the point of the elbow.

There are other bursae, at the ankle, the hip and around certain muscle tendons. All can get inflamed from over-use.

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REPETITIVE STRAIN INJURY (R.S.I.) - Cumulative Trauma

Usually this is a much later stage in over-use and under-healing process. Often it has gone on for some time. One way that it happens is that some job - maybe processing chickens in a chicken factory, or operating a VDU machine in a vast insurance firm. Even playing and practising for some famous orchestra a difficult instrument that involves contorting one wrist - becomes too painful to do. Maybe the work did seem pretty continuous, with very little rest or change. Perhaps after a while you get to accept an acheing wrist at the end of the day.

But then comes a different kind of problem :- It may be a kind of tingly numbness in the hand, coming on at the end of a hard day or even in the middle of the night. It may be a short-lived agonising pain in the shoulder, like a searing hot knife, that is brought on simply by reaching for something up on a shelf. Or a most unpleasant pain in the arm - just from reaching back for a safety belt. All of these pass off quite quickly, but they are symptoms that quite another tissue is involved - the nerves.

What is happening is that the nerves, that pass nearby the overworking tendons and joints, are getting inflamed in the same way. And scar tissue may even be getting laid down in the nerves themselves. Slow accumulation of scar tissue will gradually affect the blood supply and stretchability of the nerves. Patches of skin will become less sensitive, even numb; muscles may feel weak and look wasted. And some stretching movements will become frightfully painful.

RSI had a checquered history. At first at was not believed in, only the poor workers who had it believed in it. Outsiders though they had compensation-itis, not pain. It is now accepted, but there is no test for it, nothing that proves it is present. So Advice: Go to some-one who believes you, who understands it, who will be very gentle. An old and wise and competent physiotherapist or osteopath is best. They will treat gently, and advise.

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INFECTION IN A JOINT - Septic Arthritis

Bacterial Arthritis: This is certainly one thing that must be considered when faced with a hot red swollen joint. Classically the patient is an adolescent - to add to the difficulties this group (and their parents) has to endure. They will feel unwell also. The typical bacterial infection is too painful to move (they may stop you moving it), but more subtle joint infections also turn up. The clinician may find a raised temperature, and a source of infective bugs elsewhere in the unfortunate patient - a nasty boil, very infected gums, or an ear infection. Sometimes the infection follows needling the joint to remove fluid, or even surgery. It can even follow a bang to the bone. Blood is sent off for analysis - a raised white cell count would confirm infection. Blood culture and/or culture of fluid from the joint would enable identification of the the bug and the antibiotic it is sensitive to. These patients are best referred without delay.

Viral Arthritis, Post-infective, Non-specific (Unknown Cause) and other arthritides: These are usually less florid. They are either caused by viral infection, or by a reaction to antibodies circulating in the blood. Thy can be caused by a reaction to some medication - say, an antibiotic. All these need referral for investigation.

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THE MEDICAL JOINT

This rather puzzling description means that the joint (or possibly joints) is neither injured nor infected, but is a symptom of some general medical problem that is starting in the sufferer. In other words, it is not caused by some outside factor - a knock or a twist, a bug or a virus - the cause is ësui generisí, beginning in itself, ie. part of something happening in the patient. What is actually wrong may take some time (and many blood samples) to discover. In fact the cause of a single inflamed joint is never found in some patients. These are put in the Non-Specific category - cause unknown.

The chief disorders in this group are Gout and Rheumatoid Arthritis, but other less common afflictions are Psoriatic Arthritis and the connective tissue diseases. In all of them the main problem is the presence of a painful joint (or joints) that is also warm and swollen, that is, an inflamed joint. Gout is a metabolic disease. For some reason there is a high level of uric acid (normally excreted in urine) in the blood, and it crystallises out in a joint, often the big toe joint. Gout is commoner in men, shows a hereditary tendency, often starts in middle age, and typically starts in the middle of the night. The joint is inflamed, swollen, and extremely tender. Sufferers receive medication that helps moderate the attacks, but they cannot be cured of the disease.

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CONNECTIVE TISSUE DISEASES AND OTHER REACTIVE INFLAMMATIONS

Sometimes the inflammation at a joint is not specifically in the joint, but in the tissues locally. The body reacts in many ways to harmful bugs and chemical in the environment, and sometime the reaction is in the form of inflammation. It can be inflammation of the arteries, of the gut, or of the skin. The connective tissue diseases can all cause joint inflammation, amongst other things. No one knows what causes them, but blood tests always show that antibodies to the body's own tissues are present Most clinicians sort these out by recognising the pattern of problems, but blood tests will also help.

A farmer complained of red, lumpy swelling all around the right ankle, and the same but less on the left. He drove a tractor most of the day, but had done for 20 years. It was assumed this was a tenosynovitis (inflammation in the tendon and its sheath, commonly caused by over-use), but blood was sent for tests. A specialist found he had Erythema Nodosum, a kind of skin reaction to an infection. He recovered in due time, fully. This disease is not a connective tissue disease, but is typical. There too many of them to list here.

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RHEUMATOID ARTHRITIS (Rh A)

Joints In Rh A are usually affected symmetrically - both wrists, or both knees. The sufferer is often generally unwell, and may have other problems that turn out to be related. The chief complaint is of morning stiffness, gradually coming on, with acheing pain. Most commonly the small joints of the hands and feet are affected first, but one joint, the knee for instance, may be the first culprit.

It should be investigated thoroughly, and treatment started early. Most people are alarmed , if not shocked, by hearing that the cause of their swollen painful joint is Rh A. They have seen the misshapen hands of a severe case, in a wheelchair, and do not know that only a few people suffer such terrible effects. So every Rh A sufferer should be given an opportunity for a thorough chat about their condition, the possible medication, and what can be done for them.

Rheumatoid Arthritis is a lifelong illness with painful or aching swollen stiff joints. Commoner in women than men, with a hereditary tendency. It makes you feel ill, and in some people the joints get worse quickly, whereas others remain well with good joints all their lives. Unlike gout or psoriatic arthritis , which generally cause trouble in one joint or perhaps several, rheumatoid generally affects a group of joints - say in the hands, or feet - on both sides, left and right.

It is described as a symmetrical polyathritis. Typically it is a disease of small joints and the spine, whereas osteo-arthritis is usually a disease of large joints and the spine. Rheumatoid disease may also attack ligaments, so the joint may become unstable. It can affect other any other organ or system. The most obvious problems are in the hand, which can become deformed by multiple joint problems. Knee and foot RhA can produce a lot of problems, as can RhA of the spine, especially the neck.

What is Happening in Rh A ? Ultimate cause probably allergic-reactive; the body develops antibody reaction to some outside protein, which somehow becomes attached to or identified with structures in the joint. The defensive processes then attack the tissues of the joint, using Inflammation. [See Inflammation]. The inflammatory mass (new capillary vessels secreting exudate and cells) brings macrophage and polymorph cells, which erode and eat away the synovial lining and articular cartilage, as well as ligament, tendon and bone. With time the articular cartilage (bearing surface of the joint) gets thin and ulcerated, and in late stages the damaged and deformed joint may descend into Osteo-arthritis.

Findings

History: If there seems to be no traumatic cause, the clinician will want to check other things:- Are you feeling well in yourself ? Nothing else going wrong ? Have you got any other illness ? On any medication ? Any joint problems in the family ? Anything else you feel is relevant ? Joint problems can be linked to many things - certain drugs, a virus infection, any general upset. Such questions may point to the cause.

Examination: Clinicians will check whether just one joint is inflamed (mono-articular arthritis), or more than one (polyarthitis), and if the many painful joints are symmetrical (typical of RhA).

When the joint is examined, the clinician will find that pain limits the amount that it moves - the range of movement is far less than normal, often half the normal. The usual reason is pain away from the mid-range.

Investigations: Other causes of inflamed joint should be eliminated - are we sure this joint is not infected? Blood is sent off for a blood screen [? raised white cell count]. Is the temperature raised ? If a knee, could it be caused by a deep vein thrombosis ? [?Ultrasound scan] Does it look as though an X-Ray could help? - Most clinicians will request one. In the blood tests, the presence of ëRheumatoid Factorí (an abnormal antibody), would raise a high suspicion of RhA.

Management: It depends on the severity of the condition, but the choice is usually a mixture of drugs, physiotherapy and exercises, and splints. At a very late stage surgeons will consider joint replacement . Discussions with the patient about their problem comes very high on the list.

Methods of Management: Anybody who is told he has Rheumatoid Arthritis should expect to be given a comprehensive leaflet about the disease, or pointed to a source of information This should inform and educate, thus explaining about the disease, enabling the sufferer to join with the clinician in choosing options for treatment.

The clinician should advise how best to look after joints, how to get things done without hurting their joints, and about work. She should give physical treatment, manipulative treatment, and hydrotherapy to improve joints or prevent worsening.

If the joints are particularily painful, rest splints can be given to prevent painful movement, or enable work to be done. (Just as, after a sprained wrist, the patient is given a splint, to enable him to mash potatoes despite his sprained wrist.) These splints also can conserve the joint and help to prevent deformity.

Advanced cases will get special tools (for taps, cutlery, cars &c), using the skills of occupational therapists and social services. Your doctor will prescribe analgesics, other tablets, and possibly steroids.

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ATTITUDE AND OPENNESS TO EVERYTHING

Very little is known about the actual cause of many arthritises. Cases have been documented where giving up coffee, or red wine, has cured the pain or improved it out of all recognition. A change of diet or a change of scene can also change everything, because we are what we eat. Anybody with this illness should try everything, follow up every little lead, and never give up trying to beat it. One day, some-one is going to find something that works !

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© Copyright Philip Evans