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Knee pain and swelling (it's been well over a month and a half)

I have been having pain and swelling with stiffness in my right knee. It has been going on for over a month and a half. No injury,that I know of.It was about 5x the size of my other knee. I have seen a few doctors and have had it drained. I have also had MRI and Xray's that have shown nothing but fluid. Here's what's going on and has happened. NEED HELP!!!
I am 23 years old. I was a groomer for almost 5 years,most of it full time. After moving across country my knee started hurting.I didn't think anything of it.Then it started swelling,and it got REALLY big!I was really worried!It hurt to walk,sleep,stand,drive,ect. It sucked!Couldn't do anything.At this point in time (about 1 and a half months ago) I was only working part time and school full time.I am a cosmetology student,so of course I was standing a lot..which wasn't helping or making it feel any better.I went to the ER and they just looked at it and said it will get better in a few days,no testing or anything.I was so mad,but it has only been a week so I just gave it time. After about another week or two it was just getting worse. So yet again went to another doctor. I informed him that I had seen another doctor prior and its worse. He didn't seem too alarmed. Gave me some anti swelling meds and told me to take otc pain meds. I was in tears leaving the doctors because I was in so much pain,and could hardly walk. Finally after another week of hell I found an urgent care close to my house. I had to have someone drive me because I was in so much pain I was unable to drive,or hardly move my leg. The doctor there was awesome and seemed alarmed from the minute I showed him my leg!I thought I was getting somewhere. He drew blood,and sent me for an xray right away. The blood came back with a slight infection,and the xray showed a bunch of fluid. At this point the doctor scheduled and MRI for the same day. (He thought I tore my meniscus.) He told me to get that done and see the Orthopedic doctor in 2 days for the results and further treatment. I was excited for this all to be over with. So I went to my appointment with the Ortho doc. He let me know that everything looked good as far as the MRI went. He said for the fluid he had no idea why it was swollen. He decided to drain my knee and give me a cortisone shot. He did get the fluid tested (unfortunately,some stuff came up and had to move back across the country,and was unable to talk to him for a few weeks.) I have called his office a few times in the past few days to talk to him,or have someone give me the results...and nothing. Either knee is starting to do the same thing. It's starting to become very painful and swollen again. I'm debating going to another doctor out here. I haven't been on my knee as much lately and no longer groom. So I feel like it is not that. Has anyone had this problem before? They ruled out gout and as of then lymes also. Please help!
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replied October 30th, 2012
Especially eHealthy

Sorry about your problems.

It sounds like you most likely have one of the hundreds of inflammatory arthropathies.

You stated: “The blood came back with a slight infection”. That is always very concerning to orthopedic surgeons, if there is an infection in side of the joint (called septic arthritis). Except in rare cases, septic arthritis is a surgical emergency. The joint must be surgically drained and wash-up, nowadays, usually with an arthroscopic technique. If the joint cannot be completely cleaned this way, then the joint is opened and formally debrided.

So, if was a little confusing when you stated you had a “slight” infection. Was that in the joint, or somewhere else? Sometimes, some blood markers are used for both infection and inflammation (because inflammation is a component of infection). So, a patient can have elevated inflammatory markers (ESR - erythrocyte sedimentation rate, CRP - C-reactive protein), but not have an infection. That is something that would need to be looked into.

Also, most of the time, x-rays, MRI, CT scan are not of too much use (except to rule out injury and advanced degeneration) when working up swollen joints. The exam will tell you that you have a lot of fluid in the joint (called an effusion).

Actually, analysis of the synovial fluid (the fluid which came out of the joint) is probably the most important study. Be analyzing the fluid, the surgeon can tell what “Class or Group” the fluid is in.

If it is mostly red blood cells, called an hemarthrosis, this is usually due to trauma (such as a torn ligament or cartilage, a fracture into the joint), a problem with the patient’s clotting mechanism (such as in hemophilla), or certain types of tumors (PVNS - pigmented villonodular synovitis or an hemangioma). This is Group IV - Hemorrhagic.

If it is mainly white blood cells (pus), then this is usually a bacterial infection, a septic arthritis. This is Group III - Septic.

In Group I - Noninflammatory, the fluid will look like “normal” joint fluid, just a lot more of it. The fluid will be clear, viscous, and with very few cells in it. This type of fluid is seen disorders, but the most common one is osteoarthritis, also called DJD - degenerative joint disease.

Group II - Inflammatory is the fluid class which the majority of the inflammatory arthropathies will produce. This fluid will be cloudy, thin (not very viscous), the mucin clot will be friable, and there will be a lot more cells in the fluid.

Besides the above analysis of the fluid, it will also be looked at for any type of crystals and will sent to microbiology for a culture to rule out any bacteria which could cause an infection.

So, by analyzing the fluid, most of the time the physician can narrow down what is going on in the joint. But, the analysis will usually not make a diagnosis. That is going to take a bit more investigative work.

The blood work, for things like the inflammatory markers, and for markers of other diseases such as Lyme disease, Rheumatoid Arthritis, Lupus, etc will be done.

A thorough history and physical examination must be conducted.

Usually, the best physician to see about this would be a rheumatologist. Orthopedic surgeons are not really the best physicians to see for this type of problem. They are trained more to take care of trauma and degenerative problems. They can operate on the deformities caused by the arthropathies, but for the medical management of the disease, that is the rheumatologist’s scope of practice.

So, you need to follow up on the results of the synovial fluid. And, you may want to get a referral to a rheumatologist. Don’t expect to be diagnosed on the first visit. It may happen, but most of the time, it does take some time to figure out exactly which of the many arthropathies you actually have.

However, many times, even if the exact arthropathy is not determined, the symptoms can be treated, to make the patient feel better.

In the mean time, you are going to have to adjust your lifestyle a bit. You need to be off of the leg as much as possible. If you wish to continue your present occupation, you need to sit down whenever you can. You need to live with the idea of being in a “joint protection” mode at all times. Heavy impact activities are probably out for you, so no slam dancing, running marathons, jump rope competitions, and the like. You might want to get light neoprene sleeve for the knee, just for comfort when you have to be up and about. When your knee is really acting up, you should be using a cane in the hand opposite the swollen knee. Use it in the opposite hand, so that your gait mechanics are as normal as possible. Using it on the same side causes limping and leaning.

When the knee is swollen you should use ice/heat, elevation, and some light compression to try to reduce the swelling. The NSAIDs will help with the inflammation. If you can get the inflammation under some control, then the discomfort should be less.

But, at least you are now on the right track. You do have to follow up. Again, you should probably be seen by a rheumatologist. Also, you might want to see a physical therapist for a visit to show you how to protect your joints and for idea on exercises that you can do to stay in shape but not hurt your joints. Maintain your weight in the proper range. Keep yourself as strong as possible. Strong patients can protect the joints better and actually have less pain, than patients who are totally out of shape. Keep your cardiovascular status in excellent condition.

Good luck. Hope you find out what is going on soon. Wishing you the best.
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replied March 10th, 2014
I have been having the same exact symptoms, it sounds like I wrote this word for word!!! I'm 23 same age no injury and same as everything you said, I have an appointment with a Rhumatologist tomorrow and already feel like he won't have an answer.
***if you find any thing out pleasseeeee let me know, I'll do the same.*****
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