Choose the right visit and know when to go

Get same-day help for sudden warning signs

Sudden heat, redness, and swelling in one joint can come from an infection, even without a fever. Please seek same-day care when swelling comes fast or you feel ill. A major injury, a changed joint shape, or strength that disappears also needs prompt attention.

Don't test those problems at home.

Urgent help is also needed when an arm or leg becomes cold or pale. New weakness or numbness with loss of bladder or bowel control can't wait. An X-ray may follow the doctor's exam. The doctor may also use a needle to draw fluid from inside the swollen joint for testing.

Make a routine visit when soreness lingers

Primary care is a sensible starting place when the ache has no clear cause. It also fits soreness in several joints or trouble after a medicine change. Long morning stiffness, swollen knuckles, or soreness in several joints may call for rheumatology, which means an appointment with a doctor who checks for swelling caused by inflammation throughout the body.

One injured joint may need another kind of visit.

An orthopedic surgeon can examine a known injury or a joint that may need surgery. That visit lets you ask about an operation without agreeing to one. When walking, sleep, or basic chores keep getting harder, you don't have to wait until you can hardly move.

Bring details that help the doctor decide

A brief account is enough. Note when the ache appeared, whether it started suddenly, and what eases or worsens it. Include swelling, fever, old injuries, new medicines, and tasks you now avoid. Take your medicine and supplement bottles, along with an earlier X-ray report if you have one.

Clear notes save time.

Tell the office if you'll need help hearing, walking, or completing forms. You're welcome to bring someone who knows your health history. Ask what the doctor noticed during the exam. Then ask whether more swelling, worse walking, fever, weakness, or another fall means you need different care or an earlier return visit.

Sources

1. In a structured review of 14 studies covering 6,242 patients with an acutely painful swollen joint (653 with confirmed septic arthritis), no single symptom rules the diagnosis in or out: joint pain was present in 85%, a history of joint swelling in 78%, and fever in only 57%. The most powerful bedside data came from aspirating the joint - the summary likelihood ratio rose with the synovial fluid white cell count, from 0.32 below 25,000/microL to 2.9 at 25,000 or more, 7.7 above 50,000 and 28.0 above 100,000.

   Margaretten ME, Kohlwes J, Moore D, Bent S — Does this adult patient have septic arthritis?. JAMA, 2007. DOI: 10.1001/jama.297.13.1478.

2. A EULAR task force of 18 rheumatologists, 3 health professionals, 2 patients and a methodologist defined which joint symptoms, in the absence of any visible swelling, should make a clinician suspect that inflammatory arthritis is coming. Seven parameters survived: symptom duration under one year, symptoms in the knuckle (metacarpophalangeal) joints, morning stiffness lasting 60 minutes or more, symptoms worst in the early morning, a first-degree relative with rheumatoid arthritis, difficulty making a fist, and a positive squeeze test of the knuckles. The combination identified at-risk patients with an area under the ROC curve of 0.92 (95% CI 0.87-0.96).

   van Steenbergen HW, Aletaha D, Beaart-van de Voorde LJJ, et al. — EULAR definition of arthralgia suspicious for progression to rheumatoid arthritis.. Annals of the Rheumatic Diseases, 2017. DOI: 10.1136/annrheumdis-2016-209846.

3. In a matched case-control study of 40 early rheumatoid arthritis patients followed for 36 months, those who started DMARD therapy at a median disease duration of 3 months improved significantly more than those who started at 12 months. At study end the DAS28 had improved by 2.8 (SD 1.5) in the very-early group versus 1.7 (SD 1.2) in the late-early group, and radiographic joint destruction by Larsen score progressed significantly more slowly in the very-early group.

   Nell VPK, Machold KP, Eberl G, Stamm TA, Uffmann M, Smolen JS — Benefit of very early referral and very early therapy with disease-modifying anti-rheumatic drugs in patients with early rheumatoid arthritis.. Rheumatology (Oxford), 2004. DOI: 10.1093/rheumatology/keh199.

4. A matched cohort of 405,965 Veterans Affairs primary care episodes of non-specific low back pain without red flags compared those who had lumbar MRI within 6 weeks against those who did not. Early MRI was associated with more back surgery (1.48% vs 0.12%), more prescription opioid use (35.1% vs 28.6%), a higher final pain score (3.99 vs 3.87) and higher acute care costs ($8,082 vs $5,560), all p<0.001. The association held in a system largely free of fee-for-service incentives.

   Jacobs JC, Jarvik JG, Chou R, et al. — Observational Study of the Downstream Consequences of Inappropriate MRI of the Lumbar Spine.. Journal of General Internal Medicine, 2020. DOI: 10.1007/s11606-020-06181-7.