I went to urgent care 3 days ago bc my

Patient : I went to urgent care 3 days ago bc my left knee was swollen and in tremendous pain. Since i didn't injure it the dr said it was probably my arthritis. No xray, nothing except the advice of rest. Rest is difficult bc of the arthritis tho...i have to get up every 2 hours-even during the night-to stretch a lil otherwise all the joints swell up and get too stiff. Now, however, i can't straighten either leg! Both calves feel like rigamortis has set in, left knee is now swollen on both side and i have very limited mobility, cant bend all the way, cant straighten it. The inside of my thigh is also starting to ache.The right knee i can bend but not straighten. I cant walk. I kind of can, but my gait is so extreme and its wiping me out because the pain is overwhelming. I think i need to go to the er but i would like to know in advance what kind of tests should be done and how persistent i should be about them doing it. 10 years ago i was put on a medication to help with my arthritis after neurontin and lyrica didn't work.... i cant take narcotic analgesics bc they upset my stomach too much. Unfortunately this medication when combined work another medication makes a whole new medication that's now used exclusively for treating drig addiction. I take bupenorphine. I know there is some controversy about whether or not it works for pain- but i don't care about that controversy. It works for me. But as soon as the drs at the er or urgent care see that they dismiss me. The dr from 3 days ago asked me how long i had been on suboxone. I said never, im on subutex. He said "its the same thing. I don't know what you want from me. I can't give you painkillers if your on that stuff". I said to him "thats not true, i can-and have when my tooth was pulled-take painkillers. But thats not what i want, id like an xray to see why my knee looks like someone put a golf ball in it." He told me he was sure it was the arthritis and that i didn't need an xray, to just stay off it and keep my leg elevated. Now i can't walk and i need to know what to say so i can get some help. I have great insurance, so cost is not an issue...but am i allowed to insist on things like xrays while at the emergency room or urgent care? Can i tell them what i think it might be? I have no idea what it could be but if you tell me can i insist they consider what i tell them? I normally lead a very active, albeit slow paced, life style. Sun up to sun down i never stop moving...this laying down in agony is for the birds and isn't getting any better and im scared.
Doctor :   Hello, Thanks for posting your detailed history. You mainly wish to know how to go about and get an x-ray done for th e knee. Osteoarthritis of knee is very common and the characteristic swelling and pain, along with the feel of joint movement clearly points towards the diagnosis of osteoarthritis knee. If deformity or knee bending is also present, it points towards the condition being of severe grade. However x-ray is required for objective confirmation of the diagnosis and for comparative evaluation of x-ray after few months time to see the progression of disease. You can ask your ER doctor politely for an x-ray, treatment can be discussed depending upon the stage of the disease. Feel free to discuss further. Regards

Comments / Follow Ups

Patient: Please read my whole follow up (and previous question if you didn't already.)Would osteoarthritis cause the pain and stiffness in my calves? And the pain on my inner thigh which is now up to my groin? Its not just my knee that wont straighten, my calves feel like they will tear off if I try to stand erect, Ive had arthritis for 15 years so I know what it feels like. ..this doesn't feel like that. Every day I wake up and think arthritis sucks. But this pain is waking me up and making me actually cry. If it cant be anything else I will suck it up bc Im not going to go to the er for a 15 year old problem. But I don't want to go without a clue as to what this could be either because just getting there is going to be an excruciating ordeal and will exhaust me. I'm paying for this question to be answered so I don't have to go thru all that for nothing AGAIN.
Doctor: With osteoarthritis the joint space gradually decrease, in most of the cases the decrease in the medial compartment (inner side of knee) is more than the outer side (lateral compartment). This results in increasing deformity and altered weight bearing axis of the lower limb, so the more strain is over the muscles and can result in pain in calf and thigh musculature.
With increasing deformity and altered gait biomechanics it can alter spine curvature too.
Groin pain in knee pathology can be due to two reasons, first reason I have mentioned above and the second reason is similar nerve supply of hip and knee region (obturator nerve- anterior and Posterior divisions) so a pain in one region can present or progress to other region as well.
With osteoarthritis, repeated knee swelling, and decreased muscle activity there is atrophy of a part of quadriceps muscle called as VMO (Vastus Medialis Obliqus) which help in straightening of the knee. Therefore last few degrees of knee extension(straightening) is difficult.
There is a small muscle in the upper part of calf region that contrats during last stages of knee straightening. Since knee straightening and the knee angulation changes with severe osteoarthritis the muscle exerts in attempt to lock the knee (required for effortless standing) and this its fatigue and overaction is also the cause for calf pain.
Treatment of osteoarthritis depends upon the stage of disease where in early cases medication, hylan injection, and physiotherapy can be effective but in later stages only joint replacement can provide pain relief and the medication is ineffective in pain control.
Please share your doubts, I'll be happy to answer them for you.

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