Joint pain without swelling

An ache in a joint that looks and feels normal from the outside has a long list of possible causes. The usual ones, each with the pattern that gives it away:

• Strain and overuse. After a new sport, a long walk or a weekend in the garden, a joint asked to do more than it is used to aches for a few days and settles with rest. If it does not, or if it keeps returning, it deserves a closer look.
• Wear. From 45 onwards, osteoarthritis, the commonest arthritis in the UK, is the first thing to consider: pain that grows the more the joint is used, stiffness after sitting still or on waking that is gone within half an hour, and over time hard, bony knobbles at the finger joints or at the base of the thumb. The knees, the hips and the small joints of the hands are its favourite sites.
• Joints that are unusually flexible. People whose joints move further than most can get pain and stiffness in the joints and muscles, especially towards the end of the day and after activity, along with clicking joints, sprains that keep happening and joints that slip partly out of place and back; a joint that has come out and stays out, as the list at the end of this guide says, or, after an injury, a shoulder that is painful, bruised or swollen after it slipped out of place, is a 999 or A&E emergency. The joint hypermobility syndromes guide covers the pattern.
• A virus. Aching, stiff joints can trail a flu-like illness. In adults they can be a feature of slapped cheek syndrome, a parvovirus that is common in children, rarer in adults and can be harder on them, and the joint pain can go on for many weeks after the illness has passed. Joint pain and aching muscles are also among the common symptoms of Long Covid. Our viral arthritis guide sets out which viruses do this, how long the aching lasts and when it needs a doctor.
• The menopause. Perimenopause and menopause can cause aching and painful joints as oestrogen falls, and have a section of their own below.
• An underactive thyroid, or too little vitamin D. An underactive thyroid can bring aches in the joints and muscles, weakness and cramps, alongside its better-known signs of tiredness, feeling the cold, weight gain and low mood. A shortage of vitamin D can soften the bones and weaken the muscles, so that the back, the shoulders, the ribs, the pelvis or the legs ache and stairs become hard work. Both are found on a blood test and put right by replacing what is short.
• A medicine. Statins, the cholesterol-lowering medicines, have muscle pain among their common side effects, and atorvastatin's include aching muscles and swollen joints; letrozole and anastrozole, the hormone treatments for breast cancer, have aching muscles, bones and joints among their common effects. A medicine that began not long before the aching did is a question for whoever prescribed it.
• Widespread pain. Pain felt all over, with an increased sensitivity to pain, muscle stiffness, sleep that does not refresh and a foggy head, is the pattern of fibromyalgia, in which the joints look normal because the pain does not come from the joints themselves but is thought to come from the way the nervous system processes pain signals.
• Early inflammatory arthritis, before the swelling shows. Inflammation of a joint lining usually makes the joint swell, but at the start it can be felt before it can be seen, and the clue is stiffness on waking that goes on for more than half an hour, often more than an hour. That pattern earns an assessment of its own, and our guide to early inflammatory arthritis explains why those weeks count.

The joints themselves usually give the answer before any test does, if the right questions are asked:

• Pain that rises with use, in a few joints, in someone of 45 or older, points to wear
• Stiffness that is worst after rest and goes on for more than half an hour in the morning points to inflammation, even with nothing to see
• Aching towards the end of the day, in joints that bend further than other people's, points to hypermobility
• Pain everywhere at once, with tiredness and unrefreshing sleep, points to fibromyalgia
• Aching that began soon after an illness, or that others around you also had, points to a virus
• Aching alongside changed periods, hot flushes and broken sleep, between 45 and 55, points to the menopause
• Aching with tiredness, feeling the cold and weight gain points to the thyroid; aching bones with weak muscles and difficulty on the stairs points to vitamin D
• Aching that began soon after a new medicine points to the medicine
• Aching, stiff shoulders and hips in someone over 50, with morning stiffness that goes on well past half an hour, point to polymyalgia rheumatica, whose guide carries the signs that go with it

Two things change the picture whatever else is true: swelling, and stiffness on waking that lasts more than half an hour. Either is reason enough to see a GP within days rather than to wait (a joint that has swollen has a guide to itself, joint swelling), and a joint that has turned hot as well as swollen goes into the same-day list at the end of this guide.

Aching joints are one of the ordinary symptoms of the years around the menopause. As oestrogen levels fall, joints can be aching and painful, and muscle aches and joint pains are among the symptoms that come with hot flushes, night sweats, broken sleep, changes in mood and memory and changes to periods. Perimenopause and menopause usually affect women between 45 and 55, though they can begin earlier, and hormonal contraception can hide the change by altering the periods that would otherwise announce it. The symptoms as a whole tend to run for seven to nine years and can change over that time, and joint pain is one of the symptoms that can carry on after the menopause itself.

The joint pain of the menopause is real and manageable. A GP, a nurse or a pharmacist can talk through the options, including hormone replacement therapy (HRT), of which oestrogen is the main type, taken as tablets, patches, a spray or a gel, and the alternatives where HRT is unsuitable or unwanted. Regular exercise, with the weight-bearing and strength exercises that protect bone, matters here too, because the same fall in oestrogen weakens the bones; calcium-rich food and some sunlight on the skin for vitamin D protect them as well.

The menopause is a reason to look at aching joints, not a reason to stop looking. Rheumatoid arthritis is commoner in women than men, most often begins between 40 and 60, and often starts in the years of hormonal change, the menopause among them; osteoarthritis, also commoner in women, usually begins from 45, and osteoarthritis of the hands, with its bony knobbles, often starts around the time of the menopause, so aching finger joints in those years have two ordinary explanations before an inflammatory one. Joints that swell, and joints that stay stiff for more than half an hour in the morning, are assessed on their own terms, whatever else the menopause is doing, and a hot, swollen joint goes to the same-day list at the end of this guide.

The history comes first, and usually points the way: when the aching began, which joints, what makes it better and worse, how long the joints take to loosen in the morning, what else has changed in your health and what medicines you take. Each joint is then examined, pressed and moved, alongside the muscles and tendons around it; the flexibility of the joints is scored where hypermobility is the question, and the skin, the nails and the neck are looked at for the clues to psoriasis and to the thyroid.

Point-of-care ultrasound is part of the consultation with Dr Borukhson, so the joints are scanned in the same visit. Its value here is that it can find inflammation in a joint's lining or a tendon's sheath while there is still nothing to see or feel. Just as usefully, it can show when there is none: a normal scan of an aching joint is real reassurance and narrows the question, though on its own it does not rule inflammation out. And a scan that finds a strained tendon or an irritated bursa behind the ache is a diagnosis with a treatment of its own, a loading programme for the tendon, which our tendinopathy guide describes, or the measures our bursitis guide sets out, with a guided injection where one would help. The ultrasound clinic page explains the scan itself.

Blood tests are chosen to match the question: the inflammation markers CRP and ESR; thyroid function, measured as thyroid-stimulating hormone and thyroxine; vitamin D and calcium; and rheumatoid factor and anti-CCP antibodies where the pattern suggests inflammatory arthritis. Normal results are reassuring, and with fibromyalgia the tests tend to be normal, but early inflammatory arthritis can run with normal markers and without the antibodies, so normal tests, and a normal scan, in someone with prolonged morning stiffness do not close the question. An X-ray is not usually needed for wear, and is added where a fracture or an inflammatory arthritis has to be ruled out. The understanding blood tests in rheumatology guide explains what each test can and cannot say.

Some go home with a cause named and a plan; some with the knowledge that nothing inflammatory is at work, which is itself worth having; and some are found to have early inflammatory arthritis after all, for whom the assessment has come at the right time.

What is done depends on what is found, so the assessment comes first.

• Strain and overuse settle with rest for the joint, cold for a sore one, simple painkillers and keeping it moving without overdoing it.
• Wear is managed as its own condition, from exercise and weight to footwear, painkillers and, where a joint needs it, a guided injection: the osteoarthritis guide sets it out.
• Hypermobility is treated first by building the strength and fitness of the muscles that protect the joints, with a physiotherapist's help; painkillers, warmth and pacing ease the days when the joints ache.
• The aching a virus leaves needs time and painkillers, and the assurance that it usually passes.
• The menopause has its own options, hormone replacement therapy among them, which a GP can discuss.
• An underactive thyroid is treated with a daily thyroid hormone tablet, usually for life, and a vitamin D shortage with supplements of vitamin D and calcium; the symptoms improve as treatment takes hold.
• A medicine that is the suspect is reviewed by the person who prescribed it, not stopped on your own account.
• Fibromyalgia has its own guide and its own approach, built around sleep, activity and pain.
• Early inflammatory arthritis follows the route its own guide describes, where the first weeks matter.

Where the assessment finds a tendon or a bursa behind the ache, the plan follows the tendinopathy or bursitis guide, and an ultrasound-guided injection, where one would help, is usually possible at the same visit. You and Dr Borukhson settle the plan together.

While an aching joint is settling, or while the cause is being found:

• Rest the joint when it is sore, but keep it moving: stopping altogether stiffens a joint and weakens the muscles around it
• Cold for a sore or newly strained joint, an ice pack in a cloth for no more than twenty minutes at a stretch and no more often than every two or three hours; warmth for a joint that is stiff, a hot water bottle, a warm bath or a wheat bag, which loosens it before you use it
• Ask a pharmacist which painkiller suits you: paracetamol, or an anti-inflammatory gel or tablet where they are safe for you, with care not to double up on gels and tablets. Clothing that has had ibuprofen gel on it burns more readily, so for as long as you use it, do not smoke, nor go close to any naked flame
• Keep to a healthy weight, eat well and exercise regularly: extra weight loads the knees and hips with every step, and building activity up gradually is covered in the arthritis and exercise guide
• Note down which joints ache, when, and how long they are stiff for in the morning, since the pattern is what the assessment is built on
• If a medicine is the suspect, keep taking it until you have spoken to whoever prescribed it, unless one of the two medicine signs named at the end of this guide applies
• Do not smoke

An aching joint that looks normal can usually wait for a routine appointment. Five pictures cannot wait, and two signs tied to particular medicines, named below, join them: the signs that an infection has become sepsis or has reached the lining of the brain; an injured joint or one that will not bear weight; a joint that could be infected; an eye gone red or painful, a change in what you see, or sight lost all at once; and a severe allergic reaction to any medicine.

Treat any of these as a 999 or A&E emergency: call 999 and do not drive yourself to A&E.

• Severe illness with suspected sepsis: a high fever with shaking, confusion, rapid breathing, or feeling dramatically worse over hours
• With a fever or feeling unwell, a rash that does not fade when you press it, a stiff neck with eyes that cannot bear bright light, or skin, lips or tongue turning blue, grey, pale or blotchy, since these can be signs of meningitis or sepsis, as can a very bad headache, confusion or a first seizure with a fever or feeling unwell; on black or brown skin the rash and the change of colour may be easier to see on the palms of the hands or the soles of the feet
• A joint you cannot put weight on or move, or that has moved out of place, or, after a fall or injury, very bad pain or any tingling or numbness
• Lips, mouth, throat or tongue that suddenly swell, a throat that feels tight, very fast breathing or a struggle to breathe or to swallow, skin, tongue or lips turning blue, grey or pale (on black or brown skin this may be easier to see on the palms of the hands or the soles of the feet), becoming suddenly very confused, drowsy or dizzy, or fainting and not being able to be woken, since this can be a severe allergic reaction, anaphylaxis, which can follow a dose of any medicine
• An eye that suddenly and completely loses its sight

Any of these needs an assessment that is urgent, on the same day, from your GP or NHS 111:

• A joint that is hot and swollen, with a fever or feeling unwell, since an infected joint has to be ruled out at once, at A&E or through NHS 111
• A joint that has become hot and very swollen suddenly, or is worsening quickly, even without a fever, since an infected joint does not always announce itself with one
• Joint pain with a fever, or feeling hot, cold or shivery, or generally unwell, since an infection in or around a joint has to be found the same day
• A new red, painful eye, or sight that has blurred, dimmed or changed, which needs an eye casualty or urgent eye clinic the same day, as does an eye that light hurts, since a red or painful eye can be the work of an inflammatory arthritis that has not yet declared itself, psoriatic or reactive arthritis for instance; our uveitis guide explains

After an injury, a shoulder that is painful, bruised or swollen after it slipped out of place is a 999 or A&E emergency. See a GP if two weeks of home treatment have not shifted the pain, if it is limiting your normal activities or disturbing your sleep, or if it keeps returning or is getting worse; and see a GP within days, rather than waiting, if a joint has swollen, the pattern our joint swelling and early inflammatory arthritis guides cover, or if your joints stay stiff for more than half an hour after waking up, because either can mean inflammation. A specialist assessment can be booked without a referral, and in this practice next-working-day appointments can almost always be arranged, and same-day appointments are sometimes possible. Two signs belong to the medicines this guide names: on letrozole or anastrozole, a sudden attack of pain in a joint needs a doctor or NHS 111 that day, because these medicines can weaken bone; on a statin, muscle pain with weakness, a fever or red or brown urine needs a doctor or NHS 111 that day. If you cannot tell how urgent something is, asking is never a mistake.

Aching joints often settle; where they do not, the cause is commonly an ordinary one. A specialist assessment earns its keep with the rest: a thyroid or a vitamin D level that nobody had checked, a medicine nobody had suspected, a tendon or a bursa that a guided injection can settle, and most of all a joint lining that is inflamed before it has begun to swell, where the weeks saved by an early answer are the weeks that protect the joint. With the examination, the ultrasound and the blood tests brought together in one visit, the question is usually well on its way to an answer before you leave, with the blood tests to complete it, and the right plan, or an all-clear, follows.

Can it be arthritis if my joints are not swollen?

It can, in two ways. Osteoarthritis, the wear form, aches with little swelling except at the knee, most often affects the knees, hips and the small joints of the hands, and is worse the more a joint is used. Inflammatory arthritis usually announces itself with swelling, but not always at the start: more than half an hour of stiffness on waking is the clue that a joint lining may be inflamed before the joint is visibly swollen, and ultrasound can show that inflammation while there is still nothing to see or feel, which is why that pattern is worth seeing a GP about within days. Aching joints with no stiffness to speak of and nothing to see have other explanations, which this guide takes in turn.

Is joint pain a symptom of the menopause?

Yes. Perimenopause and menopause can cause aching and painful joints as oestrogen levels fall, and muscle aches and joint pains are among their recognised symptoms, with hot flushes and broken sleep. They usually affect women between 45 and 55, though they can start earlier, and the joint pain can continue after the menopause itself. A GP can talk through the options, hormone replacement therapy among them. Joints that swell, or that are stiff for more than half an hour in the morning, are not put down to the menopause without an assessment, because rheumatoid arthritis often begins in the same years.

Which blood tests help?

Four help most: the inflammation markers CRP and ESR; thyroid function, since an underactive thyroid can cause aches in the joints and muscles; vitamin D and calcium, whose shortage can cause bone pain and weak muscles; and, where the pattern suggests inflammatory arthritis, rheumatoid factor and anti-CCP antibodies. Normal results are reassuring without being the last word, because early inflammatory arthritis can run with normal markers, and the history, the examination and the scan count alongside the blood.

Could a virus be the cause?

It can. Flu and other viral illnesses can leave the joints aching and stiff, and an adult who catches slapped cheek syndrome, a parvovirus infection, can be left with joint pain that lingers for many weeks after the fever and the rash have gone; joint pain and aching muscles are among Long Covid's common symptoms as well. The aching a virus leaves usually clears by itself, in weeks and sometimes months; a giveaway can be that others in the household went down with something at the same time, and an ache that has outlasted a fortnight is still worth a GP's look, since the same ache can be the start of something else. Joints left swollen rather than aching are for a GP within days: our viral arthritis guide covers the pattern a virus leaves, and joints that swell in the weeks after a bout of food poisoning or an infection caught through sex are a pattern of their own, reactive arthritis, with a guide to match.

Can my medicines cause joint pain?

Some can. Muscle pain is a common side effect of statins, the cholesterol-lowering medicines, and aching muscles and swollen joints are among atorvastatin's; the hormone treatments for breast cancer, letrozole and anastrozole, commonly bring aches in the muscles, bones and joints. Two exceptions do not wait for a conversation: a sudden attack of pain in a joint on letrozole or anastrozole, and muscle pain with weakness, a fever or red or brown urine on a statin, each a same-day question for a doctor or NHS 111. Otherwise, if a medicine is the suspect, raise it with whoever prescribed it rather than stopping it yourself, since the dose or the medicine can be changed, while stopping a statin or a cancer treatment without advice brings risks of its own.

When should I see someone?

A joint you cannot put weight on or move, one that has come out of place, or very bad pain or any tingling or numbness after a fall or injury is a 999 or A&E emergency; after an injury, so is a shoulder that is painful, bruised or swollen after it slipped out of place. So are a high fever with shaking, confusion, rapid breathing, or feeling dramatically worse over hours, and, with a fever or feeling unwell, a rash that does not fade when you press it, a stiff neck with eyes that cannot bear bright light, or skin, lips or tongue turning blue, grey, pale or blotchy (on black or brown skin the rash and the change of colour may be easier to see on the palms of the hands or the soles of the feet), and a very bad headache, confusion or a first seizure with a fever or feeling unwell, since any of these can be sepsis or meningitis, and so is sight lost all at once, as are the signs of a severe allergic reaction to a medicine, which the first list under When to seek help sets out. Call 999 and do not drive yourself to A&E. See a GP for an ache that is limiting what you can do or disturbing your sleep, for one that keeps coming back or is getting worse, for one that two weeks of home treatment has not shifted, and, within days, for a joint that has begun to swell or for joints that need more than half an hour to free up after waking. Where the answer will not settle, you can book a specialist assessment yourself, without a referral, and in this practice next-working-day appointments can almost always be arranged, and same-day appointments are sometimes possible. A hot, swollen joint needs the same day: feverish or unwell, A&E or NHS 111 is the place; otherwise your GP, urgently, or NHS 111. Joint pain alongside a fever, or shivers or feeling generally unwell, is also one for your GP or NHS 111, that day. An eye gone red or painful, any other change in what you see, or an eye that light hurts needs an eye casualty or urgent eye clinic the same day.