Clicking joints returned after DCI

[Diver X]

Hi Dr Deco,

I would really like some help with this one.
I am currently suffering from clicking and popping in most of my joints having recently finished up work as a commercial diver. Last year I suffered DCI while diving to around 40 meters. If you need more details I can provide them. I was experiencing discomfort in many joints when I took myself into hospital. During a 5 hour re-compression session in the hyperbaric chamber my joints began to click and pop as they loosened up and the pain began to subside. (Should I have been in for a second soaking for 2 and a half hours?) This clicking and cracking in my joints gradually got worse in the following weeks. Do you know why this is? The majority of these symptoms eventually passed. I returned to diving this year and after a time these symptoms began to reappear. I have since resigned. When I did, I was expecting these symptoms to go away, they did in fact get worse - to the point that I was experiencing pain in my joints in the following weeks. The pain has susided but the clicking and popping hasn't yet. Do you know what is happening? Is there a name for it? What damage has been done? Why did this happen in the first place and why had it returned with diving? I am concerned that my days as a diver are limited to very easy recreational dives.

Regards

Diver X

 

[Dr Deco]

Hello Diver X:

Hyperbaric Arthralgia

This certainly is a tricky question, and one for which I do not have an answer. If this was at depth, and it remitted in a few hours, I would say it was hyperbaric arthralgia.

With this problem, the pain at depth starts at about 100 fsw and is worse the deeper the dive. This has been studied in saturation diving conditions.

At depth, pain gradually decreases in intensity and is gone by 24 hours. Divers complain that their joints seem to be dry, and they whimsically refer to it as “no joint juice.” I have not heard of the pain persisting after reaching the surface, and saturation decompression requires days.

The joints are, in order of severity, shoulders, knees, wrists, hips and back; the least affected are the ankles, fingers, and elbows. This problem is known to occur during short bounce dives, but is more common in saturation diving. It is this type of saturation diving where I first heard about the problem when I was at the Ocean Systems laboratory in Tarrytown, NY, in the early 1970s.

Cause

There is no explanation for hyperbaric arthralgia, but osmosis has been proposed as the mechanism to remove synovial fluid from the joint spaces. Divers, for example, are not able to crack their knuckles when they have this condition.


I would not expect the condition to persist for a period of days when back on the surface. If hyperbaric arthralgia is the cause, you might be a record holder!:depressed: Possibly, recreational diving is your only recourse.

Dr Deco :doctor:


Brian A. Hills, PhD Clinical Implications of Gas-Induced Osmosis. Arch Intern Med. 1972;129 (2):356-362.

A review of the evidence for believing that gas concentration gradients can induce water movement in vivo shows that this could be a significant physiological parameter in many tissues, depending upon the magnitude of the gas-osmotic pressures. Estimation of these has suggested two experiments whose results show (1) that reflexion coefficients for gases may be appreciably higher than determined previously, (2) that water flow rates are high, and (3) that the list of semipermeable tissues should include articular cartilage. The clinical implications of gas-induced osmosis are then discussed with particular reference to gaseous anesthesia, hyperbaric arthralgia, gouty arthritis, aseptic bone necrosis, hyperbaric urticaria, pulmonary edema, and the edematous separation of tissue boundaries in general.

 

[Curadh]

Hi, I know this is an old thread but it is the closest thing I have come to an answer on the internet - no doctors know what it is - I did 30 sessions of hyperbaric oxygen therapy at about 2.0ATA over 6 weeks. It was for nerve damage. I noticed after about session 20 my bones, particularly my sternum was popping more often, after 25 sessions I realised most of my body particularly my cervical spine and spine are snap crackle and popping... I am guessing it is tightening of ligaments, but after seeing this thread maybe could be joint dryness..? I stopped 6 weeks ago but it hasn't cleared. I am trying diclofenac 75mg twice a day, just started.
I must also say around the time it got very bad - about session 27 or so, I had a vitamin injection reaction which gave me tinnitus and orchitis and a cold sore breakout, along with a lot of tightness in the neck.
Not sure if sounds familiar to anyone but thought would try!

 

[Duke Dive Medicine]

Hi, I know this is an old thread but it is the closest thing I have come to an answer on the internet - no doctors know what it is - I did 30 sessions of hyperbaric oxygen therapy at about 2.0ATA over 6 weeks. It was for nerve damage. I noticed after about session 20 my bones, particularly my sternum was popping more often, after 25 sessions I realised most of my body particularly my cervical spine and spine are snap crackle and popping... I am guessing it is tightening of ligaments, but after seeing this thread maybe could be joint dryness..? I stopped 6 weeks ago but it hasn't cleared. I am trying diclofenac 75mg twice a day, just started.
I must also say around the time it got very bad - about session 27 or so, I had a vitamin injection reaction which gave me tinnitus and orchitis and a cold sore breakout, along with a lot of tightness in the neck.
Not sure if sounds familiar to anyone but thought would try!

I've seen the compression arthralgia described by Dr. Deco in hyperbaric patients but I hadn't heard of this so asked the medical director of our hyperbaric unit, Dr. Moon, and he hadn't either. Sorry, I wish I could be of more help here. @Dr Simon Mitchell - Simon, any ideas?

Best regards,
DDM

 

[Curadh]

I've seen the compression arthralgia described by Dr. Deco in hyperbaric patients but I hadn't heard of this so asked the medical director of our hyperbaric unit, Dr. Moon, and he hadn't either. Sorry, I wish I could be of more help here. @Dr Simon Mitchell - Simon, any ideas?

Best regards,
DDM

Thanks a lot for going to the trouble of asking around, and for your response, - I'm really clutching at straws with it. Another theory I have is I might've had an interaction between hyperbaric treatments, dry sauna, and sleeping with an electric blanket on all night. I know from past experience the electric blanket left on all night usually leaves me feeling 'baked' and achy, the dry sauna might've added to that 'drying out' of bones and joints, and maybe the hyperbaric added to it somehow - maybe contributed to formation of nitrogen bubbles in joints causing them to pop? Or some sort of change in synovial fluid? No ideas, I spoke with an orthopedic doctor who was stumped but said he was betting on viral activity.

 

[Duke Dive Medicine]

Thanks a lot for going to the trouble of asking around, and for your response, - I'm really clutching at straws with it. Another theory I have is I might've had an interaction between hyperbaric treatments, dry sauna, and sleeping with an electric blanket on all night. I know from past experience the electric blanket left on all night usually leaves me feeling 'baked' and achy, the dry sauna might've added to that 'drying out' of bones and joints, and maybe the hyperbaric added to it somehow - maybe contributed to formation of nitrogen bubbles in joints causing them to pop? Or some sort of change in synovial fluid? No ideas, I spoke with an orthopedic doctor who was stumped but said he was betting on viral activity.

Interesting idea. In theory warmth would decrease the amount of dissolved gas in your joint capsules and maybe make them less likely to cavitate / crack, but that's strictly conjecture. Please post back if you get a definitive answer!

Best regards,
DDM

 

[Curadh]

So sorry, I could've sworn I replied to you DDM, thanks for that. Well here I am 4 months later and the problem is still there, drives me mad popping in my ears when I tilt my head or turn it, when I'm talking or anything it would drive a dog to drink. What's worse is I've also now developed pain in my left shoulder, right wrist, right knee, and lower back/ hip which can be very sore, it is as if I cannot straighten out my back without pain, just seemed to come out of nowhere. I think I have eustachian tube dysfunction since February, but I don't know whether to take the chance on HBOT diving again for nerve damage recovery.

 

[Duke Dive Medicine]

So sorry, I could've sworn I replied to you DDM, thanks for that. Well here I am 4 months later and the problem is still there, drives me mad popping in my ears when I tilt my head or turn it, when I'm talking or anything it would drive a dog to drink. What's worse is I've also now developed pain in my left shoulder, right wrist, right knee, and lower back/ hip which can be very sore, it is as if I cannot straighten out my back without pain, just seemed to come out of nowhere. I think I have eustachian tube dysfunction since February, but I don't know whether to take the chance on HBOT diving again for nerve damage recovery.

No worries at all. Re the pain, knowing nothing of your medical history I wouldn't want to speculate on causes, and would recommend you circle back with whoever was seeing you for the problem that was referred to hyperbarics. The ear popping is something else - if a GP can't address it, you might need to see an ENT.

Best regards,
DDM

 

[Curadh]

Many thanks, I have thought about an ENT also ! Think my GP is probably fed up of seeing me at this point though, I'm afraid to ask for a referral! Thanks for the response