COVER FEATURE could account for such intense suffering. I’ve seen three cases of necrotizing fasciitis (NF) in my career, all after the fact. These patients recalled their pain the same way Florence was describing it to me now – it was so unusual, so intense and so coloured with shades of fear and dread. I knew it was critical that she get to the hospital for emer-gency care because NF can and does go bad very quickly. Then she told me that this mystery pain started two days after her total knee replacement surgery – and that was four years ago. So I wouldn’t be calling 911, but I did need to know more. Over all this time, what has her doctor said and done? Try this drug, then this one, then a different one. Nothing has worked to relieve her pain in any meaningful way and they all otherwise made her feel awful inside. Florence didn’t know what this was or what caused it, and if her doctor knew, she wasn’t talking. Apparently this “knee” problem was the surgeon’s problem. Florence had been back to see him four times, maybe five. The surgeon did three different sets of X-Rays. “It looks like the prosthetic is all good. These things happen some-times. So sad, too bad.” If she wanted, they could amputate. All I could think was that she’s spent four long years in a constant state of apprehension, fiercely guarding her knee from any touch that would set off that pain. And now her low back has gone bad. Her low back pain was a clear-cut case of mechanical dysfunction – the flexion antalgia, altered muscle tone, joint play restrictions, and facet inflam-mation all pointed in that direction. Other than the mystery pain at her knee, there were no radicular signs or symp-toms and muscle power/deep tendon reflexes were normal, so there wasn’t likely to be any space occupying lesion (disc bulge, osteophyte or tumour). She revealed that she had experi-enced similar episodes of back spasms more than a dozen times in the past, and recovered well each time with physiotherapy. I advised her that con-servative treatment for her low back pain would be perfectly appropriate. Restoration of better function could be expected to relieve her bad back signif-icantly. The pain of her knee is a whole other issue. It does not appear to be a www.canadianchiropractor.ca PRACTICE DEVELOPMENT “Causalgia” A curious case of a crazy kind of pain BY DAWN ARMSTRONG L ast month, a rather elderly woman presented with a bad case of low back pain. Getting out of the waiting room chair was a huge struggle – she fought her way through harsh back spasms just to stand up, gritting her teeth and relying on a walker to make her way to the exam room. Not once did she cry out in pain, not a whimper escaped from her lips. “Florence” was tough-as-nails, a real trooper. She said she’d been this way for nearly six weeks and was deter-mined to not let it get the best of her. As we first sat down for the interview, face to face, she made one thing abun-dantly clear: “Whatever you do” she said, “DO NOT touch me there!” She pointed to the outside of her left knee. That’s a tough request to a hands-on healthcare professional. Palpation is what we do, but I said I would respect her wishes and made a mental note to to dig a little deeper. Not 30 seconds later, as she spoke of the challenges of caring for her beloved ailing husband, I reached out in sympa-thy to touch her hand. My arm inadvert-ently brushed up against the side of her knee and she yelled. Her face twisted and grimaced with pain, as though I’d just “dragged a sheet of sandpaper across freshly scalded skin.” (Her words, not mine). I had so many questions. Because my very first thought was that if this wasn’t a case of shingles, she might have the first symptom of ne-crotizing fasciitis – flesh-eating disease. It causes extreme, agonizing pain in a particular area of the skin with no ap-parent history of local trauma that DR. DAWN ARMSTRONG is a graduate of CMCC and has been in practice for over 30 years. She is currently focused on promoting life-long learning and professional development and has created a continuing education course – Clinical Record Keeping: A Hands-On Approach. Learn more at auroraeducationservices.ca. 10 Canadian Chiropractor October 2019 Photo: istock
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