Monthly Archives: January 2017

Focusing solely on the location of the pain may not reveal its source

leg-pain

Just before Christmas I was watching TV with the family, but unusually I was sitting on the floor, a carpeted but hard surface on which to sit. Every now and then I would shift my position as you might expect to to regain a more comfortable position.

I started to get a tightness in my outer thigh and a little discomfort in the knee, thought little of it and went to bed as usual. In the night the tightness awoke me and I tried to stretch the thigh to ease it with some improvement enough that I was able to get back to sleep.

The following morning I awoke and swung my self out of bed as usual but as my leg lifted I felt a monumental jolt of pain through the hinge of my knee, leading to an
unstoppable cry in pain and surprise.Knee and hamstring injury

I could hardly bear weight on the right leg a
nd found it hard to stand. I immediately called the GP and managed, luckily, to get an appointment with the practice nurse. Upon seeing me the course of action was as you might expect i.e. painkillers, advice to keep moving and to come back if things did not improve or deteriorated within a week.

Well, over the next two nights I found I could not sleep in bed as either the weight of my leg or the slight twist that you experience when lying on my side, even with a pillow under the knee did not afford any relief to the extent that I had to make my way with stifled cry downstairs to my fireside chair. Only here in a “W” configuration , i.e. sat upright knees bent and under the influence of Codeine could I manage the odd hour or two of restful sleep. This continued for three more nights by which time the good lady said that she could take no more of my visible discomfort so she advised that I return to the nurse, which I did the following day to be told that my only course of action was to visit my local A&E, something that I would have avoided normally so as not to burden the stretched service with a non life threatening situation, but unfortunately I had no other option as the pain and discomfort was not easing over time.

ae

Upon arrival I was dealt with quite quickly being mid morning on a weekday, but it became clear quite early on that they were more concerned about my pain relief activities than my pain. This became further evident when I revealed that I had been taking Codeine routinely every two or three hours for the last 48 or so hours. I had not been taking Codeine -i.e. Codeine Phosphate but Cocodamol which contains paracetamol and as such I had involuntarily overdosed by some considerable margin.

This resulted in a 30 hour stay in the A&E observation ward whilst they pumped three bags of detoxifying fluid into my system. Paradoxically I knew quite well that Paracetamol should not be consumed above the recommended dose but being racked with pain and making the false assumption that I was taking Codeine Phosphate I had simply self medicated without checking the label. (Embarrassing at best and potentially fatal a mistake at worse).

That done, we had an X-ray and an ultrasound scan to look for mechanical sources of the knee pain and also to check for a potential aneurysm or clot bit of which came back negative. The only other non invasive option was an MRI scan to detail soft tissue damage but this was not possible so upon completion of the detox and the all clear from the blood tests I was discharged with Codeine Phosphate this time and an appointment for the aforementioned MRI.

paracetamol

By this time the pain was starting to improve and the tablets allowed me to sleep lying down but not on either side. However what came through was the numbness in the out thigh accompanied by a sense of surface discomfort akin to having been scalded by hot water. I realised that this had been there and I had reported it, but it had been less significant and as such I had not made much of it. But now, the knee pain being controllable, it became quite obvious.

I had mentioned this in A&E but as you would expect the clinicians were focused on the knee as this was the primary complaint. But now I started to think along lines of a machinery diagnostician, remembering that root cause may not be initially obvious.

mri-knee

More of that in a while, however I went to see the orthopaedic consultant, a very professional and practical clinician who reviewed the MRI and indicated his disappointment that we had not been able to have it done during the most acute period of the discomfort. He reported that there was evidence of swelling and some wear and tear as you might expect for the patient, but that there was no evidence of any mechanical anomaly that might be addressed by surgery or the like. His only advice was to keep moving and report any changes at the next appointment to follow up in 5-6 weeks. Meanwhile he recommended a consultation with the physiotherapy team at my local hospital.

This was the most productive of the meetings as we discussed the system and not the components. I found that my knee and the muscles involved were each as strong as each other and that there was no specific reason why my pain should be referred here, however the knee is part of a lifting device which has elements in the spine, the hip the thigh and the lower leg, all of which refer to the knee as one of two primary mechanical hinges the knee and the hip.

I mentioned the numbness, the burning sensation, the tightness in the outer surface of my thigh, the pain in the knee and the particular ways in which I could initiate the knee pain by twisting or hanging the leg off the bed etc.

root-cause-analysis

My therapist then lay me on my side and gently, using her elbow strangely enough, worked each muscle from my knee to my hip and at the hip stimulated a pain that referred to the exact spot that had been keeping me awake. So our conclusion was that there had been a compression of the nerve that controls sensation in the outer right thigh, this had lead to a tightening of he IT band that connects the hip to the knee and this had lead to the discomfort in the knee. So no knee injury, but lots of referred pain as a result.

At present this is only a theory but as the patient and one who has some logic built in, it makes complete sense.

What I conclude form this episode however, and the point I wanted to share with you is that the symptoms may not necessarily point to the source of the problem and if you do not take into consideration all the “actors” in the scene that is the fault, then it is possible that you will fix the symptom but fail to fix the root cause.

I know that a great many engineers replace pumps and motors when they fail, only to replace them again a short time later because the forces acting upon them are not right. I am also aware that you lose the hunger to get to the nub of the problem once the plant is up and running again.

Learning – We may get fewer unnecessary sleepless night if we simply undertake and completed a thorough root cause analysis each time we find a component in a failed or failing state.

 

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