Beyond Praying for Death’: A PA Battles Constant Pain
August 30, 2007
On a mid-September Sunday, two days after my 52nd birthday, an unusual burning pain began in my left forearm extending to my palm. I made the presumptive diagnosis of herpes zoster. Later, as I sat at my computer, just gently resting my palm on my desk triggered a lancing pain that took several minutes to diminish. I searched for typical zoster lesions and found none. Sleep was disrupted that night by relentless, burning neuropathic pain from axilla to palm.
Two days later, I developed my first lesions on my back in the T1 dermatome. They were painless. That evening after work, I went to a local urgent care clinic. Thinking that this pain would be of short duration with an antiviral, I returned to work the next day.
By the end of Wednesday, finding no relief with the antiviral and with hydrocodone, I was exhausted from the constant pain and the lack of sleep. Zoster lesions occurred in the T1 and T2 dermatomes down my arm and across my back. (Dermatomes often overlap.) My supervisor kindly told me to stay home, which is a dual-edged sword, because although a few of the scheduled morning patients would be seen by a newly hired PA, most of my patients would be scheduled into my already full schedule over the next two weeks. For that reason, I returned to work two days later and implored a PA student to work with me and type my progress notes. Because of the sedation that can be associated with the gabapentin I had been prescribed, I was titrating up the dose gradually to try to achieve some pain relief while still being able to work. But before I reached maximum dose, the pain ended as abruptly as it had began three weeks earlier.
I was relieved to be over that saga of my life. Of course, I had no idea of what was to happen later.
A Temporary Reprieve
At first myalgias anteriorly of all four limbs came and went intermittently. By mid-November, though, the aching anterior pain had increased in my legs to the point that I couldn’t get up my townhouse stairs without using the banister. Concerned about polymyalgia rheumatica and worse, I returned to the urgent care center two months after my first zoster lesions. Feeling as if I must have an ESR of at least 70, I was surprised (and relieved) that it was 4 (normal is up to 20).
However, that was the beginning of, “Well your tests are normal,” combined with increasing pain that would plague me. My internist repeated the ESR and also performed a CK; “Well, they’re normal. Let’s do an EMG.”
In the meantime, I decided to utilize the expertise of a rheumatology fellow at my work; he offered to get me an appointment at the University. Knowing that the University Medical Center is very busy with patients, I was surprised that the secretary paged me that afternoon and offered to schedule an appointment; I was less surprised that the appointment was three months away. Nonetheless, a few days later, the rheumatology fellow left a message that there had been a cancellation and I could be seen the next week. Feeling that this would surely reveal an answer, I was disappointed again that all the blood tests were normal. I needed a diagnosis and treatment. In December, the constant aching pain increased to a constant burning pain, still anteriorly in all four limbs. Because of the pain, I avoided such normal activities as putting anything on my lap and crossing my legs.
I went to a neurologist for follow-up of the EMG, which I already knew would be normal. Because three doctors had evaluated me by then, the neurologist felt compelled to order a cervical MRI to evaluate for anterior motor neuron disease. The MRI, of course, was normal. He prescribed muscle relaxant. When that didn’t relieve my pain, he advised tonic water in case the pain was secondary to “muscle cramps,” which didn’t fit my burning anterior limb pain.
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About a month after the zoster episode had begun, I had also developed a constant pain in the tuberosity of my left fifth metatarsal�a new problem. I searched out a podiatrist close to my home, who diagnosed a stress fracture of my metatarsal. My X-rays were, of course, “normal.”
A stress fracture was the only diagnosis I would have come up with as a primary care PA, but I thought it was unusual, since I’d stopped my walking exercise during the zoster pain. He treated me with a surgical boot, and the foot pain decreased in a month. I began having some mild lumbar pain beginning in November, but I didn’t think much of it. I’d had worse pain in the past secondary to internal disk disruption, but I had learned to avoid this pain by not torquing my back.
The day before Christmas, on my way to visiting my parents, I walked seemingly for miles in the airport, wearing hiking boots in case I returned home to snow. On Christmas Day at my parents’ house, when I got out of bed, pain began immediately in my left foot from my heel to the metatarsal region. Plantar fasciitis, I thought. My parents were both coughing severely, so we all went to the local urgent care center the next day, where they received antibiotics and I got crutches.
When I got home from visiting my parents, trying to work at a large medical center on crutches was a challenge, which I ended up doing for two months. I became very grateful for the rides and support from family, friends and colleagues. It was a change from my lifelong independence. The podiatrist decided that the recurrent metatarsal pain was secondary to flat feet and a subluxating cuboid, which caused plantar fasciitis after my long airport walk. Having never had foot pain before, I’d never even examined myself for flat feet, which is impossible to accomplish. He advised orthotics but delayed casting my feet for two weeks; making the orthotics took another two weeks. I was frustrated that he hadn’t examined my feet better in October and advised support shoes and orthotics then. That would have prevented the plantar fasciitis and crutches, which added additional pain to my increasing four-limb pain.
A nurse at work, who had experienced arthritis foot pain for years, provided more information about the best support shoes than I’d even known. I didn’t mind having to wear “grandma” shoes two decades before I had expected�as long as they prevented further foot pain. Eliminating any source of pain had become a primary goal in my life.
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