Diagnosing intermittent pain

by SJ
(USA)

Modic effect

Modic effect

How does one determine what might be causing intermittent symptoms (and therefore how to correct them)?

For example, I might feel hip pain every day of the week for several hours per day, but during my chiropractic appointment my hip feels perfectly fine.

Or I might have intermittent claudication after every run, but this is long gone by the time I see my chiropractor.

Although the pain comes and goes, sometimes it can be intense enough to interfere with normal movement or induce an antalgic posture; but not during my chiropractic appointment.

It seems that a big part of diagnosing a problem is if a doctor can "catch it in the act," and do some tests to determine what might be causing it; but how can we do that if the pain is absent when the doctor is present?

Perhaps I can do tests at home when I feel it? But will my chiropractor believe me when I say Spurling's was positive this morning, and now it is negative? How much might a pain questionaire help my chiropractor if I am not feeling pain during my appointment?

I am interested to get a series of MRIs, but my chiro said if I am not feeling the pain during the MRI, it likely will not show anything; and insurance is unlikely to cover it anyway.

I appreciate your insights and ideas for diagnosing ephemeral issues.

Hello again, SJ,
Are or were you a smoker? If not, you are unlikely to have intermittent claudication.

What comes to mind, which may offend you, is the classic line from Julius Caesar, "Yon, Cassius, he thinks too much."

What also comes to mind, is the research done where nine of the world's leading authorities were asked to examine a number of patients, look at the x-rays and scans, and make a diagnosis. They were in agreement in less than 50% of the cases.

Back pain is notoriously difficult to diagnose.

What I believe is important is the summing up of subjective symptoms and objective signs; usually they are more or less in agreement, but sometimes radically different; therein lies the conundrum you find yourself. You have a pain, your chiropractor, and the rest of those who examine you are unable to explain it.

It could be that you are allowing your imagination to run away with you, but more likely there's some vital point that every one is missing.

An example. A man has chronic unexplained lower back pain; there really aren't a lot of hard orthopaedic or neurological findings. He has no leg pain, so an MRI is not usually indicated. An orthopaedic surgeon dismisses his pain. Yet when the MRI is finally done, deep seated bone oedema called a modic effect is clearly visible. Happily despite ten years of pain he is responding well, not perfectly, to chiropractic care.

Reading between the lines, and I may be totally wrong, it's time to trust your chiropractor, and let him get on with what he needs to do. You do your part; be careful with bending and lifting, sit less and do the exercises he has prescribed. He's doing his best, and yes, it may not be enough, but in life one has to trust folk who one knows are doing their damnedest to help.

What more can I say?

Dr B

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Jan 30, 2018
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starstarstarstarstar 		Intermittent claudication
by: SJ

Intermittent claudication: I have never smoked. Near the end of my ~1 mi. run and for 1/2 to 1 hour afterward, the posterior muscles of my right leg are sore. Left leg does not have this problem. Claudication seemed to fit this condition, but it is easily possible that I am using the wrong term. What would you call this?

I also have a right side-left side strength difference (waist down) determined by horizontal side bridge tests and 1-legged squats (ratio left side/right side = 1.15 to 1.38). This after >5 months of symmetric strength training. Does this sort of thing often follow sciatica?

A year ago a MRI suggested modic effect in L5. Does this ever go away? How do you treat it?

Quite probably I am thinking too much. However I doubt that I understand even part of my condition(s), and I am not confident that my chiropractor understands my condition(s) either. So I read a lot, think a lot, and ask a lot of questions. What else can I do?

Hello SJ,
Then it's most unlikely to be intermittent claudication and in any case hopefully somebody by now has tested the pulses in your leg; it's not difficult to diagnose, though often missed as a cause of leg pain.

That modic effect is very significant; it's caused by fluid seeping into the bone, a sort of bruising on the vertebra, and shows that you've had a lower back injury.

Lower back pain is extremely complex. One research project asked 10 of the world's top specialists, with all the tests available to examine 20 patients with lower back pain. More than half the time they came up with different diagnoses.

So, it's little wonder that even the average seriously thinking chiropractor, PT, and certainly medical doctor is often at loss.

My best advice as always is to sit less and choose your chairs carefully, faithfully do your back exercises, don't lift grand pianos and go for a regular, but not too frequent adjustment of your lower back and pelvis.

That's my formula and it's also not adequate for all of my patients either. Not many of us are gurus!

Dr B

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Interesting challenges of the day

1. Mr S is a 76 year old man with neck pain of some 9 months duration. Luckily, most of the discomfort is upper cervical which is only rarely arthritic; his lower cervical spine is a degenerative mess that I've left alone. After seven treatments his pain and stiffness is 50 percent better, and he's happy in the circumstances. He can sleep through the night now and that makes a huge difference.

2. Mr P is 32 year old man with very severe lower back pain radiating to the big toe which is 30 percent numb. He had an episode three weeks ago, took anti inflammatories and was soon better as is typical of the medial disc herniation. But before it healed, after a trivia it came roaring back, much worse. The characteristic crossed sign was evident; sitting in a chair, straightening the right leg provoked severe left back pain and tingling in the leg. He's doing well.

3. Severe lower back pain is scary; just ask Mrs P. Just watching her get out of the car I she was in trouble; she had a slipped disc at L4 making her lean towards the opposite side; luckily she had no pain in the leg. Despite family pressure that this was far too severe for a chiropractor, she persevered. Within five days she was standing upright, and after two weeks almost painfree. 

Despite a hectic job, she wisely took my advice and stayed home for what I call exercising bed rest.

4. Mr S has had lower back, groin and back of thigh and calf pain for fourth months.

He has a pincer deformity in the hip causing the stabs in the groin, and a degenerative facet causing the sciatica. Both are responding well to chiropractic and he's well pleased; sixty five percent better after three treatments.

5. Mr T is a wise man; he's taken a warning TIA seriously and has lost 15 pounds, and has at least as much again to lose. A change to a low starch diet and half hour daily walk has made the difference; but the walking is making his foot and back miserable. The expensive orthotic is hopeless; luckily his hips and back are fine, but he needs a simple heel lift.

6. I too have had serious lower back issues, luckily fixed by my own chiropractor; so I too have to do my exercises, take care when lifting supers full of honey, gardening and using the chainsaw. Regaining the function of your spine is just as important as the pain.

7. My own granddaughter, only 7 is hypermobile giving her pelvic, knee and ankle issues. Xrays show a mildly dysplastic hip. Years ago we would have called it growing pains. She too regularly needs chiropractic care and luckily responds well. Increased range of motion is more difficult than too stiff in my opinion. Our care is for kids too.

8. This 65 year old lady is a serious gardener; every day she is bending, lifting and digging for 2 to 3 hours a day. It regularly catches her in the sacroiliac joint, so she has a treatment once a month that sorts it out. She does her lower back exercises faithfully.

9. This 88 year old lady is an inspiration; every day she is busy in the community. With a nasty scoliosis she manages very well with a chiropractic adjustment every six weeks and exercises faithfully done.  

10. Mr X is a 71 year old retired man who wants to continue with maintenance care every six to eight weeks; he had suffered from two years of lower back pain when he first came a year ago. He has no discomfort now after 8 chiropractic treatments, but is aware that danger lurks.

11. Mrs C has been having severe headaches, and taking a lot of analgesics. It's a non complicated upper cervical facet syndrome, and she's doing well.

12. Mr D is a 38 old year man with chronic shoulder pain after a rotator cuff tear playing cricket. It responded well to treatment, but he knows he must do his exercises every day; for two years he couldn't sleep on that shoulder.

13. Mr D, a 71 year old man, has a severe ache in the shoulder and midback since working above his head. Trapped nerve tests are negative but he has advanced degenerative joints of Luschka; after just two treatments he is 50 percent better. Can we reach 90?

And so the day goes; chiropractors shouldn't be treating the elderly most medical sites state but that's so much bunkum.

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Greetings, Dr B.
You helped me quite some time back with a soothing and professional response which turned out to be exactly correct. I now consult a local chiropractor. You write a superb newsletter, too.

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Knowing that up to 70% of the time the correct diagnosis is made with no examination, no special tests, no xrays, but just from the history, there's a fair chance I can add some insight to your unresolved problem. But at least 30% of the time, I may be quite wrong! Give plenty of detail if you want a sensible reply.


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