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 Barrie Lewis DC
 

 

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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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