When Pain Gets Confusing: Sometimes You Have to Look Through a Different Lens

I’ll admit something. I like confusing cases. Obviously, I don’t like that someone has been hurting for six months, has seen three doctors, tried physical therapy twice, had an injection, gotten an MRI and still has no idea why they hurt. But medically? Puzzles are fun.

A lot of musculoskeletal medicine is pretty straightforward. You hurt your ankle, it swells, we examine it, get an X-ray and figure out what happened. But sometimes the pieces just don’t fit that neatly. Those are the cases where I think we need to look at things through a different lens.

One of the most common things I hear from patients is some version of, “They told me it was my back,” or “They said I have bursitis,” or “My MRI showed a rotator cuff tear.”

Maybe.

The question I usually have is whether that diagnosis actually explains what you are feeling. Take hip pain. Someone may have been told for years that they have hip bursitis, when the gluteal tendons are actually playing a significant role. Someone with “sciatica” may have nerve irritation, but the source is not always where they assume it is. Tennis elbow can occasionally have a nerve component nearby. And plenty of people have impressive findings on an MRI that have been quietly sitting there minding their own business while something else is causing the current problem.

This is where the history and physical examination become so important. Where exactly does it hurt? What makes it worse? What can you no longer do? Does the pain travel? Is there weakness? What treatments have already been tried, and probably more importantly, what happened when you tried them? Even a treatment that failed can give me information.

If you have had three injections aimed at the same diagnosis and none of them helped, I’m probably not going to get overly excited about scheduling injection number four. At some point, we should reconsider the problem. Sometimes that means using diagnostic ultrasound to look at an area dynamically. Sometimes we use a targeted diagnostic injection to help determine where symptoms are coming from. Sometimes we need different imaging. And sometimes I need another physician, physical therapist or specialist involved because they bring a piece to the puzzle that I don’t.

I think of that as quarterbacking your care. My job does not always have to be performing the procedure or providing the final treatment. Sometimes my job is figuring out where the next play should go.

And honestly, some of my favorite appointments end without a perfect answer that day. There are times when I’ll sit there, look at everything again and tell a patient, “I need a few days to stew on this. Let me think it over and I’ll get back to you.” I’m never afraid to admit that.

Medicine is complex. People are complicated. Sometimes the history, examination, imaging and response to previous treatments don’t immediately point in the same direction. I would much rather take a few days to think through a difficult case, talk to a colleague or look at something again than force an answer just because we are sitting together in an exam room. Sometimes I just need to think.

Is this a joint problem? A tendon? A nerve? Is pain being referred from somewhere else? Are several things happening at the same time? Or have we become so focused on an MRI finding that we stopped asking whether it actually explains the symptoms?

Persistent pain can be frustrating, especially when you feel like you have already “done everything.” But doing everything and finding the right thing are not always the same. Sometimes the answer is not another treatment. Sometimes we just need to look at things through a different lens. 

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