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Pain Before X-rays

Many of our readers have asked for my opinion about chronic pain and the absence of identifiable injuries on X-rays. In other words, why do we have chronic pain when there seems to be nothing wrong. 

As a general rule, most people can develop an ache or pain without having an abnormality on present radiological equipment. For instance, many of my patients have chronic knee pain and cracking, known as crepitus. They may have been diagnosed with patellofemoral syndrome. Many however, are commonly left with knee pain that has no specific diagnosis or treatment, even after knee joint arthroscopy.

Similarly, many of my patients are diagnosed with back or neck pain and have no known abnormality on X-ray, CT, MRI and other scans. Many have been in accidents and are left with chronic spinal pain but have no apparent injury. 

Fibromyalgia is classically a chronic pain condition with little to find on scanning devices. Many researchers have scrambled to find some blood test abnormality, in a hope of  "clinching"  the diagnosis but this single test has not yet been found.

People who suffer chronic headaches, often have had more than one CT scan and several MRI scans within one year. These x-rays are often normal. Patients may be unaware that most headaches are now attributable to neck generated pain referring into the head

Similarly, people who suffer from IBS or Irritable Bowel Syndrome often have had many tests, such as barium enemas and colonoscopy exams and find nothing. (by definition of diagnosis).

I believe that all these tests and more are important to rule out possible causes and I hope better testing and imaging will be developed in the future. I also believe, we will very soon be able to demonstrate why you ache and why "nothing appears on X-ray." However, in the meantime, I will try to explain why sometimes our pain is just ahead of the scan.

As an example, if I were to develop osteoarthritis in my low back, how would this first appear? Would it appear on X-ray (or some scan) first or would it first appear as a pain? Which is more sensitive, the humanís ability to scan or the human nervous system?

The answer may surprise you but it is a little of both. As a general rule, older people often discover the pain long after the X-ray changes and younger people often develop the pain before any X-ray changes. Many people will deny an ache or pain in their back or their joints. However, on x-ray, it is often very obvious that they are developing for example, advanced arthritis and degeneration in the base of their neck , low back, knee or hip. They may not complain. At least not right away.

This is probably because they have been fortunate enough not to overstrain the joint and muscles around that joint. They probably have not yet developed a significant neuropathy in their spine or limbs. However, the reality of muscle dysfunction and joint compression are real and they will likely develop progressive joint destruction. The pain of this gradual deterioration is initially not felt due to lack of sensation of many joint parts and because of the presence of a "part specific pain tolerance." The person may be unaware of the back problem because the pain is gradual, not physically over-stressed and is partially blocked. However, if you were to push these individuals at a specific joint, by chopping wood or on moving day, they can very quickly get into problems with a chronic pain.

I frequently hear a variety of statements from patients such as, "the pain seemed to come out of the blue. I did not have any pain yesterday."

My answer often is,  "Well of course you didnít, chronic pain has to start some time." That "some time" is once the part specific pain tolerance is surpassed and you develop pain. If your pain level drops below your tolerance, then your pain will disappear. This idea is derived from my concepts on "Constant Pain Theory."

Now those who have pain with a normal scan are actually just as common as the person with a painless arthritic x-ray.  It has been well documented by many, that chronic pain and arthritis is more common in an athlete, present or in the past, professional or amateur. Much of the pain is from persistent nerve pain in the spine or limbs, in association with muscle dysfunction.

Typically disk or bone abnormalities are simply a complication of the muscle and nerve process that is going on in the spine or limb. This is why the active athlete will have neck pain that no one can find. Their massage therapist will say something such as, " Your muscles are so tight and there is scar tissue in your muscles or there are all kinds of oxidants and toxins in your muscles." 

The truth is, much of these statements are true. Unfortunately, none of these possible changes show on X-ray. However, they can be felt and appreciated by both the therapist and the patient upon direct needling of paraspinal and limb musculature. Eventually, these abnormal but common muscle forces will contribute to joint degeneration. At that point, the X-ray will explain the chronic pain. 

So next time you have a pain in your head or legs, or numbness in your arms or legs and it seems that nobody can find the cause of your pain, ask your doctor if it is possible that you have a neuropathy. It may originate in your neck, spine or in the shoulder or pelvic girdles or the nerve may be entrapped in your arm or leg. The result will commonly be a pain syndrome and it probably wonít show on X-ray.

Stretching will increase the pain at the time of stretching but usually offers relief for minutes to hours after the stretch.

As always, keep long and strong.



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  Last Updated: May 11, 2015

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