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Pain is a Liar

Where the pain is often has little to do with where the problem is

Physical therapists spend a lot of time asking about, thinking about, and trying to decode pain. Complaints of pain are what brings a client to my office more than 90 percent of the time. I'll ask questions about where the pain is, how it behaves, how intense it is, what makes it better or worse, in order to get a clear picture of what my client is experiencing. The answers to these questions give me important information about the structures that are likely causing the pain, the stage of recovery a client might be in, or whether they may have a more insidious medical problem. This is valuable information, but it is virtually useless in planning the specifics of a physical therapy intervention. In short, pain is a liar (with thanks to Dr. Ed Stiles for introducing me to this concept, and this phrase, many years ago).

The overwhelming majority of the time, in PT practice, the location of the pain gives little information about the location of the PROBLEM. Let's say someone comes into my office looking for help with resolving some knee pain. Is there a structure in the knee causing pain? Almost certainly. Is that where treatment needs to be directed? Almost never. Sticking with our example of knee pain, the most important question to answer is: "WHY is the joint painful?" Excluding obvious exceptions like direct trauma, pain in the knee is almost always the result of a problem elsewhere in the lower half of the body. Knee pain can result from hip muscle weakness, ankle or mid-foot joint stiffness, great toe stiffness, hamstring stiffness, quadriceps weakness, asymmetrical gait patterns, trunk muscle weakness, or any combination of the above. A successful resolution of the problem requires an accurate mechanical diagnosis (see my previous post for more on this concept) in order to begin the treatment plan effectively. Exercise almost always helps, but which exercises? A clear mechanical diagnosis gives these answers.

This theme repeats itself with back pain, neck pain, shoulder problems, ankle pain, and most other musculoskeletal complaints. I was fortunate enough to have great teachers when I started doing this late last century. My mentor encapsulated it best. She said: "There are two ways you can approach PT practice. The most common way is to ultrasound what hurts, strengthen what doesn't, and pray for improvement. The best way is to find the problem and address it. " (Thanks, Nanci !)

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