The art of asking where it hurts

Norman Grant was a new patient. He had chronic back pain, not helped by surgery or a dozen injections after that. It all started with an industrial accident in 2001. He had settled his case and was on chronic OxyContin, which far from kept him functional. But as of January 1, his insurance was no longer covering that drug. He only had two weeks left of it.

He told me he hurt when he rolled over in bed, when he walked or if he sat or stood still too long. He didn’t have sciatica. His legs had normal strength and sensation. He could bend his back forward or back without too much pain.

I was puzzled.

“Show me exactly where your back hurts,” I asked him. He pointed low, to the right. I banged with my fist on his spine and palpated the muscles along his lumbar spine. No pain. Then I pressed over his left sacroiliac joint. No pain. But the right one was exquisitely tender.

I asked him to lie down on my exam table. I tested the range of motion in his hips, and it was pretty normal. Then I checked for pain in his left SI joint by flexing his hip and knee and pushing his left leg to the side and toward the exam table.

“It hurts on my right side,” he said.

I repeated the procedure on his right side.

“Ouch, I feel a click when you do that,” he exclaimed.

“Did anybody X-ray your SI joints or your pelvis or talk about that area?”

I asked.

“No, but I kept telling them it wasn’t my spine that hurt; it was down there.”

“We need some X-rays of that area, and there may be things we can do for you besides giving you more or stronger pain pills,” I explained.

He grinned and thanked me.

“I kept telling them I hurt down there, but they wouldn’t listen or check it out the way you did.”

“Well, we’ll see, maybe we’re on to something,” I said. I wondered to myself, could it really be that he had a disc herniation that really wasn’t causing any of his symptoms, and his SI joint problem had been overlooked for all these years?

Hans Duvefelt is a family physician who blogs at A Country Doctor Writes: and the author of A Country Doctor Writes: CONDITIONS: Diseases and Other Life Circumstances.