By Eric Hochman, M.D.
Musculoskeletal pain is one of the most common reasons that patients visit their doctors. In fact, odds are you visited your doctor sometime over the last year for a musculoskeletal issue. Pain is most commonly managed by rheumatologists, physiatrists, anesthesiologists, and orthopedic surgeons. Each of these providers is considered an expert in dealing with pain. However, not all pain is the same.
When evaluating a patient for a painful condition of the musculoskeletal system, it is necessary to determine if the pain is due to an inflammatory cause or not. Most pain can be classified into one of two categories, inflammatory pain, or non-
inflammatory pain. Although there are hundreds of specific causes of pain within each category, proper diagnosis of the category is more important than exact diagnosis of the cause of the pain.
Causes of non-inflammatory pain include: osteoarthritis, tendonitis, bursitis, fibromyalgia, and many others. Although the cause and presentation of each of these conditions can be very different, the treatments are often very similar. All of these conditions can be treated with non steroidal anti-inflammatory drugs (Aleve, Advil, Mobic, etc), Tylenol, and other pain medications, injections, physical therapy, and in some cases, surgery. The treatments do not vary dramatically based on the diagnosis.
Inflammatory causes of pain are very different. Although some of the above treatments can be helpful in treating systemic inflammation, they are not the main component of treatment. Steroids and disease modifying anti-rheumatic drugs (DMARDs) are the mainstay of treatment for systemic inflammatory conditions. Making the right diagnosis in regards to the category of pain can be life altering.
A patient with end stage osteoarthritis of the knee or hip basically has the equivalent of a worn out part. No treatment is able to “repair” this part. Treatment may help alleviate the pain, but the part is still damaged beyond repair. The only definitive treatment for a symptomatic end stage knee or hip is to replace it. On the other hand, in a patient who has an inflammatory cause of joint pain, such as rheumatoid arthritis, the problem is not a worn out part, but rather the systemic inflammation itself. If the inflammation can be appropriately controlled with the right medications, it is possible to completely neutralize the cause of pain (reduce inflammation), and restore the part back to normal.
It is often easy for an experienced practitioner to differentiate between inflammatory and non-inflammatory pain, but sometimes too much weight is placed on the results of imaging studies when making a diagnosis. Although Xrays, CT scans, and MRIs can be very helpful in diagnosing musculoskeletal causes of pain, they always need to be considered in relation to a patient’s history and physical exam. Patients can have very abnormal imaging studies and not have associated pain. An abnormal imaging study does not always warrant a joint replacement.
Throughout my career, I have seen numerous patients who initially presented to their providers with new onset pain that was ultimately diagnosed (incorrectly) as symptomatic osteoarthritis based on imaging studies. Unfortunately, several of these patients even had joints replaced in an attempt to treat their pain. As these patients did not improve after surgery, they consulted me for another opinion. By obtaining a detailed history, physical exam, and appropriate laboratory tests, we were able to identify an inflammatory cause for their pain. Once started on the correct medical regimen, years of pain could sometimes be alleviated overnight.
Not all pain is the same. Before definitive treatment can be initiated, the type of pain must be appropriately categorized. If there is the possibility of an inflammatory cause of pain, Rheumatology evaluation should be strongly considered.
Eric Hochman, M.D.
Gulfshore Concierge Medicine focuses on the whole well-being and health management of patients by offering them the WELLStrides™ Plan, a personalized four-step approach to optimize health, maximize longevity and experience well. Gulfshore Concierge Medicine follows the “concierge medicine model” in which patients pay an annual retainer to receive more personalized care, 24/7 access and care, extended appointment times, same day or next day appointments, assistance with medical needs during travel, and “virtual” consults. It is a cutting edge facility with large screen monitors in each exam room allowing Dr. Hochman and the patient to view all records, exams, labs, and other results together. The annual retainer fee covers a range of preventative medical services including annual physical exams, recommended screening tests, nutrition and weight counseling, immunizations, electrocardiograms and in-office lab testing, among other services. For more information, visit www.GCMedicine.com or call 239-325-1020.