Last week, a patient presented with intractable right sided knee pain of five days duration following a fall in his home. I evaluated him and found no swelling, no limitation in the range of motion, no tenderness, no instability and no bruising. I caused an X-ray to be taken and it was “negative”.  He sat in my office rubbing his painful knee. I remembered that when he first became my patient four years earlier, he had presented for a second opinion pertaining to his knee and had been scheduled at a major medical center for arthroscopy the following week. After my complete assessment at that time, my diagnosis was spinal stenosis and right lumbar radiculitis; that is nerve root irritation in the back at L3-L4 referring to his knee. I arranged for an epidural steroid injection at that time and he has lived without pain for four years until the aggravation of the preexisting spinal arthritic disorder by the fall last week.  He was experiencing referred pain to the knee from an arthritic back.

A second patient had presented two weeks ago with a very painful right knee limiting his work and interfering with his activities of daily living. His examination excluded swelling, warmth, tenderness, instability, limitation in the range of motion or a limp. The X-ray of the knee excluded any significant abnormal changes. I referred him for an MRI of his spine and the report came back Friday consistent with a herniated nucleus pulposis (slipped disc) at L3-L4. That latter patient is scheduled later this week for an epidural steroid injection.

The third scenario is equally informative as it involves a colleague at a major medical center in Chicago. He was experiencing calf cramps with severe night pain. Because he concluded the problem was from his leg and ankle, he sought attention from a foot and ankle surgeon who promptly sent him for imaging of his leg. Because of a long-term personal relationship, I recalled that ten years ago, he had had an epidural for radiculitis (referred pain down a leg) having to do with an arthritic low back. I asked him to share his recent MRI and there was the diagnosis “severe stenosis”. Both the physician patient and his foot and ankle specialist had discounted the MRI result because of the absence of back pain.

The lesson to be learned from this Blog is that all symptoms may not necessarily arise from the point of discomfort and you can have disabling extremity pain, no back pain and the source may still be the spine. If your doctor doesn’t know that, teach her or him.

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