Yesterday we covered lower back pain stemming from overexertion of some sort. Pain of this sort is generally easier to identify and manage. However, there is a whole host of other reasons for lower back pain. The lists that follow may prompt questions you can ask the patient to help narrow down the cause. Before we get to that, though, let’s review the questions to ask a patient with lower back pain to differentiate between injury-related musculoskeletal origins (the subject of the previous article) and non-injury-related and internal organ origins of lower back pain.
QUESTIONS TO ASK
Was there an acute injury (fall, strain, twisting, blow)? When? Some injuries take time to produce pain. While pregnant with baby #5, I was out taking the dog for a walk when he suddenly decided it was time to chase a cat or something like that. It was a sudden jerk and really tweaked me at the time, but the pain soon dissipated. The next morning, however, when I got a gallon of milk out of the fridge, I suddenly found myself in excruciating pain at the exact spot that the dog tweaked the day previous.
Is there a chronic injury? Even if someone regularly lifts heavy weights, over time injury may occur.
Where does it hurt? Most musculoskeletal pain is below waist level. Mid- to upper back pain may issue from the stomach, heart, lungs, or kidneys.
How much does it hurt? More than asking a patient to rate their pain on a scale of 1-10, doctors look at whether a patient is able to function. A patient who cannot function is in greater pain than one who is chatting on his phone.
How long has it hurt? If the pain has been there a long time but only recently worsened, it’s probably nothing new or serious.
Has the patient experienced this previously? If so, it’s probably chronic and less concerning.
What makes the pain worse? What makes it better? Musculoskeletal pain almost always worsens or improves with a change in position. This is far less common with internal problems. Is the pain better if the patient is sitting or standing? Is it worse or better with urinating? Worse or better with eating? Fatty foods may make gallbladder pain worse. Deep breathing is painful with pleurisy.
Has the patient taken any pain relievers? Pain meds may relieve most pain. They may worsen an ulcer.
Does the pain radiate anywhere? Internal causes generally radiate pain into the abdomen. Musculoskeletal causes may radiate pain into the legs.[2]
Narrowing down the possibilities to arrive at a diagnosis and treatment takes time, especially when the actual cause originates someplace else. Back pain caused by internal organs other than the kidneys may be difficult to diagnose, particularly if there aren’t additional typical symptoms.[1] Considering the following may help diagnose more quickly.
· Men
o Varicocele[2]
o Enlarged prostate[3]
o Middle-aged and older men with back pain and urinary symptoms (frequent urination, dribbling, pain, difficulty starting to urinate) may have chronic prostatitis rather than a bladder or kidney infection.[4]
· Women
o Middle-aged and older women are often overlooked because many in this group already experience some daily back pain.[5]
o Lower back pain often occurs in women during pregnancy or menstrual periods. [6]
o Very low back pain may issue from problems in the uterus or ovaries.[7] [8]
· Elderly
o Chronic compression fractures of the spine and neck result in a hunched appearance.
o Shingles may cause back pain that is difficult to diagnose until the blisters erupt.[9]
o Urinary tract infections may only cause back pain with no noticeable change in urination.[10]
o Other causes difficult to diagnose without advanced technology
§ Aortic aneurysm[11]
§ Cancer[12]
§ Chronic back pain is often arthritis. [13]
§ Heart attack.[14] A good friend experienced excruciating back pain for several hours without any other symptoms. Changing positions did nothing and he finally asked his son to take him to urgent care. That resulted in a quick trip to the hospital in an ambulance where he was immediately operated on.
· Gastrointestinal
o Gallbladder and kidney disease[15]
o Gastric ulcers[16]
o Hemorrhoids[17]
o Large intestine[18]
o Pancreas[19]
o Rectum (very low back pain)[20]
o Stomach[21]
· Musculoskeletal (other non-injury-related causes)
o A heavy abdomen[22]
o Arthritis
o Bone disease may itself cause pain or may cause the patient to assume unnatural positions which then cause pain.[23]
o Foot conditions cause the patient to walk or stand unnaturally[24]
o Muscle spasms may cause an abnormally straight back
o Poor posture[25]
o Prolonged standing[26]
o Scoliosis (more easily identified if the patient bends forward)[27]
o Sleeping on a sagging mattress[28]
· Neurological
o Fatigue[29]
o Nervous exhaustion[30]
o Shingles[31]
· Systemic
o Acute infectious disease[32]
o Lead poisoning[33]
· Urogenital
o The kidneys are the most common of the internal organs to cause back pain, especially when the pain is one-sided and occurs just below the ribs posteriorly.[34] Tapping (a gentle pound) over the affected kidney usually causes more discomfort than applying pressure to it.[35]
o Urinary tract infections[36]
[1] Cynthia Koelker, Armageddon Medicine, 2012, 524.
[2] The Ship’s Medicine Chest and Medical Aid at Sea, 1978, 197.
[3] The Ship’s Medicine Chest and Medical Aid at Sea, 1978, 197.
[4] Cynthia Koelker, Armageddon Medicine, 2012, 383.
[5] Cynthia Koelker, Armageddon Medicine, 2012, 383.
[6] David Werner, Where There Is No Doctor, 1992, 173.
[7] David Werner, Where There Is No Doctor, 1992, 173.
[8] Cynthia Koelker, Armageddon Medicine, 2012, 524.
[9] Cynthia Koelker, Armageddon Medicine, 2012, 383.
[10] Cynthia Koelker, Armageddon Medicine, 2012, 383.
[11] Cynthia Koelker, Armageddon Medicine, 2012, 384.
[12] Cynthia Koelker, Armageddon Medicine, 2012, 384.
[13] David Werner, Where There Is No Doctor, 1992, 173.
[14] Cynthia Koelker, Armageddon Medicine, 2012, 384.
[15] The Ship’s Medicine Chest and Medical Aid at Sea, 1978, 197.
[16] The Ship’s Medicine Chest and Medical Aid at Sea, 1978, 197.
[17] The Ship’s Medicine Chest and Medical Aid at Sea, 1978, 197.
[18] Cynthia Koelker, Armageddon Medicine, 2012, 524.
[19] Cynthia Koelker, Armageddon Medicine, 2012, 524.
[20] David Werner, Where There Is No Doctor, 1992, 173.
[21] Cynthia Koelker, Armageddon Medicine, 2012, 524.
[22] The Ship’s Medicine Chest and Medical Aid at Sea, 1978, 197.
[23] The Ship’s Medicine Chest and Medical Aid at Sea, 1978, 197.
[24] The Ship’s Medicine Chest and Medical Aid at Sea, 1978, 197.
[25] David Werner, Where There Is No Doctor, 1992, 173.
[26] The Ship’s Medicine Chest and Medical Aid at Sea, 1978, 197.
[27] The Ship’s Medicine Chest and Medical Aid at Sea, 1978, 197.
[28] The Ship’s Medicine Chest and Medical Aid at Sea, 1978, 197.
[29] The Ship’s Medicine Chest and Medical Aid at Sea, 1978, 197.
[30] The Ship’s Medicine Chest and Medical Aid at Sea, 1978, 197.
[31] Cynthia Koelker, Armageddon Medicine, 2012, 383.
[32] The Ship’s Medicine Chest and Medical Aid at Sea, 1978, 197.
[33] The Ship’s Medicine Chest and Medical Aid at Sea, 1978, 197.
[34] Cynthia Koelker, Armageddon Medicine, 2012, 523.
[35] Cynthia Koelker, Armageddon Medicine, 2012, 524.
[36] Cynthia Koelker, Armageddon Medicine, 2012, 383.
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