Diagnosing painful musculoskeletal conditions: Is it absolutely necessary?

No one likes being in constant pain and often pain has an accompanying diagnosis to go along with it. In many cases this is absolutely warranted and the sooner a competent clinician can make a diagnosis, the sooner people can seek the right care for optimal recovery. For example, take the patient who presents with left constricting chest pain and associated radiating pain or pins and needles into either the inside of the left arm or the neck. A diagnosis under this circumstance could literally be the difference between life and death.

However, pain arising from the musculoskeletal system (bones, ligaments, tendons, muscles and cartilage) isn’t always as clear cut and while it’s essential to still screen for red flags in any presentation the vast majority of cases are not life threatening. Mind you, they can still be very painful for the person experiencing it and thankfully it’s often responsive to treatment (particularly in the earlier stages after it starts).

So perhaps a better question – and what this article is based upon – becomes: Do we have to diagnose every single presentation of musculoskeletal pain?

I’ve been brewing this concept over for months and there’s two lines of thought that predominate when I think of making the distinction between folks presenting with pain related to their musculoskeletal system.

1. Diagnosing painful musculoskeletal conditions can give people peace of mind and allow them to move forthrightly in the direction of their healing and recovery. There’s a lot of stock – and much conventional wisdom – in this idea. Establishing a definitive diagnosis has been taught for centuries in medicine and healthcare, so it fits with what’s perceived as otherwise normal. That is, when someone has pain arising from their muscles (or anywhere for that matter), they have a right to a diagnosis and work from researcher’s in the US seems to confirm this.[1] Some people though, don’t want all of the particulars and many also just want to know if it’s able to be treated effectively so they can move forwards and be free of pain. This is what brings me to the second consideration with giving people a diagnosis.
   

2. Diagnosing painful musculoskeletal conditions can label a person with a disease, illness or syndrome that pervades their mindset in such a way as to deter or diminish their capacity to recover optimally. Often the focus of this diagnosis that receives more criticism is in the psychological fields and the mental health professions, where there could be far-reaching danger in giving a mental health condition something of a badge to be worn. However, given some new evidence and more of an understanding of the emergence of the biopsychosocial model in musculoskeletal pain, we can no longer simply isolate potentially harmful diagnoses to mental health conditions only.[2] Furthermore, evidence is (and has been) mounting for pain having a psychogenic component far beyond tissue damage. There’s been very supportive literature to suggest that pain can exist in the absence of joint, ligament and muscle damage in the extremities, disc herniations, degeneration and back strains.[3,4] This by no means doesn’t imply that the pain is just in the person’s head either, there are neuroplastic changes taking place in the brain, especially as pain becomes more chronic in nature.[5] Perhaps being aware of these changes, alters the way we communicate with our patients so as they have more optimistic outcomes – nothing positive or so disempowering comes from the expression ‘You’ve got very bad arthritis in your hip and spine and you’re just going to have to live with this pain forever.’

There’s always the case for a third option…

And then there’s the third consideration I didn’t mention initially: Maybe it’s just fine to have both methods as acceptable rather than an either/or situation depending on the needs, wants and expectations of our patients.

Some may want a specific diagnosis and every specific little detail about what, how and why the condition arises and how they can use that knowledge to recover. Others might prefer to have no diagnosis at all and be reassured that their condition – when appropriately assessed – isn’t medically dangerous and is readily treatable, manageable and capable of a great recovery.

We also want to teach our patient’s to be resilient in managing their own condition. It can often be wise to sit in the passenger seat while they drive and reassure them that they can work through their pain and improve their condition(s), diagnosis or not. This aids in evidence-informed self-care, supporting our patient’s journey in health-literacy and is self-empowering which are all components in their own right of adopting a strength-based approach.[6,7]

When it comes to musculoskeletal pain and attaining a diagnosis for every single individual, consider that while under certain conditions it can and will absolutely be paramount for their health outcomes. However, some may respond better with a ‘less is more’ approach and each presenting person we see has a right to their personal treatment preferences. Unless the assessment reveals something sinister, some may actually respond better without a formal diagnosis.

What do you think? I'd love to hear your personal thoughts.

References:

[1] Sullivan RJ, Menapace LW, White RM. Truth-telling and patient diagnoses. Journal of medical ethics. 2001 Jun 1;27(3):192-7.

[2] Darnall BD, Carr DB, Schatman ME. Pain psychology and the biopsychosocial model of pain treatment: ethical imperatives and social responsibility. Pain Medicine. 2017 Aug 1;18(8):1413-5.

[3] Gallo RA, Silvis ML, Smetana B, Stuck D, Lynch SA, Mosher TJ, Black KP. Asymptomatic hip/groin pathology identified on magnetic resonance imaging of professional hockey players: outcomes and playing status at 4 years' follow-up. Arthroscopy: The Journal of Arthroscopic & Related Surgery. 2014 Oct 1;30(10):1222-8.

[4] Borenstein DG, O'Mara JW, Boden SD, Lauerman WC, Jacobson A, Platenberg C, Schellinger D, Wiesel SW. The value of magnetic resonance imaging of the lumbar spine to predict low-back pain in asymptomatic subjects: a seven-year follow-up study. JBJS. 2001 Sep 1;83(9):1306-11.

[5] Bosnar Puretić M, Demarin V. Neuroplasticity mechanisms in the pathophysiology of chronic pain. Acta Clinica Croatica. 2012 Oct 1;51(3.):425-9.

[6] West C, Stewart L, Foster K, Usher K. The meaning of resilience to persons living with chronic pain: an interpretive qualitative inquiry. Journal of clinical nursing. 2012 May;21(9‐10):1284-92.

[7] O'Donnell PJ. Psychological effects of a strength-based intervention among inpatients in rehabilitation for pain and disability. Prescott Valley (AZ): Northcentral University; 2013 Sep.