My thoughts drifted back to another young man with a similar duration of back pain, but an entirely different trajectory.
I met Michael T. in my first year of practice. Wearing wire-rimmed glasses and dressed in khakis and a button-down white shirt, he was of normal height and weight, and lacked the hang-dog slouching shoulders of chronic pain. He appeared fit, relaxed and comfortable in his own skin. The referral was from a neurosurgeon who had reviewed an MRI demonstrating low-grade congenital spinal stenosis. The stenosis was so mild it couldn’t possibly account for his painful, stiff back. Surgery was out, the surgeon told Michael T. Maybe I could shed some light.
“So you’ve had back pain for six years,” I noted as I reviewed his chart and looked over his normal plain films of the lumbar spine and pelvis. “Any injuries?”
“Oh sure, I mean I’ve been dinged up from time to time. Nothing serious. I fell off our roof shoveling snow when I was 16, then, fell again rock climbing a year later, but that was no big deal. I’ve never connected any injuries to my back pain; it’s just there. Every morning I wake up like Groundhog Day, and there it is, again.”
“Car accident? Litigation? Are you applying for disability?”
“Are you crazy?” he bristled. “I’m a physics major. My hero, Steven Hawking, has Lou Gehrig’s disease and can’t move his arms and legs, but the guy is rolling out mathematical solutions to stuff Einstein passed on. Listen, I’ve got a bad back. It’s not the end of the world, but I’ve tried all the stuff you guys tell me to do. Took the drugs, gone to therapy, stretched like crazy. Hey, my sister dragged me to her Yoga class, and that was cool. I felt good for maybe an hour. I don’t even know why they sent me here. Don’t rheumatologists see a bunch of old people with arthritis?”
“Okay. Sorry,” I said, ignoring the dig. “Let’s start over. Where exactly do you hurt?” Mike stood up and slid his hands around the lower lumbar region and sacrum. “Does this hurt?” I firmly palpated the para-lumbar muscles and the sacroiliac region.
“No,” he shrugged. “That’s the thing. When I reach back there, I can’t find a spot that’s particularly tender. It’s a deeper ache. Mornings are tough. I feel like the tin man.”
“Stiff?”
“Yeah, like major stiff. I shower and stretch before class, but if I sit for more than 10 minutes it all rolls back. So I’m constantly stretching, trying to loosen up, which is the only thing besides naproxen sodium that helps at all.”
