Which of these is you?

Pain comes in through a handful of doors. Most people who find this page came through one of these.

• A line down the leg or the arm. Pain that leaves the spine and travels in a line you could trace with a finger. That is usually a nerve root problem, not a muscle one. Sciatica.
• A joint that has quietly become the center of your day. A knee, hip or shoulder that catches, aches on stairs, or has been called “arthritis” without anyone checking which part inside the joint is actually firing. Knee pain.
• Burning, numbness or a limb that overreacts. True nerve pain — feet that feel wrong at night, or a hand and arm that stayed swollen and strange long after a small injury should have settled. Peripheral neuropathy.
• A crash, a fall, a shift injury. You were fine, then you were not. Now you are also dealing with an insurer, an employer or a lawyer on top of your body. After a car accident.
• The operation happened and the pain came back, or never fully left. Hardware on the film, relief that did not match it. Failed back surgery syndrome.
• The injections used to work. Now they barely dent it. That is not you getting worse at responding to treatment. It is usually the treatment telling you something. When injections stop working.

Why doesn’t my MRI explain my pain?

An MRI shows structure. It does not show which part is sending the pain you feel. A large share of disc bulges, facet arthritis and frayed rotator cuffs show up on scans of people who have no pain at all. Treat the picture as the diagnosis and you will sometimes treat the wrong thing very well.

Two things explain why scans and pain so often disagree. First, the body. A part can break down slowly enough that the nervous system adapts around it, so the film looks scary and the tissue is quiet. Second, the blood. The inflammatory load in a person’s blood sets how touchy their nerves are at rest, no matter what any picture shows — which is why two people with the same scan can have opposite pain levels. And third, the system. A fifteen-minute visit built around a radiology report gives little reason to keep examining a body once there is a film to point at. That is a system problem, not a judgment on the person doing the pointing.

That is why the exam here starts before the images come up. It is also why we will sometimes tell you the part your scan blames is not the one causing your symptoms. What to expect at the first visit.

How do nerve blocks and injections find the pain source?

Most of what looks like a procedure list — blocks, injections, ablations, implants — is better seen as a set of tests. A medial branch block does not fix anything. It quiets one nerve for a few hours. If your pain goes quiet with it, that tells us the joint is the source. A diagnostic epidural is a question about a nerve root before it is treatment for one. The costly, permanent step — radiofrequency ablation, a stimulator, an implant — comes after the question has an answer, not instead of asking it. Medial branch blocks.

Can inflammation and blood sugar make pain worse?

Pain is a signal, not a diagnosis, and the spot that hurts is rarely the whole story. Metabolic inflammation turns up the baseline sensitivity of every nerve in the body, no matter what is torn or bulging. High blood sugar, year after year, glycates (sugar-coats and stiffens) the collagen in discs, tendons and joint capsules. Those are the very parts we are trying to get to heal. And behind both sits a food supply, a work schedule and a shortage of time. Each makes sleep, movement and real food harder to come by the longer someone has been hurting — the social driver under the two biological ones.

Dr. Gurpreet Singh Padda, MD, MBA, MHP spent the first twenty years of his career telling patients their bloodwork was “not too bad” while their pain got worse. It was not bad by the reference range. It was bad by the standard that predicts who heals and who does not. That is why bloodwork happens at a pain visit here, not as an upsell later. The metabolic terrain and pain.

If an accident or an injury is part of this

An adjuster works on a timeline that assumes soft tissue heals in six weeks. Your nervous system does not read that file. If people treat you as if you are exaggerating a slow recovery, the fix is not a louder complaint. It is a record, made close to the event and kept up the same way, that holds up when someone reads it looking for holes later. After a car accident. Work injuries run on a separate and different clock. Injured at work.

What does a pain management doctor examine?

Facet joints, the sacroiliac joint, the nerve roots leaving the spine, the discs, the canal they run through, and the nerves further out. Also the joints — knee, hip, shoulder — that get blamed on “age” before anyone has tested which part inside them is firing. Each has its own exam findings. Where imaging alone cannot settle it, each has its own diagnostic block. Facet joint pain.

The physician

Dr. Gurpreet Singh Padda, MD, MBA, MHP is the medical director: a trauma-surgery-trained anesthesiologist and interventional pain physician, board certified across pain medicine, interventional pain management, addiction medicine and obesity medicine, who has run the Center for Interventional Pain Management since 2001. About Dr. Padda.

What happens at the first pain management visit?

Call, text or book online. The first visit is a history and an exam, not a procedure. Unless a diagnostic block is the whole point of the visit, nothing will be done to you on day one. What to expect.

Common questions

Related reading

• About Dr. Padda
• What to expect at the first visit
• The metabolic terrain and pain
• Sleep, movement and behavior
• When it is an emergency