Consistent vs. Variable Pain

Perhaps the most important question I ask patients is: "Is the pain consistent or variable?" It tells me a lot about what the problem could be.

Consistent pain (or other symptoms such as tingling or numbness) is brought on by the same motion or activity EACH AND EVERY TIME, IN THE SAME LOCATION. For example, every time I reach in the back seat of my car my shoulder kills me. Or, every time when I hit the 10-minute mark walking, my calves goes numb. Or, my neck hurts each time I turn to the left.

Variable pain is a different beast. The patient would report something like: sometimes my elbow hurts when I play tennis, and sometimes it doesn't.  Or, on Monday I could walk 30 minutes before my knee started hurting, but on Tuesday I could barely make it 5 minutes. Or, usually I can sit without pain in the mornings, but other times when I sit I get sharp pain in my buttocks.

Constant pain can be consistent OR variable. Constant pain that is always at a 4/10 pain level would be considered consistent. Constant pain that sometimes registers as 1/10 pain and other times feels like 8/10 pain would be considered variable for my diagnosing purposes.

When I understand that the pain is consistent, I start thinking about a few things. For one, tendon or muscle pathology will produce consistent symptoms because each and every time you stress that tendon (or muscle), it should hurt. Consistent pain also makes me think of bony changes such as arthritis; pain due to arthritis should be consistent since the bones don't change on a daily basis! Consistent pain can also be produced by dysfunctional tissue such as scar tissue; every time the scar is stretched, it hurts.

Variable pain is often produced by an obstruction in a joint, also known as a derangement. Sometimes the joint moves well and without pain, but sometimes (either due to the day's activities or a sleeping position, etc.), the joint gets stuck and therefore produces symptoms -either locally or referred away from the joint. 

As far as constant pain, there could be an inflammatory process going on or a mechanical obstruction/derangement that is obstructing a joint at all times, to name two common examples.

Based on the patient's answer to this one question, I know a lot about what is going on. When combined with "the how" of the injury and and where the symptoms are located, I have a solid diagnosis in mind before I start the manual testing.