Finding the cause of chronic pain How doctors work out where your pain is coming from

Pain that has lasted more than about three months is chronic, and by that point many people have tried rest, pills and a few rounds of exercises without a clear answer. Treatment works best when it is aimed at the right structure, so the first job of a pain management doctor is detective work (more in what does a pain management doctor do?). The videos on this page show some of the tools we use, from nerve conduction testing to a test nerve block, and this post explains how they fit together.

Why the cause of chronic pain is often not where it hurts

Nerves carry pain signals along their whole length. A nerve root irritated in the lower back can make the calf or foot ache, and a nerve pinched in the neck can show up as shoulder, arm or hand pain. That is why the second video traces leg symptoms back to the L5–S1 level of the spine, and the third traces arm symptoms to the C5–C6 level of the neck. Joint and muscle problems can also refer pain: an arthritic facet joint in the spine can ache across the buttock, and a tight muscle knot can send pain several inches away.

Step 1: history and physical exam

Most of the answer comes from talking and examining. Expect questions about when the pain started, what makes it better or worse, whether it wakes you at night, and whether you feel numbness, tingling or weakness. The exam checks movement, strength, reflexes, sensation and the specific positions that reproduce your pain. If there are warning signs, such as unexplained weight loss, fever, or trouble with bladder or bowel control, those are dealt with first.

Step 2: imaging, when it answers a question

X-rays show bones and joint space, MRI shows discs, nerves and soft tissue, and diagnostic musculoskeletal ultrasound lets a clinician look at tendons and joints in real time in the office. Imaging is useful, but many people without pain have disc bulges or arthritis on an MRI, so findings only matter when they match your exam.

Step 3: nerve conduction testing and EMG

When symptoms point to a nerve, a nerve conduction study measures how fast and how strongly signals travel along it. Small electrodes are taped to the skin and a brief electrical pulse is applied, which feels like a quick tap or snap. An EMG adds a fine needle electrode in a few muscles to see how they respond. Together they can show whether a nerve is pinched at the neck or lower back, compressed further down (for example at the wrist in carpal tunnel syndrome), or affected more widely. In the first video, our team runs this kind of test, and our guide to what to expect from an EMG test walks through it step by step. Read more on our EMG and nerve conduction testing page.

Step 4: a test nerve block

Sometimes the best way to confirm a pain source is to switch it off briefly. In a diagnostic block, a physician uses X-ray guidance to place a small amount of numbing medicine next to a specific nerve or joint, as in the last video. If your usual pain drops a lot for the next few hours, that structure is likely involved. A medial branch block tests the facet joints of the spine this way, and a good response can make someone a candidate for radiofrequency ablation. Nerve root pain may instead be treated with an epidural steroid injection; our post on transforaminal epidural injections for sciatica shows one targeted at a single nerve.

What happens once the cause is found

Knowing the source changes the plan. A pinched nerve in the neck might be treated with physical therapy and, if needed, an injection (see chronic neck pain treatment). Facet joint pain in the lower back might be treated with exercise plus a block or ablation. A muscle-driven problem might respond best to hands-on care and strengthening. Physical therapy is part of most plans and is offered at our Brooklyn and Staten Island offices; see our physical and occupational therapy services.

When to see a pain management doctor

• Pain has lasted more than three months, or keeps returning
• You have numbness, tingling or weakness in an arm, hand, leg or foot
• Pain spreads from the back into a leg, or from the neck into an arm
• Treatment so far has not helped and nobody has explained why (see what to do when chronic pain is not improving)

Go to an emergency room or call 911 for sudden severe weakness, loss of bladder or bowel control, or pain with fever after a recent infection or procedure.

Related care at Precision Care Medical & Sports Performance

A pain management doctor near you

Precision Care Medical & Sports Performance physicians evaluate chronic pain at all three offices. For a pain management doctor in Brooklyn, Ashley Marcus, MD sees patients at our Brooklyn pain management office, close to Sheepshead Bay, Midwood and Manhattan Beach. Jake Stephen, DO sees patients for pain management on Staten Island, convenient to New Dorp, Dongan Hills and Great Kills. Yuri Gordin, MD leads the Precision Care Spine & Pain Center in Midtown Manhattan at 150 E 55th St, a short subway ride for patients from East Harlem (Spanish Harlem), Washington Heights, Turtle Bay and the Upper East Side, and the closest office for anyone searching for a pain management doctor in Midtown East.

Pain procedures are performed at all three offices, and your physician explains where and when yours will be scheduled. Physical therapy is offered in Brooklyn and Staten Island only. If you are looking for pain management near me, request an appointment or call the office closest to you.

Questions patients ask

Educational only, not medical advice. These videos and this article explain common problems and treatments in general terms. They are not a diagnosis or a treatment plan for you. Results vary from person to person. See a qualified clinician about your own symptoms, and call 911 or go to an emergency room for an emergency.

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