If you ask the average person in the street why we had an economic meltdown in 2008, usually you’ll get a quick answer, something like, “It was greedy dishonest brokers on Wall Street.” Well, sure, but we’ve had greedy dishonest people on Wall Street for 100 years. So that’s not why we had a crash.

If you asked the Chairman of the Federal Reserve the same question, the answer is an 8-hour lecture. There wasn’t one cause. The economic crash resulted from a system of interacting factors: dishonest mortgage brokers, toxic mortgage loans, greedy banks that borrowed way too much money, weird financial derivatives nobody understood, and so forth. When they all moved together, they caused a crash. But you don’t have to change the entire system to prevent another crash. Improve just a few things, and the risk goes away.

In the same way, pain in most people is not simply cause and effect. It’s a system, where each factor makes the next better or worse. That’s not bad, because it gives you an opportunity. You might be able to fix something far removed from the original problem to restore normal function.

Let’s say someone stuck an invisible nail in your back, which for some reason no doctor could find or cure. That could certainly be a major cause of pain. The pain would keep you awake. Lack of sleep would make your pain worse. It would make you irritable, and anger worsens pain. Your friends and family would start to avoid you, and you’d become isolated and lonely: even more pain. Then depression would set in, which definitely makes pain worse. You’d become exhausted and stop moving around — lack of exercise typically makes people hurt all over. You’d tense up and try to avoid any activity that worsened your pain. All those tense muscles become sore. Many people gain weight when they become inactive, and increased weight causes fatigue, increased muscle pain, and trouble sleeping. Anxiety and tension due to fear of hurting worsens pain directly. If you couldn’t work, you’d face financial stress, which would aggravate insomnia, depression, and anxiety. By this point, most people begin to feel bad about themselves: they can’t do anything and they feel like a burden to their family.

Each one of these factors makes all the others worse. You’ve become a walking collection of vicious cycles.

But all is not lost. If you could improve even a few things in the system, your pain may improve dramatically, even if no one could remove the nail.

The patients I worry about the most are the ones who say the loudest, “Doc, there’s nothing wrong with me except this,” pointing to the body part that hurts. They want me to fix them while they wait in their car parked outside.

I call this a “transfer of responsibility,” meaning the patient wants to make their pain my responsibility, not theirs. It’s exactly the same as the alcoholic who walks into my office and tells me, “Doc, you’ve got to make me stop drinking.” Since we all know this isn’t possible, this is the same as saying, “Doc, I might want to stop drinking, but I’m not sure. The truth is, I’m not serious yet. I might be interested in quitting if you can do it for me, without any effort or discomfort on my part.”

Let’s say you’ve had twelve back surgeries. The MRI looks fine but you’re miserable. Who can tell exactly why you have pain? The question is ridiculous — that part of your body is a tangled mess. There is no single, neat cause. But believe it or not, if you do the exercises and honestly work on yourself, a lot of people get better.

At this point, you might say, “Wait, wait, I’m not the doctor! It definitely is your job to find the cause of the pain and fix it.” But there is no single clear-cut cause of pain in 85-90% of people with chronic pain. Or else the cause is obvious, and the mystery is why they’re not better.

If you’re confused, wait. It gets worse.

The myth of the MRI

If you do an MRI scan of the lumbar spine in a hundred healthy 50-year-old people who have no pain at all, nearly half will have a herniated disc. Three-quarters have bulging discs. The risk a healthy person will have a serious abnormality in an MRI of their back or neck is related to age — a little more than 1% per year. So if you’re 40 years old, your risk of an abnormal MRI is about 40-50%. If you’re 60, the risk is 2/3 or more.

Remember, this is the risk of a normal person without pain having an abnormal MRI.

So, you come into my office with back pain. We do an MRI and see a herniated disc. What does that mean? Does it show me the cause of your pain, or is it a red herring? (The same problem arises for MRIs in many areas of the body. They are notorious for showing you problems that don’t matter.)

The answer lies in doing a thorough history and physical examination. If on clinical exam, you have a herniated disc, then the finding on the MRI means something. If you have muscle spasm and no pinched nerve, I’ll overlook the MRI.

Frankly, I’m a little old fashioned in this regard. I know countless doctors who treat the x-ray or MRI, not the person. They wind up doing needless surgeries and injections. Unnecessary invasive treatments often make pain worse.

One of my favorite misdiagnoses is “arthritis.” You can see some degree of degenerative arthritis on the x-ray in virtually everybody over 40. Certainly arthritis often causes pain. But if you did x-rays of a particular joint in 100 random people, some would have substantial arthritis and some wouldn’t. Some would have chronic pain and some wouldn’t. But there would be very little correlation between their x-rays and their symptoms.

I treat the patient, not the X-ray.

Sometimes there is a simple cause

Recently I worked with a delightful 78-year-old woman who had suffered for several months with headaches. The entire evaluation was negative for serious illness: physical examination, MRI, lab tests, you name it. She had a long history of depression, known to be a frequent cause of mysterious aches and pains. We treated her depression, and she felt much better. But her headaches persisted.

A few months later, her dentist found an abscessed tooth. He fixed it and her headaches went away.

Missed diagnoses certainly occur in patients with chronic pain. Rarely, one finds a scary disease like a serious infection or cancer, but these are usually discovered on imaging and other tests. (The MRI is more useful to rule out a serious disease than it is to tell you “why you have pain.”) On occasion someone will have a nerve problem, like peripheral neuropathy, pernicious anemia, thoracic outlet syndrome, or cubital or carpal tunnel syndrome. Again, most physicians can figure this out. Thyroid problems occasionally cause chronic pain. Unusual illnesses frequently missed include chronic sinusitis, tertiary syphilis, polymyalgia rheumatica, temporal arteritis, seronegative spondyloarthropathy, and heavy metal poisoning. (Each of these illnesses is a whole separate discussion, but you can find more details if you search the web.)

The most common missed diagnosis by far is myofascial syndrome. Though it’s not serious—it’s not even a disease—it is the most frequent cause of chronic pain, and it often mimics more serious problems like pinched nerves. I also often turn up missed depression, addiction, and emotional and family issues. One caution: if you have a serious underlying problem causing pain, myofascial syndrome may also be present. So having sore muscles doesn’t rule out having another problem.

Recently I’ve become impressed by how often people with mysterious chronic pain turn out to have obstructive sleep apnea syndrome (“OSAS”). If you have this condition , your throat tissues collapse when you fall deeply asleep. Your airway seals off, and you stop breathing. In a few seconds when your oxygen level drops, you partially awaken and take a deep breath. As a result you keep waking up all night, and you never get a good night’s sleep. OSAS causes chronic pain, severe fatigue, depression, high blood pressure, and a variety of other problems. It can be fatal. Though it’s unlikely to kill you, it usually makes you miserable. Severe fatigue, loud snoring, repeatedly waking up with a sore throat, and falling asleep during the day when you’re relaxed are key symptoms suggesting OSAS. Here’s one discussion of this common problem.

Lessons learned

Even though rare diseases occur rarely, it’s important to have at least one thorough evaluation. The history should be particularly comprehensive.

Indeed, some doctors believe all patients with chronic pain should be seen one time by a neurologist. (A neurologist is not a surgeon but an expert on diagnosing diseases of the nervous system.) If at the end of the visit, the neurologist scratches his/her head and asks why you’re there, you know he/she hasn’t found anything serious. (This is the most common outcome.) A neurological evaluation is particularly important if you think you may have a pinched nerve.

If several doctors have told you they can’t find the cause of your pain despite a good workup, the most likely cause is myofascial syndrome. This is part of an overall system that maintains your pain. You have to treat the whole system.

Once you’ve had a thorough evaluation, the most helpful question is not why do you have pain? It’s why aren’t you better? Sometimes the answer is something your mother never told you.