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Your point about lifesaving hand washing to prevent diarrhoeal illness1 is well made. I have found that the inattention you have noted to such clinical fundamentals in textbooks on sports medicine is mirrored by the absence of any notation, affirmative or otherwise, in many textbooks on pain, correlating the symptom (pain) with the physical sign (tenderness), a rudimentary clinical confirmation of the validity of pain, according to my clinical training in Ireland, that could distinguish malingering from a genuine complaint of pain, for example. Perhaps I have received a false impression but, if so, the utility of eliciting tenderness, a longstanding custom during physical examination, seems a mystery.
In November 2002, I attended a conference in Florida on prescribing addictive drugs. None of the purportedly expert presenters mentioned the issue spontaneously. When I collared one of them after his lecture and enquired specifically about the point, he claimed that chronic, non-malignant pain and tenderness are usually “dissociated”—that is, a patient can suffer chronic, non-malignant pain in the absence of tenderness of the painful part, on physical examination. This assertion seemed contrary to my own, admittedly anecdotal, experience over some 24 years. Furthermore, it would seem to (a) render chronic, non-malignant pain, and maybe all pain, unknowable and undetectable (except perhaps to the alleged sufferer, although nobody else can tell), (b) place the assessment of pain in the realm of “pathological science”,5 and (c) invalidate the very idea of regulation of narcotic drugs to ensure that the practitioner prescribe one only when it “corresponds to the ailment”.5
The silence on the subject in the medical literature seemed anomalous. A Boolean Pubmed search on the keywords “pain” and “tenderness” revealed no relevant articles. I examined all 114 textbooks on pain in the medical library of the University of Southern California (USC) and found two2,3 that addressed the issue.
Physical therapists contradicted the foregoing opinion:
Tenderness always occurs in chronic pain syndromes.(p 86)2
The only textbook I found that physicians had authored and that discussed the subject agreed:
If any doubt regarding the existence of pathologic basis for the pain patient’s complaint is present, the findings can be confirmed or discounted by repeated palpation, approaching the region from a different direction each time. If this is done while the patient is distracted evocation of pain in the same region is some indication of a pathologic process.(p 272)3
Bonica thus suggests distracting the patient and approaching the painful area by stealth, presumably to prevent the patient from dissembling, but offers no references or other evidence based assessment of the efficacy of stealth and no expert opinion about any other best practices for considering tenderness. It would seem appropriate for authoritative references, which presumably promulgate best practice doctrine, consistently to hold tenderness to distinguish malingering from sincere complaint of pain, or to be dissociated from pain, or to be otherwise equivocal and therefore to hold elicitation of tenderness to be a sacred cow that has no place in scientific medicine.
Some allege that British clinicians accord more value to physical diagnosis than do Americans, who reputedly rely too much on laboratory tests. The sample bias from predominance, at USC, of American books on pain could explain my finding of widespread silence on the correlation of tenderness with pain. However, the only textbook I found at USC from the United Kingdom6 was likewise silent on the topic.
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