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Harvard Commentaries
Harvard Commentaries
Reviewed by the Faculty of Harvard Medical School

What Your Doctor Is Saying What Your Doctor Is Saying

Symptoms -- Location, Location, Location

February 27, 2013

By Robert H. Shmerling M.D.

Beth Israel Deaconess Medical Center

Last reviewed February 27, 2013

When buying or selling a home, they say the three most important things are: Location, location and location.

When it comes to any type of symptoms you're having, doctors might say much the same thing: Location is the big player when it comes to sorting out the cause of your symptoms.

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"Where Does it Hurt?"

Consider the person in pain or with other symptoms calling his doctor. It's likely his doctor's first question will be, "Where does it hurt?" The answer quickly narrows down the long list of possible causes. Here are some examples:

    • Abdominal pain – Severe pain in the right lower part of the abdomen could be caused by appendicitis, while lower abdominal pain on the left side is more suggestive of diverticulitis.
    • Joint pain – Pain throughout the knee may be due to arthritis, especially if there's swelling. Pain behind the knee or just below the knee is less likely to be from arthritis. A cyst (called a Baker's Cyst) is a common cause of pain behind the knee while pain below the knee may be due to tendonitis or bursitis rather than arthritis.
  • Hand numbness or tingling – When these symptoms affect the thumb, index and middle fingers, it's usually due to carpal tunnel syndrome. Carpal tunnel syndrome is due to pressure or irritation of the median nerve, a large nerve that travels through the tight confines of the wrist. This nerve provides sensation to those fingers. While numbness may extend up the forearm, it's rarely felt above the elbow in carpal tunnel syndrome.

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Symptoms That Change Location

Your doctor may repeatedly ask you, "Where was the pain when you first noticed it?" "Did it move anywhere?" "Was it still in the original location when it moved elsewhere?"

Here are a few examples of how the movement of symptoms can provide clues that can help your doctor sort out their causes:

    • When low back pain "travels" or radiates down the back of the leg, it suggests a condition called "radiculopathy." It occurs when a large nerve near the spinal cord is compressed or irritated. Disc disease (often called a "slipped disc") is the most common cause, but spinal arthritis or injury may also cause this type of radiating pain.
    • With the most common types of arthritis, pain is localized to the joint and stays there for as long as the condition is present. But certain diseases tend to cause joint pain that "migrates." That is, pain is centered in one joint for a few days, then it moves to another joint as the previously painful joint improves. Rheumatic fever and the arthritis that may accompany gonorrhea are two causes of migratory joint pain.
  • Pain in the right lower abdomen is typical of appendicitis. Initially appendicitis symptoms often include more widespread abdominal pain. It may take hours or even days for the pain to become more localized. This pattern of symptom movement (from widespread abdominal pain to pain focused in the lower right abdomen) is so characteristic of appendicitis that doctors tend to ask specifically if a person's abdominal pain has changed in this way over time.

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When Location Is Misleading

Sometimes where the symptom appears isn't the original location of its cause. When the symptom is pain, it's called "referred pain." Doctors know the patterns of referred pain (or should!) and so the true cause of potentially misleading symptoms can often be quickly sorted out.

Some common examples include:

    • Heart disease – Some people have little or no chest pain with heart disease, but instead experience pain in the left arm, jaw or neck.
    • Shoulder arthritis – Disease in the shoulder is often felt in the upper arm, well below the joint. In fact, the name of one disease (polymyalgia rheumatica) was based on this: "Polymyalgia" means pain in multiple muscles, yet the condition is due to inflammation around the shoulder, not the muscles.
  • Phantom limb pain – When a person has a limb amputated, there's no way for disease in the missing limb to cause pain; yet, it's not rare for a person who had a leg amputation to experience pain in the missing foot.

Many cases of referred pain occur because the nerves sending the pain signals to the brain are also providing sensation to other nearby structures. When the brain receives the signal, it's confused about the origin of the pain. The same explanation may account for nausea, belching or sweatiness that is often a symptom of a heart attack. For phantom limb pain, one theory is that the brain "re-wires" input from the missing limb. These new connections allow the brain to experience sensations from the missing part.

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Are Your Symptoms "All in Your Mind?" Of Course!

Whatever the symptoms are — pain, numbness, shortness of breath or something else — it's impossible to experience the symptom without communication from the body part to the brain. Patients sometimes ask me, "Could my pain be "all in my head?" I say, "Of course," because that's how it must be for everyone, for every condition.

But that doesn't help explain the source of the pain. Stress, anxiety, fear and other psychological states can contribute to many symptoms (including pain). But those symptoms are just as "real" as symptoms caused by something you can see, such as a serious injury. For this reason, I discourage debates about whether a symptom is "real or just in a person's mind" — and prefer to focus instead on sorting out the cause and treatment.

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The Bottom Line

Symptom location is important to your doctor. But it's just one of many pieces to the puzzle. Combined with other features (such as intensity, variability, quality, and context), your doctor can often sift through dozens of possible causes and arrive at the most likely. By giving your doctor an accurate account of your symptoms' location, you're helping him or her figure out what's going on.

So, the next time your doctor talks to you about the location of your symptoms, you'll know better what your doctor is saying.

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Robert H. Shmerling, M.D. is associate physician at Beth Israel Deaconess Medical Center and associate professor at Harvard Medical School. He has been a practicing rheumatologist for over 20 years at Beth Israel Deaconess Medical Center. He is an active teacher in the Internal Medicine Residency Program, serving as the Robinson Firm Chief. He is also a teacher in the Rheumatology Fellowship Program.

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