Back pain is one of the most common reasons people see a doctor. While most back pain is real, some people may exaggerate or fake their symptoms. But can doctors actually tell if someone is faking back pain?
As it turns out, there are many techniques doctors use to determine if back pain is genuine or not. With a combination of physical exams, imaging tests, observation, and questioning, physicians are often able to detect exaggerated or fabricated back pain.
Why Patients Fake Back Pain
Before diving into how doctors detect fake back pain, it’s important to understand why someone might pretend to have back pain in the first place. Some of the potential motivations include:
- Seeking opioid pain medication – Many people fake injuries to obtain opioid painkillers to abuse or sell illegally. Back pain is one of the easiest symptoms to fake when “doctor shopping.”
- Covering up other issues – People may claim to have back pain to justify issues with work performance, school attendance, or to excuse behavioral problems.
- Seeking disability benefits – Faking or exaggerating back injuries is sometimes done to try and qualify for disability or insurance payments.
- Attention seeking – In some cases, feigned back pain is a (misguided) attempt to gain attention or sympathy from family, friends, or medical providers.
- Avoiding responsibilities – Pretending to have severe back pain can be a person’s attempt to get out of responsibilities at work, school, home, or in the military.
- Psychiatric issues – In rare cases, fabricated injuries stem from psychiatric conditions like factitious disorder or malingering.
While these reasons are not excuses to fake back pain, it provides doctors some context for this behavior. With awareness of why patients might malinger, physicians can better approach the process of detecting falsified back injuries.
One of the first things a doctor will do when evaluating back pain is perform a hands-on physical exam. This allows them to look for objective signs that indicate whether the reported pain is legitimate. Some techniques doctors use include:
Doctors will first visually observe the patient’s movements. Someone experiencing true back pain will often walk, sit, and move in a distinct way to avoid pain. An inconsistent or exaggerated gait or posture can tip off a doctor to potential faking.
Range of Motion
Testing range of motion is commonly done during back exams. Doctors will have patients bend forward, extend backwards, twist, and bend side-to-side while observing their movements.
- Real back injuries will cause limited flexibility and pain at certain points in the movement.
- Fakers often display exaggerated guarding or claim limited motion that doesn’t correlate with actual physical restrictions.
By feeling along the muscles and spine, doctors can check for muscle tension, swelling, areas of sensitivity, and find potential injury locations.
- Patients faking back pain may claim excruciating tenderness when minimal palpation is applied. Or they might not flinch even when extensive pressure is placed on the supposedly exquisitely sensitive area.
Testing a patient’s strength in their arms and legs helps determine if claimed weakness matches up with suspected spinal issues.
- People with real compressions or damage to spinal nerves will have corresponding measurable weakness. Fakers tend to give poor effort instead.
Various special tests exist that check for pathology in the back that a malingerer is unlikely to know about or be able to fake.
- Straight leg raise test – Checks for nerve root tension caused by herniated discs or spinal stenosis. Those faking back injuries may not react as expected.
- Braggard’s test – Assesses for true weakness in a leg that would occur with lumbar radiculopathy. Malingerers may give poor effort.
- Femoral stretch test – Stretches nerves exiting the lower spine to elicit radiating pain. People faking back issues are unlikely to report pain that precisely follows true nerve patterns.
By comparing reported symptoms and examination findings, doctors can start identifying potential inconsistencies or red flags that indicate fabricated back pain.
Discussing a patient’s medical history provides doctors with more context to help determine if back pain is falsified.
They will ask about:
- Past back issues and injuries
- History of the current injury – how/when it started, inciting factors
- Location and nature of the pain – constant/intermittent, dull/sharp, radiating, etc.
- Aggravating and relieving factors
- Treatments tried and response to them
Genuine back conditions often follow a typical history. Malingers may describe atypical pain patterns, vague injuries with delayed care seeking, and inconsistent or illogical aggravating/relieving factors. Evidence of doctor shopping or seeking multiple medical opinions can also raise suspicion.
Asking about psychosocial factors can also provide clues. Those with fabricated back pain may describe life, work, or family stressors indicative of a motivation for faking.
Comparing the history given with physical exam findings and objective evidence helps identify potential deception.
Doctors have an array of diagnostic tests that can provide objective evidence of true back pathology. These include:
X-rays, CT scans, and MRI scans give doctors detailed views of the spine to look for issues like:
- Disc herniations
- Spinal misalignment
People faking back injuries will not have corresponding damage on imaging. However, minor spinal changes like disc degeneration are common even in those without pain. So tests must be carefully correlated with symptoms.
Nerve conduction velocity and electromyography tests measure how well nerves are functioning. They can confirm nerve compression causing radiating pain and weakness that patients would be unable to fake.
Inflammatory markers in blood work can detect infection or arthritic changes contributing to back pain. Potential psychiatric causes like depression or substance abuse may also be identified.
Formal tests like symptom validity testing objectively measure effort and consistency in answering questions. Results help determine if the patient is providing truthful responses versus fabricating or exaggerating symptoms.
Injecting lidocaine into supposedly exquisitely painful areas provides information about pain veracity.
- If pain is genuinely coming from that spot, it should dramatically improve with anesthetic.
- Fakers are unlikely to have their made-up pain resolve with precise injections.
Imaging and other test results provide doctors with evidence to corroborate or refute claimed back symptoms.
Observation of Behaviors
Doctors also carefully observe patient behaviors during interactions for signs of exaggerated or dishonest symptoms. Red flags include:
- Overly dramatic grimacing, grunting, or moaning
- Movements and abilities that contradict claimed disabilities
- Resistance to treatments that should reduce true pain
- Anger when narcotics aren’t prescribed
- Making frequent demands of providers
- Non-anatomic sensory or strength deficits
People with legitimate back injuries tend to appear more stoic and prefer non-opioid treatments. While those faking pain exhibit behaviors aimed at convincing doctors of false symptoms.
Doctors have techniques to ask questions in ways that help identify fakers versus those with genuine injuries. Examples include:
- Asking open-ended questions that force detail about symptoms – those fabricating information tend to be vague.
- Having patients demonstrate or point to exactly where pain is located – inconsistencies can reveal falsehoods.
- Asking how pain impacts specific activities – fakers often have non-anatomic or illogical responses.
- Requesting detailed timelines – real vs made up events don’t always match up.
- Double-checking to identify inconsistencies in reported symptoms.
Careful listening and targeted questioning provides doctors additional tools for discerning real versus feigned back pain.
Consultation with Specialists
In complex or uncertain cases, back specialists like orthopedic spine surgeons, pain management physicians, physiatrists, neurologists, and psychiatrists may be consulted.
With their advanced training and experience treating many back conditions, they can assist primary doctors in determining pain legitimacy and identifying potential motivations for faking.
Multidisciplinary evaluations add expert opinions and additional techniques for making an accurate determination.
Putting the Pieces Together
No single finding can definitively prove or disprove back pain. Doctors must synthesize details from all gathered information to make an informed determination.
By combining findings from the history, physical examinations, diagnostic tests, observations, and consultations, physicians can reliably detect most cases of exaggerated or fabricated back pain.
Red flags they look for include:
- Non-anatomic or inconsistent pain patterns
- Normal exam findings except extreme tenderness
- Poor effort on strength testing
- Vague or shifting details about an injury
- Lack of physicians or treatments tried early on
- Report of pain but no objective signs of discomfort
- Extreme focus on narcotic pain medications
- Negative or minor findings on diagnostic studies
- Overly dramatic appearance and behaviors
While each sign alone is not conclusive, together they allow doctors to effectively determine true versus fake back pain in most situations.
Why Identifying Fakers Matters
Many people think white lies about back pain are harmless. But false claims about back injuries can:
- Lead to inappropriate, risky, or addictive treatments
- Prevent patients from getting more effective care
- Waste medical resources better spent on those truly in need
- Contribute to opioid misuse problems
- Fraudulently divert disability payments
- Cause emotional harm to friends and family
By identifying falsified back conditions, doctors can avoid enabling deceptive behaviors and guide patients to any psychosocial care they may benefit from instead.
Approaching suspicions professionally and compassionately is important, as there may be underlying issues driving the deception. Open communication without judgment creates potential for patients to acknowledge issues and seek proper help.
How Patients Can Avoid Appearing As Fakers
No one wants to be mistaken for faking, especially when their back pain is real. Here are some tips to avoid sending wrong signals to your doctor:
- Be detailed and consistent when describing your symptoms – don’t exaggerate or embellish.
- Report all treatments tried and how much they helped or didn’t.
- Avoid requesting specific medications and trust your doctor to determine appropriate options.
- Mention how pain impacts function but don’t claim excessive disability.
- Notify providers of psychosocial factors like work stress that may contribute.
- Demonstrate exercises/stretches you do at home to help manage pain.
- Avoid displays of dramatized discomfort during exams.
- Participate actively and positively in all recommended treatments.
Being honest, compliant, and establishing trust with your doctor is key to avoiding any misperceptions about your reported back pain.
When to See a Doctor
Not all back pain requires medical attention. But see a doctor if you experience:
- Pain lasting more than 1 week without improvement
- Worsening weakness or numbness in a leg or foot
- Difficulty standing, walking, or controlling bladder/bowel
- Unexplained weight loss along with back pain
- Back pain after a major trauma like a car accident
- Fever, nausea, abdominal pain with back discomfort
Contact your doctor any time your gut says something feels off with your back. Don’t tough it out or worry about being judged. Getting an accurate diagnosis leads to proper treatment and prevention of long term damage.
The Bottom Line
Can doctors tell if a patient is faking back pain? In most cases, yes – physicians have many techniques to accurately detect exaggerated or fabricated back symptoms.
By combining a thorough history, physical examination findings, diagnostic testing, careful observation, expert consultations, and strategic interview questioning, doctors can identify factitious back injuries.
While not perfect, their detection skills are quite good. So if you’re thinking about faking back pain, you’ll likely get caught.
Instead, be upfront with your doctor about any challenges you face and work together to find solutions. Honesty and trust leads to the best care and outcomes.