The first structure is a muscle. Muscle pain is perceived a day after a strain injury occurs, such as lifting weights in the gym, or raking leaves, or lifting the baby, or falling or tripping. In other words a trauma or accident is the cause. Muscle pain typically lasts for 3-4 days maximally. There is a general soreness where the strain took place. Palpation or squeezing the muscle will produce a typical soreness. There will be no referral of pain to the leg or arm or tingling. Muscle pain will resolve itself in the expected 3-4 days. Aspirin is the best drug for this pain because it is an anti-inflammatory medication. The injury to the muscle may not be clear, but the time for improvement is clear.
The second pain producer is nerve. Any nerve has a beginning and an end point. There are two components of any peripheral nerve, which is a nerve away from the spine. These components are the sensory, which allows you to feel, and the motor, which produces movement. If the sensory component is affected there will be a sensory change, a tingling and mild loss of touch sensation. If the sensory component is severely affected there may be complete numbness in the areas of the body that the nerve serves, which are well known to your physician. If the motor component is affected there will be weakness in the muscles that the nerve goes to. Pure nerve diseases, such as polio and amyotrophic lateral sclerosis, or Lou Gehrig's disease, are never painful. Those afflicted have weakness in a specific distribution of the nerve. Another well known example is when someone strikes the back of the elbow hitting the “funny bone”, which is actually the ulnar nerve. They will notice a tingling sensation, but it will not be described as a pain usually. If you have a pain in the leg or the arm without the above sensory or motor changes, it is likely that there is no “pinched nerve”, but there are other structures causing that pain. A nerve does not usually cause a pain but when compressed, it will produce a tingling sensation in a specified area that is well known. A typical nerve from the low back such as L5 will cause tingling to the big toes, but very little pain. The surrounding structures causing the nerve to malfunction is actually causing the pain. A nerve should never be touched, or injected, but the surrounding structures must be treated to relieve the pain. The success of treatment is noted very quickly as the tingling is resolved. The principle to understand here is that a pain down the leg is not necessarily a pinched nerve as some will espouse. There are other structures that will cause pain in the arm or leg. Without the tingling and sensory loss in specified areas, there is probably no nerve damage. This will be discussed further in this book later.
The third structure is the ligament that joins bones together. Also included in this category are joint capsules, which surround every joint in the body, and connect the bones to each other across the joint. Examples are the hip, knee, shoulder, ankle, and spinal joints. The genius of the design is that the ligament permits the normal motion of the joint, but will not permit motion outside what we call the normal range of motion. When a trauma or accident takes place, the physical stress on the ligament will cause pain where it connects to bone structures, resulting from small pull injuries on the outer lining of the bone, called the periosteum. These injuries cause an inflammatory change at that site. The pain from a joint, or facet joint in the spine, is actually from the capsule, or specifically where the capsule-bone connection takes place.
It is important to realize this fact because it makes the treatment so much easier and predictable. In the spine, the facet joints allow the left and right rotation of the spine in the thoracic area. The facet in the cervical spine permits you to look down, or put your chin to your upper chest, and to turn to the left and right. When one cannot turn to a side, then you know it is a joint pain. Aspirin is the only choice, usually, but steroids such as prednisone are the best anti-inflammation drug. More severe cases of facet pain should be treated with this drug. Another fact to remember: there are two facets working together. This must never be forgotten.
The annulus, or spinal disc, is a ligament as well, joining one vertebral body to the one above and below. The annulus permits rotation and extension and thus is easily examined. An injury to that annulus, which is at the ligament-bone connection, causes an inflammatory change and severe pain which is diagnosed by bending backward, known as extension, and the typical symptomatic pain pattern which will be unique for each annulus. For instance, the annulus between the L4 and the L5 vertebral bodies refers to the outside of the calf in the lower leg and down the side of the thigh. The location of an abnormal ligament is the problem, not the structure. It is of interest to the reader that the size of the annulus is about one inch in length and one-half inch in height, but can cause severe and incapacitating pain. The main point here is that if you can bend backwards without pain in the lower back there is no disc to treat. Likewise the cervical disc problems will not permit looking up, but looking down or chin-to-chest is able to be done. When there is a pain in the neck, or between the shoulder blades, or in the lower back and you are able to bend backwards there is no disc pain.
The fourth and fifth pain producing structures are the muscle-bone connector. In some muscles, the attachment to the bone is by a tendon, which transmits the contraction of that muscle to the bone. An example of this is the quadriceps muscle, which has a tendon around the patella, or knee cap. In other muscles, the main muscle mass attaches directly to the bone without forming a tendon. An example of this type of muscle is the adductor group along the inner thigh. In any case the pain producing structure is where the muscle and bone join, or where the tendon and bone join. An injury at this site causes an inflammatory change with pain and is called an enthesitis. A typical example is a muscle cramp, also a “hamstring injury.” More severe forms of this injury type can cause a tingling in the leg or arm but this is in a more general area than what a nerve would cause. However there will be pain with motion, and sometimes the source of this can be hard to find.
Common to all of these injured structures is inflammation at the injury site. An example of this is a “bone spur”, which can occur from a hamstring injury, or in a ligament in the lower back. The body will repair any injury, which is an inflammation, by laying down bone at that area as a repair process. This is sometimes described as spur formation on x-ray and often called “arthritis”. The term arthritis should not be used for this process because it is merely the result of the process of repair.
The goal for treatment therefore is to decrease the inflammatory change that is occurring, and therefore decrease the pain. All pain is derived from the described structures, either singly or in combination, with inflammation always involved. This concept eliminates several approaches to pain problems, like narcotics, muscle relaxants, and any other mind-altering drugs which are not anti-inflammatory, manipulation, or exercise during pain. It also eliminates the concept of weakness causing pain.
The diagnosis and treatment of the pain producing structures is a combination of the above. Sometimes the annulus and joint are injured at the same time. The treatment of both of these structures can be done simultaneously. When I examine a patient for pain syndromes, the part being examined, such as the neck, lower back, shoulder, or hip, the normal physiology, or design and function, of that structure goes through my mind. The location of the structure is recorded and then an X-Ray film is used to develop the approach to treat it.
How does an injury occur? To understand how an injury occurs we must first talk about form and function. For example a sphere is designed to roll but a cube is designed for weight bearing. The design of the body for weight bearing, that is mainly the spine, is designed with three points in mind: two joints in the back and the ligament in the front. This is called the “failed physiology of weight bearing.” When we discuss physiology we mean the smooth workings of the muscles and ligaments and nerves in the way they were designed. In order for the neck to do the marvelous movements that we all know, several things must take place simultaneously. There is a complex coordinated set of motions using the bone structures, ligaments, and muscles. The abnormality, or pain source, is accompanied by a lack of motion. In other words, a pain can be defined for this examination as the inability to stretch. The ligament causing pain will not be able to stretch. This makes sense because motion is normal, no motion, or painful motion is abnormal, and this is treated so the motion returns to a pain free state, which is a freely moveable, or as we say a “normal range of motion.”
The body was designed to bear weight as we stand upright and also in motion. The spine was designed with a three component structure in a triangular formation to allow maximum motion. There are two facet joints in the back at each corner and the vertebral body/disc which bears the weight at the front corner. This has nothing to do with muscle or nerves but has everything to do with ligament structure. The ligament holds the bones together to support the weight. The study of how it performs this is what I call the “normal physiology of weight bearing”, which is that the structures described above can only perform the way they were designed to do so. Therefore the smooth two-sided motion of the normal spine is the normal physiology of weight bearing. Flexion, extension, and rotation are only possible if all three components are freely moveable on all sides. Any restriction, then, will cause a deviation of the spinal column wherever that restriction takes place. This then is the failure of the physiology of weight bearing and will be painful. The location of that pain, and the reason for that, is where the clinician must understand the intricate detail of how the spine works. Misunderstanding of these principles is the basis for chronic pain.
If a joint on one side were to have restricted motion there will be a hyper mobile joint movement on the opposite side. This is because of the “swivel effect”—the spine will swivel on the injured, restricted side, causing the mobile joint to assume more of the motion of that segment. And as we mentioned above, a ligament structure allows a limited range of motion, and any movement beyond this defined range will be painful. Conversely, pain can originate from the scarred side as well. The clinician must be well versed in this understanding to discriminate the actual pain generator. Extending these basic principles leads us to determine that a flexion, or forward leaning pain, is from the facet joints, while a pain with extension, or bending backward, originates from the annulus. This scenario has been tested and retested over 45,000 patients and is absolutely true.
The cervical spine as it connects to the skull has the most movement, with the most movement in the first three segments as it attaches to the skull. This allows most of the head movements. This is also the source of headache, a dull migranous type of head ache. All headache comes from the inability of the neck to bear weight of the head, which stresses the ligament structure, which causes referred pain which we perceive as head ache. The cervical annulus causes dull headache, while the facet joint complex causes the throbbing type headache. The remainder of the cervical spine is designed to allow maximal motion of the head, lateral rotation to 90 degrees and neck extension to 40 degrees or so. There are 6 prime motions of the cervical spine and any pain of the ligament structure will cause a decreased movement in one or more of these prime motions. The bone and ligament structure allow the normal movements and any injury to the ligament structure causes a decrease in the normal movement with a typical pain pattern.
The thoracic spine has less motion overall than the cervical spine and permits flexion, extension, and rotation of the torso. Any injury to the ligamentous structure holding these bones together leads to a decreased motion of the 4 cardinal thoracic movements.
The lumbar spine permits only flexion and extension because of its design and its construction. The facet joint is vertically aligned with a 30 degree angle toward the middle of the body thereby providing only a limited side-to-side motion and no rotation. This construction determines that rotational components are not present here, only bending forward or backward, and this is easily shown. Any manipulation or forced rotation causing a “pop” should never be done. Knowing the normal physiology of the spine determines what weight bearing the spine can do. For the reader, if there is pain produced only with bending forward, you can be assured this is a non-surgical condition, and MRIs, epidurals, manipulation, or physical therapy are not necessary. The correct approach will be a forward bending exercise and aspirin.
Of the major joints in the body that produce pain the actual pain producing structure is the ligament, or bone to bone connector. As stated earlier, the ligament allows normal motion and inhibits abnormal motion, thereby allowing a “normal range of motion.” When the ligament structure of the major joints exceeds the allowable motion designed in the joint, an injury occurs and, therefore, a pain occurs. This is the same process in all of the joints, including shoulders, hips, knees, ankles, elbows, and wrists. All these concepts will be described in detail in later chapters.
Join us for these future speaking engagements, when we will explain our approaches and answer your questions regarding your painful condition.
Monthly pain seminar on a variety of topics
- Headache/Neck pain
- Arthritis
- Physical Therapy and Modalities
- MRI Findings