The current treatments for musculoskeletal pain are failing because our fundamental understanding is flawed.

Our misunderstanding of musculoskeletal pain has caused unnecessary surgeries, ineffective treatments, avoidable exposure to radiation, loss of function, and high costs. Despite this, patients do get better with time, but many others become chronic.

We need to change these false beliefs, starting with the very foundation – The Cause of Pain.

Pain is your body’s way of telling you that something has gone wrong. It is a warning signal to change what you are doing before the damage progresses. Not all pain is the same, nor is all pain bad. Knowing what?type of pain?you have is of?utmost importance?for, without the proper diagnosis, you cannot receive the proper treatment. Too often, we assume that all pain is chemical or inflammatory and overuse NSAIDs and steroids.

**Most musculoskeletal disorders are of a mechanical nature and should receive a mechanical NOT a chemical (drug) treatment.**

Pain is triggered by three different stimuli: Chemical, Mechanical, and Thermal.?

Mechanical Pain?occurs when stress is placed on a joint or soft tissue, such as when you bend your finger back. If you go back far enough, you will feel pain. As soon as you release it, this pain immediately abates. There is no injury or damage to the tissue. Mechanical pain arises when a mechanical force stresses tissue (i.e. meniscal/labral tear, herniated disc, scar tissue, dislocation). The mechanical cause of pain resolves with the removal of stress by a change in movement and/or position. Mechanical pain is usually intermittent, but it can be constant when the stress is constant, such as maintaining your finger bent backward.??

When you have pain that comes and goes (intermittent) or changes with different movements and/or positions, it is MECHANICAL.

Chemical pain, on the other hand, is caused by the body’s inflammatory response to injury. It is a complex chemical reaction and occurs to aid tissue damage by releasing chemicals from the blood, fibroblasts, and local macrophages to clean up the area and start the healing process. An example of chemical pain is hitting your thumb with a hammer or a toothache.??Chemical pain is described as throbbing,?constant, and does not change with movement. Inflammation can be uncomfortable, but it is part of the miraculous natural healing process. It usually lasts only a few days to weeks. (Symptoms that continue after a few weeks result from re-injury / re-tearing of poorly healed tissue or an unresolved mechanical problem.)

Pain that comes and goes (intermittent) cannot be chemical. For example, back pain that is worse with sitting/bending and better with walking is not chemical or inflammatory because it changes with movement. (Other examples: Shoulder pain that only hurts when reaching overhead; Knee pain only when climbing stairs; Tennis elbow that only hurts with activity.)?

Musculoskeletal injuries may have a combination of mechanical and chemical factors, especially when acute, but the chemical element is usually minor. A dislocated shoulder requires morphine because the pain is so severe. As soon as the dislocation is reduced (mechanical stress eliminated), the pain drops significantly. The trauma does cause tissue tearing, which triggers a chemical process and chemical pain, but the chemical symptoms are much less than the mechanical.

Treatment Differences:

Differentiating between pain caused by a mechanical or chemical irritation is critical because the two treatments are completely different - One requires the removal of mechanical stress and the other requires managing an inflammatory process.

Only a correct diagnosis will produce the proper treatment and good outcomes.

Thermal pain?is caused by heat (i.e., holding your hand over a lit candle.) The obvious treatment - remove your hand from the heat! Imagine instead giving an anti-inflammatory and pain killer first while leaving your hand over the flame? Similarly, when there is a mechanical cause of pain, treatment must be first to remove the mechanical cause.

Unfortunately, the current triage for pain is to start with a chemical treatment (anti-inflammatories, muscle relaxers, pain killers). Just like moving your hand away from the flame, we should first remove the causative factor.

We have to understand the cause of the pain to provide proper treatment, and this MUST start with a MECHANICAL ASSESSMENT.

Why do so many develop chronic symptoms and disability from an apparent minor diagnosis or have persistent symptoms with no definitive pathoanatomical diagnosis?

1. We rely on imaging instead of a thorough physical exam.
2. Patients are given an inaccurate diagnosis with resultant ineffective treatments.
3. When passive treatments fail to bring relief, the patient feels more and more out of control, anxiety builds, and this starts fear-avoidance behavior and the chronic pain cycle.

CHANGE is needed!

Every individual who has a musculoskeletal disorder must be cleared first by a mechanical assessment to determine the CAUSE of their symptoms. An x-ray and MRI do not show pain nor determine if symptoms are localized or referred from the spine, organ, or sinister pathology. If symptoms are determined to be mechanical, then the therapist should treat them accordingly. If the symptoms do not show a mechanical basis, the therapist must immediately refer to a physician for further work-up. Unfortunately, this is the opposite of our current process: Physician first followed by prescription, x-ray, MRI, ortho (surgery), and finally conservative care/physical therapy. But passive care must not be the focus and even be avoided or minimized. Instead, the emphasis is on patient education that empowers and reduces fear while also maintaining activity.?

When patients are empowered and understand the mechanical cause of their musculoskeletal ailment, they control their symptoms and learn to self-treat. Empowerment reduces fear and eliminates fear avoidance behavior and the chronic pain cycle.