Where Does It Hurt?

Where does it hurt???

I think we can all agree that experiencing pain is not much fun and one of the biggest factors that prevents us from reaching our goals. While it is normal to have injuries or minor aches and pains with any exercise program, most usually resolve within a few weeks. It’s the pain that comes on for no apparent reason or the pain that has been unchanging despite getting care (physical therapy, chiropractic, massage, acupuncture, etc…) that becomes more of the barrier to improved performance. If you have been experiencing this then read on because new research is emerging that could change the game for you.

Traditionally when a patient presents to a medical provider with an apparent injury, the provider will aim to direct interventions at the body part they perceive to be the source of the patient’s problem. Hence, a basic requisite for the successful local management of a shoulder or hip problem is that the symptoms are emanating from the shoulder or hip itself. 1-4 New emerging evidence is showing that a majority of shoulder, hip, and knee injuries are actually due to pain emanating from the spine and in fact not the extremity itself. The current research shows that isolated extremity pain of spinal origin is quite high, for example studies show that 27% of shoulder pain is actually due to the neck. Regarding the hip and knee studies show that 32% and 54% being due to the low back.5-8 Meaning a large portion of people with extremity pain in fact do not have any issues with the extremity and actually have a spinal problem.

Our clinic was recently involved in a study over the past year looking at people who had extremity pain of spinal course. This means that patients would come into the clinic with an extremity problem (shoulder, elbow, hip, knee, ankle, etc.…) and our goal was to see if the problem was coming from the extremity itself or referred from the spine. We looked at 369 patients who had extremity pain with no spinal pain. Here is what we found:


Meaning 43.5% of the patients who presented to physical therapy with an extremity complaint had pain that was spinal related and were quickly able to resolve their problem with treatment to the spine and not the painful area. You can see above the percentages we found at each joint.

The problem with current medicine is how clinicians attempt to differentiate between a spinal source of symptoms and an extremity source. The clinician will take a history, perform an examination, and rely heavily on imaging (x-ray, MRI, etc…) to come to a conclusion. Research has recently demonstrated a high prevalence of abnormal finding in imaging for pain free individuals. For example.


Even though this differentiation process is pivotal in guiding management, as you can see it is fraught with challenges. If pain of spinal origin is interpreted incorrectly as a local extremity problem, it can initiate a cascade of poor decision making, inappropriate management, and a slower return to lifting.

I recently evaluated a collegiate pitcher who ended last season with elbow pain, that was after winning a national championship! After the season we underwent imaging on his elbow which showed a small chip in the bone. His elbow was immobilized for eight weeks to allow the bone to heal. After the eight weeks he got a follow up x-ray which showed the bone had healed but any attempt to throw a baseball still caused pain. Since he was still having elbow pain he went through rehab he got an MRI to rule out ligamentous injury. The MRI was negative and the medical team was unsure what to do but were suggesting “exploratory” surgery on the elbow. He was referred to us for an evaluation and while he did not have any neck pain it was found that his elbow pain was coming from the spine. After six visits his elbow pain was completed resolved through performing neck exercises and was pitching again and throwing in the mid 90mph range. So the questions come into play, what would have happened if nobody looked at his neck?

From our research we identified some helpful factors to confirm where the pain is coming from. If you are having unresolved joint pain then answering these quick questions can help determine if it is spinal related (1) did the pain start for no apparent reason, (2) is there numbness/tingling associated with the joint pain, and (3) do you also have spinal stiffness associated with the joint pain. By answering yes to more than one of these there is a high likely hood you have a spinal problem.

If you have any questions regarding pain and injury that is preventing you from performing the way you want, we are here to help.

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 1.      Bokshan SL, DePasse JM, Eltorai AEM, Paxton ES, Green A, Daniels AH. An Evidence-Based Approach to Differentiating the Cause of Shoulder and Cervical Spine Pain. Am J Med. 2016;129(9):913-918. http://dx.doi/org/10.1016/j.amjmed.2016.04.023

2.      Sembrano JN, Yson SC, Kanu OC, et al. Neck-shoulder crossover: how often do neck and shoulder pathology masquerade as each other? Am J Orthop. 2013;42(9):E76-80. http://www.ncbi.nlm.nih.gov/pubmed/24078971

3.      Buckland AJ, Miyamoto R, Patel RD, Slover J, Razi AE. Differentiating hip pathology from lumbar spine pathology: Key points of evaluation and management. J Am Acad Orthop Surg. 2017;25(2):e23-e34. http://dx.doi.org/10.5435/JAAOS-D-15-00740

4.      Saito J, Ohtori S, Kishida S, et al. Difficulty of diagnosing the origin of lower leg pain in patients with both lumbar spinal stenosis and hip joint osteoarthritis. Spine 2012;37(25):2089-93. http://dx.doi.org/10.1097/BRS.0b013e31825d213d

5.      Gill T, Shanahan E, Allison D, et al. Prevalence of abnormalities on shoulder MRI in symptomatic and asymptomatic older adults. Int J Rheum Dis. 2014;17(8):863-71. http://dx.doi.org/10.1111/1756-185X.12476

6.      Schibany N, Zehetgruber H, Kainberger F, et al. Rotator cuff tears in asymptomatic individuals: a clinical and ultrasonographic screening study. Eur J Radiol. 2004;51(3):263-8. https://doi.org/10.1016/S0720-048X(03)00159-1

7.      Bedson J, Croft PR. The discordance between clinical and radiographic knee osteoarthritis: A systematic search and summary of the literature. BMC Musculoskelet Disord. 2008;9:116. http://dx.doi.org/10.1186/1471-2474-9-116

8.      Silvis ML, Mosher TJ, Smetana BS, et al. High prevalence of pelvic and hip magnetic resonance imaging findings in asymptomatic collegiate and professional hockey players. Am J Sports Med. 2011;39(4):715-721. https://doi.org/10.1177%2F0363546510388931



Jordan Lutz