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Rules of Referred Pain
Many soft tissue may refer pain Lesion does not necessarily lie in the painful area Does not cross midline Occurs mainly in a distal direction Mainly segmental Discrepancies exist between dermatomes and myotomes Pain can be felt anywhere in the dermatome, not necessarily everywhere TERM 2
What types of Soft Tissues can refer
pain?
DEFINITION 2 There is no difference in the ability to cause pain or in the quality of the pain caused by Muscle Tendon Ligament Other soft tissue All of above refer the same quality of pain TISSUES THAT SHARE AN EMBRYOLOGICAL ORIGIN CAN SHARE PAIN TERM 3
What is a big rule about referred pain?
DEFINITION 3 The lesion causing referred pain does not necessarily lie in the painful area Local tenderness alone has poor diagnostic value Tenderness must always correlate with other data Example: Shoulder joint arthritis may cause tenderness to palpation anywhere in the C5 dermatome TERM 4
Lack of Variation in Lesions of Referred Pain
DEFINITION 4 Every lesion has its typical story History similar Clinical image is similar ex. There are only so many ways to sprain an ankle TERM 5
When the story or clinical image vary too
greatly, we have what?
DEFINITION 5 An inherent unlikelihood The lesion is outside orthopedic medicine The patient is a malingerer or psychoneurotic Example: A patient complaining of low back pain demonstrates full forward flexion and limited extension when standing. When lying supine, the same patient is unable to perform a full straight leg raise
Referred Pain not crossing the midline
A unilateral lesion can only cause unilateral painExample A unilateral SI or facet joint lesion can only cause unilateral pain A central disc protrusion, with pressure against the dura mater and/or nerve root, could cause central, unilateral, or bilateral pain TERM 7
Referred pain occurring on mainly a distal
direction
DEFINITION 7 Abnormal for local distal lesion to refer proximally Reference in the proximal direction is only slight Examples Shoulder tendinitis may give rise to pain as far distal as the thumb (C5 dermatome) A tendinitis at the thumb does not cause pain at the shoulder An SI lesion can cause pain as far as the heel Retrocalcaneal bursitis will not cause pain at the buttock TERM 8
Referred Pain is mainly segmental
DEFINITION 8 Pain is referred according to the embryological origin of each structure Any structure of C5 origin could cause pain in the C dermatome Example : A shoulder arthritis or bursitis, supraspinatus or infraspinatus tendinitis all provoke similar pain in the arm (forearm) It is important to know the embryological derivation of all structures and dermatome/myotome maps TERM 9
What is a sequestered disc?
DEFINITION 9 trauma pinched annulus fibrosus piece of nucleus pulposus comes completely out of annulus fibrosus piece sits on nerve causing constant pain that doesn't change with movement TERM 10
Progression of Disc
Pathology
DEFINITION 10 Pressure on the dura mater may cause extrasegmental or multisegmental pain Pressure on the dural sleeve of the nerve root may cause pain somewhere in the dermatome More pressure, reaching the parenchyma, causes pain AND paresthesia Stronger pressure through the dural sleeve and parenchyma on the nerve fibers causes motor, sensory, jerk deficits
Describe how discrepancies exist between
dermatomes and myotomes?
A muscular structure does not necessarily lie underneath its dermatome This fact does not necessarily have important clinical value TERM 17
Example of how Referred pain can be felt
anywhere in the dermatome, not necessarily
everywhere
DEFINITION 17 Do not be misled by referred pain confined to only one area of the dermatome Example: A patient who complains of anterior knee pain may have a hip lesion and Osteoarthrosis of the hip can be felt at the groin down the front of the thigh at the knee in the upper buttock at the front of the leg as far as the medial malleolus TERM 18
-Osis vs. -Itis
DEFINITION 18 -Osis = change in tissue-Itis = inflammation TERM 19
Factors Affecting Pain Referral
DEFINITION 19 Strength of stimulus Depth of the affected structure Position of lesion within dermatome Nature of the affected structure TERM 20
Strength of
Stimulus
DEFINITION 20 Stronger stimulus, more pain referral Centralization vs. Peripheralization
Depth of affected structure
Deeper structures refer more except bone Bone does not cause referred pain Example Patient with lumbar pain complains of severe, central- bilateral pain, after trauma, without radiation red flag for fracture TERM 22
Position of lesion within
dermatome
DEFINITION 22 A proximal lesion will more likely refer distally TERM 23
Nature of Affected Structure
DEFINITION 23 Always ask, Where did your pain start? The first pain is always felt near the lesion EXCEPT with nerve structures. Example Patient with posterolateral disc protrusion pressing on S nerve root may initially complain only of calf pain TERM 24
Two types of non-referred pain patterns
DEFINITION 24 ShiftingExpanding TERM 25
Shifting
DEFINITION 25 Pain moves from left to right or from medial to lateral Suggests instability: Patient complains of pain when lying on either side for long Suggests loose bodies: Patient complains of pain moving from one place to another within joint Suggests progression: Pain began as lumbosacral and gluteal pain (extrasegmental), but back pain disappears and pain is in leg as compression on nerve root progresses
Chronological Order and Referred Pain
Where did pain start? How did it progress? What do you feel now? Where do you feel it now? TERM 32
Recurrences and referred pain
DEFINITION 32 How many? When? How long did they last? Were there any pain free periods? TERM 33
What influences symptoms?
DEFINITION 33 Certain positions? Movements? Activities? Treatments? Ice? Heat? Showers? Prior episodes of PT Medications? TERM 34
Neutral Questions and referred pain
DEFINITION 34 Do not put words into the patient's mouth Does your pain radiate down to your left toe? Does your pain travel? Where to?
