B – Non-Structural Pain

posted in: Stage 1, Stage 1: Step 1

Patients often wonder how soft tissues can be so painful. It’s because they have a high density of pain receptors arranged in a spider web type pattern. These irritated soft tissues give rise to some of the most painful conditions such as plantar fasciitis, tennis elbow, muscular tension headaches, chondromalacia of the kneecap, and countless more. Even a heart attack is fundamentally a muscular pain because the of the lack of blood flow stimulates pain receptors.



It can be difficult for patients to accept that their problem is, essentially, “undetectable” while experiencing so much pain, it seems impossible that so many tests would come up negative. Here are some points to consider.

  • Since people generally keep moving the injured part, the irritation will last a while. Although immobilization may calm it down more quickly, the resulting stiffness can also be a problem.
  • Soft tissue pain can occur in any part of the body. Most musculoskeletal pain originates from the soft tissues and the diagnosis is made by the location of the symptoms, what movements make it better or worse, the time of the day, and response to medications.
  • Rarely are imaging studies helpful. The problem is manifesting itself at a level below the sensitivity of any diagnostic test.
  • Regardless of the source of the pain, it becomes memorized by your brain in about six to twelve months. Then the solution lies in addressing both the soft tissues as well as the nervous system. Soft tissue work alone won’t resolve it.
  • Back pain is the most common reason for disability and chronic pain. The reason why is it that it hurts–a lot. The inflammation/ irritation can arise from the fascia, ligaments, tendons and the discs. The worst part it that intense muscle spasms may occur, which is the body’s guarding response. The intensity causes one to worry about the severity of the injury. Often, patients are told that their backs are in bad shape, which isn’t reassuring. The vast majority of the time, patients backs are fine, as the spine normally degenerates with age.
  • So, physicians can make an exact diagnosis of the source of low back pain only about fifteen percent of the time. (1) Generally, we do not know the exact cause because of the nature of soft tissue pain.

“No one believes me”

Patients may become frustrated when pain from an “undetectable” injury doesn’t let up. They begin to feel that no one believes them. Unfortunately, this type of injury is far more likely to persist than, say, a broken bone. In the spine, once the soft tissues are irritated, they may stay irritated through normal daily activities, sometimes almost indefinitely. If you severely sprained your ankle and kept re-spraining it on a daily basis, how long would it remain painful? For a long time.  On the other hand, broken bones heal in three to four months. The prognosis for a fractured spine has been shown to be better than the prognosis for a muscle sprain.

My tennis elbow

One of my own muscle/tendon afflictions is tennis elbow. I may set it off when I lift too heavy of a weight at the gym or when I practice my terrible golf swing. I can suffer for six to 18 months with severe pain in either one or both my elbows. It hurts to shake hands, reach up and adjust the lights during surgery, use the surgical instruments, and countless other routine activities. The pain is as severe as any pain I have experienced, and it is persistent. Two years after my last episode, I could still push on the spot on my elbow and slightly feel the irritated area. Yet if I were to have an X-ray, MRI, CT scan, or bone scan of the area, the results would be completely negative. If I were to have a biopsy, there would might be some inflammatory cells in the tendon area. However, since a biopsy would not change treatment, there would never be a need to do one.




Although we often cannot identify the exact structural source of the pain, we do know that pain fibers are being stimulated and are sending messages to the brain. The intensity of the pain may increase if more pain fibers are stimulated or if the sensitivity of the brain increases. The final perception of the pain will depend on how many pain areas that are stimulated in the brain.

Additionally, as mentioned above, chronic pain evolves into a brain disease regardless of the source.

  1. Nachemson, A. “Advances in low back pain.” Clinical Orthopedics and Clinical Research (1985); 200: 266-278.