What Structure Is Causing The Pain?

There are four main sources of pain and each produces a specific pattern of pain.

  1. Central Somatic Structures

E.g. Dura mater, posterior longitudinal ligament, annulus fibrosus of the intervertebral disc

Mulisegmental pain

This can be central, central unilateral, bilateral, proximal or distal

Referred tenderness

2. Central Neurological Structures

E.g. Spinal cord

No pain

Multisegmental reference of parasthesia (bilateral hands and/or feet)

Upper motor neuron lesion: spastic muscle weakness, increased reflexes, spastic gait, extensor plantar response (Babinski reflex)

3. Unilateral Somatic Structures

E.g. Bone and periosteum

Minimal reference of pain

Local tenderness

E.g. Ligament, tendon, muscle, joint capsule, bursa

Segmental reference of pain

Depends on strength of stimulus, position in the dermatome, depth of the structure

E.g. Dural nerve root sleeve

Segmental reference of pain in all or part of the dermatome on compression of the structure – depends on strength of the stimulus

The greater the compression, the more distal the referral of pain

No edge or aspect

4. Unilateral Neurological Structures

E.g. Nerve root

Compression phenomenon

Segmental reference of parasthesia (pins and needles) at the distal end of the dermatome

Depends on strength of stimulus

No edge and no aspect

Lower motor neuron lesion: flaccid muscle weakness, absent or reduced reflexes

May become pain sensitive, sharp, lancinating pain

E.g. Nerve trunk

Release phenomenon

Onset related to the length of the compression time

Deep, painful parasthesia in cutaneous distribution of the nerve trunk

Some aspect, no edge

E.g. Peripheral nerve


Edge and aspect

Reproduced for educational purposes from the orthopaedic medicine postgraduate diploma in clinical reasoning section.  

referred pain, what structure is causing the pain?

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