When examining back pain, doctors and physiotherapists still focus on the spinal column with its intervertebral discs and peripheral nerves emerging from the spinal column.
Radicular vs. nociceptive pain
The diagnosis of radiating pain in an arm or leg as neuropathic (nerve) pain is based on an 18th century hypothesis that nerve fibers can be irritated by damage, causing (nerve) pain. This hypothetical (albeit modified) concept is still current and widely accepted in the medical and paramedical world.
On the other hand, there is the scientifically based concept of nociceptive pain, which is based on the activation of nociceptors. Ligamentous structures in the joint as well as the subchondral bone plate are abundantly supplied with nociceptors, among others. Although the exact mechanism of radiating pain in joint dysfunction is not well understood, the close association of these structures with myofascial and osteofascial tissues may be the explanation for radiating pain. There is a growing body of clinical evidence to support this concept. An increasing number of well-documented case reports and cohort studies show that radiating pain, which could just as easily be diagnosed as radicular symptoms, has completely disappeared after joint replacement surgery. In addition, there is increasing empirical evidence of the nociceptive nature of radiating pain. Specific training of joints in symptomatic arthrogenic dysfunction leads directly to reduction of the radiating symptoms for a shorter or longer period, depending on the nature of the arthrogenic dysfunction.
Real physical damage to nerve fibers results in sensory and/or motor irreversible deficits (i.e., no pain), not to be confused with (partially) reversible arthritic symptoms such as loss of strength, sensory disturbances and pain.
Radiological - clinical examination
Although the diagnosis of neuropathic pain is "confirmed" by radiological diagnostics that clearly show stenoses and disc pathology such as herniated discs, more and more researchers are pointing out the lack of a clear correlation between the results of radiological examination and clinical symptoms. Persons without complaints frequently show similar radiological abnormalities and persons with complaints just as often do not show any abnormalities.
Clinical motor examination, on the other hand, can, if properly performed, provide accurate information about the function and condition of the locomotor apparatus (pain - mobility - strength) and thus establish clear links between symptoms and their causes.
There are more and more scientific publications showing that in advanced arthrosis, joint replacement surgery leads to significant pain relief in most cases, and motor treatments for symptoms of incipient and moderate arthrosis lead to a significant reduction in (radiating) pain and even freedom from pain. Advanced stages of arthrosis are much more difficult to treat with movement therapy due to their low resilience, and surgical therapy with the aim of joint replacement then comes closer into focus.
The spine - an indestructible framework
Although radiological images show a fragile spinal column with frequent abnormalities, the spinal column is in fact extremely robust. The stable construction of the individual building blocks and their mutual arrangement, combined with only slight mutual movement, make the spine very suitable for absorbing high loads from, for example, arms and legs and for protecting the spinal cord and its peripheral nerves.
The most vulnerable parts of the lumbar spine are the connections of the sacrum with the intestinal bones (SI-joint) and the lumbar spine (L5-S1-joint).
The cervical spine is vulnerable due to its movement function for the head and its related complex and fine construction. Motoric dysfunctions of the shoulder joints alter the stance of the cervical spine and can lead to overloading of its ligamentous structures; even slight motoric dysfunctions of the hip weight alter the stance of the lumbar spine and thus lead to overloading of the ligamentous structures of the SI complex, the most common cause of lower back pain.
For rehabilitation management, these clinical facts have great consequences. The cervical and lumbar radicular syndrome, intervertebral stenoses and herniated discs lose a large part of their diagnostic value, while an accurate assessment of motor joint functions gains considerable clinical significance in back pain.