From where does the pain originate? The major diagnosis (70-80%) of low back pain is "Non-specific" or "Idiopathic" ( most likely associated with sprains or strains of soft tissue). Therefore the most likely source of pain would be soft tissue, such as muscles. We do not have agreement as to how muscles should be examined. As I mentioned in a previous post (4/29/09), pressure to an area is not an accurate means to identify a muscle thought to be the cause of pain. In addition there is no agreed method as to how one should inject muscles that are identified as the source of pain. i.e. containing trigger points. Diagnosing the source of pain through the use of imaging such as x-ray, MRI or CT is confusing beacause the majority of patients having these studies will show some pathology that may have nothing to do with their pain. For example, 40% of patients with no pain in their back have been found on MRI to have herniated discs and 70% to have degenerated discs. Therefore just the presence of an abnormality does not tell you if that is the cause.

So the short answer is, yes pain can come from discs and joints but much less so than from muscles. It does appear that fascia is an important aspect of clinical pain and this will be an important area of future investigaton.

The Muscle Pain Detection Device (MPDD) is a step toward clarifying a specific muscular source of  pain. The instrument can make one muscle move at a time recreating what happens in real life when a person with painful muslces experiences an increase in pain. If the stimulated muscle is painful and the surrounding muscles are not then that muscle is thought to be the one causing the pain in that region. We don't identify trigger points but call the painful muscles so identified as having Muscle Pain Amenable to Injection since the trigger point is only one area where the pain originates. With our approach the muscle-tendon and bone-tendon attachments, the areas with the greatest number of muscle pain receptors, are thoroughly injected along with the muscle belly. We call these injections Muscle-Tendon  Injections (MTIs) rather than Trigger Point Injections (TPIs).

There is no agreement about the type of injection that is most effective, i.e. size of the needle, what is injected, the area to be injected (muscle belly or the attachments to tendon and bone) or the aftercare. The muscle injections that are given, from our experience , must be painful if they are  to be effective. Causing pain signifies that you are in the area where the pain originates. In order to minimize the discomfort of the injections we first provide  intravenous pain medicaton and a local anesthetic in the skin over the muscle to be injected. We believe that it is important to have 3 days of physical therapy which includes muscle stimulation to produce passive contraction in the injected muscle and an exercise program that was developed at the Columbia University Shool of Medicine in the 1960s and successfully given to 300,000 particiapnts at the YMCA with an 80% success rate in reducing or eliminating back pain associated with muscle deficiency (weaknes and/or stiffness) which  frequently acompany muscles that require injections.

Before I answer the question I want to address the injections that we provide. The injections that I have given to you, although similar to trigger point injections, are called Muscle Tendon Injections. The reason we have a different name is because the majority of nerve receptors for pain in the muscle are not in the muscle belly but are mostly in the region where the muscle attaches to the tendon and the tendon attaches to the bone. Our injections address all the areas where pain originates and that is why they are more effective than trigger point injections or prolotherapy.

In addition, the success of our treatment is very much a function of the instrument we use to identify a painful muscle, the MPDD, which was shown in a recent study at NYU School of Medicine to be more effective than manual pressure in finding a specific muscle that should receive injections.
 
Now for the answer to your question; When a muscle is injected, it is usually in the region of which you complain the most. If the pain is relieved, a less painful muscle region may now become apparent. This mechanism is sometimes described as Diffuse Noxious Inhibitory Control (DNIC), meaning that when you feel pain in one place it suppresses pain in other areas. Sometimes the reverse happens, namely when you have pain in one region in causes pain in another area. More about that at another time.      Dr. Norman Marcus