Jonathan E Fenton, DO, FAAPM&R,

C-AOCPM&R, C-AOBSPOMM, C-AAOM,

RMSK

Interventional Regenerative Orthopaedic

Medicine

Osteopathic Diagnosis & Treatment

321 Main Street, Suite C

Winooski, Vermont 05404

(802) 859-0000

www.JFentonDO.com

Referred Pain Patterns

• Dermatomal (nerve roots) • Myotomal (fascial planes) • Sclerotomal (deep bone--spinal) • “Enthesopathic” (ligament/tendon) • Myofascial (Trigger Points) • Dural • Thermotomal (sympathetic nerves) • Visceral • Other (Chapman’s, Counter-strain, etc)

TOMAL PATTERNS

from Practical Pain Management Volume 3 #6 Woessner

DEMATOMAL/SEGMENTAL PAIN

DEMATOMAL/SEGMENTAL PAIN

Cervical Dermatomes

From Ombregt A System of Orthopaedic Medicine

Cervical Dermatomes

From Ombregt A System of Orthopaedic Medicine

Thoracolumbar Dermatomes

From Ombregt A System of Orthopaedic Medicine

Lumbar Dermatomes

From Ombregt A System of Orthopaedic Medicine

Sacral Dermatomes

From Ombregt A System of Orthopaedic Medicine

From A VISUAL AID TO THE EXAMINATION of NERVE ROOTS,

S. Hernandez and M.L.Argote,

PERIPHERAL NERVE REGIONS OF THE UPPER EXTREMITY

PERIPHERAL NERVE REGIONS OF THE LOWER EXTREMITY

From Chiropractic & Osteopathy 2009; 17: 9.

From Chiropractic & Osteopathy 2009; 17: 9.

From Chiropractic & Osteopathy 2009; 17: 9.

Derm-Myo-Sclero TOMES

Derm-Myo-Sclero TOMES

Figure 3 Cervical and lumbar facet joint pain referral patterns

Gellhorn, A. C. et al. (2012) Osteoarthritis of the spine: the facet joints Nat. Rev. Rheumatol. doi:10.1038/nrrheum.2012.199

Part a adapted with permission from Lippincott Williams & Wilkins © Dwyer, A. et al. Cervical zygapophyseal joint pain patterns. I: A study in normal volunteers. Spine (Phila Pa 1976) 15, 453–457 (1990)

Facet Referral Patterns

REFERRED PAIN LIGAMENTS AND JOINT CAPSULES

Enthesopathic (~Sclerotomal) Referral

C5 enthesopathic referral

From Diagnostic and Injection Techniques In Orthopedic Medicine, Dorman & Ravin

C6 enthesopathic referral

From Diagnostic and Injection Techniques In Orthopedic Medicine, Dorman & Ravin

C7 enthesopathic referral

From Diagnostic and Injection Techniques In Orthopedic Medicine, Dorman & Ravin

Transverse process of C7 enthesopathic referral pattern

From Diagnostic and Injection Techniques In Orthopedic Medicine, Dorman & Ravin

HACKETT LIGAMENT PAIN

HACKETT LIGAMENT PAIN

from Practical Pain Management Volume 3 #1 Woessner

HACKETT LIGAMENT PAIN

Hackett

From Diagnostic and Injection Techniques In Orthopedic Medicine, Dorman & Ravin

From Diagnostic and Injection Techniques In Orthopedic Medicine, Dorman & Ravin

From Diagnostic and Injection Techniques In Orthopedic Medicine, Dorman & Ravin

From Diagnostic and Injection Techniques In Orthopedic Medicine, Dorman & Ravin

Trigger Point Referral Patterns

Guteus Minimus Trigger Points

From Travell & Simons Myofascial Pain and Dysfunction

Quadratus Lumborum Trigger Points

From Travell & Simons Myofascial Pain and Dysfunction

From Travell & Simons Myofascial Pain and Dysfunction

Dural Referral

From Ombregt A System of Orthopaedic Medicine

Dural Referral

From Ombregt A System of Orthopaedic Medicine

SPINAL THERMOTOMAL PAIN REGIONS (AUTONOMIC)

From Practical Pain Management Volume 3 #6 Woessner

Visceral Pain Referral

Viscero-Somatic Points

Viscero-Somatic Points

Counter-Strain (Jones) Points

CONCLUSIONS

• Most pain is non-dermatomal

• Many overlapping referral patterns

• Ligaments and joint capsules most common

• Muscles often secondary, not primary

• Diagnosis based on history, passive joint testing and active muscle testing, then palpation!