The Difference Between the Location of Symptoms and the Source of Dysfunction

kinetic chain ripple effectLast week we talked about the kinetic chain ripple effect theory and how the kinetic chain has an impact throughout the body, but more of an impact closer to the source of dysfunction.  For this week, I wanted to discuss 3 common injuries that we all see that may actual just be a symptom, and not the actual injury or source of dysfunction.

As a general rule of thumb, we should probably consider that many of our traditional “injuries” that seem to be relentless and not responsive to treatments may actually be coming from elsewhere in the body.  Think back to how patellofemoral pain has been referred to as “the black hole” of orthopedics and how surgery and rehabilitation to correct patella alignment is often unsuccessful.  Perhaps patellofemoral pain is actually just a symptom and not the source of dysfunction.

Below are what I have found to be 3 common “injuries” that may actually just be symptoms from dysfunction somewhere else within the kinetic chain.  There are many more than 3, but these are likely to be some of the most common that you may encounter.  Feel free to leave a comment of more examples that you have encountered.  Furthermore, all three fit into the kinetic chain ripple effect theory as the source of dysfunction is pretty close to the location of symptoms

Groin Pain – Source: Hip Joint

I have to admit that in my career I have been stumped by groin strains that seem to be difficult to treat or frequently reinjured.  I am sure we have all seen this in our practices, groin pain that doesn’t really look like a groin strain, but what is it?  As our understanding of the hip has improved, we find that many people with intra-articular hip joint pathology present with groin pain, which is a common pain referral pattern from the hip joint.

Next time you have a patient with groin pain, clear the hip, you’ll be surprised how many times we find that the symptoms are coming from the hip and that will drastically change our treatment program.

Lateral Epicondylitis – Source: Cervical Spine

lateral epicondylitisAnother commonly misdiagnosis that I have seen involves lateral epicondylitis.  The C6 nerve root is one of the most commonly involved nerve roots involved in cervical radiculopathy as it exits between the 5th and 6th vertebrae.  Any radiculopathy from this nerve root can cause weakness in wrist extension.  I have seen even a subtle loss of strength of wrist extension cause a raging lateral epicondylitis.  Sometimes this weakness is so subtle that the person doesn’t even realize they have weakness until it is too late.  We continue to function and use our hands with this weakness and overload the area.  So, we can treat the heck out of the lateral epicondylitis, but if we don’t solve the nerve root issue at the cervical spine we will never regain the wrist extension strength that is needed to decrease the symptoms of lateral epicondylitis.

Patellofemoral Pain – Source: The Hip

patellofemoral painWe’ve spent a lot of time discussing the contribution of the hip has on symptoms of patellofemoral pain.  [If you haven’t yet, this would be a great time to sign up for my newsletter and receive a bunch of goodies, including my eBook on Solving the Patellofemoral Mystery.]  Over the last several years, we have made a giant leap in our understanding of why some forms of patellofemoral pain occurs.  More often than not, weakness and dysfunction of the hip muscles, specifically the abductors and external rotators, is a leading cause of biomechanical faults at the knee and subsequent patellofemoral pain.  Similar to lateral epicondylitis above, you can treat the symptoms all day but you aren’t going to solve the problem if you don’t address the source, weakness and dysfunction of the hip.

Take Home Message

I’m sure that many of my readers have observed all of the above findings.  Please do comment and add more examples.  So what is the take home message?  For the younger clinicians in the audience, I guess it would have to be that we should probably take a step back a rethink all of the injuries that we see that we consider “difficult to treat” or “unrelenting” such as lateral epicondylitis and patellofemoral pain.  Maybe we need to think of the bigger kinetic chain principle.  Perhaps we are only treating the symptoms and not the true source of the dysfunction.  So next time you seem to have a patient that is not responding to your treatments, take a step back, re-evaluate and assess elsewhere in the kinetic chain and make sure that you haven’t missed the true source of the person’s symptoms.

41 replies
  1. Jura Kendrik
    Jura Kendrik says:

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    Connie Guts says:

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  3. Will Freeman, DPT, ATC
    Will Freeman, DPT, ATC says:

    Great information. Another one I’ve just started looking at is upper cervical hypomobility causing pain at the superior angle of the scapula.

  4. angie
    angie says:

    Hi Mike,

    I have a question regarding lateral epicondylitis and issues with the nerve root c6 irritation. If there is irritation, how do you resolve this and achieve full movement in the wrist? I have tenosynovitis of the left wrist flexor muscles mainly flexor carpi radialis which is the key culprit. I know that this muscles is innervated from the median nerve and that it’s origin is c5/6. It’s just now clear how to resolve this issue? I work a desk job and I can’t not work so I need a solution to resolve the pain. I understand that if there is imbalance or dysfunction that in order to get rid of the pain, I need to restore function. I’d just like to know how to do that.

    I am not convinced that there is evidence base for nerve root injections either. I’d appreciate your thoughts on this.

    • Jayc Dryden
      Jayc Dryden says:

      Hi Angie,
      Have you heard of/tried ESP for it before? We’ve got some great results with irritation relief and range of motion increase, usually in minutes. It’s non-invasive and involves no drugs or equipment so I would consider trying it before you think about nerve root injections

      • Angie
        Angie says:

        Hi there
        I haven’t heard of ESP. I’ve tried iontopheresis and it has worked wonders when I had bicep tendonitis. How does ESP work and can a physical therapist do this?

        I’m also trialling cranio sacral to try to calm the nervous system down which is definitely helping

        • Jayc Dryden
          Jayc Dryden says:

          Hi Angie

          Cranio sacral is definitely worth trying but from my experience of both ESP is definitely the best thing to use for calming the nervous system and for increasing range of motion.

          Most physical therapists don’t know ESP, in fact it’s quite rare.

          It’s a combination of CBT and Exposure therapy combined with pressure point stimulation similar to acupuncture (only without the needles) but in a nutshell it addresses the freeze/flight/fight response that’s often behind many problems.

          It’s also been shown to inhibit production of the stress hormone, cortisol, and increase oxygen absorption.

          It’s good because you can learn and use it yourself fairly quickly and you can be shown it over a video feed or even the phone.

          I offer sessions with it over the phone and skype and seeing as you’re a friend of Mike’s I’d be willing to give a no-obligation consultation and show you it on a complementary basis to help you restore full function in your wrist.

          I worked with a guy recently who had a similar (from what you’ve wrote so far) range of motion problem in his knee which he has had for 6 years.

          I followed up with him 3 days ago (it’s been over two weeks now) and none of the symptoms have returned :)

          He also said he’s happy to share his experience with others so if you want to talk to him in person I can provide his number too (he is in the UK).

          Mail me at [email protected] or go to if you want to know a bit more – but I’d say it’s definitely worth a shot.

  5. Jayc Dryden
    Jayc Dryden says:

    Excellent post. The depth of knowledge in traditional physical therapy is incredible! Sometimes it’s definitely handy to have.

  6. Peter A. Sprague, PT, DPT, OCS
    Peter A. Sprague, PT, DPT, OCS says:

    Thanks for throwing this concept out there. These ideas are the “nuts and bolts” of what we do as PTs. Movement is fluid and involves many different components which are regionally interdependent. We have some very smart colleagues (yourself included) that are bringing these ideas into the forefront of thought for practitioners via con-ed, books, websites, and most importantly, peer reviewed research. Wainner et al wrote a very good editorial in the JOSPT (Nov. 2007) that defined this topic and illustrated the importance of regional interdependence.

    Another example of this could be found in psoas syndrome. Bilateral shortening can contribute to janda’s lower cross syndrome which sets of a whole firestorm of regional dysfunction. Unilateral shortening, if
    left unattended, can result in contralateral sciatic irritation (sequalla too involved to post in a commentary). We can treat the piriformis all we want and even correct sacral dysfunction, however if we don’t recognize the shortening of the psoas, the rest of the dysfunctions will persist or return.

  7. Braedan@PhysioSurrey
    [email protected] says:


    You’re preaching to the converted here. As a matter of practice, I will often treat the potential distant causes of the pain disorder before I even do anything with the perceived “pain generator.” This gives me some clue as to where I should spend my time

    I teach my clinicians that it is like inheriting a plot of land in Texas and doing test drilling for oil, of the land, to determine where best to put your efforts. It’s a good analogy, except that there is no longer any oil on land in Texas.

  8. Becky Swan
    Becky Swan says:

    Great post, I feel we must always look for alternate sources of cause of pain. Many of my client have become accustomed to me exploring other areas of their body when they come to me with an issue. Once you explain the reasoning behind it many most are quick to understand. These often are patients who have been to a different therapist already and spent weeks on end having them treat the area of pain with no positive results.

    JHIH CHANG LIN says:

    Good points, Mike. These examples are excellent to explain the cause and source of the pain. Sometimes the main cause of the dysfunction is not what you look like before.

  10. Joseph Brence
    Joseph Brence says:

    I think another point that you failed to mention is that nociception is not necessary for pain. So for individuals with chronic symptoms, the origin of pain may not be mechanical but rather as an output from the brain based on suspected or anticipated tissue damage. As a profession, I believe this is the one point we fail the most to consider.

  11. Rupa Patel
    Rupa Patel says:

    Great post, Mike! I am a SPT in my last year and just recently did a in-service at my current affiliation on Myofascial Trigger Points for pelvic floor pain. During the research, it was interesting to learn how LBP/hip pain/groin pain can be referral from pelvic floor muscles dysfunction and how dysfunctional SI joint can affect the PFM as well. Just something to think about. I really enjoy learning from your posts, Mike so keep them coming!

  12. Mike Sanderson
    Mike Sanderson says:

    Great clinical pearl I got from Gray Cook seminar is to look at myofascial triggers in medial soleus with “plantar fasciitis” diagnosis. Have used this with some degree of success in past year.

    • Matt
      Matt says:

      I’ve definitely seen that as well. When I was battling my own “plantar fasciitis,” getting those triggers mashed definitely helped, but the big breakthrough came when I finally got the post. glut. med. fibers to kick in and stabilize the hip joints. It was like a breath of fresh air! Just one more link in the chain!

  13. Craig Liebenson
    Craig Liebenson says:

    Mike, Not only does your post hit the nail on the head, but the comments too –
    ankle dorsiflexion & PFPS; thoracic kyphosis & shoulder issues; core & the hammies. Karel Lewit of Prague said “he who treats the site of pain is lost.” It is great to see that this regional interdependence systems approach is gaining more & more traction.

  14. Brendan Smith, PT, ATC
    Brendan Smith, PT, ATC says:

    Thanks for the good post. I am a fan of the “double crush syndrome” idea. This states that a proximal neural irritation will exacerbate distal symptoms. With this syndrome, there may be two sources of dysfunction ie. L3-4 and patellofemoral issues. I have seen therapists spend lots of time treating either the proximal or distal problems when both need to be addressed.

  15. Jesse
    Jesse says:

    Great Post Mike. This is exactly the type of rehab my clinic preaches…find the cause, fix the problem. Chasing pain is VERY tempting and easy caue patients like it. However, it seldom helps with the real condition.
    How about subacromial impingement as a result of a kyphotic and stiff Thoracic spine? Treat the shoulder all day, but if you don’t open up the thoracic spine you will get minimal results.

  16. Jenn Reiner, DC, CSCS
    Jenn Reiner, DC, CSCS says:

    Great topic! I have found that taking a step back and evaluating functional movement (such as the Selective Functional Movement Assessment) is right along these lines. Considering the mobility/stability at each joint often leads you to the cause of the patient’s symptoms.

  17. Steve
    Steve says:

    Interesting stuff! Can you explain a bit more about how C6 nerve root compression would cause lateral epicondylitis-like symptoms? I would have guessed C7 would be responsible.

    • Mike Reinold
      Mike Reinold says:

      ECRB is innervated by C6, however I don’t always feel these are 100% accurate in ever person and C7 can be involved. If you look hard enough you can find both.

  18. Matt
    Matt says:

    Great post!

    One of the ones I like is bilateral reduced abduction of the glenohumeral joints due to a very strong thoracic kyphosis.

    And then there’s the unilateral shoulder pain (around the traps and at anterior deltoid) due to spinal erector disparities in the lumbars and low thoracics.

  19. Travis Morisoli
    Travis Morisoli says:

    Great post.
    One of the areas that I have seen in the clinic that seem to have a different source is that chronic hamstring strain patient. There has been a lot on the core and hamstring function recently, but I have been addressing the neurodynamics of the affected extremity with some great success.

  20. Lindsay Day
    Lindsay Day says:

    Hi Mike and others,

    With regards to the case of weak hip abductors and external rotators associated with PFPS, I was wondering to what extent you also find tight adductors, and if so, if part of your treatment approach includes stretching them.


  21. Casey
    Casey says:

    Hey Mike – I already subscribe to your newesletter but would like a copy of your ebook on PFPS. How can I get a copy? Can you send me one? Thank you very much. Great job on your newsletter and website. I enjoy keeping up by reading it.


  22. Christopher Johnson
    Christopher Johnson says:

    Great post Mike. Do you focus on seated hip flexion strength in any of your patients presenting with PFPS. There definitely seems to be an underappreciated role of the iliospoas complex in terms of spinal stability and hip external rotation. Dr. James Nicholas used to always preach seated hip flexion in patients with PFPS and I have definitely found it to be helpful in conjunction with several other key exercises you often cite. Good to see the Sox back on top! Hope you are getting some rest…


    • Mike Reinold
      Mike Reinold says:

      I havent, I know you guys have been saying that but I am not sure if I felt like this was the answer… This sounds like a great guest post, Chris, why you want to work on hip flexion.

  23. Ryan D
    Ryan D says:

    I have seen a lack of ankle dorsiflexion cause the same type of patella symptoms. Ankle eversion to increase motion sets off the same type of dynamic valgus you get with weak hip abductors.

  24. Stephen Thomas, PhD, ATC
    Stephen Thomas, PhD, ATC says:

    Mike they are great examples. Another theorized example would be between posterior shoulder tightness and elbow pain. During late cocking phase of pitching the shoulder should be in the scapular plane to minimize stress on the anterior capsule and elbow. However, when the pitchers develops posterior shoulder tightness it is thought that the pitcher assumes a more hyper horizontal abducted position during late cocking to release tension on the posterior capsule/cuff (horizontal adduction places the posterior shoulder structures in tension). This hyper horizontal abducted position will cause increased valgus stress at the elbow therefore causing elbow pain and potential injury. By improving the posterior shoulder tightness the pitchers elbow pain commonly subsides if addressed early prior to a major tissue injury.

  25. Dale Giessman
    Dale Giessman says:

    As a chiropractor I am always on the lookout for the “source” or “cause” of pain. I regularly see patients who wonder why I am working on their forearm muscles when there wrist hurts or neck when their shoulder hurts. What is nice is they can usually see instant improvement in mobility and pain minimalization after you chase down the real problem.

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