Dr Norman Marcus
Across the United States, patients with chronic pain enter healthcare systems that promise answers, relief, and solutions. Yet for millions, the experience quickly becomes a cycle of uncertainty: imaging tests that show “nothing significant,” medications that dull symptoms but do not resolve them, and specialist referrals that lead to conflicting diagnoses.
At the center of this pattern is a persistent gap in how chronic pain is evaluated: muscle-related pain is frequently underrecognized despite being both common and treatable.
This issue reflects a broader systems problem rather than a single point of failure, involving gaps across clinical training, diagnostic frameworks, reimbursement structures, and care pathways.
Modern healthcare systems were built on a biomedical model that prioritizes visible structural pathology: fractures, nerve compression, arthritis, or organ disease. As a result, clinicians are trained to search for anatomical defects, most often using tools such as X-rays, CT scans, and MRIs.
Soft-tissue dysfunction, including muscle overload or sensitization, can significantly influence pain while leaving little structural evidence on conventional imaging.
Research consistently shows:
Despite these facts, clinicians’ diagnostic protocols often default to the findings they can see overlooking possible pathophysiological mechanisms related to the structures that imaging cannot reveal.
The underrecognition of muscle pain begins during professional training.
Medical schools provide limited time for musculoskeletal medicine, and even less for practical evaluation of muscle and fascia. Students often become highly skilled at interpreting imaging studies, but receive almost no formal instruction in hands-on muscular assessment or in the pathophysiological mechanisms of muscle generated pain.
This creates a systemic cascade:
Effective muscular treatments remain underused because clinicians:
Lack confidence in diagnosing muscle generated pain having been mentored by superiors who for the most part ignored muscle pain or treated it as a peripherally important contribution have difficulties in believing that soft tissue is the possible source of pain when they see images that support a spine or joint based source of the pain.
The result is a persistent mismatch between where pain often originates and where the healthcare system is trained to look.
Even when clinicians recognize muscular involvement, the healthcare system often makes it difficult to act. Muscle-focused diagnostic approaches are not yet recognized as valid means to identify painful muscles and treatments such as manual therapy, targeted physical therapy, and muscle injection techniques are frequently undervalued or inconsistently reimbursed while high-cost imaging, nerve directed injections and ablations, and surgical procedures are often readily covered.
This creates an incentive structure where:
The result is not only misaligned care, but avoidable healthcare spending on unnecessary invasive procedures and imaging.
Reforming how healthcare systems address muscle pain requires coordinated action across multiple layers of the system.
Guidelines must explicitly require muscle assessment in the evaluation of chronic pain, particularly for back, neck, and shoulder pain.
Muscle evaluation and myofascial science should be embedded in medical school curricula, residencies, and continuing education.
Reimbursement should align with evidence: conservative muscle treatments must be accessible and financially viable.
Innovations such as electrical muscle stimulation diagnostics and biochemical muscle pain markers need institutional backing.
Collaborations between physicians, physical therapists, and pain specialists to create standardized protocols for evaluation and treatment of soft tissue pain will improve accuracy and outcomes.
When muscle-related contributors to pain are not systematically evaluated, patients may experience delayed diagnosis, escalating interventions, and prolonged discomfort.
Correcting this blind spot is not just an academic exercise, it is a public health imperative. Expanding recognition of muscle pain within healthcare systems could lead to earlier diagnoses, more targeted treatments, and improved quality of life for many individuals living with chronic pain.
The change is overdue, the evidence is clear, and the opportunity for impact is enormous.
