For decades, pain guidelines internationally have shaped how clinicians diagnose and treat millions of people living with chronic pain. These guidelines influence what physicians learn, what insurers reimburse, and ultimately, what care patients receive. Yet despite their broad impact, these guidelines share a critical omission - one that may explain why chronic pain remains one of the nation’s most persistent and costly health challenges.

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Muscle pain is almost entirely absent from national pain guidelines.

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This absence is striking when viewed against the backdrop of national data. As of 2023, nearly 64 million American adults live with chronic pain. Low back pain alone is the number one cause of disability worldwide, and much of this pain originates not from defects in the spine, but from muscles and soft tissues surrounding it. Muscles constitute nearly 45 percent of the human body, yet they receive a fraction of the clinical attention given to bones, nerves, or joints.

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In many clinical settings, a patient reporting back or neck pain will undergo an MRI, receive medication, and, if symptoms persist, may be referred for injections or surgery. What is missing from this sequence is a thorough examination of soft tissue, even though evidence increasingly shows that muscle dysfunction - tightness, spasm, trigger points, and impaired movement patterns - plays a central role in many chronic pain conditions.

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The omission is not due to lack of importance but lack of institutional integration. Medical education does not equip clinicians with the tools to diagnose muscle pain accurately. Few residency programs offer training in myofascial assessment. Insurance reimbursement models do not incentivize muscular evaluation or treatment. And in the absence of national guidelines explicitly identifying muscle pain as a key diagnostic consideration, clinicians continue defaulting to the systems they know best.

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This has profound consequences. Consider the cascade that follows an incomplete diagnosis: unnecessary imaging, inappropriate medication use, invasive procedures, and in some cases, surgeries that offer little improvement. The patient, frustrated and often financially burdened, cycles through the healthcare system without meaningful relief. Meanwhile, the underlying muscular cause remains untreated.

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National pain guidelines exist to prevent precisely this kind of systemic failure - to ensure that clinicians follow evidence-based pathways that lead to effective and appropriate care, however reviews of the literature on treatment outcomes for various chronic pain syndromes finds sub optimal success and a consistent request for more research on diagnostic and treatment approaches. When muscle pain is omitted, common sense suggests that successful outcomes are elusive. The case for inclusion is strong. Research in the past decade has clarified how dysfunction in specific muscle groups can generate pain that mimics nerve compression, joint pathology, or structural spine abnormalities. The phenomenon of referred pain - where a muscle in one region produces pain elsewhere - further complicates diagnosis but underscores the necessity of muscular assessment. Studies have shown that when clinicians treat muscle-based causes early, patients recover faster, avoid invasive procedures, and report significantly higher satisfaction.

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Beyond clinical outcomes, there is an economic imperative. Chronic pain costs the U.S. hundreds of billions of dollars annually in medical care, lost productivity, and disability. A meaningful portion of these costs is tied to misdiagnosis and overtreatment. By incorporating muscle pain into national guidelines, the healthcare system can shift toward earlier identification and lower-cost interventions that reduce the burden on patients and the economy alike.

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Updating national guidelines would also send a powerful signal throughout the healthcare ecosystem. Medical schools would be required to teach muscular assessment. Insurance providers would need to cover evidence-based muscle treatments. Hospitals and clinics would standardize their evaluation protocols. Electronic medical records (EMRs) would be required to include templates that allow the recording of the results of a soft tissue examination including specific muscles associated with various pain presentations i.e. low back pain, neck pain, shoulder pain, hip pain, etc.) And patients would finally receive care that aligns with comprehensive modern scientific understanding.

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Inclusion is not merely a technical adjustment - it is the foundation for a long-overdue paradigm shift.

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The science is clear. The impact is undeniable. And the cost of inaction is too high.

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To improve outcomes and reduce unnecessary suffering, muscle pain must be formally included in national pain guidelines. Until that happens, the healthcare system will continue overlooking one of the most common and treatable sources of chronic pain - leaving millions without answers, and without relief.

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