The influence of spinal pathology on extremity pain: a clinical framework

Musculoskeletal extremity pain is frequently diagnosed based on symptom location and region-specific musculoskeletal special tests despite evidence demonstrating limited diagnostic accuracy and increased risk of misdiagnosis. Literature suggests that a proportion of extremity pain is influenced by nociceptive spinally mediated somatic referred pain, which can occur in the absence of spinal symptoms, often misclassified as radicular pain or radiculopathy. Overreliance on pain location and special tests with poor clinometric properties increases the likelihood that spinal contributions are overlooked, potentially resulting in suboptimal management strategies. Nociceptive input from spinal structures can produce non-dermatomal extremity pain patterns through mechanisms of spinal convergence and cortical reorganization. This clinical commentary proposes a structured approach to spinal screening in patients presenting with extremity pain, emphasizing targeted subjective questioning, spinal motion assessment, neurological and neurodynamic testing, and identification of a comparable sign using a test-treat-retest framework. Incorporating spinal screening into extremity evaluations may support more effective hypothesis-driven clinical decision-making and promote more effective management of musculoskeletal extremity pain.