How Structural Misalignment Can Cause Pain and Dysfunction

Erik Dalton’s
Myoskeletal Alignment Techniques

Pain is neurologically transmitted and typically classified based on its presumed underlying pathophysiology. Different types of inputs may or may not cause pain sensation.

Instead of “pain receptors” sending pain signals to the brain, there are different types of sensory receptors found in various bodily tissues and areas of the brain that can influence pain signals and perception. Sensory nerve classifications include proprioceptors that provide information about balance and position in space and between body parts and are abundantly found in articular regions, other mechanoreceptors that detect deep pressure, stretch, vibration and temperature, and nociceptors which detect noxious stimuli or things that may threaten the system.

Nociceptive pain refers to pain arising from activation of nociceptors in response to a noxious stimulus such as injury, compression, disease, or inflammation that can involve skin, fascia, muscles, tendons, joints, organs and bones. Nociceptors are sometimes mistakenly described as the exclusive pain receptors, but pain can be detected by non-nociceptive processes caused by signals arising from more than one specific type of nerve.

The nervous system can be affected chemically, physiologically, psychologically and mechanically and one aspect can influence another.

Pain can involve various inputs to different areas of the brain, such as cognitive related areas that hold memories of past experiences, meaning, fears, beliefs and consequences; emotional related areas such as the limbic system that involve mood, stress and homeostatic mechanisms; sensory signals coming from issues in cutaneous, visceral, connective, myofascial, articular tissues or skeletal areas.

Abnormal structure per se – whether it involves misalignment issues or dysfunctional movement on a global or focal level – may not cause immediate or short term pain, but the factors that often cause abnormal structure and the effects it produces often lead to degenerative and painful consequences.

Degenerative and painful consequences are commonly seen in the causes and effects of structural abnormalities, especially in chronic cases that cause degradation of tissue that ultimately affects the nervous system through impingement, irritation, or inflammatorily erosive insult.

Causative precursors to structural abnormalities include poor postural positioning, movement and weight bearing issues, and in most cases they include psycho-neuro-myofascial issues that cause the musculoskeletal system to compensate. Such issues include sympathicatonically induced myofascial hypertonicity, unresolved soft tissue injury, contractures, and restrictive adhesions. These and other unresolved soft tissue tensions and restrictions are often the primary cause of structural misalignments and pain.

Hyper-facilitated myofascial tension, spasm and/or resultant structural misalignment related compressions can cause pain in many short term instances and ultimately lead to pain and/or varying degrees of tissue degradation in chronic situations.

Confusion may loom because in many cases of obvious postural or joint misalignment, or those involving osteoarthritic degenerative joint misalignment, patients often experience no pain. That’s because in less advanced stages pain-signaling nerve irritation has not occurred. But in their more chronically advanced severe stages, pain most often occurs. Basic examples include knee or hip misalignments, hyperkyphotic thoracic spines, or degenerative disc disease that causes progressive osteoarthritis that may not cause pain for years, but commonly produces pain when it reach advanced stages of degeneration and neural irritation.

Conditions commonly treated by manual therapists such as tension, myofascial hypertonicity, fibrosis, joint fixation, and osteoarthritic conditions, commonly cause or perpetuate structural misalignment issues, and either the causes or effects of such structural misalignments can create compressive force insults, irritations, biochemical alterations and inflammatory responses that affect the related tissue and nervous system, causing tissue erosion and pain.

Chiropractic, osteopathic and medical colleagues observe patients daily who present with sudden severe pain in their spines or other joints, with no history of prior pain complaints, yet X-rays reveal advanced degenerative arthritis that has now progressed to activating sensory receptors that relay pain signals.

A variety of measurements are commonly used to assess structural abnormalities seen on X-ray, such as George’s line, spinolaminar line, and sacral base angle lines on lateral X-ray, and sacral rotational and pelvic misalignment measurements on A-P views. Such misalignment measurements are strong predictors of dysfunctional, degenerative and painful consequences that are likely to occur if left unresolved.

It’s well documented that long term structural abnormalities are key etiologies of altered function (movement) in involved joints and supporting soft tissue – and the opposite is also true – soft tissue and joint fixation caused by hypertonicity, contractures, adhesions, and articular fixations can cause structural misalignments and functional limitation, resulting in increased compression and frictional forces that cause irritation, inflammation, end plate and cortical erosion, and consequent nervous system pain activation that’s commonly seen in advanced osteoarthritis.

When treating patients with spinal pain complaints stemming from vertebral fixations, joint mobilization and functional restoration is my first treatment objective because it’s the immediate cause of their pain. Addressing longer term functional stabilization also involves soft tissue care, because both skeletal and soft tissue issues ultimately affect function and pain. Proper soft tissue manual therapy can in many cases help prevent or diminish the effects of such spinal-neurological problems.

Numerous studies such as those published in the American Journal of Medicine and Arthritis and Rheumatism discuss how restricted motion, which often results from combinations of hypertonicity and misalignment induced compression forces, causes much higher incidence of osteoarthritis and pain, probably due to abnormal frictional glide, inhibited nutritional exchange and inflammatory responses.         

Erik Dalton sums up the need for proper skeletal and soft tissue function to avoid long term degradation, dysfunction and painful consequences caused by structural misalignment:

“Working from the knowledge that the body’s myofascial and skeletal systems are inseparable – what affects one always affects the other. It is sufficient to say that ‘whole body’ alignment requires both the myofascial and osseous structures be systematically treated to prevent strain patterns from becoming pain patterns.

In order to completely restore symmetry, range of motion, and pain free movement to the spine, the therapist must also be prepared to manually restore proper biomechanics to the individual dysfunctional facet joints. The truth is, optimal body alignment is impossible with the exclusion of structural facet work. Dysfunction in the bony framework jams neurological pathways and causes inhibition in muscles, rendering myofascial work useless in many cases. In some chronically locked vertebral segments... if a few attempts do not succeed, a referral is made to a chiropractor or manipulative osteopath for a high velocity/low amplitude adjustment. Left untreated, the dysfunctional joint and its hypercontracted myofascial create sympathetic spasm in neighboring structures, leading to widespread chronic pain [and erosive degeneration].”

Likewise, the famed medical researcher K. Lewit states in Management of Muscular Pain Associated with Articular Dysfunction:

"Function, however, is not limited to any single structure but implies correlation and interplay between many structures, forming characteristic chains. A single structure is but a link in a chain and if its function is impaired, the entire chain is affected. However, one link may be more relevant than others and, by giving treatment to one, we may affect the entire chain.”

A recent abstract titled The Roles of Mechanical Stresses in the Pathogenesis of Osteoarthritis summarizes the roles of mechanical stresses and misalignment in the pathogenesis of osteoarthritis.

“Excessive joint surface loadings, either single (acute impact event) or repetitive (cumulative contact stress), can cause the clinical syndrome of osteoarthritis (OA).

Cumulative excessive articular surface contact stress that leads to OA results from post-traumatic joint incongruity and instability, and joint dysplasia, but also may cause OA in patients without known joint abnormalities. Fibronectin fragments released from articular cartilage subjected to excessive loads also stimulate matrix degradation...these cells also release chemokines and cytokines that may contribute to inflammation that causes progressive cartilage loss.

Distraction and motion of osteoarthritic human ankles [and other joints] can promote joint remodeling, decrease pain and improve joint function in patients with end-stage post-traumatic OA.

These advances in understanding of how altering mechanical stresses can lead to remodeling of osteoarthritic joints and how excessive stress causes loss of articular cartilage, including identification of mechanically induced mediators of cartilage loss, provide the basis for new biologic and mechanical approaches to the prevention and treatment of OA.”

In summary, massage and other forms of manual therapy play important roles in treating musculoskeletal tensions, restrictions or other dysfunctions that can cause structural misalignments, pain, and degenerative advancements.

Manual therapy treatments, in combination with proper patient exercise, nutritional and other self care help, can help reduce tension induced compression forces, structural misalignments and fixations, and can help slow down progressive osteoarthritic advancement – in many cases preventing or significantly reducing functional limitation, degeneration and pain.



Dalton, Eric: Myoskeletal Alignment Techniques, Freedom From Pain Series - Vol. 1, p 79, 1998

Lewit, K: Management of muscular pain associated with articular dysfunction. Ch. 21 in Advances in Pain Research and Therapy, Vol. 17. Edited by J.R. Fricton and E. Awad, New York, Raven Press, Ltd., 1990, pp.315-323

American Journal of Medicine 2001; 110(8): 651

Arthritis and Rheumatism 1984; 14:122

Buckwalter JA1, Anderson DD2, Brown TD2, Tochigi Y2, Martin JA2. The Roles of Mechanical Stresses in the Pathogenesis of Osteoarthritis: Implications for Treatment of Joint Injuries. Cartilage. 2013 Oct 1;4(4):286-294.

The Roles of Mechanical Stresses in the Pathogenesis of Osteoarthritis: Implications for Treatment of Joint Injuries, Cartilage. 2013 Oct 1;4(4):286-294.

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