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November 11, 2025
Marianne Waldenfels
Back pain is a ubiquitous problem - but often the cause remains hidden. Prof. Dr. Musa Citak, an orthopedic surgeon and trauma specialist, explains why 80 percent of patients are treated incorrectly and how his innovative 6-quadrant method alleviates back pain
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Back pain is not just back pain – many sufferers are trapped in a system of painkillers, physiotherapy, and ultimately surgical recommendations. Could it be that the cause of the pain is often not recognized at all? Prof. Dr. Musa Citak, specialist in orthopedics and trauma surgery, knows this vicious circle as a doctor - and from personal experience: For ten years he himself suffered from chronic back pain.
This period led him to develop the 6-Quadrant Method, an innovative diagnostic approach that addresses precisely where classical methods fail. In his new book "The Back Revolution," Citak shares his personal experiences and shows how to precisely locate pain triggers, specifically deactivate them, and finally live pain-free.
80% of Germans suffer from back pain. What are we doing wrong?
The biggest problem is that in the area of back pain, incredibly many mistakes are made – starting with diagnosis to therapy decisions. This is mainly because we cannot objectively measure pain in modern medicine. We can take blood, make images, determine lab values – but we cannot see, touch, or measure the pain itself. And what cannot be measured is interpreted.
So when wear or a slipped disc is seen in an MRI, it is quickly interpreted as the cause of pain – and then surgery is performed. But that is often a fallacy. Because back pain is not just back pain.
We distinguish between specific pain, i.e., those with clearly identifiable causes, such as nerve root irritation, and nonspecific pain, where we find no clear explanation in MRI or lab tests. The latter are the most common—and at the same time the most difficult.
Many patients have pain radiating to the leg that has nothing to do with the nerve root. A tense pelvic muscle or an irritated tendon can cause the exact same sensation. Nevertheless, such complaints are often operated on or 'adjusted.' Why? Because every practitioner initially does what they do best.
The surgeon operates.
The chiropractor adjusts.
The fascia therapist treats the fascia.
The physical therapist trains the muscles.
But if you only have a hammer, everything looks like a nail.
And this is exactly where the crux lies: Pain is complex. It is never just physical, but always also biochemical, neural, and emotional. If we reduce it to a single cause, we are only treating a fraction of the problem.
Another point is that most pains disappear on their own within six to eight weeks – without any therapy. This means: No matter what treatment is done during this time, it seems to work because the pain would have subsided anyway. This explains why nearly every method celebrates 'successes' in the first few weeks.
The real challenges begin where the pain becomes chronic – that is, lasts longer than three months. These patients do not need occupational therapy, but precise, holistic diagnostics. But this is exactly what is missing in the system. There are hardly any specialized facilities that focus on researching the causes of chronic pain. Instead, many affected individuals end up in back courses or psychosomatic programs, where they are supposed to learn to 'live with the pain'.
But I am convinced: We should not accept the pain – we should understand it. Only those who recognize the true cause can bring the body back into balance and enable genuine healing.
What does a classic back pain patient look like?
Back pain is not just back pain – and the patients who come to us are also very different. Essentially, we encounter three types of back pain patients in practice.
The first type is the classic acute patient – the 'lumbago'.
These people often come to the practice completely desperate: bent over, walking carefully, hardly able to sit down or get up. Every movement is painful, the body is trapped in a kind of protective posture. They can't find a position where it really gets better – neither standing, sitting, nor lying down.
This condition seems dramatic, but in most cases, there is no dangerous structure behind it. If the right cause is recognized and treated specifically, the body usually recovers quickly.
The second type are the chronic-latent back pain patients.
For them, the pain is like a quiet background noise that never completely disappears. Some days it's stronger, on others almost imperceptible – but always there. Now and then there are pain peaks, which then subside again until everything returns to the familiar noise. Many of these patients have come to terms with their pain. They change their daily routine, avoid certain movements, plan their energy. They live – but they live around the pain. And that's exactly what's dangerous because the longer the body remains in this state, the more poor postures and neural pain pathways solidify.
The third and most dangerous type are patients who have no back pain at all – only pain in the leg.
These people are convinced that their problem lies in the leg. In reality, the cause often lies in the spine: a herniated disc or nerve root irritation that radiates into the leg. It becomes particularly alarming when the pain suddenly disappears – but the leg becomes numb or loses strength. This is not a good sign, but a warning signal from the body: The nerve is already severely damaged. This is an acute emergency that must be clarified immediately to prevent permanent damage.
Back pain is therefore not just a symptom – it is a mirror of the body's internal dynamics. Every pain tells a story, and those who listen closely can learn a lot about its cause. Only when we understand these patterns can we really treat the pain at its root – and not just alleviate it on the surface.
Is it different for men and women?
Yes, back pain manifests differently in men and women – in its frequency, progression, and causes. Women are affected more frequently overall, which is partly due to hormonal fluctuations, different pelvic statics, and stress during pregnancy and childbirth. Pain perception itself is also hormonally co-regulated – as a result, pain can be perceived more intensely and processed more slowly.
In practice, we also see that gynecological causes are often overlooked in women. Conditions such as endometriosis, fibroids, or cysts can cause or exacerbate back pain without the back itself being the actual problem. Sometimes patients come to us with back pain that actually originates from the pelvis or internal organs – or they first go to the gynecologist, even though the cause is orthopedic.
This shows how closely everything is connected. Back pain is not just an orthopedic issue, but often interdisciplinary.
Those who understand the connections between muscles, organs, hormones, and nerves can treat more precisely – and avoid many unnecessary therapies. Because especially for women: Not every back pain comes from the back.
What often goes wrong during the first doctor's visit?
During the first doctor's visit, significant things often go wrong – not because someone does something 'wrong', but because the system functions exactly as it is organized today. Due to strong budgeting and enormous time pressure, there is hardly any room in many practices for truly individual diagnostics. Instead, treatment is often based on fixed schemes – and this is particularly problematic with back pain.
Many patients simply make an appointment with the first available orthopedist, without knowing that there are numerous specializations within orthopedics. One focuses on shoulders and knees, another on feet – back pain often isn't even part of their main focus. As a result, patients are 'orthopedically treated', but not truly understood.
In addition, thorough physical examinations are becoming increasingly rare. I regularly see patients with back pain who already bring an MRI of the lumbar spine – even though the real cause comes from the hip or pelvis. This shows how quickly misdiagnoses occur when too much reliance is placed on images instead of examining with hands.
Another problem is legal safeguarding: those who discover a herniated disc on the MRI often refer to the surgeon as a precaution – not necessarily because surgery is needed, but to be legally "on the safe side." Many of these cases could be successfully treated conservatively.
However, no therapy works without mutual trust. If the patient dictates the treatment and the doctor is only supposed to issue prescriptions, the trust relationship is disrupted. In such cases, it's better to end the treatment so the patient can find a doctor they truly trust.
We also observe growing impatience on both sides: if pain does not disappear within a few weeks, the patient becomes restless – and the doctor is under pressure to quickly present a solution. This creates a spiral of overdiagnosis and overtreatment.
We need exactly the opposite: more time, more attention, and the courage to truly understand the pain – instead of just silencing it. Every effective therapy begins with a precise diagnosis, and that requires one thing above all: time and listening.
What is special about the Six-Quadrant Method?
The biggest problem in modern medicine is that patients today can hardly expect quick, yet precise diagnostics. Many are sent from one specialist to another, receive images, injections, or medications – but rarely a clear answer to the most important question: Where does my pain really come from?
This is where my six-quadrant method comes in. The basic idea is simple: you must distinguish whether the pain is radicular or pseudoradicular.
Radicular pain originates at the nerve root – it cannot be provoked by pressure on the back because the cause lies deep within the nerve. Pseudoradicular pain, on the other hand, comes from muscles, tendons, or fascia and can be reproduced by targeted pressure.
The method divides the back and pelvis into six functional areas. This way, I can determine within 30 seconds whether a nerve is affected or if the cause is muscular or fascial – and at the same time see which muscle group is overloaded or irritated. Based on this, I can immediately choose the right treatment or exercise.
I have been working with this method for over ten years now – and the results are remarkably reproducible. Of course, there are also complex cases: patients who show both radicular and pseudoradicular symptoms. In such situations, the pain usually improves significantly by treating the muscles and tendons but does not disappear completely – then an MRI is useful to assess the nerve more precisely.
The six-quadrant method doesn't replace high-tech diagnostics, but it fills a crucial gap: it brings the doctor back into direct contact with the patient – with his hands, his feeling, and his experience. And this is where real medicine begins.
How did you develop the six-quadrant method?
It arose from my own experience – specifically from the search for the cause of my own pain. At that time, I noticed that there is a very particular point that is repeatedly noticeably painful in many patients. This made me curious.
After intensive research, I came across the work of the German neurologist Dr. Knappe, who had already described this exact point. He suspected that there was a fascial gap through which a nerve passed—and that this nerve caused the pain. This theory was exciting, but it didn’t explain what I observed in daily practice.
I began to systematically investigate this point—initially manually, later with high-resolution ultrasound. I found that the pain originated not from the nerve but from the tendon. This was a pivotal moment. The pain pattern was identical to what we know from chronic tendon inflammations—like the Achilles tendon or tennis elbow: the pain flares up under strain, subsides at rest, and returns with renewed strain.
This insight fundamentally changed my understanding of back pain. I realized that many so-called "neural" back pains are in fact myofascial-tendinous in nature—originating from the transitional area between muscle, fascia, and tendon.
This also explained why therapies that influence muscles or fascia, such as osteopathy, fascial therapy, or stretching exercises, often provide short-term relief but no lasting cure. It also showed why muscle training or strength building improves stability but doesn’t resolve the actual pain: the irritated tendon remains the weak point.
Over time, I found several of these points in the back and pelvis area that could be reproduced in almost all patients with chronic back pain. These points today form the basis of the Six Quadrant Method.
Of all the patients I’ve seen over the years, I could identify only a single true nerve pain—the one Dr. Knappe described. This showed me that he had identified the right point, but as a neurologist, he attributed it to the nerve. In reality, the pain in most cases originates from the tendon itself.
With modern ultrasound technology, we were later able to objectively confirm these observations: You can see tiny changes, microcalcification, or local inflammatory reactions there – similar to calcific tendinitis in the shoulder. For the first time, it could be demonstrably proven that many chronic back pains are actually tendon pains.
After I was able to clearly identify this point, I subsequently developed an integrative therapy that addresses this very issue: It specifically treats the affected tendon, reduces chronic irritation, and sustainably improves the pain.
At the moment, we have only published the examination method in the new book – the therapy regime remains our secret for the time being.
These insights were the starting point of my Six-Quadrant Method – a method that helps to clearly differentiate pain, treat it specifically, and finally address causes instead of symptoms.
What can I do myself against back pain?
When someone has back pain, it is usually not by chance. The pain is the end result of a longer process where something has already fallen out of balance beforehand – be it due to poor posture, lack of movement, or muscular imbalances. Therefore, the most important step is to understand where the pain comes from. Only those who know the cause can choose the right therapy or exercise.
Back pain often announces itself early – through a feeling of tension, a pulling sensation, or limited mobility. These are the moments when you should take action before the pain becomes chronic. It is crucial to identify the right muscle group and specifically stretch or activate it. Fascia rollers or gentle stretching exercises can be a good first aid to release tense structures.
In muscle training, the rule is: The back only works as a team. A stable spine is not achieved by the back extensor alone, but by the interplay of the back, gluteal, hamstring, and abdominal muscles, as well as the adductors. Only when all muscle groups work harmoniously together can the pelvis remain stable. If you only train individual areas, an imbalance quickly arises, which in turn causes pain.
Equally important is the statics of the body. Many people do not know that a slight leg length difference or a pelvic tilt can cause back pain in the long term. It is crucial to recognize why the statics are altered:
Is one side too high because the muscles have too much tension – or too low because the leg is actually shorter? This distinction is crucial to initiate the correct correction and prevention.
Back pain prevention does not just mean doing sports. It's about understanding your body, listening to signals, and training the muscles intelligently – in a balanced, mindful, and cause-oriented way.
Can nutrition help with back pain – and if so, how?
Nutrition actually plays a more important role in back pain than many think. Of course, chronic back pain cannot be cured by diet alone, but it can significantly help to slow down inflammatory processes and alleviate pain phases.
Basically, many chronic pains are the result of acidity in the tissue, especially in the area of the tendons and fascia. If the environment in the body is too acidic, healing processes are slowed down, inflammation is promoted, and pain is intensified. Therefore, we recommend an anti-inflammatory, antioxidant diet that relieves the tissue and supports regeneration.
These include mainly:
• a lot of fresh vegetables and fruits, especially green leafy vegetables, berries, avocados, citrus fruits,
• Omega-3 fatty acids from fish, linseed oil, or walnuts,
• Spices with anti-inflammatory effects like turmeric, ginger, garlic, or cinnamon,
• Sufficient water and herbal tea to eliminate metabolic waste products.
On the other hand, you should avoid anything that promotes inflammation – such as sugar, white flour, alcohol, nicotine, and heavily processed foods. Excessive consumption of meat and dairy can also worsen tissue conditions due to the acids and metabolic waste products they produce.
Such a diet not only has a positive effect on the back but also on arthritis, muscle pain, and general well-being. Many patients report that their pain episodes become less frequent and milder when they consistently change their diet.
So you could say: Nutrition does not replace therapy, but it is a crucial enhancer for healing and regeneration – and it is one of the easiest ways to actively do something for your own body.
Back pain be gone! An innovative approach to chronic pain. The book "Back Revolution" by Prof. Dr. Musa Citak has been published by ZS Verlag.
© Jan Russok
Prof. Dr. Musa Citak is a specialist in orthopedics and trauma surgery. With his health center in Hamburg, he has made it his life's mission to set new standards in pain therapy.
