Nov 14, 2016 by spinalcare
“Why are you working on my abdomen? My pain is in my back.”
If only we had a dime for every time we hear that question. Often when working on a patient, he will move my hand to the area of pain and say “the pain is here – this is where you need to be”. It seems logical that the pain we experience would be coming from the same location where we feel it. If you cut your finger, the pain is generally coming from the finger. You wash and bandage the finger and the problem is solved. Unfortunately, with musculoskeletal (MSK) injuries, it is often more complex. Most people are aware that all the structures and organs of the body are connected to some extent, but when it comes to muscles, tendons and connective tissue, things get very complicated. The key to resolving pain always lies in what is causing it. That is why a thorough exam is so crucial to good care. The structures causing the pain are often nowhere near where you feel the pain. Pain can radiate from other areas, it can be referred from other areas and it can be a response to imbalances in other areas. We find that often, the pain originates in a completely different zip code from where you feel it.
Radiating pain is pain that originates at a nerve root or at the spinal cord and is felt at a point further along that nerve – usually in the arms or legs. Herniated discs are prime examples of a causes of radiating pain. When a spinal disc (think of it as a jelly doughnut) herniates, the interior material will extrude through the wall of the disc and can hit a nearby spinal nerve. If enough the nerve is irritated, the impulse will travel along the length resulting in pain, weakness, and/or numbness at any point many feet away from the original injury. Calf pain, foot drop, weakness, and numbness in the legs are all common symptoms of a herniated lumbar disc. In these cases, if we were to treat the legs and not look for the actual “pain generator”, we would make very little progress in resolving the pain. (Note: All too often herniated discs are seen on imaging and are the scapegoat of the MSK world. We have seen numerous cases of patients who have herniated discs on imaging but further exam reveals that they are not the pain generators. Very often the surrounding muscles will be compressing the nerve and causing the radiating pain. We have seen too many patients go to surgery for disc repairs that come back with no relief and additional symptoms because the pain was not fully investigated. That however, is a topic for another blog post.)
If the pain is not traveling down a specific nerve to affect a separate region of the body, it can be referred pain. Referred pain is pain that the brain interprets as coming from one area, while it is coming from another (often unrelated) area. This is usually the result of pain interpreting nerves hitting the spinal cord at very close proximity and the brain mis-reading it. One of the most common examples is a key symptom of a heart attack. Left jaw and shoulder pain are often reported in heart attack cases. While the heart is in distress, the jaw and shoulder are unaffected. The brain is however picking up on signals coming from the heart and “misreads” those signals as coming from the shoulder and jaw. A more common example of referred pain that we see daily is the pain referred from trigger points in the muscle and fascia. While there are several different types of trigger points, they all can cause pain in areas other than where they are located. One of the most common referral patterns is headache pain many people feel in the side of the head and over the ear and/or eye. This pain is often a result of trigger points sitting in the scalene and levator muscles found along the sides of the neck. Again, we cannot stress the importance of a thorough exam to find these referral sources. If you come in with right shoulder pain and we simply look to the shoulder, it is easy to miss the potential gall stone that can be causing it.
One lesser known (but more common) cause of pain is muscle imbalances that develop over time that can cause pain in distant locations. These pain patterns are often the result of repetitive motion combined with heavy load, weakness, and poor form. We see this type of pain more frequently in athletes. Throwing a baseball 120 times in a week for 8 months with an overdeveloped pec and a weak rotator cuff will inevitably lead to elbow issues. When you stress a joint, your amazing body will adapt and look for the next most stable area to carry the load. Knees are an area of pain that is often a result of poor mobility elsewhere in the body. In 95% of non-traumatic knee pain, the hip plays a major role. Patients are amazed when they come with knee pain and we don’t treat the knee. Just by working the hip, the pain will often drop by 80-90%. Poor hip mobility can lead to plantar fasciitis and foot pain. Wrist pain is often a result of limited motion in the elbow. This list is long and varied, but you get the point.
CS Lewis said that “Pain insists on being attended to”. If we only look to the site of pain, we will be attending to it for quite some time. It is far more important to find the source of pain and resolve that. So, the next time we start pressing on the abdomen to treat your low back pain, trust that we are getting to the root of the pain. Just like the butterfly flapping its wings in Africa can cause a hurricane in Miami, the hip flexor straining in the abdomen can cause the crippling pain you feel in the low back.