Referral Patterns

My referred pain journey began in January of 2020. (Remember January of 2020? It’s been 84 years, give or take). My top hit on Google defines referred pain as “pain perceived at a location other than the site of the painful stimulus/origin.” In typical medical fashion this is not a very helpful definition. Let me try again: referred pain is when bodies, those stupid and wondrous things we inhabit, get a little confused. Something going on in one part of your anatomy is making something else in your flesh container hurt, which is a both weird and weirdly persistent reminder that the only reason we “feel” pain at all is because our brain tells us to. Referred pain, from what I gather, seems to most commonly originate in the spine, the physiological 12-lane highway that basically forces you, at even the slightest hint of impending traffic, to pay attention. Alas, that uniquely humane shift from quadra- to bipedal once again fucking all of us over.  

That fateful year started out so stereotypically that, in retrospect, perhaps the ensuing and instant disbursement of pain was to be expected, or even justified: I had decided, after 3 years of graduate school, 6 months of geographic transiency, and 6 weeks into life in a new city, that it was time to “get back into shape”. (Added context: The months prior to starting grad school in the fall of 2016 were some of my strongest ever, in terms of both literal muscle and rock climbing ability, driven by the type of motivation only the combination of a personal trainer and break-up induced trauma can induce). January 2nd, 2020: I immediately jumped into a kettlebell class at the climbing gym to which I was a nearly anointed member. While difficult after not having touched a weight in years, nothing seemed amiss during the class other than the seeming impossibility of doing as many crunches (ew, why were we doing those) as were demanded by the peppy instructor. The trouble would start a week or so later, on the snowy descent of Grandeur Peak, where a slight hitch in my step and discomfort in the front of my hip would end up progressing to a full limp and excruciating pain with somewhere around half of the descent still to go. It is, of course, impossible to say whether each of these activities alone would have caused the same outcome or there was something particularly fucked about their combination and quick succession. Either way, the damage was done. 

Said damage (i.e., constant pain) would go on for enough days that I, lacking a primary care doctor in my new locale, would have to chance an urgent care visit for a diagnosis. The sensations were strange; a deep and sometimes throbbing ache in my upper groin that followed the crease of my hip upwards. A physical exam showed no hernia (a fact proven untrue much later under ultrasonic examination) and I was told I had a “sprained gut sack” (a fake diagnosis disproven much sooner), and to rest for two weeks and take ibuprofen. Flash forward those few weeks of rest with little to no improvement and I’m off to see a Physical Therapist, at a clinic I had been referred (heh) to through a number of outdoorsy folks.  

There, within mere minutes of entering, I was forced to radically shift a world view in which you treat pain where it is occurring because duh. Again, I had been given the name of this clinic and so, frankly, had done very little to no research into what I was specifically getting into. I had been to a number of PTs and clinics before as an injury prone asshole (see: sprained wrist, AC joint issues, fractured ankle) and I thought I knew what to expect. My lovely PT, Amy - and the whole clinic in fact - followed something new to me, called the Mckenzie Method: “The McKenzie Method is a biopsychosocial system of musculoskeletal care emphasizing patient empowerment and self-treatment. This system of diagnosis and patient management applies to acute, subacute and chronic conditions of the spine and extremities.” Once again, let me translate medicalese for you - at its simplest level, and just stating from my own experience, this methodology boils down to “rule out the spine first, you idiot.” To expand beyond that, it involves identifying the source of your pain before treating the symptoms, and then finding a repeated motion at that source which then, seemingly through witchcraft, alleviates your original, referred symptoms. 

After explaining to me that a “gut sack” is not a real thing and therefore cannot be sprained (thanks urgent care), Amy had me demonstrate my range of motion. She quickly identified something I had known, at least partially, but had done almost nothing about: my back was roughly as solid as brick and approximately as flat as a sheet of plywood. Whatever arch should have been present had been erased, likely due to the usual suspects of modern Millenial living: sitting too much at a desk, stretching only when forced to once a quarter, and having generally terrible posture. The repeated motion that immediately alleviated the worst of my aching has a cute shorthand - REIL, or repeated extension in lying. If you’ve done an upward facing dog or cobra pose in a yoga class you’ve done this basic motion. I was, to put it extremely lightly, bewildered. I distinctly remember Amy opening up one of the McKenzie books and showing me an illustration of common referral patterns; while many folks often feel pain through the backs of their legs when the origin point is the lumbar (lower) spine, mine appeared to refer to the front of my body instead.  Through this repeated motion, we focused on “centralization”, meaning can we get the sensation to return to whence it came? Movements that caused my sensation of pain to move closer to the lumbar spine were good; conversely, anything that “peripheralized” pain was bad (for example, if the pain moved further down my leg that was a sign that the motion wasn’t beneficial). When the original movement stops centralizing or diminishing sensation, you adjust in some way. In my case, we uncovered that my cement back required lots of pressure to fully abolish symptoms.  

Now if you’re reading this all with a hefty dose of raised eyebrow skepticism, I do not blame you one bit. I am still following this method more than two years later and, despite successfully treating more than one ailment through its teachings, I still find myself feeling often like there’s a leap of faith happening in every appointment or every stretch. I am allowing myself to believe that there’s room for more beneath the surface when it comes to how I experience my body, and that I have the ability to influence what happens in the parts of my anatomy that are too complicated to comprehend fully. You may have caught the word “biopsychosocial” in the McKenzie Method’s definition of itself; in my experience, the psychosocial part is just as, if not more, important than the bio stuff. We talk often in sessions about what might be affecting how my body is existing in the real world outside the exam room - stressors, sickness, travel…And in that biopsychosocial process, I am (slowly) building a deeper and more compassionate relationship with my body in an attempt to rewire my instincts to shame, blame, and make a martyr of my own flesh and bones. It is not unlike my experience in talk therapy in that way; both require the metaphorical (sometimes literal) looking of oneself in the eye and acknowledging that sometimes we must thank the things that have protected us from harm - and then be able to let go of that which is no longer serving us. Often our body is compensating for an injury or deficiency by throwing some other muscles at a problem, but eventually you have to address the source - even if it means feeling the pain your body has been protecting you from. Sometimes emotional pain is referred as well, the deep tendrils of trauma flicking out at seemingly unrelated situations until you let yourself adjust the frame or the aperture. 

In my time in physical therapy over the last 2+ years, I’ve been able to start building a map of my own personal referral patterns. Though there are some common pathways, bodies are unique. Past injuries can sear deep roads in the brain that linger long after the muscle has healed - and these roads often cross. Working on some shoulder pain from climbing, for example, led us back to my neck and cervical spine. My exercise in that case: retract neck by pressing on my chin, then extend to end range by looking up and back. Repeat (and repeat and repeat until the pain abates). But it turned out there was more going on in my neck as well, leading to headaches shooting up from my neck - so add a touch of flexion before the extension to the mix as well. All that neck work led us to the jaw, and treating the tinnitus that was coming up too (left ear, for me, came from right jaw which required some very specific wiggling). When my chest is tight, I focus on thoracic extension - a week of poor posture can cause so much stiffness in my sternum I feel short of breath. Both my right knee and right hip act up after hiking and tumbling, respectively; both come from the lumbar but in different ways and require separate but similar motions. For most of these motions I require the most intense variations - meaning the most angled, the most pressure applied. This might all sound overwhelming to keep track of but, as someone who has been consistently dealing with the nagging injuries that come from preternaturally tight musculature, it has unlocked a deeper understanding of what’s going on in my body. This map lets me tackle what comes up as I continue to do the activities that bring me joy. The diagram of arrows and interconnections are imprinted on my mind in a way that is comforting, not terrifying. 

My goal in writing this post was not to serve as an unpaid spokesperson for the McKenzie Method or simply as an ode to Amy (whom, to be clear, I do adore professionally and personally and deserves all of your business if you want to try this method out). Besides the usual disclaimers that absolutely none of this should be taken as medical advice, talk to your doctor etc etc, you dear reader may or may not actually respond the same way I did. Bodies are different, remember? Your injuries may or may not actually originate or can be traced back to the spine like many of mine have. Amy has told me stories of patients who seemed to get better only to relapse worse, indicating a different modality is more suitable. I encourage you to research practitioners and methodologies - while I walked into the clinic unknowing that day, in the intervening weeks of my sessions I looked into some of the numerous, peer reviewed studies of McKenzie that have shown positive effects specifically for people suffering from lower back pain.

What I offer to you is not a dictation of how you should or shouldn’t go about treatment; rather, I hope my reflections shed insight into what’s possible when we let ourselves imagine a body that defies your own instincts or perhaps conventional logic. I encourage us all to be in wonder just a bit more often of what evolution hath wrought and let that wonder replace any limiting or self defeating narratives of what we are capable of, ones that we are so often told and then repeat to ourselves unendingly. (I could go on a whole other rant about the stories told about what queer bodies are capable of or not, but that’s a rant for another time and blog post).

In the meantime, I beg you to give a little love to your spine. (When was the last time you arched it?) It will thank you. I promise.