Danny Dinh

My treatment philosophy is guided by 2 core principles: 1. I optimize my patients' recovery time frame as much as possible. 2. I empower my patients to be as independent in their rehab as much as pos...

The Power of the Spine: Explaining Referred Pain

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Danny Dinh
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Do you have shoulder pain that isn’t improving despite multiple visits to different physical therapists, chiropractors, and other specialists?

Does your elbow just feel different from the sprains that you’ve had in the past?

Does your knee pain come even when you’re sitting and not doing anything?

Does your wrist pain seem to change day by day for no reason?

Do you feel numbness and tingling near your knee? 

If you answered yes to any of these questions, you may have what is known as referred pain.

What is referred pain?

To understand referred pain, we need a minimum understanding of our anatomy. Nerves are cable-like bundles of fibers that transmit electrical impulses that link our nervous system to our muscles, organs, ligaments, etc. Those electrical impulses can either be sent from the brain to our tissues or from our tissues to our brain.

Referred pain is when the pain you feel in one part of your body is actually caused by irritation at another part of your body. When there is an irritation or injury at a nerve, usually in the spinal cord, it is possible for the brain to interpret the signal as pain in the referred-to area.

Typically, the nerves originating from your neck and upper back are responsible for sensation in your arms and face, whereas the nerves originating from your mid to lower back are responsible for sensation in your genitals and legs.

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The most known example of referred pain is a heart attack. Someone suffering from a heart attack may feel pain in their left hand, jaw, teeth, or shoulders. Referred pain occurs much more commonly in conditions other than heart attacks, however, and can often masquerade as normal-seeming musculoskeletal pain (tendinitis, bursitis, muscle strains, etc.).

Let’s use the analogy of the wi-fi router. If your router is malfunctioning, it may not be sending wi-fi to your bedroom. Your bedroom would be feeling the symptoms of the malfunctioning, but it would be unproductive to try to restore wi-fi by staying in your room, no matter how much time you spend in there. You would only get to the root of the problem by going to the living room, where your router is, and diagnosing the issue!

This is why, as a physical therapist, it is so important for me to recognize the signs that my patients have referred pain, so that we may treat the right area to obtain the results we want. 

How likely am I to have referred pain?

All of this may sound quite strange. I don’t blame you. You come here trying to get rid of your knee or wrist or shoulder pain, and here I am suggesting that we have to look at your spine!

But referred pain is actually more common than you may believe. In a prospective cohort study conducted in 2020, “A study exploring the prevalence of Extremity Pain of Spinal Source (EXPOSS)”, which evaluated 369 patients with pain not originating from a trauma, 43.5% had a spinal source of symptoms.

This number was greatest in the hip, at 71%, and in the forearm, at 83%! Now, we have to keep in mind that the study was not randomized and that it is but one study, but it is still enough to make us consider the spine as a possible source of pain in the arm and leg.

What could indicate that I have referred pain?

Here are 6 signs to look out for that could indicate that your pain may be referred from the spine:

  1. You experience numbness, tingling, or heat near or at your usual pain location.
  2. You have a history of neck, upper back, or lower back pain or stiffness.
  3. You experience the same pain on both sides of your body (e.g.: both knees).
  4. Your pain is vague and moves around. It does not stay at one particular spot and/or you can never pinpoint exactly where it is.
  5. Your pain had an insidious onset, meaning that it did not originate from any accident or specific trauma. It developed gradually over the years, or perhaps you one day just woke up with it.
  6. Your pain is variable: you can spend days and maybe even weeks at a time with no pain, and then it will suddenly come back for no apparent reason. Or perhaps you do feel the pain every day, but it can vary from a 1/10 to a 6/10 without being provoked.

Not having any signs does not necessarily rule out referred pain, just as how having all 5 doesn't mean you definitely have referred pain. It is simply a way of measuring the odds.

But how do I know for sure that my pain is referred from my spine?

When hypothesizing that my patient’s pain could be originating from their back or neck, I only confirm my hypothesis once we observe a significant reduction in the pain over a period of 2 days or more by performing a single spine exercise.

In this section, I will walk you through a "cause and effect assessment" to help you see if your pain may be referred.

  1. Baseline collection: The first and most important step of the cause and effect assessment is collecting baselines. A baseline is any movement or position that consistently reproduce your pain. This could be as simple as raising your arms overhead, squeezing your fist, lifting something object, straightening your knee, walking, or getting up from a chair. Think about all the little activities that provoke your pain on a daily basis, those will typically be good baselines!
  2. Trying a spine exercise: Now, perform the spine exercise. Aim for 15-20 repetitions of one of the following exercises: neck retractions+extensions if your pain is anywhere in your arm (shoulder, elbow, forearm, wrist, hand), or cobras if your pain is anywhere in your leg (hip, thigh, knee, shin, ankle, foot). Refer to the pictures below.
  3. Re-checking baseline: Now, re-perform the movements you chose in step #1 as your baselines. Try to analyze any change in each of them: are you better, worse, or did nothing change? If you are unsure, feel free to do another set of 15-20 repetitions of the spine exercise before checking again.
  4. Continuing the exercise: Continue doing the spine exercise at a frequency of 15 repetitions every 2 hours for the next 48 hours. If the pain in your arm or leg feels significantly better or worse following the spine exercise, you have confirmed that your pain is referred from your spine! If your pain is worse, stop doing the spine exercise. If it feels better, you can continue it to see if you can get a full resolution.

These 2 spinal exercises are 2 common reductive exercises for patients experiencing pain referred from their spine, but they are by no means exhaustive: the spine moves in many other directions! Even if you do not experience any change in your symptoms with this simple cause and effect assessment, your pain may still be referred from your spine.

Neck retraction+extension, to be performed if your pain is anywhere in your arm or shoulderblade<br>
Neck retraction+extension, to be performed if your pain is anywhere in your arm or shoulderblade
Cobras, to be performed if your pain is in your leg/thigh/hip/knee/ankle/foot<br>
Cobras, to be performed if your pain is in your leg/thigh/hip/knee/ankle/foot

How do I treat referred pain?

The way I treat referred pain begins the same way I treat any issue: with an interview. By attentively listening to your stories and asking specific questions, I aim to see if the signs of referred pain are present. These include the 6 cardinal signs of referred pain discussed previously as well as a host of other clues in your pain history.

Then, depending on whether or not I judge that there is a likelihood that your pain is referred from your spine, I would conduct a spinal screen and put you through a cause and effect assessment very similar to the one I guided you through.

If the referred pain ends up being confirmed (a spinal movement decreases or worsens your usual pain), I would spend time optimizing the spinal exercise to achieve full resolution of symptoms.

How long does it take to treat referred pain?

This depends greatly on the patient. In the following section, you’ll see 3 examples of patients I recently treated for referred pain and how long it took for them to achieve full abolishment of symptoms. Typically, once your pain is confirmed to be spinal in source and a reductive movement is found, full resolution can be expected within 2 weeks.

My experience treating patients with referred pain

As a physical therapist, I encounter patients with referred pain multiple times per week. Here are some recent notable examples and their symptomatic presentation, so that you may see if you see something of yourself in them:

Knee pain: Mr. P. experienced pain in the inner part of his left knee, which started a week ago after a session at the gym. The pain sometimes goes to his right knee as well but is mostly in the left knee. It is most experienced when standing and walking for hours at a time. He also has had low back pain for many years.

After a week of performing repeated lumbar flexions (bending forward), the pain in his back and knees disappeared completely.

Lumbar flexions performed by Mr. P.<br>
Lumbar flexions performed by Mr. P.

Wrist pain: Ms. G. started having right wrist pain 5 months ago, which suddenly appeared one morning despite not having done anything particular with it. This pain could spread to her whole right palm and be provoked whenever she held anything heavy with it and after using a computer mouse for over 10 minutes. This was a major limitation for her, as she was working as a programmer. This really impacted her performance at work since she had to take breaks every half hour. A physical therapist she had seen had told her that she had wrist tendinitis, and so she spent 2 months doing wrist strengthening exercises and experimenting with using different types of computer mice.

After 3 days of performing a neck exercise, her pain had gone down by 40%. After adding some manual therapy treatments and progressing the previous neck exercise, her pain was completely gone after a week of treatment.

Neck retraction+extension performed by Ms. G.<br>
Neck retraction+extension performed by Ms. G.

Shoulder pain: Ms. S. found me through a friend in common. She had a severe presentation: her right shoulder pain had appeared 3 years ago for no specific reason, and it had grown progressively worse since the start of the pandemic. It was provoked whenever she cleaned her apartment, held anything heavier than a small book, wrote, drew, and worked out. 

Not only had this pain forced her to cut down her hours as a graphic designer, but it was also slowly eroding away at her identity: the activities that had once given her an escape had become tormentors that reminded her of her shoulder pain.

Ms. S. did not experience as quick a resolution as Mr. P. and Ms. G. Similar to Mrs. O., her rehab had a few ups and downs. 

Nonetheless, following five treatment sessions over a month, we not only confirmed the spinal origin of her chronic shoulder pain, but it had completely abolished with an upper back exercise.

Thoracic extensions performed by Ms. S.<br>
Thoracic extensions performed by Ms. S.

Moving forward

If any of the information or stories in this article speaks to you, feel free to check out my profile to read more of my articles or to book a 1-hour private room evaluation with me.

If you’d like to discuss any of the points raised in this article in more detail, I would love to speak to you. You can contact me by email at dannydinh.physio@gmail.com or by phone at 438-801-0417. I currently offer free no-strings-attached 15-minute phone call sessions to discuss how I can best assist you.

Further reading

Here are some suggestions of articles I have written recently, organized by topics.

An in-depth explanation of my physiotherapy philosophy: Part 1, Part 2

Neck pain: a case study, answering common questions from patients

Low back pain & sciatica: case study 1, case study 2

Knee pain: case study 1

Shoulder pain: case study 1

An explanation of referred pain

Why choose telerehabilitation

7 reasons why I love my profession

Images courtesy of: Atlanta Spine Institute, iStock, Spinal Cord Injury BC, Physiopedia, Exhale Pilates London, Neck Solutions, Spine Universe, 

Disclaimer: All stories published on paperminds are educational in nature and do not represent medical advice. Stories are not a substitute for an assessment by a licensed health professional. You can book a professional directly via paperminds to get a more accurate picture of your problem.

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