Upcoming Events


Sunday, January 20, 2013
Is it Myoskeletal or Visceral Pain?

What is referred pain? Referred pain is pain perceived at a location other than the site of the painful stimulus. An example is the case of ischemia brought on by a myocardial infarction(heart attack), where pain is often felt in the neck, shoulders, ,jaw, and back rather than in the chest, the site of the injury.[3]

When a client presents with pain in the shoulder coming up to the neck but only on the right side and,the muscles are hypotonic and it looks like there is no muscular problem. No matter what you do you can’t help them. They also have history of digestive upset. Your first thought is .pain in the shoulder indicates injury or disease to the muscles or tendons that affect the shoulder, such as the subacromial bursa or a rotator cuff tendon problem.[1] Visceral pain would be suspect especially if you do some testing to find that none of the structures are referring pain..

If we always look at musculoskeletal pain as part of the picture and we miss the fact that the client has digestive or kidney problems as well, we may overlook the referral pain from visceral problems such as the pain referred from the kidney, gall bladder or liver. Another interesting peculiarity of visceral pain is the fact that it is often felt in places remote from the location of the affected organ. This is known as 'referred pain' and it is often a very useful tool to diagnose diseases of internal organs.[4]

It is unlikely but possible that  shoulder, low back or mid thoracic pain is a sign of something injurious happening in one of the visceral organs, gallbladder, stomach, spleen, lungs, or pericardial sac (the connective tissue bag containing the heart). Interesting isn’t it? Conditions as diverse as liver abscesses, gallstones, gastric ulcers, splenic rupture, pneumonia, and pericarditis can all cause shoulder pain. How is that possible?[1]
Neuroscientists still don't know precisely which anatomical connections are responsible for referred pain, but the prevailing explanation explains it pretty well. Referred pain happens when nerve fibers from regions of high sensory input ,such as the skin, and nerve fibers from regions of normally low sensory input  such as the internal organs, happen to converge on the same levels of the spinal cord. The best known example is pain experienced during a heart attack. Nerves from damaged heart tissue convey pain signals to spinal cord levels T1-T4 on the left side, which happen to be the same levels that receive sensation from the left side of the chest and part of the left arm or even the jaw. The brain isn't used to receiving such strong signals from the heart, so it interprets them as pain in the chest and left arm or jaw.

Visceral pain shows peculiarities that make it very different from pain affecting the somatic organs (the skin, muscles, joints and bones). For instance, not all internal organs are sensitive to pain and some can be damaged quite extensively without the person feeling a thing. Many diseases of the liver, the lungs or the kidneys are completely painless and the only symptoms felt by the patient are those derived from the abnormal functioning of these organs[4]
Pain receptors in the brain don’t have the same connection with organs that they do with the muscles ( diaphragm.)[1]

So how exactly does the gall bladder and or liver refer to cause shoulder pain? All of organs bump up against the diaphragm, The diaphragm is innervated by two phrenic nerves (left and right), which emerge from spinal cord levels C3, C4, and C5  ( “remember these spinal cord levels using the mnemonic, "C3, 4, 5 keeps the diaphragm alive"). The phrenic nerves carry both motor and sensory impulses, so they make the diaphragm move and they convey sensation from the diaphragm to the central nervous system.[1]
For example, because the bladder is located in the low back, an infection in this organ may cause referred pain to the lumbar area. Other examples include but are not limited to:

the gallbladder may refer pain to the shoulderblade

the pancreas may refer pain to the back

the appendix may refer pain to the umbilical area

the heart may refer pain to the left chest, shoulder and jaw.[4]

Most of the time there isn't any sensation to convey from the diaphragm, But if a nearby organ gets sick, it may irritate the diaphragm, and then sensory fibers of one of the phrenic nerves are flooded with pain signals that travel to the spinal cord (at C3-C5). It turns out that C3 and C4 don't just keep the diaphragm alive; neurons at these two spinal cord levels also receive sensation from the shoulders (via the supraclavicular nerves). So when pain neurons at C3 and C4 sound the alarm, the brain refers the pain to t the shoulder. As massage therapists we always look at pain from a myoskeletal view point,usually that's a good assumption, but sometimes it's wrong.[1]
Looking at our complete picture of the client from the intake paperwork we may notice that there are digestive problems or kidney and bladder problems. If they are coupled with muscular pain that corresponds with visceral pain we may want to refer them to the doctor.

Keep in mind that we don’t diagnose just suggest to the client that they see their doctor and if you are not helping them let them know that and let them make the decision to come to see you for further treatment or not.

Another example that seems bizarre until you know the anatomy is disease in the stomach causing pain between the shoulder blades. Gastric cancer, a relatively aggressive and often incurable disease unless it's caught early can refer to the area of the rhomboids, or mid back. Some of the nerve fibers to the stomach;:specifically, visceral afferent nerve fibers that travel in the greater splanchnic nerve, convey pain signals to the same spinal cord levels (especially T5 and T6) that receive pain signals from the skin between the shoulder blades.[1]

 I am not suggesting that we send our clients off to the doctor at the first sign of pain that “could be” visceral pain. I am suggesting that we look more closely at the whole intake and if a client has pain in referral patterns that could be from visceral pain and we have other evidence such as complaint of digestive problems or prior kidney or bladder problems we should suggest that they see their doctor, especially if they are not getting better or the muscles are not hypertonic.

I hope you will check out the chart on the You Tube video.

Aurora Green


1. http://anatomynotes.blogspot.com/2006/10/referred-pain.html Dr Brad


3. http://en.wikipedia.org/wiki/Referred_pain

4 http://www.wellcome.ac.uk/en/pain/microsite/science3.html

5. http://www.youtube.com/watch?v=VHdGrkqkT7M

Posted by: Aurora Green @ 12:00:00 am 
blog comments powered by Disqus