“I Think I Hurt My ___”: You Aren’t Feeling What You Think You’re Feeling

We are often led to believe that our ability to objectively experience and measure our world through our senses is accurate. This can be heard in the conventional saying that “seeing is believing.” When applied to our own bodies and musculoskeletal system, we can find ourselves thinking about the things that we feel, either within our bodies (creaking, snapping, tearing, clicking, etc) or by externally through poking with our hands, or with the hands of a trained professional. Some examples of these include sore spots, body landmarks, differences in movements, and alleged trigger points.¹ While the breakdown between perception, sensation, and what’s “real” or not should be saved for another time, the discussion in this article will revolve around physical feelings and the imperfections surrounding them. 

While in physical therapy school, and from my understanding most other medical schools, there is are certain categorizations that are taught when receiving subjective information from a patient; Reports of the feeling of burning fall under nerve type involvement, feelings of crunching or creaking fall under arthritis type involvement, feelings of catching might fall under cartilaginous type involvement and aches might fall under muscle type involvement. The issue that occurs when attempting to practice within this categorization model is that 1) the things that people are feeling are unique to their own reality and are not what someone else might feel and 2) it allows us to fall back into the trap of the biomedical model in which we are trying to relate every symptom that someone feels to a pain generator or something that is physically “wrong”, which is antiquated and harmful. 

The meniscus is a small “C” shaped piece of cartilage in your knees that catches a lot of blame for symptoms. In fact, arthroscopic debridement or “cleaning up” of the knees is the number one most common orthopedic surgery in the USA. In a 2018 study looking at meniscal abnormalities and subjective patient reporting, it found that there was not a strong relationship between the reports that people were giving regard to the classical symptoms of catching and clicking in the knee and meniscal tears.² It states that “presence of self-reported mechanical symptoms has limited utility as an indicator for the presence of meniscal tears” and that “considerable heterogeneity exists with regard to presence of self-reported mechanical symptoms in patients undergoing meniscal surgery” meaning that there are a lot of things that are different regarding symptom reporting before meniscal surgery. This relates back to the previous paragraph when considering the differences in what individual people might come to experience with their knees.

It can be difficult as a person seeking out help from a provider or authority figure to be told that the thing you are feeling might not actually be what is happening. Feelings that normally drive a person to seek help are those that they think are outside of their ability to control, and if those feelings are inaccurate then it is more likely less severe than originally thought. 

The general public is not the only group that has a less than stellar ability to feel and use their x-ray vision so to speak. The high level of trust in medical authorities is part of the reason that there is so much misinformation in the medical and rehab field. Many healthcare providers have a feeling of needing to have an answer to everything that a client or patient asks or is concerned about, rather than saying “I don’t know” or doing what’s called watchful waiting, which means just seeing how things progress. With this feeling of needing to provide information for every little bump and ache that a person perceives, providers using a thought process of “it just makes sense” or “let’s poke on it and see how you feel” can lead down an irreversible rabbit hole of misinformation and guessing.

For those who have sought out medical advice in regard to low back pain, you might be familiar with the examination of what’s called the posterior superior iliac spine, or those little dimples that you have in your low back (see figure below).

A 2016 study asking the question of the reliability of between clinician and repeat clinician palpation for sacroiliac joint bony landmarks revealed that “there is little evidence at this time in support of these contentions with regard to PSIS palpation.”³

While this examination seems simple enough, the conclusion of the study shows that we as trained clinicians also don’t have a great grasp on what we are feeling as well as what to agree on when looking at the same thing. Now, I am not here to say don’t trust the things that your trusted providers are telling you, but there should always be a grain of salt when receiving information as everyone, including us providers, have our own biases. 

There is a movement in the medical, rehab, and training world of needing to know as much as possible. Surely with more information, we can make better decisions and progress/heal quicker than if we were just shooting in the dark, right? This thought process stems back to the body-as-a-machine theory in that if we could just pinpoint the thing of issue, it could all be fixed. There is also an inherent discomfort in uncertainty that many people, patients/clients, and providers alike, strive to avoid. As has been covered in previous articles, the nocebo effect can and does play a large and detrimental role in body status and pain perception. While more information might be an attempt to shed light on a situation, the current evidence is telling us that even with the poking and prodding, we are still shooting in the dark. 

While we might not be able to diagnose something based on how you are feeling inside or what you are feeling when poking around, we are most definitely not shooting in the dark with our confidence in your ability to continue to train. As referenced in “Understanding Pain And Working Out: ‘Should I Continue To Exercise'”, your body is robust and is able to adapt to a very wide range of stimuli. Those sensitive spots that you might be feeling are normal and likely don’t need to be mashed or flossed or rolled out. Accepting that feelings outside of your baseline comfort are part of the process and understanding that the very act of training is making you more resilient every day and it will make training more enjoyable and those unplanned feelings less concerning. 

References:

1. John L. Quintner, Geoffrey M. Bove and Milton L. Cohen. A critical evaluation of the trigger point phenomenon. Rheumatology 2015;54:392 399 doi:10.1093/rheumatology/keu471
2. Cullen KA, Hall MJ, Golosinskiy A. Ambulatory Surgery in the United States, 2006. National health statistics reports; no 11. Revised. Hyattsville, MD: National Center for Health Statistics. 2009.
3. Robert Cooperstein, Michael Hickey. The reliability of palpating the posterior superior iliac spine: a systematic review. 36 J Can Chiropr Assoc 2016; 60(1)