The Visceral Connections To Foot And Ankle Pain
On this week’s episode of the Unreal Results podcast, I’m still going deep into the foot and ankle but this time it’s all about connections to the viscera. Following up on last week's discussion about the role of nerves, this week I explore how referrals from the intestines and urogenital system can manifest as pain and dysfunction in your ankles and feet. You’ll hear specifics regarding lower leg regions you can’t forget about including the proximal tib-fib joint and how the LTAP™ can help you identify the root cause of your clients’ pain. Some other topics that you’ll hear are how hormonal changes, especially in women, can impact foot structure, and why a holistic, whole-body approach is key to achieving lasting results. There are tons of valuable resources mentioned in this episode that you won’t want to miss when it comes to treating the foot and ankle complex.
Resources Mentioned In This Episode
Episode 97: A Neural Approach To Treating The Ankle Joint
Episode 96: Understanding Foot Pain Through The Lifespan: Beyond Orthopedics
Episode 76: The Hidden Signs: Detecting Red Flags & Visceral Referrals
Episode 61: The Lung Connection To Foot Pain You Didn't Know About
Episode 54: A Better Way To Assess The SI Joint
Episode 45: The Kidneys - Visceral Connections To Movement
Episode 8: Unlocking The Fibula
Episode 6: The Mysterious, Misunderstood, and Mistreated SI Joint
Exercise Video: Obturator Nerve Glide
Learn the LTAP™ In-Person in one of my upcoming courses
Considering the viscera as a source of musculoskeletal pain and dysfunction is a great way to ensure a more true whole body approach to care, however it can be a bit overwhelming on where to start, which is exactly why I created the Visceral Referral Cheat Sheet. This FREE download will help you to learn the most common visceral referral patterns affecting the musculoskeletal system. Download it at www.unrealresultspod.com
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Anna Hartman: Hey there, and welcome. I'm Anna Hartman, and this is Unreal Results, a podcast where I help you get better outcomes and gain the confidence that you can help anyone, even the most complex cases. Join me as I teach about the influence of the visceral organs and the nervous system on movement, pain, and injuries, all while shifting the paradigm of what whole body assessment and treatment really looks like.
I'm glad you're here. Let's dive in.
Hello! Welcome to another episode of the Unreal Results podcast. I just changed the position of my camera because the lighting has changed in here and I'm like, oh you can see the reflection in the mirror to my living room. That's kind of funny. Um, anyways, uh, welcome back! Uh, this episode we are talking about the foot.
yeah, we're talking about the foot and ankle still, uh, last week we talked about the nerves, things, neuro, neuro, uh, considerations. And this week we're talking more about the viscera and some of this will be a review. Like I've talked about this on other podcast episodes, um, so I just want to talk a little bit about.
So, you know, especially since we have that whole long episode diving in on the nerves, I want to talk about how the viscera also relates to the nerves. And this is again why having the LTAP is important because we want to know is the, is the, is the problem, right, we're always trying to know is the problem visceral, neural, or the musculoskeletal itself.
Um, basically, like, is it strategic or is it structural? And if it's nerve, we want to know, is it nerve because the viscera is irritated the nerve or because a visceral message is being relayed through the nerve or is it the nerve itself for its own reasons of, you know, Something interfering with the message somewhere between the spinal cord or the brain even and the periphery.
So um, I was thinking too, I'm like, Oh, there's not. I'm, I will like, after this, at one point, double check my notes, especially as I'm writing the foot and ankle course. I'll double check my notes, but I don't actually think there are visceral referrals to the ankle joint. I don't really recall them. There's visceral referrals to the foot, there's visceral referrals to the knee, there's visceral referrals to the tib fib joint, proximal tib fib joint, which you could argue is part of the ankle joint, so that would be your ankle referral.
Um, there's visceral referrals to the hip, to the SI joint, to the spine, to the shoulder. To the hand, not to the elbow, uh, to the neck. Uh, so, but yeah, I don't recall learning any specifically to the ankle. So, um, there's that. But, a little bit too, we talked about, I'll have Joe link it in the show notes, I believe it was the episode about red flags.
We talked about the difference between Um, visceral referrals and musculoskeletal pain or movement dysfunction driven by visceral issues or visceral, visceral protective patterns, which may or may not be the same as the visceral referral. So the most common example of visceral referrals, the one that we all know the best is going to be like a heart attack.
We all know that when you're having a heart attack, more than likely you're going to have maybe jaw, upper back, left sided arm issues. Um, we know that, like that is like very well known visceral pain. It's becoming more well known visceral pain after pelvic surgery to have shoulder pain as well.
It's also becoming more common knowledge that, um, frozen shoulder has a hormonal connection, which is, I hate to break it to you, a visceral referral, but, um, For the most part, we kind of, oh, the other really common visceral referral we know, kidneys and low back. We all, we know when you have a kidney infection, you probably have low back pain, right?
So these are already like some differentials that we know. The visceral referral cheat sheet that I have, which is that free download I have, this is all of those common visceral referrals. Different than sometimes what comes up on our exam. With the locator test assessment protocol or with general listening of the driver of the person's musculoskeletal pain, movement, dysfunction, injury, whatever, right?
This is why it's not so easy. If all pain was just a visceral referral, I wouldn't have to teach you how to figure out what viscera was. I would just give you the list. But it's not like that. So I'm going to give you the list for the foot and you can kind of extrapolate it to the ankle. I'm going to give it to you for the foot and I'm going to give it to you for the proximal tib fib joint.
But then we're going to talk about why those are the referrals. That's where we come back to the nervous system. And then we're going to talk about some examples of when it's other visceral organs, how to know when it is, and Where to go from there. So when it comes to specific visceral referrals, we'll start at the top.
The proximal tib fib joint, we talked about in the last, um, episode about how this though is also part of the knee joint. It's also part of the ankle joint, the fibula, um, we'll have a whole episode that Joe will link in the show notes, also called Unlock. The fibula to learn more about this, but the most commonly when you have a, um, issue, a like issue at the proximal tib fib joint, it is visceral.
It is driven by the urogenital organs. So the urogenital organs are going to be the bladder, the kidneys, The gonads, right? It's the gonads, if you don't know that term, it's the testes in men, the ovaries in women, um, and the uterus and the prostate. So those are all our urogenital organs. Um, the, and associated structures, right?
So I guess that would include, um, The entirety of the organs, right? So then, the, that's pretty much all it ever is, proximal tib fib, urogenital organs, if there is a visceral connection to it, which it often is.
One of my favorite ways actually to treat it is with an obturator nerve glide and I'll have Joe link that in the show notes too. And the reason why the obturator nerve glide actually works on this proximal tib fib joint is because of that reflexiveness through the urogenital organs because the obturator nerve innervates the peritoneum, specifically the lower part of the peritoneum related to the pelvis and the organs of the pelvis.
So because the obturator nerve from a, from a motor standpoint in the lower extremity has nothing to do with the proximal tip fib joint, zero. It's coming off the wrong, like plexus of nerves. It's on the wrong side of the leg, like it is nothing to do with the proximal tib fib joint. But time after time when someone has a, um, hypomobile proximal tib fib joint, I do an obturator nerve glide on them and it moves.
And so that is that visceral connection to the urogenital organs. Um, in the foot, and we can perhaps extrapolate this up to the ankle. When it's the medial foot, it's also your genital organs, so those same organs that I just talked about. And then when it's the lateral foot, it's typically the intestines.
And the intestines can be the colon. All parts of the colon, right? So the rectum, the sigmoid colon, the descending, the transverse, the ascending colon, the cecum. Or it can be the small intestines, the ileum, the jejunum, and even the duodenum. The even could potentially be the more upper part of the GI.
Intestines, the upper part of the duodenum that connects to the stomach, could even be the stomach itself, or this very important ligament, the ligament of trites, which basically reinforces the gastroesophageal sphincter, and then also connects to the duodenal jejunum.
Duodenum jejunum junction, which is the transition between the duodenum and the jejunum of the small intestine. This is right where the root of the mesentery is. Is, and the root of the mesentery is very much associated with the posterior abdominal wall and therefore associated with the nerves to the lum lower extremity, the nerves of the lumbar plexus and the sacral plexus or the lumbosacral plexus.
And so even though it's not traditionally obviously an intestine, it's sort of like, hmm, you could kind of argue that anatomical relationship probably has a driver to it. So, now we're going to talk about, we're going to talk about the parts of those visceral referrals that might result in that pain in the foot, the pain in the, I say pain in the foot or hypomobility.
Or decreased muscular motor control around those structures. Now, one thing that's interesting about the urogenital organs and the medial foot is this also comes from Jean Pierre's observation and many other medical providers observation that as women go through menopause, their arches tend to flatten out.
And we talked about this. a couple episodes ago, I'll have Joe link it in the show notes in case you missed it. It was, uh, called foot pain across the lifespan and I talked about the relationship to the medial foot and the arch and the hormones and perimenopause and lymph congestion and all those things.
And I also talked about the relationship between estrogen and connective tissue and there's a lot of very. stiff connective tissue in our arch that makes up our arch, and so when we start to lose stiffness in that connective tissue, that is often why we see the arches fall. And that is much, very much associated also with those urogenital organs because the uterus and the ovaries are very much, um, responsible for part of what is responsible for, um, our hormonal
production, right? They're not, it's not the sole piece of it, but there is, those are also considered endocrine organs. And so they do play a role in that. So that really is a big driver of that. Now, if we also look at the medial foot, um, the medial foot, the plantar surface is going to be innervated by the medial and lateral plantar nerves.
Sorry, the medial plantar nerve, the lateral foot, the lateral plantar nerve. But the plantar nerves in general come from their branches of the tibial nerve. And so the tibial nerve, you know, goes, we trace it back up, goes tibial nerve, turns into sciatic nerve, turns into lumbosacral plexus, sorry, lumbosacral trunk, turns into the roots of the lower lumbar plexus and upper sacral plexus.
So, um, This makes sense then why the urogenital organs would influence that medial side of the foot. Because the urogenital organs living inside the pelvis, for the most part, they are in very close relationship with the lumbosacral nerves. Especially the sacral. And the lower part of the right, the lumbosacral trunk sort of area there.
And so any irritation, excess fluid, pelvic congestion, vascular congestion in that area is going to sensitize and irritate those nerves. And then you can really get pain and dysfunction anywhere in the lower leg, but oftentimes our foot takes the brunt of it. So, um, The intestines, when it comes to the lateral foot, how does that relate?
So we already know lateral foot on the plantar surface is lateral plantar nerve. We already just talked about it. Lateral plantar nerve, part of the tibial nerve, part of the sciatic nerve, part of the lumbosacral trunk and the lower lumbar, upper sacral plexus. Right? And those intestines, well, where are our intestines?
We have a lot of our intestines that live within the pelvis as well. The rectum, the sigmoid colon, and the cecum are all in the pelvis. And then the small intestine loops can also be within the pelvis.
There's a lot of them. And then like I said before, the root of the mesentery is associated with that poster abdominal wall, that posterior abdominal wall fascia, which is very much related to the peritoneum and the, and the peritoneum of the pelvis. And so you'll have that same sort of relationship there.
Fluid balance is very much associated with within the mesentery of the mesenteric root. And we talked about that in two weeks ago on the podcast, the, uh, about the foot pain across the lifespan and how it drives such common like vascular and lymphatic congestion in the lower extremity, which can also be a culprit in foot pain and decreased foot function.
Um. So when we look at the viscerosomatic referrals from those organs, it also gives, um, us some insight to how it could affect the spinal segments and it's basically anywhere from T10 to L2. Any lower than that? T10 to L2. So all of those. So uterus, T10 to L1, bladder, T11 to L2. Gonads T 10 to a 10 T 11 kidneys, T 10, T 11 intestines, T 10 to L1.
Sorry, that was wrong. T 10 to L2. Um, so it's really going to be affecting those at the upper part of the lumbar area. So, and remember too, we talked about in last week's podcast when you talked about the neurological piece, there is. Um, the saphenous nerve is one of the nerves that innervates the ankle joint and the skin of the foot, um, that can relate to foot pain, relate to dysfunction around the foot.
Um, and so that viscerosomatic reflex can also drive an influence through it, right?
mechanical sort of visceral referrals that I'm talking about within the pelvis and the congestion and the irritating the nerves of the lumbosacral plexus. They're not reaching so high up as the branches of the femoral nerve, right? But all the visceral somatic reflexes for those organs lower in the pelvis come from higher up in the spine.
And those are going to relate to a little bit more of the femoral nerve, lumbar plexus type of scenario. So it's going to be more of the, um, saphenous nerve relationship. Um, interesting too, it can, the upper GI part, right? When I talked about the ligament of trites, that relationship between the ligament and trites in the root of the small intestines.
Those viscerosomatic reflexes are going to be higher up, T5 to T9. What's interesting about that is, Jean Pierre Barral reports that when there is kidney issues, there's usually, um, a restriction at T6, and Therefore, that means when there's a proximal tib fib issue, I often see a restriction at T6 as well.
And so that's right smack dab in that viscerosomatic reflex zone of that relationship between the upper GI and the mesenteric root and the posterior abdominal wall, which is going to be related to the fascia of Toldt, which connects or connects. It has a relationship between the intestines and the kidneys.
So often the urogenital organs are very much associated with the intestines too. So they're all, I mean, they're all in the same space, right? That doesn't, that shouldn't come to surprise, but there's some like really main direct connections that you start to see this stuff. And sometimes too, when I've asked, um, some of my teachers about like Jean Pierre's observations over his Um, I have an episode, I'll have Joe link in the show notes on the kidneys as well.
And I discuss my thoughts around, um, Um, the relationship to T6 too, which I think is really interesting, but, um, all this to say, like I said at the beginning, these are the visceral referrals. Sometimes people's foot pain can be driven from a visceral issue, but not at the urogenital organs or the intestines.
Sometimes it can be from the liver. Sometimes it can be from the stomach. Sometimes it can be from the lungs. In fact, I have two episodes. I'll also have Joe link in the show notes that talk about instances in my athletes that two people, two of my athletes both came to me and both came up with their lung being the driver of their foot pain.
And I treated the lung and then their foot pain was better. And so it is often not what you assume it is. And this is again, the argument for an assessment like the locator test assessment protocol or general listening to be able to tell you where to go and what the issue is. And then to be curious at how it relates to the orthopedics, biomechanics, the patient's complaint of pain or dysfunction or injury or whatever it may be.
So, the simplest way to do it, even if you're not familiar with the LTAP, and I've shared this in episodes about the, um, about the LTAP and about the SI joint, but the simplest way to go about it is to check their SI joint mobility. And if there is a hypomobility, no matter how you test it, you visualize it in gait, you test it with a march test, you test it with a, um, supine, like actual glide of the ilium on the, like the innominate on the sacrum, or whatever other way, as long as it's not in prone, any way but prone, and you have the patient hold their breath, just a gentle breath hold, not like the huge deep breath, just to take a sip of air in and hold it, and then you retest their SI joint mobility.
If it changes, if it goes from hypomobile to all of a sudden mobile. If it goes from not moving at all to moving even just a little bit, that means that the patient has a protective pattern above the pelvis. It's either visceral or central nervous system. And so you should consider visceral stuff versus if they have a hypomobile SI joint and you do a breath hold and it doesn't change, then you should go to the peripheral neural entrapments that we covered last week.
That's how simple they can be. That is the basis of the LTAP. That's the first test of the Locator Test Assessment Protocol. I'll have Joe, like I said, link the episode about the SI joint mobility and an SI joint test in the show notes. So because if that blew your mind, then welcome, you're probably new ish here.
But it's a really quick way to at least delineate, is this a peripheral issue or a central issue? Still don't know exactly where to go, right? Because I just told you it could be. Any part of the intestines, it could be the kidneys, it could be the bladder, it could be the uterus, it could be the ovaries, it could be the testes, or it could be something completely different, like the lungs or the pericardium, or the liver, or the dura in the meninges and the cranium, or the brain itself.
So many options, but at least we can narrow down that it's not in the leg or we can narrow down that it is in the leg and we get to ignore all that other stuff. So
it's very enlightening. The cool thing too about all this stuff, whether we're taking a visceral approach or a neural approach or obviously when you're doing one, you're doing kind of both, um, no matter approach you're doing, when you. Um, use this whole organism perspective, this whole organism paradigm, lens of view, whatever you want to call it, model.
You're setting yourself up for treatment that sticks. A more easy way to increase mobility or improve strength and work on the things that you know matter from a biomechanical standpoint. I'm not arguing that there might be a structural mobility issue, right? I worked on a basketball player the other day and he had a history of an ankle surgery, like a scope of his ankle to remove a bone spur and his talocrural joint is super friggin stiff.
I did a bunch of stuff and it never really changed. So that tells me that it's actually structurally the joint itself, but sometimes it, most of the time it's not, it's most of the time, it is a reflexive hypomobility, just like we see with the SI joint. And so by figuring out what is causing that hypomobility, you make it easier on yourself to make changes in the body and then you can do, go and do the strengthening exercises that they need to reinforce good movement and strength and tissue quality and whatever else you think they need to have in order to prevent future injury.
In the place that hurts or future places and to improve their overall function. I'm not saying to throw out all the stuff, you know, and throw out all the biomechanics and the musculoskeletal system thing. I am saying when you look at it from a whole organism standpoint, everything actually makes it easier to work with someone.
It makes results come faster and easier. And sometimes even, things that look weak and need strengthening exercises don't actually need it. And this is why the nervous system sometimes feels like magic is because that's how our bodies operate, right? Going back to last episode, I talked about like how pediatric PTs get it.
They understand how the sensory system has driven our motor development and our movement patterns and our, like the way we are in our bodies from the very beginning. That has always been true. So some people when they see some of this stuff done on the internet and classes, or, you know, they want to like poo poo it, they're like, Oh, it's a nervous system reaction, a sensory thing.
It won't be long lasting. First of all, there's no way to know that. And second of all is like, yeah, that's how it's been since the beginning. We are sensory beings. We have way more sensory nerves, way more sensory receptors in our body than we do motor. We have always been sensory beings and we will always adjust our output.
Our output being movement, output being pain, in response to the information going in. So this is why so many joint mobility, hypomobility things are all of a sudden not hypomobile when you address different areas of the body. You're not doing magic. You're simply reflexively changing a strategic hypomobility.
You're changing the output. This doesn't make you a snake oil salesman, right? This doesn't mean you're. like, not going to get long lasting results. This means you're going to get good results and you're going to help your people in less sessions. So anyways, that's a shorter episode for today, but, um, more links to other episodes that you might want to listen to in regards to all this visceral information.
And, um, like I said, I'm very excited to get this foot and ankle course out. I think it's going to be great. The more I sort of like write out my thoughts and notes and where I want to go with it, the more excited I get about it. And I hope I can tell you a date of launch soon. Thank you for being here.
Thank you for being patient. We'll see you next time.