A Clinical Case Study in Sacral Pain & Index of Suspicion
In this episode of the Unreal Results podcast, I walk through a recent clinical case of mine involving a Navy SEAL BUD/S candidate who came in with persistent “back pain.” Once he pointed more specifically to the sacrum, the case immediately changed direction and led us down a very different path involving visceral drivers, kidney irritation, and neurovascular patterns.
I share how location-specific questioning, structured assessment, and developing a strong index of suspicion can uncover connections between the viscera, nervous system, and musculoskeletal system that are easy to miss.
In this episode, you’ll hear:
• Why sacral pain should immediately shift your clinical questioning
• How kidney and urogenital organ irritation can refer pain to the sacrum and knee
• How tools like the LTAP® fit into broader clinical reasoning and assessment
• Why asking the right questions can completely change the direction of treatment
If you’re a health or movement professional interested in improving your diagnostic thinking and getting better outcomes with complex cases, this episode will help you refine how you assess presentations that don’t follow the usual patterns.
Resources & Links Mentioned In This Episode:
Ep. 45: The Kidneys - Visceral Connections To Movement
Ep. 49: Pain On The Sacrum
Ep. 147: Why Expectations Shape Clinical Outcomes
Kidney Regen Session
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 in 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. Hello. Welcome back to another episode of the Unreal Results Podcast. Oh, here we are, another day, another episode. I've been, I mean, in full disclosure, I've been like very unmotivated to work on business stuff. Uh, don't know why. Um. Just, that's the way it goes sometimes. I think for everyone. Well, at least for me, I can't speak for everyone, but, um, yeah.
Um, it's, it is funny 'cause it's not that I don't have a lot to say. I have a lot to say about the industry. I have a lot to say about the body rehab, manual therapy, working with clients, et cetera. It's just, um. Sometimes the constant creation of content for social media and podcasts and email lists and all the things.
It just gets to be a lot. And, uh, yeah, sometimes I'm like, I just wish I could, uh Have, I just wish I could do simpler life and just like, treat patients and like live, live my life. Uh, which I do treat patients a lot and um, there's nothing wrong with that. I love that life. Uh, but then I'm like, ah, but also I have so much to share and I'm out here trying to change the world, trying to change the industry, trying to like.
Get us, get the industry out of this. Like mediocrity the status quo, this missing of the red flag in itself of people not getting better. The red flag of mediocrity. So it's also like as much as I get tired and I'm like lose motivation, I'm also like, well, I can't stop. I don't want to stop. Um. So here we are showing up anyways.
Oh, the, um, funny thing about teaching and about social media. 'cause I mean, at the end of the day, social media, all those things are teaching. Um, and whether we're teaching anyone, fellow clinicians, children, teenagers, college students. Um, our patients, no matter the level of our patients, our family members, the funny thing about teaching is we have to repeat ourselves over and over and over again, and, um, I've talked about this before.
I tie, I, I am blessed with a brain that absorbs information really well and doesn't have to hear it. I don't wanna say it doesn't have to hear it more than once, 'cause I have to hear it more than once too. But like I retain a lot of information once I hear it. I don't need as many repetitions as I think a lot of other people do.
So when I'm teaching. That means sometimes I go to teach something. I'm like, well, I already taught that. Why would I reteach it? And it, it really is like one of those things where it's like, Nope, it's, I gotta reteach it. I gotta say it again. I gotta say it again, again in a different way. I, from a new perspective.
Um, so it's like I can't worry about repeating myself. The podcast, you know, there's, it's been around for a few years now and I've been fairly consistent. I'd say, obviously I miss weeks here and there, but for the most part I've grinded out like a new episode every week for, you know, two, three years. And, um, sometimes I'm like, there's only so much I can talk about.
So inevitably some of the episodes are going to be on topics I already talked about. Um, but I think there's, I, I think it's important to hear. And um, so that's what like today is, and like today's gonna be an episode that I share about a case to get a point across, and I was looking through all of the archive of the past episodes and in 2024, I had two episodes on similar subjects, and I'll make sure that Joe links those in the show notes. But, um, I'm also like, well, this is still important to say. So without further ado, we're gonna talk about how, um, often people, clients come in complaining of back pain. And when you ask them to point to where their back hurts, it's their sacrum.
And more times than not, when someone has pain on their sacrum, it is driven by the viscera and specifically your genital organs at the viscera. So this person specifically came to see me and he is, um, one of my. BUDs, um, candidates. So a Navy SEAL candidate. And, um, he's been having some back pain that he hasn't been able to, you know, uh, train his way out of, or like stretch and mobility wise, this, so one of the reasons I love working with these BUDs guys is 'cause they're just like my athletes in terms of like, they'll do a bunch of things to try to help themselves, um, in addition to see practitioners to try to help them, um, and they don't settle for mediocrity. And so that's exactly what the, what the case is for him. Like he's gone to PT, he's gone to doctors. You know, uh, nothing's really come up. Exercises haven't really helped.
Mobility stuff hasn't helped his mobility's actually great. I looked at him move and I was like, honestly, I could see how somebody could watch you move and be like, you don't have a mobility issue. We're gonna get a little bit more specific. I was like, but uh, yeah, I see how you could go into traditional physical therapy and not get great results and then also not feel like the clinician maybe like is treating you uniquely right? Like probably feels a lot like a cookie cutter type of treatment. And he is like 100%. And then so often, like they give people exercises and these people are already exercising a lot and doing all the strengthening things.
And they're not weak. They're rarely weak. The, the story that clinicians give clients about glute weakness, hip weakness, quad weakness, and core weakness is just that it's a story that is not accurate. So anyways, um, I'm asking him questions, but once he points to where he hurts, that's the first, you know, obviously I'm doing the LTAP on him, right?
The locator test assessment protocol. I'm, I'm seeing where the body's taking me, but also we have to remember that. The locator test assessment protocol, even though it's a really important part of my assessment and it helps me to figure out where to go for treatment and sometimes uncovers deeper drivers to the pain or the injury or whatever's going on, um, it is not like a direct A plus B equals C.
Right. So basically the LTAP is telling me, presenting to me the person's first layer, right? Like I, I like the onion principle. Their shk principle is like, this is the first layer that the body is presenting to me that the body is protecting. And when it's in a protection pattern around something that may or may not be related to the thing that hurts, it's preventing the body from shifting into the self-healing capabilities it has to make the thing that hurts, feel better.
And so, um. You know, so it's like I still need to do my due diligence in being like, what brings you in today? And then before I do treatment where the body's directed me doing a thorough diagnostic, um, exam and questioning on that. And so, you know, that's what I did. So I do the LTAP and the LTAP was taking me to his like.
Right lower leg. And I was like, well, what brings you in today? And he was like, back pain. And I was like, okay, tell me about your back pain. And he pointed to it and I was like, okay, well that's your sacrum, which doesn't mean a difference to you. Like it's still the back of your body, lower down in your torso, still back pain.
But to me, that triggers a whole different series of questions than when they're pointing to their lumbar spine. Or when they're pointing to their mid back or when they're pointing to their leg in like sciatica type pain. Right. So once he pointed to his sacrum, I was like, oh. Okay, there is a visceral driver to this.
Interesting right, that the LTAP actually didn't direct me to his visceral right out of the gate. It directed me to the lower extremity on the right side, which means it's peripheral neurovascular entrapment or the SI joint itself there. And, I did further, uh, you know, using the LTAP. It was not the side joint itself, it was down in his lower leg is where the protection pattern was.
And so I was like, okay, so pain's on your sacrum And I was like, for me, that is a trigger of like, well, this has a visceral driver. Pain on the sacrum always has a visceral driver for men and women. And so I was like, okay. Um. I have some questions for you that are gonna maybe feel a little out of nowhere because maybe nobody's even asked you these things.
I was like, but, and I explained to 'em, I was like, most of the time when we have pain on our sacrum actually is, um, often coming from visceral organs, the urogenital organs. So I'd like to ask you questions about the urogenital organs and the other organs of the pelvis. And so I was like, tell me about your bowel movements.
Tell me about your bowel movements for the last couple months. 'cause I'm like, how long has this been going on for? And he is like, oh, you know, like month and a half or so. And I was like, okay. And I'm, and so we're talking about that and then I'm like, tell me about peeing. Like, you know, are you able to, you know, do you have any pain when you pee?
Are you able to? How frequently do you pee? Um, when you pee, do you feel like you go all the way? Like, are you able to stop? Um, do you have any incontinence issues? And then he, you know, and he was like, oh, actually, yeah, I do. I was like, oh, interesting. Tell me more about that. And so we talked about that, and he was like, actually, so about a month and a half ago, I, I think I passed a kidney stone.
And according to what I read on the internet, like it was exactly the, the feelings of passing a kidney stone and then All of a sudden it was gone. Which is like often like, yeah, when you pass, when you pass a stone, whether it's a kidney stone or a gallstone, once it's passed a lot of the pain and discomfort just goes away.
And so I was like, oh, okay, that's really interesting. And he is like, yeah, now that I say that, like that was right around when this all started and I was like, okay. There you go. And um, in case you didn't listen to one of the last podcast episodes, I'll have Joe link that in the show notes too, like the, um.
Questions that you need to ask people. To set expectations. I, I, I mentioned in that podcast how sometimes when you ask the right questions, the athlete or the client ends up telling you exactly what's going on. This is a really good example of that is I asked the right question and then all of a sudden he was like, oh, shoot.
Yeah. My back pain actually started right after that, and I was like. Isn't that interesting? Okay. So you think you passed a kidney stone and then since then you've had back pain. And then two, as I continue to ask him questions about urogenital organ stuff and leg things, he proceeds to tell me, not only does he has since then has had incontinence, but he is having sensory issues in that area.
Um, erectile issues like. Pain down his leg, numbness, um, temperature regulation issues, like so many more physiological symptoms than I probably would've caught on a normal subjective history. And that's all because of knowing that when someone has pain on their sacrum,, it's almost always driven by the viscera.
Now here's the thing, and I told 'em, I was like, listen, like some of this stuff is very much. Out of my scope and well, not my scope, maybe not my scope. A little bit outta my scope, but definitely out of my wheelhouse. It's definitely outta my wheelhouse. A lot of these more functional complaints and or like physiological complaints.
I am like, I don't know where to start, but here's the thing. They're concerning. Very concerning to me. I was like, I know you didn't think you were coming to me to talk about these things. I'm like, but these are the things that are related to your daily living, your quality of life, and your quality of life through your whole lifespan, not just you getting through BUDs. And he was like, oh yeah, no, I understand. I was like, so I'm gonna, I'm gonna do what I always do. I'm gonna treat you the way that, in the sequence that your body re, you know, presents to me and I'm going to gather all the orthopedic and biomechanical data that I think is, um, maybe making you not feel very good from a performance, a movement standpoint.
And that side of the back pain, and I'm gonna treat the things and I'm gonna see how they change. But at the same time, I'm. I said, I want you to monitor these physiological symptoms, and ideally they start to feel better as we treat where your body's directing me. As we make things happier, as we start knocking out, you know, checking the boxes of all this mechanical stuff, we'll have a con concurrent improvement of these physiological symptoms.
However, if we do not, I was like, this is, I'm like, I would like to. Potentially think about referring you to a pelvic physical therapist or a um, urologist or some sort of doc. You know, like we need to maybe do a little bit further workup, but right now I'm not gonna jump the gun. Nothing is like emergency level of physiological effect.
But I was like, you know, these are not ideal. And could be connected to what's going on. And so it was just a really good example of like, oh, okay, this is, this is gonna take us down a little bit different road potentially than just back pain. Now, what I wanted to like then. Talk about is like, yeah, okay, so what, so, so here's the, you know, like I want to present the case.
That's kind of the backstory. He was also, he's also complains of knee pain, which visceral referral for knee pain is the kidneys. So I'm gonna have Joe link in the show notes, the episode on the kidneys and the episode, um, called Pain on the Sacrum, um, because these both really relate to this, obviously, this case.
And those are the ones that I said that I had recorded in 2024. But anyways, um, so do the LTAP. it directs me to the right lower leg, like, um, proximal tib fib anterior compartment area, and um, which is a big neurovascular entrapment. Interesting enough, the, um, proximal tib fib joint is a, um, osteoarticular.
Um, fixation that often comes with urogenital symptoms. So that tracks, um, so I, I treat there first and um. A couple other spots in his low leg and then that change. That change, you know that that improved the part of the locator test assessment protocol that was directed me there. So I retested some of the orthopedic things that were off his hip mobility, though he can easily, comfortably sit in a full deep squat. His hip mobility was limited on that side in hip flexion and hip internal rotation. His tibia was limited in internal rotation and his ankle, um, was limited in dorsiflexion. And, um, he had, um, he has significant bilateral actual, um, n neural tension in a slump test.
Um. And then in the prone knee bend, which is the femoral nerve Lesague's test, he, um, was uh, had quite a bit of tension there, um, at about 90 degrees of knee flexion and prone. So I treated that lower leg area and then retested and improved his hip flexion quite a bit. Still was a little restricted, improved his internal rotation quite a bit.
Still a little restricted, normalized his dorsiflexion, improved his tibial internal rotation and actually, um, helped his femoral nerve tension quite a bit. Did not retest the slump test at that point. Then retested the locator test assessment protocol. Um, and he, this time his test took me to a central nervous system.
So he did indeed have a central nervous system tension pattern also on the right side. So I treated that with neural manipulation and then retested some um, of the things, and again, improved hip flexion, improved hip internal rotation, decreased femoral nerve tension, retested the slump test, and it was like a little better.
Bilaterally, but not like still. I didn't love that. Still the, not as much. And interesting enough on his slump test, he actually gets anterior hip pain on this, on this. Oh. So a very abnormal neurodynamic test, um, but fits his symptoms. Because if we look at kidney, if we look at urogenital organs, um, one of the complaints often is anterior hip pain along with the knee pain.
Um, and actually on one side of the slump test, he had pain in his knee with it too. So, um, very interesting. So then third time around, um, LTAP did not direct me anywhere,, meaning that LTAP presented, um, that there was not a protection pattern. And so then it's like, okay, cool. Now I can treat wherever I want in terms of, there's still work to do, right?
So sometimes students when they go through the ltap course, they get to the spot where the body is like not directing you somewhere, and they're like. I don't know what to do and I'm like, this is what you would normally do then, right? Like go back to what is your index of suspicion and what are the other objective dysfunctions that you wanna improve.
My index of suspicion is that there's a visceral piece because of his pain on a sacrum. And then some of the other objective dysfunctions that I wanted to improve upon, um, was some lumbar stiffness in like L two. Um, L one, kind of the upper, um, the upper thoracolumbar junction area. Um, and then when I just listened locally to the viscera, um, I got a very strong listening to his right ureter, and that made so much sense with his history of passing the stone.
What I wonder is when he passed the stone, right, he caused some damage to that ureter and the body's not very happy. Happy. So then I was able to add on my visceral skills and listen more specifically to the kidney. Listen, you know, um, test the mobility of the kidney, test the motility of the kidney, check the pulses.
Um, treat the fascial containers, right, the fascia tolt, and the, just the general peritoneum. Um, I connected. Um, I, I treated the ureter via a kidney and bladder technique, um, and made quite a bit of change in that, in the listening to the ureter and then in the mobility of the kidney and the mobility of the bladder, um, and in the SI joint, um, and sacrum mobility in general.
And so, um, that was a really interesting feeling, you know, and then I had him, his mobility. All the things or all the orthopedic things that I was looking for. Improved hip flexion, improved hip internal rotation, improved tibial internal rotation, improved ankle dorsiflexion, um, improved prone knee bend.
Slump tests was still a little more restricted than I would like, but improved instead of hip flexor pain and knee pain. During the slump test, he was just feeling just normal neurodynamic tension, which is more like hamstring and just limited mobility. So that was improved, but still like significantly something. And um, then his discomfort, he really kind of was feeling it this like achiness in the area of his lower back sacrum area, um, down in a squat. And that got a little bit better. He definitely felt like the squat felt better, easier to get in and out of from all the mobility changes in those lower extremity.
But the achiness still remained. And I was like, Hmm, let's, let's see what your body does with this. I was like, I've done a lot now. Now I've done a lot now where I'm encroaching on territory of like doing a little, do it too much if I want the body to help me out. And so I was like, we've done enough. We did three round, well, two rounds of the L LTAP and then like some very specific visceral work and um.
I gave him some take home for it to support all of those things. So I gave him Coregeous ball to do sideline, visceral massage for the like, um, right side tolts fascia colon to kind of slack the area of the fascial container there on the right side to support that ureter and the kidney and the bladder.
I gave him, um, anterior compartment of his leg. I gave him, you know, because that relates to the, your genital organs. And then I gave him the pain on the sacrum video, which is has like sacral float and the pelvic clock exercises in. And then he was telling me some of the stuff he'd been doing on his own, which was using like a really hard massage tool on his kidney area and in his hip flexor area, and I was like, Ooh, please throw that away, and here's some videos of using the soft balls in those areas that are going to be much better for you. And so, um, I gave him some other stuff like that too. He is a very, like, has a lot of time, free time on his hands right now for the next four weeks.
Um, and so I could tell too, he like is really into learning about his body, learning about movement, doing things right, very um. You know, he is like a breath work guy and like does all the things. And so I gave him way more videos and information than I would normally give a client. But that's also because I was like, listen, there's gonna be a lot of things that we can do supportive in a, in a less forceful way than you're used to, and I want to expose you to that.
So I gave him like embodied viscoelastic breathing into the kidney. I gave him the entire kidney region session, which I'll have a Joe link, um, in the show notes. And so I'm just like, let's see if we can make this kidney happier. And, um, I have a feeling not sticking a hard massage tool, psoas thingy, in it is gonna make it feel much better too.
But, um, I'm really curious to see how he feels and, and I told him the homework was one, just pay attention to how he feels in the next few days. And, um, you know, try these new approached self massage in these areas around the trunk, around the kidneys, around the pelvic bowl. And then, um, also pay attention to the physiological things, the incontinence, the erectile stuff.
Um, I wanna know if, uh, oh, and the numbness, the sensory changes in his, like, um pelvic area, leg, upper, upper leg area. Like I want to know if those start to change a little bit too. So, um, yeah, super inter interesting case and like, I wish, I wish sometimes when I shared these cases I'm like, I wish you could have felt what I felt in my hands when I was connected in the ureter because I was like, oof, oof.
This is a very unhappy ureter. And so, um, yeah, that's it. Like short case, but like a reminder that one, have somebody point to where they hurt because they don't know the anatomy very well and they just think their low back is like the lower part of their trunk and the more specific you can get on, like where they're feeling it.
Sometimes it changes the entire sequencing of questions that you're gonna ask somebody because it gives you a different index of suspicion in your brain. And that is really important. Having an index of suspicion is so important to guide you in the data that you're collecting in their body, the data that you're collecting in their subjective history, as well as when you get to the point of the LTAP when the LTAP's like, great, you've eliminated the protection patterns.
Now what you have a plan of like what you're trying to do and what you're trying to support. So, um, yeah, super great case to share and hopefully when I see 'em again, I'll have a good update. And I, you know, and this is what I tell patients too, I have no way of knowing if my index of suspicion was correct or not.
Um, I have no way of knowing. Especially a patient like that, which is like, I shifted all the objective dysfunctions that I think are going to help, but he still felt the achiness and he's like, I can't test the, some of the physiological symptoms just right there in that moment. So it's like, okay, I think I've shifted the needle enough.
We'll know in the next three to five days of how you feel if I really did or not. And then when you come in for the next session, we'll either continue along on this index of suspension of suspicion, or we'll change it up, find a different index of suspicion, find a, you know, have different information, which then that's what I, what I, what I encourage them to do is like, you need to communicate with me.
And then you also need to know that whether your symptoms, it get better. Don't change at all or get worse. All of that is really good information. I was like, so don't ever feel bad about telling me when something's worse or doesn't change. I don't take it personally. It's good information for us, for our next visit to decide do we need to change our index of suspicion or not?
Did we do what we thought we did and should we proceed or should we. Take another look, take another deep dive, right? This is, these are the, this is the process of combining a more specific assessment like the LTAP and then my other assessment tools. With an index of suspicion asking the right questions.
All of this relates to how we get to people to guarantee the results in one to three visits. It's not just that I'm treating where the body wants me to treat, it's, I'm treating where the body wants me to treat in the sequence it wants within this index of suspicion based still on what brings them in?
Like what? What is their problem? Right. So everything we've learned as a clinician, we're just putting it all together in a thoughtful, thoughtful way. So hopefully this like hammers home a a few points for you, but happy to share it. Thank you for being here, and we will see you next time.