The body is a collection of systems that work together for a common goal. Likewise, when one system is stressed and unable to work efficiently other systems can be affected.
I love it when real life experiences remind me of this inner connectedness.
I also love that life consistently presents opportunities to learn, re-learn and level up.
Last week this is how it went…
At the suggestion of her boyfriend’s mom, I saw Renee for an appointment.
A couple days before our visit she started having pain out of the blue on her left side: her upper abdomen and ribcage - BUT MOSTLY her left shoulder. She didn’t think much of it and did what many might do: popped an Advil. The pain got better, and she went to sleep.
The next day the pain returned - stronger. Standing up straight and breathing became painful. Anxious about these worsening symptoms she went to urgent care.
Here is the summary of symptoms she experienced:
It is important to know that Renee DID NOT associate her symptoms with the any event.
It wasn’t until she was questioned at urgent care that she remembered having a fall on her abdomen while snowboarding a few days prior. As a snowboarder she is used to shredding and the falls that going for it entail.
Patients don’t always perceive information as salient until they are guided in an interview. I’ve even had patients forget to disclose a cancer history in the same region we were assessing.
The takeaway here is that we can’t always rely on the patient to understand what symptoms and experiences are pertinent.
A subjective exam is usually the starting point to a new patient encounter and helps guide the rest of your assessment. For Renee, that included bloodwork and a CT scan confirming a diagnosis of a lacerated spleen - likely the result of her fall while snowboarding.
In physical therapy our goals are mostly biased toward the nervous system and the musculoskeletal system. Wanting help with pain or movement related complaints in most states one can see a physical therapist without first consulting a doctor.
This direct access places the onus on the physical therapist to take a good present and past medical history as part of their evaluation. Getting a detailed subjective history helps one make connections between bits of information that may be relevant.
Each of Renee’s subjective symptoms can be explained by appreciating anatomy, movement, and systems of the body.
She didn’t injure her nervous system, her respiratory system, her digestive system, or her musculoskeletal system yet all of these were impacted as her immune system did its job in response to injury.
APPRECIATING ANATOMY IS A GOOD START
The spleen is the largest organ of the immune system, filtering blood, recycling red blood cells, and storing platelets and white blood cells.
In the left epigastric region of the abdomen, it lies just under the far left of the diaphragm.
Protected by the ribcage, it hangs out between one’s 9th and 11th left ribs.
In the abdominal cavity, the spleen connects with the stomach (via the gastrosplenic ligament), the left kidney (via the splenorenal ligament) and the colon at the left colic flexure (via the splenocolic ligament).
If you’ve ever had the opportunity to participate in a fresh cadaver dissection, you’ll know that the abdomen is tightly packed so if inflammation or internal bleeding occur with an injury, the increased space occupation of fluid requires an internal shifting.
All these adjacent organs make quite the impression(s)
Referred pain is the experience of perceiving pain in a location distant from the stimulus. Pain that is felt in the left shoulder or by the scapula in this case is known as Kehr’s sign. It is thought to occur because bleeding &/or inflammation in the peritoneal cavity irritates the phrenic nerve. Kehr's sign is a hallmark symptom of a ruptured spleen.
Diagrams of referred pain show the spleen, lungs and diaphragm mapped in close proximity on an individual’s left side.
When a patient feels pain in their left shoulder they likely aren’t thinking “I hurt my spleen”
Under normal conditions, the diaphragm functions like a piston within the ventral cavity. Descending with inhalation it displaces the abdominal contents caudally (downward). Snuggly positioned under the left dome of the diaphragm the spleen moves inferiorly and anteriorly when one inhales.
Inflammation and/or bleeding from trauma to the spleen may lead to irritation of the left phrenic nerve thereby impacting the descension of the left hemidiaphragm. This may result in a perception that taking a “deep breath” is painful or restricted.
Due to its proximity to the stomach, an enlarged spleen can cause a feeling of fullness or indigestion due to compression of the stomach.
Burping is a symptom of your respiratory and digestive systems working together to manage pressure in your stomach. Burping occurs when excess gas from the upper digestive tract is released from the mouth. When not associated with eating or drinking it can be a symptom of dysfunction in the sphincter at the top of the stomach.
Inflammation is a normal response of the immune system to injury. When you sprain your ankle, it typically gets swollen. Depending on the amount of swelling, nerves may be sensitized leading to pain and limited motion. This often affects larger body movements like gait. The same thing can occur with inflammation from internal injuries. Greater body movements like standing erect and breathing can be affected.
When one thinks of neuro-musculo-skeletal impairments and painful movement and postures, one often thinks of physical therapy.......
WAIT, PHYSICAL THERAPY for a SPLEEN?
Why would you go to physical therapy for a lacerated spleen?
In this acute presentation a physical therapist can help with:
restoring pain-free movement
respiration strategies aimed at restoring optimal patterns and decreasing pain
positioning for comfort
guidance with meds, diet
reinforcing graded exposure to exercise
It is common that folks will seek out a PT before they go to a doctor for what feels like musculoskeletal pain.
A ruptured spleen is an emergency and if suspected, immediate referral is necessary. I luckily did not have to do that since this patient came to me after diagnosis and clearance by her MD. Surgery for a splenectomy was not recommended and she was encouraged to return to non-impact exercise.
The body gives us clues when there is something wrong, but they aren’t always crystal clear. That’s why a good subjective history is critical.
Understanding how systems influence each other via several different connections: location and movement, inflammation, overall systemic changes and neural connections can help us as practitioners.
Lastly, I’m not sure how long it would have taken me to connect the dots or if I would have put these pieces together on my own. Going forward I know I benefitted from my review of the anatomy, visceral referral patterns and the interplay of systems. Hopefully you did too.
Afif Kasuma from Unsplash
Sora Shimazaki from Pexels
Vishy Mahadevan, Anatomy of the pancreas and spleen, Surgery (Oxford), Volume 37, Issue 6, 2019, Pages 297-301, ISSN 0263-9319
Luc Peters and Gregoire Lason, Osteopathic approach to the spleen, the AAO journal, Volume 19, Issue 2, 2009, Pages 15-22