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From the Townsend Letter
November 2018

The Truth About Pain – A Different Paradigm
by Hal S. Blatman, MD
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I played golf with sharp and disabling lower back pain for twenty-five years before I learned how to make it go away. Trigger point injections and myofascial work always helped; but when I learned about inflammatory food, there came my first almost pain-free nine holes. Then with platelet-rich plasma, prolotherapy, and repairing tendon injuries, I can hit golf balls as hard as I want with no pain on any swing…unless my food is contaminated with gluten…and then I am in pain for three weeks.
Twenty years ago, I walked off the tennis court with pain in my knees that was bad enough to prevent running and reaching to hit a ball. With what I researched and learned, my bow-legged knees were pain free in six months and without surgery can still ski black diamond mogul slopes and bend to play tennis.

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Do you know someone, have a patient, or do you yourself suffer with chronic pain? How many practitioners have been seen, and how many therapies have been tried? Perhaps surgery has been suggested and even already performed.
BDNF EssentialsWhat do you do if there is a paper cut on your finger and it is bleeding? Options include emergency room for the severity of bleeding, take some ibuprofen and wait until morning, or apply pressure to stop the bleeding. This answer is pretty simple. So what if your back or knee hurt after a game of tennis? Options again include emergency room, taking ibuprofen and waiting until morning, and what if you could apply pressure somewhere and make the pain go away? In actuality, this is more than possible and thoroughly changes how I think about pain and its treatment.
One of the unfortunate phenomena in medicine is that the doctor recommending your treatment, and perhaps even surgery, has likely never really touched you. A pain patient's examination and recommendations are typically based on X-ray, CT scan, MRI scan, and perhaps other diagnostic studies.
Indeed, finding these clues of what causes pain requires a different kind of physical examination than what doctors and health care providers are usually taught. It's not the stethoscope, x-ray, MRI, or pin prick test, but rather a gentle and specific touch that provides many of the necessary clues.
How can we discover the location of these important clues to a lifetime of pain-causing injuries?
Pain educators discuss a familiar theme with regard to what is called chronic and intractable pain. Practitioners and the public have been taught that acute pain comes from injury, and that if this pain persists longer than three-to-six months it becomes "chronic pain" and then it is unlikely to ever go away. Current medical treatment of chronic pain then becomes variations of making the nervous and immune systems less active. Among other choices, this can be accomplished with medications such as cortisone, gabapentin, and opiates, electrically with TENS and spinal cord stimulators, and surgically with radio-frequency and other nerve ablation procedures.
Pain education also teaches that nociceptive and neuropathic pain are distinguishable by the quality of pain symptoms. This doctrine ascribes different pathology to sensations of burning, numbness, aching, and stabbing. In addition, it is suggested that these various sensations of pain might be more effectively treated with different modalities and by different medications, or even that some are not treatable by one type of medication or another. Symptoms are presumed to be indicators of origin, ascribing specific etiology for burning, tingling, sharp, dull, achy, and more. Practitioners spend a lot of time documenting the nuances of sensation because they have been taught that this is of diagnostic significance.
These theories of pain biology and physiology have a foundation in spinal anatomy, knowledge of dermatomes, joint dysfunction, and understanding of nervous system plasticity and windup or up-regulation. All these ideas have been substantiated by anatomical study.
While the anatomy behind pain theory based on current understanding of neuropathic and nociceptive pain is not disputed here, many of the conclusions that traditionally follow are based on assumptions that may not be correct.
Janet Travell, MD, seemed to understand that a great preponderance of what we perceive as pain originates in fascia. She described myofascial trigger points in fascia causing sensations of discomfort that vary to include numbness, tingling, burning, and pain.1
A new understanding of anatomy and fascia based on the work of van Der Was J (2009),2 Langevin et al (2009),3 Schleip,4 and others leads to new ways to work with healing chronic pain.

Review of Anatomy
Anatomy and physiology teach that feedback to the central nervous system comes largely from Golgi tendon organs, Pacinian corpuscles, and Ruffini nerve endings. Anatomical studies have supported this teaching to students of medical physiology for many years. While these mechanoreceptors are important, anatomically they represent only 20% of afferent information to the brain. Approximately 80% of afferent information about our periphery comes from free nerve endings that terminate between the cords and fibrils of fascia throughout the body. These are small diameter interstitial muscle/fascia receptors, 90% of which are unmyelinated free nerve endings. The majority of these are for mechanical tension and pressure.5 This would include muscle, organs, and all of what is considered "soft tissue." Some of these nerve endings are for chemo and thermo reception, but the vast majority measure pressure and friction (shear forces). Research has shown that it is these nerve endings that originate much of the input from which we interpret both proprioception and myofascial pain. Indeed, the interaction of these nerve endings and fascia becomes the antenna for our brain to understand its periphery.
The significance of this anatomy is that the vast majority of afferent information to the brain is providing feedback about pressure and sheer force within the collagen fibrils of fascia. This would include tendon, ligament, enthesis, muscle, and even the bladder wall. As an example, as the bladder distends, the fascia and bladder wall also become thinner. These interstitial nerve endings interpret this pressure change and shear of expansion as "I have to pee," or perhaps the pain of what we call "interstitial cystitis." The balance of homeostasis is part of what keeps our nervous system thinking urination vs urinalysis and antibiotics.
As an orthopedic surgery resident in 1980 we were taught that proprioception of joint position came primarily from "goniometer nerves" in the joint. We know now that this is not true, and that instead these free nerve endings in fascia provide the input that becomes proprioception. We also know that receptors in skin are more important than receptors in joints. When a joint moves, information about this movement comes from fascia shear being different on the extensor and flexor sides of the joint. As we mature from infancy through our early years, our brain learns how to integrate this information and provide the data for understanding where we are in space.
Many people speak about a concept called muscle memory. In actuality, muscles are not capable of memory, and don't remember anything. They are simply bound muscle cells that only have the ability to turn on and turn off. Instead, it is fascia holding these cells together that remembers everything. Some feel that fascia remembers every bump and twist a body ever takes. Therapists speak of somato-emotional release as a phenomenon where fascia releases and the emotions, tied to the trauma, release simultaneously with pain. A close relative of this are the theories and concepts of "interoception." Much of the CNS neuro-input from these free nerve endings in fascia terminates in the posterior insula of the brain before reaching the cortex. This primate-only area of brain anatomy integrates emotion into our perception and reality.6 Perhaps we know how we feel about being injured even before we recognize what happened.
With consistency we observe acute injury causes acute pain that can lead to chronic pain. Statistics on resolving chronic pain show that if acute pain is not resolved by three to six months after injury, it becomes chronic pain that can likely never go away. We are also taught that our bodies become tolerant to opiate medication and doses might need to be increased over time. While these ideas represent the reality of current medical understanding, they are not the reality of our biology. While acute pain may lead to chronic pain, this chronicity only continues until the injuries that caused it are found and healed. The months or years spent in pain do not matter as much as we might think. In fact, much of the paradigm of how pain is considered, examined, and treated today does not work as well as it should if it were correct. If it were correct, wouldn't treatment be more successful? Don't doctors say they will try this, and if it does not work then try that, and so on? Perhaps figuring out the answer shouldn't take so many tries if our understanding is mostly correct.
Injuries that result in chronic pain are usually many years old and started in childhood. It is not lifting the box that started what is causing the lower back pain. It is likely to be old injuries that weakened the fascia which gave way during the lifting injury resulting in years of pain. Then the pain results when the tissue becomes even more fragile and injured. In our experience, seldom is chronic pain truly intractable. Instead, with finding and helping the body to heal from these old and new injuries, significant levels of pain can indeed be made to go away much of the time.
While theories of acute and chronic pain, inflammation, nociceptive and neuropathic pain, electric stimulator modulation, and pharmaceutical interventions have their place, our research shows that much of this is not our biologic reality.
When a patient presents asking for evaluation of pain, the practitioner is being asked to play CSI for pain. A diagnostic medical "who done it."
In diagnosing and treating chronic pain, our research has led to conclusions that form the basis of the Blatman Method-Five Rules of Pain CSI®:

  1. You, as the patient, cannot believe the pain you experience comes from where you feel it.
  2. You also cannot believe what you think the pain feels like, and the distinction is not diagnostically important.
  3. The most significant thing you can believe is that where you are specifically tender, mm by mm, is where your fascia is tied in a knot, or where your fascia attaches to you, holds you together and is injured.
  4. The specific sites where you are most tender are the locations of pain generators in your fascia that generate most of the pain you feel.
  5. If you can get your body to heal the specific places that are this tender, a large amount of the pain you experience will go away.

Amazingly, as resistance and allegiance to what we have been taught will draw you away from these rules, results of following them lead to amazingly consistent results and help answer questions from years of practice. And fortunately, this paradigm applies to healing from most pain in the body – most of the time.
Some of the various pain conditions where this directly applies include migraine and headache, neck and shoulder pain, arthritis and joint pain, lower back pain, leg and foot pain, interstitial cystitis, pelvic pain, plantar fasciitis, TMJ syndrome, and fibromyalgia. It also applies to muscle and ligament strains and sprains from sporting injuries. Indeed, condition of fascia is at the core of most injury, at the core of most pain issues, and at the core of orchestration of real healing. Not just physical, but also emotional as referred to by interoception.
Let's discuss each of the five rules. Referring to Rule 1, you cannot believe the pain comes from where you feel it. Headaches do not come from your head. The pain in your left arm could be from your heart attack. You as the patient have little idea and know only that the pain is in your head or arm. Similarly, why do you think that knee pain comes from the knee, or low back pain comes from the lower back, or even that foot pain comes from the foot or heel spur. One of the more impressive examples is the person who has had total knee replacement surgery, and still suffers perceiving pain in the replaced knee joint. Indeed, pain attributed to a joint may not be coming from the joint itself but rather from the myofascia that holds the joint together and makes it move.
Referring to Rule 2, it is not so important what you think the pain feels like. This issue has been an amazing education. It started with Dr. Travell teaching that myofascial trigger points caused sensations of radiating numbness, tingling, aching, cramping, and pain. During examination and pushing on trigger points to impress a patient these ideas, often the radiating pain would be a mixed sensation of numbness, burning, and pain. This may be why some pain symptoms are so difficult to describe. Keeping my personal faith in helping the body heal the most tender of its fascia injuries, I utilized platelet rich plasma injection therapy to treat injured gluteal tendons in a chronic low back pain patient. This man had a history of lumbar fusion surgery 10 years prior and suffered persistent pain and also numbness to the bottoms of his feet. Upon return a month after his procedure, he reported that since two days afterwards and for the first time in 10 years, he had been able to feel his dog lick the bottoms of his feet. Doesn't this mean that numbness does not have to originate in spine and nerve pathology? Numbness and tingling are consistent phenomena that are not explained by nerve, dermatome, and spine theories of pain. They are best understood as symptoms of fascia injury and repair.

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