Kidney-Nerve-Inguinal Patterns and Case Studies
I've been wanting to talk about a pattern I see more days than not in-clinic, which is one I admit that I would prefer to describe in a video instead of writing, but as I've not had any non-patient volunteers, I've decided the best way to go is to start with some case studies before getting to the nuts and bolts, which does help show a wider range of its presentation. .
Our pattern today is the strong mutual effects of the kidney, 'retro' nerves (subcostal, iliohypogastric, ilioinguinal) and inguinal canal, among some other related structures.
At the bottom is a very short summary of our process, and here are links to a great youtube anatomist who in this case talks about the path and anatomy of our primary nerves today (doesn't look like he's done one specifically for the subcostal yet):
The ilioinguinal nerve: https://www.youtube.com/watch?v=0QUh8JkPpOQ
The iliohypogastric nerve: https://www.youtube.com/watch?v=X8N1zAsHJ_g
A highly related nerve, the genitofemoral nerve: https://www.youtube.com/watch?v=ecV-CyoJW9E
Inguinal Canal: https://www.youtube.com/watch?v=eF2i8wxyINE
Inguinal Hernias: https://www.youtube.com/watch?v=hzf2rvjnUtQ
An apology in advance as well, I will vaguely mention 'neuro' based work as part of my treatment process, which is simply too big a topic to address here in any great degree of detail. It's crucial to my treatment process but its lack of inclusion here doesn't stop the rest from being necessary steps of assessment and treatment, or helpful clinical information.
The very very short description (cutting out a lot of intervening steps and physiology) is we stimulate something which has become sympathetically driving instead of neutral sensory input to the brain, and co-stimming the vagus nerve for parasympathetic input and letting the brain 'reprocess' so that a previous injury like a C-section, a broken bone, concussion, or whatever the event that made the brain, in the age old evolutionary fashion, go "This has the potential to end me" and establishes protective compensations. Here I seek to deal with WHY that protective mechanism was required, not just the consequences of it downstream, and that's the role the neuro work does; to deal with the why and not just deal with built up irritations or combat compensation pattern directly.
The Case Studies
Patient 1: Non-local priority
This patient was presenting with minor low abdominal/mons pubis to inguinal paresthesia and burning pain in the left anterior labia majora. She saw an OBGYN who gave her medication for bacterial vaginosis, never having asked additional questions that would have helped identify this symptom pattern as primarily being an irritation of the left ilioinguinal nerve (with some pudendal, genitofemoral and signs of iliohypogastric). The patient's symptoms did not subside until we treated this nerve line, with a need to treat some notable irritations in the inguinal canal (through which the genitofemoral and ilioinguinal nerves travel) and the kidney, which if mechanically restricted, can then mechanically irritate this nerve grouping profoundly (as then they don't glide and slide across each other in the way they're supposed to).
This was more obnoxious and mildly concerning than badly painful for this patient, but any irritation to the inguinal canal can really run the show in the lower half of the torso and hips, and the spinal functional restrictions that occur really mess up function and force control for the whole spine/ambulation. She had substantial symptoms in this pattern, though the cause was not actually from the kidney/nerve/inguinal region, they were just the areas presenting with the irritation.
It's also not rare to have a doctor or other medical provider not ask the appropriate questions or remember their nerve anatomy to properly diagnose issues like this and we often have to pick up after them. I wish this was rare, but;
Patient 2: Kidney priority
This patient had the full range of paresthesia symptoms from the trinity of nerves we're here to talk about, affecting the low abdomen, inguinal area, gluteal skin, upper medial thigh skin, and badly affecting her muscular activation in right sided hip/spinal flexion/extension and spinal contralateral flexion/rotation. As one of the more disappointing but at this point not surprising reports I've had from patients about their other providers lately…her doctor (a woman younger than her) told her "You'd think as a woman of 40 you'd recognize the symptoms of your period!" These symptoms were not affected by her menstrual cycle, and were constant, only really affected by mechanical tensions we'd expect to affect the iliohypogastric, ilioinguinal and subcostal nerves.
She had been kicked violently and intentionally in the right kidney with a steel toed boot some years before, causing her to have blood in her urine for months and eventually had an inguinal hernia which had to be surgically repaired, likely from the severe function and tension disruption in the area from the kidney injury. As is to be expected in this situation, we had to treat the inguinal canal, including the surgical trauma, but the kidney injury was the primary driver here (stabilize that manually and everything works close to normal). So we treat the kidney, the inguinal canal, these retroperitoneal nerves in between, and a few other affected targets (in this case the uterus, and right femoral nerve/artery, obturator nerve, and some respiratory/muscle sequencing patterns.
We had this patient for a limited time before she left the state, but is now able to not only stand without pain (initially a significant issue at the inguinal level), but is back to running with greatly reduced pain and restriction, improved stability and nearly eliminated paresthesia. She had seen a lot of providers who could not help, with the exception of one good doctor in the area who did dextrose injections into the irritated nerves, which did help calm things down a good amount, but did not eliminate them.
Patient 3: Kidney priority.
This patient I was only able to work on for some 30 minutes as she was a lab partner at a seminar I was able to work on one night after class. She noted a range of right hip discomfort and significant challenges with spinal rotation (especially left). Checking her function, she had severely limited left lumbar and low thoracic rotation, with poor left lateral flexion (quadratus lumborum) function, and noted that the right front of her hip felt like a string caught on something when it was the back leg in a lunge. This makes checking the inguinal canal the next step. What brought us here in the first place was finding irritation to her opposite side round ligament (which can happen when the uterus would rather be biased to the right to avoid tension on a right sided structure, placing the left round ligament in irritating tension. In Barral terms the LL was left round ligament, but the cause of this irritation was an issue on the right. This is common, and for that I treat the right issue causing it, THEN go back to the left round ligament for what it may need.).
If we manually stabilized the right inguinal canal, everything looked pretty damn good, and she did have some sensitivity in the canal itself, enough to suggest minor herniation or significant irritation of the deep inguinal ring (its superior entrance) or its contents. Despite this, stabilizing the nerves was more important (function maintained with holding the retro[peritoneal] nerves towards their origin and not supporting the inguinal canal), and the kidney the same over the nerves.
During this she mentioned that she had been a soccer goalie and a running forward had jumped over her but did not pick up both feet fully, and so she got kicked in the right kidney (I had to raise an eyebrow when I saw both of these patients for the first time in the same week. Not a common one, but a profound origin of dysfunction for sure). So...we knew where we were going.
More as a demonstration of the primary than as the optimal treatment order (as I usually would treat this from the 'top down'), we treated the round ligaments/uterus, then the inguinal canal, then the retro nerves, then the kidney. Each time showing her the increase in comfort, range of motion, and function, increasing with each step. But some light physical tapping over the posterior kidney body and it was like we did nothing at all to help her; all functions dropped off a cliff. This is where the neuro side comes in that we won't cover here, but always highlights the fact that we need to not just treat the symptoms but the WHY. If we only treat the irritated nerves, the canal, and so on, we're just bailing the boat and not plugging the leak (though both are important). This is still VERY necessary for many situations, let alone helps them feel better faster, but we need to get to the origin of the issue; why the boat is flooding in the first place making us do the bailing at all.
So we treated the impact 'neurotag' / 'neurological artifact' and the issues all dropped away. Contralateral rotation and lateral flexion were superb, hip flexion/extension including lumbar extension function was great, range was full and comfortable including lunging movements. This is not something I would generally have to revisit, because the origin of the pattern was gone when we dealt with that kidney injury. If there is another reason why the pattern is present, that would need to be dealt with too.
Patient 4: Inguinal focus
This patient was very athletic and normally active, and came in for bad right hip and low back pain, which took her out of any ability to exercise. Checking the function of the right hip, yeah, it was total junk; that's going to hurt. The left hip function? Perfectly…at least ostensibly…fine. We check the right inguinal canal, nothing, totally fine, comfortable. The left? Immediate overpowering giggling. We stabilized the left inguinal canal and all right hip function was perfect.
I use an expression with my patients often: If you tear both shoulders and you only have one shoulder brace, you put it on the worst of the two. Which one hurts more now? As is the case 90% of the time with the hips, the main controlling local factors are on the opposite side of where the symptoms are (or at least that's where it started or is the most severe). The body is trying to avoid tensioning or using something in a way that will add to the threat and irritation (which is part of why an irritated sciatic nerve will affect flexion and extension. Active flexion with a straight leg will pull it and stretch, and extension will activate muscles around it and compress it, so all sagittal activity in that line is neurologically down regulated and avoided where possible). This means various protective mechanisms that can only be done reasonably on one side, like a highly over active piriformis and its effect on the sacrum, can only be done on one side or it counteracts the protective mechanism being done so is downregulated.
She had irritations in the whole retro line to kidney, but for her the priority was the fact that she had a hernia. If they have significant ticklishness, tenderness or sensitivity in the inguinal area despite you using appropriate contact, including in placing and removing hands, not wiggling or other such movement…a hernia is a distinct possibility, and there does not have to be any externalized tissue for this. Hers was not externally protruding, strangulated, or causing her any direct discomfort she was actually aware of. Hernias can be sneaky little shits, frankly (I had one most of my life without knowing it and a TA fixed mine at a study group. It was life changing to say the least.). I check for these on pretty much everyone by default because of their enormous negative impact and how sneaky they can be as far as direct symptoms.
So we treated the inguinal canal, its contents, and the local intestines. Ticklishness/sensitivity gone, full function of the right hip, pain gone. We did one follow up and it was taken care of. We looked at the rest of the line but this was the local primary. She had some other intra-abdominal pressure management issues that go beyond this pattern that we would want to track down as well, as this whole pattern is still just a result of a protective mechanism and we want to look beyond it. It's just also more than we can talk about here, but the core of her situation was an inguinal focused pattern of the inguinal-retro-kidney group.
Patient 5: Nerve priority.
A simpler case in a way, an MVA came in with significantly restricted and uncomfortable gait patterns, severe pain in sitting for any duration and with the action of standing to the left anterior hip and right low thoracic spine. He had been seeking care from massage and chiro for months with no progress, the relief only lasting a day or two at a time. His injury had been from a driver side (he being the driver of the car being hit) impact just behind the drivers seat, taking him at high acceleration primarily into right lateral flexion. This appeared to injure these retro nerves. Stabilizing them improved the unsurprisingly poor lumbar extension, and contralateral rotation and flexion, reduced pain, and so on.
We treated both ends like we have for the above (in typical Barral visceral fashion with some extra neuro based steps as we did in these other cases) but the primary was the nerve bodies themselves. Given the nature of the injury, this is not surprising, but it is the least usual case as so few things will actually cause direct injury or irritation to these nerves which is not an irritation from the inguinal or kidney that with treatment will see the nerves mostly resolve on their own (or quicker with our help) as a secondary to these structures.
He had other things to treat, given how messy MVA's are, but finding the origin of his primary issue was straightforward due to checking these particulars, and his plateau was over with immediate improvement now that we were treating the body's primary issue at its origin.
Beyond the Case Studies
So, those were five presentations of essentially the same thing: significant irritation of the ilioinguinal, iliohypogastric and subcostal nerves in varying degrees, with some degree of involvement of mechanical contributions from the kidney through their path to and through the inguinal canal. Many people do not present with any kind of paresthesia, such as case number 4, and may have the kidney, the inguinal, or the nerves themselves be the most primary issue, though treating the other two elements will still be very helpful in resolving the irritation and helping them recover. It's most common for the ilioinguinal nerve to be irritated since it goes all the way through the inguinal canal, and subcostal is least likely due to its shorter route that terminates above the inguinal area, but all three are long rotationally aligned nerves so can be affected by stresses and tensions in all three planes (but especially in the transverse and then coronal plane).
I made a few important points spread throughout here, that mostly boil down to: we want to trace down where an issue is coming from instead of saying pain in location X is just from X. We want to find what's going on and treat it in depth. The better understanding we have of how the anatomy is arranged and affects each other, the more likely we are to make a quick, thorough, and, ideally, permanent impact to the patient's symptoms. In particular…weird physical medicine symptoms are very often straightforward if you know your nerve anatomy, starting with what supplies what area, and then what structures in between may be causing mechanical issues that lead to those symptoms, then lastly what may lead to these so that we can treat the whole chain in depth.
With that, let's move past these more general statements and get a bit more academic and direct.
Structures (ipsilateral) Most Likely To Be Affected/Directly Relevant:
Ilioinguinal, iliohypogastric and subcostal nerves (the core of the pattern)
Kidney (a primary driver)
Inguinal canal (a primary driver)
And its contents: round ligament (and uterus) or spermatic cord, with other nerves and vasculature, including the genitofemoral nerve.
Lumbar plexus in general.
The Diaphragm
Twelfth rib
~T12-L2 vertebrae
Quadratus lumborum
Psoas
Obliques
Presentation and Assessment
So what brings us to checking for this pattern? Any history of kidney or inguinal irritation/surgery/injury immediately takes us there. Had a kidney removed for any reason? We'll almost certainly need to work on this line. Had a hernia but there's a mesh in place now? There's definitely something to work on.
But whether there has been this kind of history or not, most people do not have irritation to the point of paresthesia, which is the easiest and most direct reason to check for this pattern (silly thoughtless patients not being bad enough to make it easy on us). What they will have is function or range limitations in contralateral rotation, and if it's bad enough, also deficits in contralateral lateral flexion. They may not be aware of this directly, but it's easily checked. This will usually be a one sided problem…unless, again, it's bad enough, then they may have bilateral deficits in range and function (at which point they are more likely to have some degree of paresthesia, but still might not).
In those with a directly injured nerve (usually from a surgery or severe injury to the area) there may be motor disruptions since these nerves do have motor fibers. I wont cover those here directly, though it certainly makes what is damaged and what pattern is involved more obvious. I may still treat these directly, and far more gently, or support the healing process as needed. As a general rule, please don't pull on injured structures.
I specifically want to check lumbar and low thoracic spinal rotational function with manual muscle testing, and their lateral flexion function (usually via quadratus lumborum in lateral function) and I can check someone’s active lumbar or multi-segmental range of motion (have them stand feet together and flat and see where they can and cannot rotate).
Once I find my most negatively affected elements (usually contralateral lumbar rotation) which gets to be my objective testing measure, I proceed to pinning down the mechanistic hierarchy:
Confirming the Primary
I would then manually stabilize the inguinal canal (gently from both deep and superficial inguinal ring, INTO the canal from both sides), which should show improvement to these functions (it is easier to do this with muscle testing than active ROM). It may not be perfect, but should be improved.
I would then manually stabilize the nerves at the thoracolumbar junction towards the spine and recheck. Again, we should see a significant improvement, if not perfect, though if the inguinal helped our measure and this doesn't, your inguinal region is the primary here.
We will then repeat this with manual stabilizing of the kidney (Ideally into its local listening [a visceral/Barral technique], otherwise you may get iffy or no useful results at all) and if it's the primary, we should get quite good results…if it's iffy but one of the previous two structures helped, then it's one of the previous two structures that is our primary.
IF one of these made things MUCH WORSE for your primary objective measure, we'll also take that as the primary structure as it probably means things are so irritated that even manually stabilizing things was too much pressure and we're in the right place. This is naturally a good place to point out that if there are any reasons to suspect acute injury, we don't want to do any of this unless you know how to approach such a fragile state appropriately (to be specific, we know what acute injuries they are coming in the door with and that touching, let alone manipulating any of this, is safe. Don't injure your patients).
Treating the Pattern
This is more complicated in a sense as a part of this includes neuro work for best results (and sometimes for any lasting results like the two kidney injury patients, or anyone with surgical history in the region). But beyond the neuro part, after the above assessment, we're going to treat the primary first, then the other two, followed by any tertiary pieces. I'm not going to go into great detail here as it is too complicated for a short(ish) article and involves a few different skill sets but I will give something of a truncated summary.
An inguinal irritation or herniation (presuming it's safe; insert appropriate cautions and contraindications here. If you're not certain, don't mess with it) would include first following the local listening from the deep/superficial rings (usually into the canal itself from either side) into that listening for an induction until it settles, and then into a tension induction until that settles. This is followed by an extremely gentle flossing like technique via the deep/superificial rings with a priority of a superior GENTLE tension to try to normalize forces here and let the body sort it out. If there was a mesh here, we would be working very differently, avoiding manipulating the mesh itself and focusing more on the neurological portion and normalizing tone in adjacent tension sharing structures.
Midline organs like the uterus (especially the round ligament), bladder, and rectum may be helpful to treat after the rest of this, if they have irritations and restrictions that bias them towards the affected inguinal canal. Working with the femoral bodies (nerve, vein, artery, potentially lymphatics) may also be needed and we specifically assess for such a need. It's also worth nothing here that femoral hernias may also be present but present differently than this pattern.For the nerves we always start with giving manual slack via tension towards their origin; midline to the thoracolumbar region spine to let them 'vent' some of their own tension, mixed with following the local listening into a slack based induction, before we gently do tension inductions here, and once that is well relieved, I will work the entire length of these nerves together, to each of their individual ends, including that inguinal 'flossing' through the whole nerve length. I may also work with the rest of the lumbar plexus if it feels significantly irritated and restricted, especially the genitofemoral nerve which does go through the inguinal canal and may elicit paresthesia when the other structures don't.
The kidney we will treat via a visceral (such as Barral) approach, with some extra neuro steps added on top. What the body needs here varies, and the kidney may not even be the primary visceral irritation, even if it's the primary of this pattern, such as an overall diaphragm problem affecting the kidney, when the key issue could be a splenic vein affecting the spleen affecting the diaphragm etc. It's easier to find and deal with than it sounds despite the radiculous range of potential permutations, if you're not familiar with a visceral skill set.
Outside of these three structures and their local components, I want to try to track down WHY this happened and treat that, if it isn't something obvious like your patient being kicked in the kidney or operated on (a removed kidney can still cause the same problems! The list of case studies could have kept going). This goes way beyond the scope of this article, but I'll repeat it in everything I write anyway: do your best to track down WHY the patient is having a problem and try to treat that. Bail the water out of the boat, but also find where the leak is coming from and plug it if you can, otherwise we are only managing symptoms, rarely getting rid of them long term.
Any muscular paths that you feel are needing help after this has all been addressed is good to touch up to get as much relief as possible. Thoracolumbar articular topics are also worth looking at, or adjacently, if a lumbar vertebrae has rotated enough to piss off a part of the sympathetic chain. And additionally adjacently; anything that may affect rotation in the same direction (splenic vein irritation affecting right thoracic rotation, temporal bone issues, triangular ligaments, etc.). Work in depth!
I do really like infrared therapies to irritated nerves and spasming muscles if you have the tools present. I'm always happy to talk about how to do this (and have been considering teaching a class if enough people were interested).
In Summary:
Take their history and note any neurogenic-like symptoms in the low abdomen and inguinal region, anterior genitals, and cutaneous gluteal or upper anterior thigh tissue. Also any potential symptoms or signs of low back to hip pain and difficulty with contralateral (or potentially bilateral) rotation or lateral flexion.
Test their function in rotation, substantiating and checking for degree of dysfunction with lateral flexion function and potentially active/passive range of motion testing in these planes.
Confirm the pattern manually: see if manually stabilizing our main 3 structures as detailed here returns some degree of function to our most deficit measures. Then see which of the three is our primary (or if it's something outside of it we need to track down and treat).
Treat the primary structure, then anything left in the other two, and any tertiary targets of need, be they nerves or muscles etc.
Retest.
(also, we want to look into WHY this happened, if it wasn't an injury along this line. I am likely to treat whatever that is BEFORE I treat this local pattern, both to get a better idea how much that issue is causing this, and to make it so there is less I have to work on in this pattern and whatever remains is simply easier to treat because there is less of a reason for it to be there after we've treated the issue 'upstream.')