| Hackett
Referral Patterns
History and background
Hackett Referral Patterns are named for George S. Hackett, M.D.,
who not only introduced the term Prolotherapy
in 1955 in the first edition of his book Ligament and Tendon
Relaxation Treated by Prolotherapy, but also discovered, after
years of treating patients, that injury to a ligament in one part
of the body can send, or refer, pain to another part of the body.
When a weakened ligament or tendon is stretched, the sensory nerves
become irritated, causing local and referred pain throughout the
body. These patterns were outlined in Hackett's observations, which
he mapped after giving 20,000 ligamentous injections in diagnosing
and treating ligament and tendon relaxation in 1,816 patients over
a 20-year period, and which are now referred to as Hackett Referral
Patterns. They are shown in the figures on this page.
Dr. Hackett was not alone in his work. Around the same time that
he was studying ligament trigger points, Janet Travell, M.D., White
House physician for presidents Kennedy and Johnson, was studying
muscle trigger points and diagramming their referral pain patterns.
Ligament laxity referral patterns and muscle trigger point patterns
are very similar because they have the same etiology, or cause.
The similarity of their findings is shown in the figure shown above.
In fact, in addition to her work with muscle trigger points and
referral patterns, Dr. Travell also reported that acute sprains
of the ankle were accompanied by multiple trigger points around
the ligament and referred pain to the ankle and foot. Others have
identified trigger points resulting from acute sprains around the
knee, wrist and metacarpophalangeal joint of the thumb that were
eliminated with Prolotherapy.
It has now been well established that an injury in one part of the
body can affect other, distant body parts, especially in regard
to ligament injury. For example, when dye is injected into the nerves
of the ligaments of the lower neck, the dye will travel four segments
above and four segments below the injection site. This implies that
ligament laxity at one vertebral level could manifest pain, muscle
tension, adrenal or autonomic dysfunction four segments above or
below the actual injury site. Knowledge of referral pain patterns,
along with a complete patient medical history, allows physicians
who practice Prolotherapy to make accurate diagnoses of specific
weak ligaments, even before performing an examination.
 Examples
of referred pain
Unfortunately, most athletic trainers, chiropractors, family physicians,
orthopedic surgeons and physical therapists do not know that ligaments
can refer pain to a distant site. And the more severe an injury
is, the more likely that a referral pain pattern will exist. Unfamiliarity
with referral pain patterns can lead to misdiagnoses as well as
inappropriate treatments, as is often the case with conditions such
as sciatica,
carpal
tunnel syndrome and tarsal
tunnel syndrome. For example, the sacroiliac ligaments, located
in the lower back, refer pain to the lateral foot, which causes
the symptoms resulting in a common misdiagnosis of sciatica. Pain
traveling down the back into the leg and foot is usually from ligament
weakness in the sacroiliac joint, not from a pinched sciatic nerve.
Other examples include the lateral collateral and annular ligaments,
which refer pain down the lateral forearm and into the thumb, index
and middle fingers. This is the source of most carpal tunnel syndrome
complaints, and often incorrectly diagnosed as carpal tunnel syndrome.
Similarly, the medial collateral ligament refers pain down the medial
aspect of the forearm into the ring and little fingers, which simulates
cubital tunnel syndrome of ulnar nerve entrapment at the elbow.
The list goes on and on:
--the hip joint ligaments refer pain down the leg to the big toe
--the sacrotuberous and sacrospinous ligaments refer pain to the
heel
--the iliolumbar ligament refers pain into the groin or vagina;
in fact, an iliolumbar ligament sprain should be considered for
any unexplained vaginal, testicular or groin pain
 Prolotherapy
and pain referral patterns
A typical Prolotherapy treatment involves a properly trained physician
palpating the exact site of the injury, reproducing the pain, and
then confirming the diagnosis with the actual injections. This is
possible because an anesthetic is contained in the Prolotherapy
solution. The pain is then usually eliminated immediately after
the treatment due to the effect of the anesthetic being injected
right into the source of the pain-the fibro-osseus junction. Familiarity
with referral pain patterns allow natural medicine specialists to
appropriately target Prolotherapy treatments to the correct site
in order to eliminate a wide range of chronic pain sources.
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