© Anthony Von der Muhll, L.Ac, DNBAO, FAIPM ☯ info@aomprofessional.com

Acupuncture Orthopedics

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Low Back, Core & Pelvic Girdle

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History & Physical Exam

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Anthony Von der Muhll, L.Ac., DAOM, DNBAO, FAIPM

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Latest version: Spring 2025

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© by Anthony Von der Muhll, LAc.

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All rights reserved.

Do not reproduce without written permission.

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Please remember: webinars are recorded for your future access

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Webinar Etiquette

• Please keep your mic muted unless invited to speak
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• Thank you for staying logged in during breaks (you may of course turn your camera off). Staying logged in reduces potential access problems and class interruptions

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Accessing Webinar Videos

• Raw videos are uploaded to your Ebook as soon as possible (usually within a week) after live webinars
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• (Annual subscription to the Ebook and videos may be renewed after the first year)

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1. Log in to www.aomprofessional.com and go to “My Account”
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Comments or Questions?

• Live webinars: please type in chat window. Questions will be monitored by the moderator, and asked at an appropriate time. I will seek to answer all questions within the webinar’s schedule.
• For distance-learning classes: (or if we don’t get to your questions during a live webinar), here is my preferred method of receiving questions/comments:
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4. I (and other students) will see your post, and I will respond ASAP
• (You can also email me at info@aomprofessional.com, but I prefer posted questions, they help facilitate discussion and improve the slideshow for all users)

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AOM ⇒ AIM, TEAHM

“Acupuncture & Integrative Medicine”

“Traditional East Asian Herbal Medicine”

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• “Oriental” (as in “Acupuncture and Oriental Medicine (AOM)) has both historical and contemporary pejorative and racist uses by Euro-American colonialists in the Far East.
• Many US-based medical organizations (including AOM Professional) have historically used “Oriental” and “AOM” as standard terminology without ill intent, but now recognize that they must be replaced by terms intended to better describe without offending.
• In the absence of broadly-recognized alternative, I have decided to begin replacing “AOM” with “AIM” & “TEAM” in class notes to describe modalities (including acupuncture, cupping, gua sha, tui na, and herbal medicine) that originated in or were developed into distinctive forms in China, and elaborated into diverse styles in Japan, Korea, and Vietnam, before the arrival of medical modalities originating in the West.
• I am monitoring discussions about appropriate terminology before beginning the process of changing my business name, as such a change is resource-intensive and would affect website domain names, webpage URLs, social media accounts, email addresses, etc., potentially inhibiting student access to courses for an uncertain period of time..
• I invite feedback and commentary on this issue, and offer my apologies to anyone I have unintentionally offended by use of “AOM,” and thank all for their patience with the process of making such changes.

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My Journey to Teaching this Material

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• Worked as sports massage therapist, physical therapy aide, and athletic training assistant, 1998-2005
• Graduated from Five Branches University, (FBU), California w/MTCM & licensed in 2003; 1st grad of FBUs’ Sports Medicine Certification Program. Supervised in FBU’s Sports Medicine clinic 2005-2018
• Founded Santa Cruz Acupuncture Orthopedics & Sports Medicine Clinic in 2003; continuous practice, including in physician-led physiatry and pain clinics
• National Board Certification in Acupuncture Orthopedics (300 hours) 2006, through Lerner Education.
• Certified Personal Trainer, American College of Sports Medicine, 2006
• Integrative Acupuncture Orthopedics program (96 hours) with Alon Marcus, L.Ac., 2006
• Self-study and use of gua sha, cupping, myofascial trigger and motor point needling 2012+
• Fellow, Academy of Integrative Pain Management (multi-disciplinary, now defunct), 2014
• Certified as Myofascial Trigger Point Therapist, Myopain Seminars (90-hour Dry Needling program) 2017
• Teaching integrative acupuncture orthopedics and pain management in DACM and DAOM programs of Five Branches University, Academy of Chinese Culture and Health Sciences, American College of Traditional Chinese Medicine, and Virginia University of Integrative Medicine
• And most important: injuries from running, cycling, swimming, rock climbing, sitting, driving, intermittent stress, performing acupuncture and massage, picking up babies, etc., i.e. life!

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© Anthony Von der Muhll, L.Ac, DNBAO, FAIPM ☯ info@aomprofessional.com

Self-Test: Clinical Anatomy of the Lumbar Spine

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1. Describe the planes of motion, & what their limitations signify
2. Describe the leg regions supplied by lumbar nerve roots
3. Explain the difference between myotomes and dermatomes

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These techniques and modalities will be demonstrated only in the context of focus on the low back, core & pelvic girdle.

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For more information regarding the techniques and modalities themselves, please see the linked classes below:

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• Orthopedic physical exam and diagnosis
• Myofascial trigger point needling
• Joint stabilization/mobilization needling (“prolo-acupuncture”)
• Electroacupuncture for orthopedic conditions
• Optimizing distant needling for orthopedics
• Myofascial gua sha for orthopedic conditions
• Advanced cupping for orthopedic conditions
• Exercise therapy for acupuncturists

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Spine: Column of Joints

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• Facets: Small synovial joints w/tiny menisci can become dysfunctional, sprained, subluxed, deranged, eventually degenerate (spondylosis)
• Discs: Acidic gel of nucleus pulposus can leak, bulge, herniate thru fibrocartilage outer ring-wall (annulus)
• Both structures:
• Have many intrinsic nociceptive (pain) fibers
• Can compress adjacent spinal nerve roots, if inflamed, hypertrophied or displaced

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Cross-section of Lumbar Vertebrae

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Image source

Intervertebral disc

“Neural Arch”

Central canal (for spinal cord)

Spinal Motion Involves Multiple Segments

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• Voluntary motions are regional
• Negligible ability to control segmental movement individually
• Injury, limitation or motion dysfunction of one segment affects adjacent segments

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Where Lumbar AROM Takes Place

By Plane of Motion

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• Sagittal plane: flexion/yangming and extension/taiyang motions
• Progressively more range as one descends the lumbar spine, with the most motion taking place at L 5-S 1
• Axial plane: rotation; shaoyang/shaoyin motion
• Evenly-distributed throughout the lumbar spine, except the most motion takes place at L 5-S 1
• Frontal plane: side-bending; shaoyang/shaoyin motion
• A coupled motion that also involves rotation; the most mobile segment is L 2-L 3

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L 5-S 1, followed by L 4-L 5 have the most total degrees of range of motion = most vulnerable to injury

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Mobility = Vulnerability

To wear-and-tear, acute injuries

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• ~90% of significant lumbar pain, injuries, disability, degeneration takes place at lower 2 segments:
• # 1: L 5-S 1
• #2: L 4-L 5
• (#3: above L 4 ≲ 10%)
• Multi-level injuries are the norm in chronic/significant low back pain; isolated lesions are the exception
• Flexion-extension motions are by far the most likely to cause, be affected by, and generate symptoms upon injury
• Lumbar spine suffers from hypermobility, until degeneration causes stiffness

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Degenerative Cascade: East and West

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Active “Core:” A Muscular Cylinder or “Drum”

Strongest possible shape to provide provide dynamic stability

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Intrinsic Paraspinals, Quadratus Lumborum:

Shaoyin (K)

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“Guy-wires” to support & control the spine inside the cylinder

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Respiratory Diaphragm:

“Ceiling,” or “head of the drum”

Taiyin (Lu)

Pelvic Diaphragm

“Floor”

Jueyin (Lv)? Shaoyin (K)?

Oblique & Transverse Abdominals:

“Walls”

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Shaoyang (GB) & Shaoyin (K)

S P I N E

These muscle groups are innervated to fire together; using them also reduces sympathetic NS overload!

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Cross-Section of the Core “Cylinder”

Outer UB line

Inner UB line

HTJJline

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Intrinsic Paraspinals: Intermediate and Deep Layers

The “Core of the Core”

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• Function: Continuously, reflexively active (even in sleep)
• Control of spinal (axial) movement
• Maintain neutral position and stability against outside forces, including gravity
• Dysfunction: difficulty maintaining stability and control
• Superficial paraspinals compensate by tightening and over-exerting
• Respiratory diaphragm compensates by breath-holding
• Increased loading on spinal discs, facet joints, ligaments pressure on intervertebral discs

Intermediate: multifidus

Deep

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Respiratory Diaphragm Muscle: “Drum” or “Ceiling”

(Accessory muscles of respiration:

Scalenes

Pectoralis minor

Intercostals

Quadratus lumborum)

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Diaphragm

Taiyin (Lu)

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Primary muscle of respiration

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• Function: slow, deep, even contraction/relaxation cycles; able to speed up, increase amplitude of contraction as needed to meet demands of exertion
• Dysfunction: rapid, shallow, uneven cycles; difficulty with exertion; compensates for weakness of other parts of the core by inappropriate breath-holding to increase air pressure inside the “drum,” which also increases intrathecal pressure on discs (coughing, sneezing has same effects)

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Abdominals: the Walls of the Cylinder

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Oblique, Transverse Abdominals

Shaoyang (GB), shaoyin (K)

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Spinal flexion; intra-

abdominal compression;

trunk stability; rotation, sidebending

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Rectus abdominis

Yangming (St)

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Outside the “Core;” only used in forceful trunk flexion, not stabilization

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• Function: Engagement during dynamic trunk motions assists with spinal stability
• Dysfunction: Insufficient engagement during dynamic trunk motions increases loading on spine (discs, facets, ligaments). (Excessive contraction from extreme exercise habits increases pressure on pelvic diaphragm and can lead to pelvic floor problems.)

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Pelvic Diaphragm: the Floor of the Cylinder

Pelvic Floor Muscles

Jueyin (Lv), shaoyin (K)

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Diverse urogenital, excretory functions

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Generally less significant/ direct role in lumbar pain and dysfunction than the walls and ceiling

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Pelvic Floor/Diaphragm:

Recommendations for Education & Training

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• This class focuses on assessment and treatment of neuromuscular pain and disability other regions of the core, low back and pelvic girdle, which may indirectly help some pelvic floor conditions.
• The special techniques and considerations in treating the pelvic floor directly are not covered in this class

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Core Stabilizers and Movers

Quadratus Lumborum

Shaoyang (GB) & Shaoyin (K) Jing-jin

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Lumbar stabilization, side-bending

Hip elevation

Restraining flexion

Accessory muscle of respiration

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Part of the posterior wall of the “Core”

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Iliopsoas

Psoas: Shaoyin (K) Iliacus: Yangming (St)

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Hip flexion

Assist spinal flexion, extension, ipsilateroflexion, contralateral rotation

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Moves the “Core”

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Ligaments of the Lumbo-sacral Spine

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The Passive “Core:” Ligaments Provide Structural Stability

Not shown, but important: thoraco- lumbar fascia

What happens if these ligaments are stretched-out, weak, degenerated?

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Extrinsic Paraspinals (not the “Core”): Superficial Layer

Spinal Erector Group

Function: On-demand

• Extension to maintain upright posture against gravity
• Dynamic exertion (lifting)
• Assist in rotation when contracted unilaterally

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Dysfunction:

• Difficulty with exertion, maintaining posture
• Excessive/continuous tension to compensate for weakness/dysfunction of intrinsics
• Increases loading on spinal discs, facet joints, ligaments

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Cerebellar reflexes attempt to maintain upright posture by balancing hyPERmobile with hyPOmobile segments in the vertebral column

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HyPERmobile

HyPOmobile

HyPOmobile

HyPERmobile

HyPERmobile

HyPOmobile

Development of Scoliosis &

Acceleration of Degeneration

• Description of shape, not a diagnosis
• Structural (bony) scoliosis will be maintained in flexion
• Functional (muscle imbalance) scoliosis will significantly reduce upon flexion (forward bending)
• Textbook: considered “clinically significant” with > 18° of angulation
• May or may not be associated with or a cause of pain
• Acquired/degenerative scoliosis can result from long-term disc, facet degeneration; more likely associated w/pain, vs. congenital which may be painless
• May also involve rotation in axial plane (rotoscoliosis), also more likely to be associated with pain
• Often found with unlevel pelvis, SI joint dysfunction

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Clinical Significance of Scoliosis?

Moderate scoliosis with right mid-lumbar apex – may be asympomatic

Progression from Bulge to Lesion

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Can progress rapidly to sequestration in severe trauma, but typically progresses over months to years

Prognosis worsens with progression

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Extrusion and sequestration typically do not resolve without surgery

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Disc has protruded & migrated to left, impinging on spinal nerve root → left low back pain + leg signs/symptoms (radiculopathy)

Early-stage/mild central disc bulge impinges on dural sheath, posterior longitudinal ligament → bilateral back pain (without limb symptoms/signs)

Spinal Flexion → Progressive Impingement

of Disc on Nerve Root

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1. Flexion squeezes anterior aspects of vertebral bodies closer together
2. Nucleus pulposus is squeezed towards posterior aspect of disc
3. Posterior bulging or herniation runs into tough posterior longitudinal ligament (PLL), highly- innervated with pain fibers
4. Over several days or weeks, bulge/herniation is forced to left or right by resistance of PLL
5. Lateral protrusion can contact spinal nerve root as it exits neuroforamen
6. Further flexion aggravates disc protrusion/ nerve root compression

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Neuroforamen: diameter reduced by spinal extension (but not enough to impinge on nerve root in a healthy spine)

If diameter of neuroforamen is further reduced by bony hypertrophy (age, injury), it can impinge on nerve root during extension– or constantly in severe cases

(Disc protrusion: does not impinge during extension)

Symptoms of Progressive

Spinal Nerve Injury

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Motor Neurons

1. Injured disc leaks inflammatory mediators: dermatomal pain

2. Bulging disc, bone spur, soft tissue, or tumor contacts sensory neurons: tingling

3. Disc, bone, tumor penetrates, crushes sensory neurons: dermatomal numbness

4. Disc, bone, tumor contacts motor neurons: myotomal tension, fasciculations, cramping

5. Disc, bone, tumor penetrates, crushes motor neurons: myotomal weakness, atrophy, flaccid paralysis

Cross section of spinal nerve

Sensory Neurons

Injury can start at any stage–and progress rapidly past point of no return

Radiculitis → Radiculopathy

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• Radiculitis: inflammation, neuropathic pain; structure and function unimpaired
• Radiculopathy: more severe, structure and function damaged

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Stages:

Radiculitis

• Pain

Radiculopathy

• Tingling, paresthesias
• Numbness, sensory loss
• Fasciculations, cramping
• Painless weakness
• Atrophy
• Total loss of motor function

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© Anthony Von der Muhll, L.Ac, DNBAO, FAIPM ☯ info@aomprofessional.com

Numbness/Tingling/Weakness

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• What nerves are being compressed, irritated, damaged, and where?
• With accompanying headache, cranial or central neurologic disturbances: brain
• Bilaterally-symmetrical N/T/W
• Proximal or whole-leg: cord
• Saddle paresthesias: cauda equina syndrome
• Stocking paresthesias: physiologic neuropathy or sacral plexus compression
• Unilateral/asymmetric leg N/T/W, distal > proximal: lumbar nerve root, sciatic nerve, peripheral nerves

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Bilaterally-Symmetrical “Pants” N/T/W:

Compression of Spinal Cord, Cauda Equina

• Cauda Equina Syndrome: older patient (particularly males)
• Saddle paresthesias
• Unable to urinate, control defecation: surgical emergency
• Central canal stenosis: older patient
• Forward-flexed posture and gait
• Provocation on lumbar extension
• Numbness, tingling extends below knees during gait: intermittent neurogenic claudication
• Anterolisthesis (fracture)
• Traumatic: 911
• Degenerative
• Tumor, infection: history, systemic signs/symptoms
• Failed lumbar surgery
• More distal = more severe

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Stocking (& Glove) Paresthesias:

Plexus Compression, or Physiologic?

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• Numbness > pain
• More proximal = more severe
• Verifiable sensory or motor loss is rare, suggests severe presentation
• Most commonly: physiologic small nerve neuropathies d/t HIV+, diabetes, chemotherapy, B12 deficiency, age-idiopathic, etc.
• Equal involvement of 4 limbs strongly suggests physiologic neuropathy
• Coldness, pallor, cyanosis suggests vasculopathy
• Sacral plexopathy: very rare, usually unilateral from major trauma or tumor

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Dermatomal Pain, Tingling, Numbness:

Nerve Root Compression

• Typically unilateral
• Provoked by flexion: usually discogenic
• Provoked by extension: usually neuroforaminal
• Occasionally bilateral asymmetric
• (Rarely bilateral & symmetrical; suspect cord)
• More severe = more constant and felt along entire dermatome, starting distally
• Mild: distal terminus only, intermittent
• Moderate: also more proximal, frequent
• Severe: constant, entire pathway

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Sciatic & Pudendal Neuropathy Pain/Numbness/Tingling

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• Sciatic nerve is comprised of L 4-S 3 nerve roots
• Sciatic nerve sensory distribution: calf (not buttock, posterior thigh, toes)
• Pudendal nerve distribution: sensory branch from sciatic nerve, supplies urogenital area
• Usually unilateral, rarely bilateral
• Bilateral suggests spinal cord injury or congenital anomalies
• Objectively-verifiable sensory, motor loss: rare
• Examine lumbar nerve roots to assess/rule out:
• Multiple-crush syndrome–irritation anywhere along nerve pathway sensitizes entire pathway

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Buttock, Thigh Pain:

Not sciatic neuropathy!

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Differential:

• L 4-S 1 radiculitis
• Buttock: cluneal, gluteal neuritis
• Thigh: posterior, lateral femoral cutaneous neuritis
• Gluteal, hamstring tendinitis
• Intrinsic myofascial pain
• Gluteals: max, medius, minimus
• Piriformis + 5 hip external rotators
• Hamstrings
• Extrinsic myofascial pain: referred
• Erector spinae
• Quadratus lumborum
• Multifidi
• Sacroiliac joint pain, dysfunction

See Neuropathic vs. Non-neuropathic Leg Pain: Differential Diagnosis

Leg-Only (No Butt, LB) Pain Numbness/Tingling/Weakness:

Peripheral Sensory Nerve Compression

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• Very uncommon, but most often at:
• Posterior, lateral femoral cutaneous
• Deep and superficial peroneal
• May be unilateral, bilateral, asymmetric, or symmetric
• Lack of low back pain does not rule out radiculopathy or spinal cord injury
• Suspect multiple-crush syndrome: irritation anywhere along nerve pathway sensitizes entire pathway
• Consider peripheral neuropathy as diagnosis of exclusion after other causes ruled out

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General Diagnostic Considerations

& Approach to History & Physical Exam

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• Nerve involvement: spinal cord, lumbar nerve roots, sacral plexus (rare), sciatic?
• Acute vs. chronic? Traumatic vs. Insidious?
1. Acute/traumatic injuries (including complicated labor/delivery) are more likely to involve discs, facet joints, and ligaments of the pelvic girdle (in addition to muscles)
• Unilateral, bilateral asymmetrical, or bilateral symmetrical?
• Unilateral/asymmetric suggests biomechanical ortho-neuro conditions
• Bilaterally symmetrical suggests spinal cord, systemic, psycho-emotional, physiologic
• Age of patient, stage of injury?
• Younger patient/earlier stage: muscle strains, imbalances, dysfunctional posture and movement patterns (spinal, core, gluteal muscles)
• Middle-aged patient/mid-stage: joint derangement (discs; facet, sacroiliac, pubic symphysis joints)
• Older patient/late-stage: degeneration (osteoarthrosis)
• Fractures: traumatic? degenerative?
• Regional problems involving thoracic spine, legs? In particular, hip, knee joint instability; gluteal and quadriceps weakness, hamstring tension?
• Role of psycho-social stress? Low back pain correlated with apathetic depression, fear, workplace dissatisfaction

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Mnemonic for Serious/Urgent Conditions:

Is the spine “STIFOR?” (stiffer :-))

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• Stenosis (bony hypertrophy impinging on spinal cord or nerves)
• Tumor (benign or malignant, can impinge on neural tissue)
• Infection (discitis, meningitis, tubercolosis etc.)
• Fracture (traumatic or degenerative)
• Organ-referred
• Radiculopathic (damage to sensorimotor function of spinal nerves)

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Red: Consider same-day referral to urgent care or emergency department

Orange: Consider prompt referral to family physician or specialist

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Lumbopelvic History Questions: LMNOPQRST

L: location; suggestive but specific nor diagnostic

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• Ask patient to point; ask about % L/R distribution
• Central only (GV) → supraspinous ligament, small central disc protrusion
• Bilateral and symmetrical (50/50) →
• Spinal cord injury; or
• Primary psychosocial pain
• Unilateral, or bilateral asymmetrical →
• Mechanical (muskuloskeletal) dysfunction/injury: muscles, facets, lateral disc protrusion
• Psychosocial factors may also be present
• Far lateral → (outer UB line, yaoyan)
• L 2-L 5 facet joints
• Quadratus lumborum, lateral erector spinae, lateral abdominals
• Thoracolumbar junction syndrome

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© Anthony Von der Muhll, L.Ac, DNBAO, FAIPM ☯ info@aomprofessional.com

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Lumbar Facet Joint Referred Pain

Provocative factors:

• Prolonged immobilization
• End-range pain in any direction, particularly extension, ipsilateral rotation

Palliative factors:

• Gentle range-of-motion within pain-free limits

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Lumbopelvic Pain Location:

Buttock pain

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• If patient also points to buttocks, consider and assess
• Joints
• Sacroiliac, pubic symphysis (covered in this class)
• Hip, knee, ankle, foot (covered in separate classes)
• Pelvic ligaments: sacroiliac, sacrotuberous, iliolumbar
• Muscles: erector spinae, multifidi, quadratus lumborum, gluteals, hip external rotators, hamstrings
• Iliotibial band hypertonicity
• Cluneal nerve entrapment in thoracolumbar fascia

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Lumbopelvic History Questions:

…MN...

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• Medications? Usage of pain meds can be indicator of severity
• Negatives: Do you have
• Radiating leg pain, numbness tingling? → lumbar spinal cord and nerve toot exam
• Numbness, tingling unilaterally, bilaterally at saddle/genitourinary area?
• Inability to urinate or control defecation?
• “Yes” to any of the above indicates prompt or emergency referral to physician for further assessment of spinal cord or nerve injury

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Symptoms of Limb N/T/W: Neural, or Vascular?

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Lumbopelvic History Questions:

…O...

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• Onset:
• Acute? Traumatic? Insidious? Slow or rapid progression? Mechanical factors, or unclear?
• Traumatic: concern for fracture
• Insidious, non-mechanical onset over weeks-to-months: concern for malignancy
• Sudden, sustained, repetitive…
• Flexion? Suggests discogenic pain
• Extension? Suggests facetogenic pain
• Rotation and sidebending? L vs. R?
• Same side: facetogenic, stenotic
• Opposite side: myofascial, discogenic

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Low Back History Questions:

…P…

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• Palliative/provocative activities? Consistent (severe), irregular (instability)?
• Sleeping positions they avoid due to pain provocation? Is rolling over in bed painful?
• Avoiding supine suggest disc lesion
• Avoiding prone suggests facetogenic, SI joint pain, stenosis
• Avoiding sidelying suggests sciatic neuropathy (ipsilateral), SI joint (either side)
• All positions painful? Which is the worst? Which can they tolerate?
• Pain provoked by rolling: suggests joint sprain, instability (facet, disc, SI)
• Avoid leaving patient in provocative position during treatment!

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Low Back History Questions:

…P…(continued)

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• Palliative/provocative activities? Consistent (severe), irregular (instability)?
• Is walking provocative?
• Pain at sacroiliac, hip joints and buttock suggests problems at those locations (vs. L-spine)
• Walking uphill or stairs painful? Suggests disc
• Unilateral calf numbness, tingling in stocking distribution, worse on unlevel, uneven surfaces, or with running, jumping: suggests sciatic neuropathy with piriformis involvement
• Bilateral numbness, tingling in stocking distribution, gets worse the longer they walk: central canal stenosis with intermittent neurogenic claudication
• Walking initially painful for the first few minutes, then improves, particularly on level, even surfaces: characteristic of disc, facet, and non-specific low back pain
• Stop-and-start walking (“shopping mall stroll”) painful: suggests spinal instability and muscular deconditioning, psychological factors
• Is running, jumping painful? Suggests disc > facet joint

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Low Back History Questions:

…P…(continued)

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• Palliative/provocative activities? Consistent (severe), irregular (instability)?
• Bending, lifting, carrying painful/limited? Suggests disc, muscle strain
• Bending backwards painful? → suggests facetogenic pain, spinal stenosis
• Rotating, sidebending to the left/right? →
• Ipsilateral pain? → suggests facetogenic pain, spinal stenosis
• Contralateral pain? → suggests myofascial pain (rarely, disc)
• Sneezing, coughing, laughing, straining to defecate painful? → suggests disc
• Prolonged sitting, standing
• Provocative is characteristic of SI joint, disc, facet
• Palliative is characteristic of muscular involvement, instability, and psychosocial (non-anatomical) factors

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Provocative Activities

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Provocative Activities (Continued)

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Low Back History Questions:

…Qualities of Lumbar Disc, Facet and Myofascial Pain

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• Acute facetogenic & discogenic pain feel similar
• Hot, burning, sharp, with reactive spasming and stiffness
• Both are often sprained together
• Chronic facetogenic and discogenic pain may be described as “dull, aching, stiffness, deep in the joint/bones”
• Myofascial pain may be described more as “tight, sore” with “knots”

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Onset and pain-limited motions are more distinctive and diagnostic than the location or qualities of pain

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Low Back History Questions:

…RST

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• Referral or radiation of pain? (already asked)
• Severity? (of little diagnostic value, but indicates distress level)
• Timing? (rarely of diagnostic value)

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• (Ask about leg injury history; even if old/asymptomatic, gait dysfunction may affect low back)

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0-10 Pain Scale?

Better ways to assess severity:

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• 0-10 Wellness scale: how good do you feel?
• Focuses patient’s attention on wellness
• Asking may reduce requests for analgesic medications
• (vs. 0-10 pain scale: focus on negatives re-enforces pain behaviors)
• Functional status questionnaires
• Standard, research-validated measures
• Useful for reporting to managed care, workers compensation
• Focuses patient’s attention on functional capacity (away from pain severity)
• Example: Oswestry Low Back Questionnaire

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Buttock, Pelvic Girdle History Questions:

LMNOPQRST

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• Location: Does it also involve low back, hip or knee joint pain?
• Medication
• Negatives: Do you have radiating pain, numbness tingling in legs?
• Onset: Acute? Traumatic? Insidious? Labor and delivery? History of fall onto buttocks?
• Palliative/provocative factors?
• Qualities of pain? (of little diagnostic value)
• Referral or radiation of pain? (already asked)
• Severity? (of little diagnostic value, but tells us about distress)
• Timing? (of little diagnostic value)

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Low Back: Overview of Physical Exam

“Oh, I Ran And Played Lots [of] Soccer Professionally” +

“Medical Doctor Referrals: Neurology, Orthopedics, Family

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• Observation: the big picture
• Inspection: for local tissue abnormalities
• Range-of-motion/joint examinations
• Active: what the patient can/will do, using their own muscles/tendons, nerves
• Passive: practitioner moves patient’s limb–generally not performed for lumbar spine
• Length: assessment of relative muscle-tendon length
• Strength: manual testing of muscles and their nerve supply
• Palpation: can also be performed during treatment

+

• Myotome, Dermatome, Reflex: neurologic exam of spine & extremities
• Neurologic special tests: CNS, cranial nerve, neural tension, provocation
• Orthopedic special tests
• Functional movement exams

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© Anthony Von der Muhll, L.Ac, DNBAO, FAIPM ☯ info@aomprofessional.com

Flow Charts for Assessment of Lumbosacral Pain

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• Guide to using these physical exam flow charts
• Flow Chart Legend
• Lumbar Flexion Active Range-of-Motion
• Lumbar Extension Active Range-of-Motion
• Leg Dysesthesias
• Spinal Radicular Exam
• Upper Motor Neuron Exam

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Anatomic Norms and Documentation for Lumbar Physical Exam

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Lumbar Inspection

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• “Flatback” (hypolordotic): suggests spinal stenosis; loads discs
• Hyperlordotic: weak abs &/or avoidance of posterior disc pain; loads facet joints
• Sideways shift of lumbar on sacrum: contralateral to lateral disc pain at that level
• Step-off deformity: suggests anterolisthesis (fracture) at that level
• Scoliosis: description of shape; may or may not be a pain generator
• Unlevel iliac crests: may or may not be a pain generator
• Does levelling with a heel wedge reduce pain?
• Iliac crest elevation is often found on same side as SI joint dysfunction, quadratus lumborum contracture/trigger points, medial knee injury, subtalar pronation (see graphic below)

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Upper and Lower Cross Postural Patterns

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More Problematic:

Acquired through injury, age

Left-right asymmetry

Associated w/pain, disability

Less Problematic:

Congenital

Bilaterally symmetrical

Not associated w/pain, disability

© Anthony Von der Muhll, L.Ac, DNBAO, FAIPM ☯ info@aomprofessional.com

Physical Exam: Lumbar Inspection/Palpation

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• ​

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Anterior pelvic tilt; loads facets; may be compen-sation for disc lesion

Loads discs; may be compen-sation for stenosis

Posterior pelvic tilt

© Anthony Von der Muhll, L.Ac, DNBAO, FAIPM ☯ info@aomprofessional.com

Stance & Gait Observation

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• Steppage gait aka foot drop: suggests L 4-L 5 radiculopathy
• Trendelenburg stance/gait: gluteus medius weakness/L 4-L 5 radiculopathy
• Forward-flexed gait: suggests facet sprain, central stenosis
• Knee dysfunction: valgus wobble, incomplete extension
• Ankle/foot dysfunction: hypermobility, sub-talar pronation
• Antalgic limping:
• Suggests leg rather than low back injury
• Report of low back pain, but no leg pain/injury/dysfunction: likely non-anatomical/psychogenic

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Common patterns of imbalance

Direction → of strain, dysfunction

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Tight quadratus lumborum elevates ilium

Lumbar facets stuck in extension, SI joint dysfunction

Tibial external rotation, weak tibialis posterior, subtalar pronation, forefoot varus

Weak/tight/painful hamstrings, IT band

Weak/tight/painful posterior calf

Weak/tight/painful gluteals, piriformis externally rotating hip

Genu valgum, medial triad hypermobility (MCL, ACL, meniscus)

• 4 planes: flexion, extension, L + R sidebending
• Method:
• Place 1st inclinometer at T 12-L 1
• Place 2nd inclinometer at L 5-S 1
• Subtract 2nd inclinometer ° from 1st
• Use best of 3 trials within 5°
• ​

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Measuring Lumbar AROM

2 x inclinometers to isolate lumbar from hip motion

Flexion: 60°

Extension: 25°

L/R sidebending: 25°

Capsular Pattern:

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Marked & equal limitations of left & right side-bending +

limitations flexion & extension

© Anthony Von der Muhll, L.Ac, DNBAO, FAIPM ☯ info@aomprofessional.com

What Causes the Capsular Pattern of Limitations?

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Seronegative Osteoarthrosis: degenerative joint disease d/t age, genetics

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Seropositive Arthritis (outside the scope of this class)

• Rheumatoid and other autoimmune connective tissue diseases (ankylosing spondylitis, psoriatic, Reiter’s, etc.)
• Infectious (Lyme, tuberculosis, viral, etc.)
• Idiopathic (e.g. DISH: Diffuse Idiopathic Systemic Hyperostosis)

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• Note provocative motions and degree of limitation
• Which plane?
• Worse on descent, or on return-to-neutral?
• What part of the arc, end-range? mid-range?
• Any scoliosis that resolves on flexion is functional (muscle imbalance), not structural (bony)
• Provocation on flexion: disc; muscle
• Moderate to severe limitation; sharp, sudden, severe, pain at end-range; worse on descent phase & alleviated by return to neutral; may be too apprehensive to perform: disc lesion
• Mid-range pain only: minor disc lesion
• Mild, progressive “stretch” pain: range may be normal, worse on return to neutral than during descent phase: strain of paraspinals, quadratus lumborum
• Provocation on extension: facet, SI joints; stenosis

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Facet, stenosis

Disc; muscle

Interpreting Lumbar AROM Pain/Limitations:

Flexion, extension (non-capsular pattern)

SI joint

• Note provocative motions and degree of limitation
• Worse on descent, or on return-to-neutral?
• Ipsilateral provocation: facet joints; stenosis
• Contralateral provocation: disc; muscle
• Moderate to severe limitation; sharp, sudden, severe, pain at end-range; worse on descent phase & alleviated by return to neutral; may be too apprehensive to perform: disc lesion
• Mild, progressive “stretch” pain: range may be normal, worse on return to neutral than during descent phase: strain of paraspinals, quadratus lumborum

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Facet, stenosis

Disc; muscle

Interpreting Lumbar AROM Pain/Limitations:

Rotation, sidebending (non-capsular pattern)

Leg Pain/Numbness/Tingling/Weakness:

Perform Spinal Radicular and Cord Exam (MDR)

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• Myotome (strength)
• Dermatome (sensory function)
• Reflex

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Abnormal findings: consider Medical Doctor Referral

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Flow charts:

• Leg Dysesthesias
• Spinal Radicular Exam
• Upper Motor Neuron Exam

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Anatomic Norms and Documentation for Lumbar Physical Exam

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Myotomal Strength Testing ✱

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• To isolate and assess the spinal nerve root supply to myotomes: functional groups of muscles that:
• Are predominantly supplied by a single nerve root and/or
• Move a limb thru a particular plane of motion
• (Simultaneously tests the musculo-tendinous strength of all muscles in the myotome)
• Small risk of injury--requires hands-on training to perform safely and accurately

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✱ Also referred to as “Resistive Range of Motion” (RROM). This name is confusing and not used in this class--while RROM is a description of the testing method, strength, not ROM is the function being assessed.

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Leg Myotomes

Hip flexion

Ankle inversion

Knee extension

Hip extension

Knee flexion

Ankle eversion

Dorsi-

flexion

Plantar-

flexion

yangming

taiyang

shaoyang (+ taiyang)

3 yin

Leg Strength Testing: by Myotome/Motion

Smooth, painless weakness: L 4-L 5 myotomal injury–refer to physician

Pain-inhibited, cogwheeling weakness: muscle/tendon problem

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• Toe walk, toe flexion S 1-S 2; taiyang
• Heel walk, toes 2-5 extension: L 4-L 5; yangming, shaoyang
• Great toe extension: L 4; yangming
• Toes 2-4 extension: L 5; yangming
• 5th toe extension: L 5-S 1; shaoyang, taiyang
• Ankle eversion: L 5-S 1; shaoyang, taiyang
• Ankle inversion: L 4; 3 yin
• Knee flexion: L 5-S 1; taiyang
• Knee extension: L 3-L 4; yangming
• Hip extension: L 4-L 5; taiyang
• Hip flexion: L 2-L 3; yangming

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• Heel and toe walk and manually testing the extension of all 5 toes are most important, as they are the most sensitive tests for myotomal weakness at the most commonly-injured levels: L 4, L 5 and S 1

Strength Testing Methods

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• “Break” testing: examiner attempts to “break” (overcome resistance of) a patient’s eccentric muscle contraction
• “Make” testing: patient attempts to “make” a motion through concentric muscle contraction
• More information regarding strength testing may be found in the Class/Ebook: Acupuncture Orthopedics Essentials II

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Contraindications to Strength Testing

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1. Any suspicion of local, recent:
1. Fracture: until unionized
2. Grade 2-3 joint sprain: until swelling, ecchymosis, redness resolved
3. Joint dislocation: until reduced
4. Grade 2-3 muscle-tendon strain, tear: until swelling, ecchymosis, redness resolved

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• Communication barriers hinder patient’s full understanding of maneuver

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Cautions When Manual Strength Testing

To avoid further injury to a strained muscle

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• Examiner must not initiate their own resistance (make testing) or motion (break testing) forcefully or abruptly
• Give the patient time to attempt their own contraction, before you apply full force/resistance!
• Immediately cease testing any given muscle upon any report of pain
• Pain is diagnostic (grade 5- or less strength d/t muscle-tendon lesion).
• Further testing does not add information, and risks injury

​

​

This is just a test, not a contest...

Slow, gentle and easy does it!

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What If Patient is Bigger/Stronger Than You?

Ways to compensate:

• Use “break” testing--eccentric contraction is more likely to reveal minor problems (more sensitive testing method)
• Maintain test for at least a minute--an injured muscle will eventually give way, even if it starts out stronger
• Test their strength on their opposite/uninjured side
• What seemed strong may be weak by comparison!
• Pay attention to other indicators besides just force...

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You

YOUR PATIENT

Learning Manual Strength Tests

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• Muscle tests are applied anatomical kinesiology:
• Resistance to muscle function of contracting between attachments
• Studying muscle attachments sites and actions allows one to understand exact technique and reduces dependency on memorization, instructors
• Kendall and Kendall were the primary original researchers who developed the methodology
• Muscles: Testing and Function with Posture and Pain: reference text
• There are now many websites and videos on-line, of variable quality
• Seek videos by medical schools and qualified professionals (DOs, MDs, DCs, PTs, ATCs)

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Detecting Injury Even When Strength Feels Intact

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• Always compare left and right sides!
• Every patient has their norm; we are looking for asymmetry that correlates with symptoms and other exam findings
• Delayed initiation, clumsy, awkward motion, patient has trouble finding and performing the required motion
• (Facial grimacing or wincing, verbal report of pain, limb wobbles, shakes

all suggest myofascial lesion, not myotomal)

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While these other findings do not lead directly to quantification on the 0-5 scale, they do indicate that there is a problem with neuro-muscular strength that needs further assessment and treatment.

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Examining Leg L 4-S 2 Myotomes

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• Heel and toe walk are more sensitive than manual testing
• L 4-S 2 muscles are too strong to find weakness thru manual testing, unless motor nerve supply is severely injured
• Report of foot, ankle pain suggests local orthopedic injury
• Report of low back pain is likely psychogenic/behavioral
• Walk on heels
• Requires ankle dorsiflexor strength, tests L 4-L 5 myotomes
• Report of low back pain weakly suggests acute/severe disc lesion (lumbar spine is slightly flexed)
• Walk on toes
• Requires ankle plantarflexor strength, tests S 1-S 2 myotomes
• Report of low back pain weakly suggests acute/severe facet joint pain, stenosis (lumbar spine is slightly extended)

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© Anthony Von der Muhll, L.Ac, DNBAO, FAIPM ☯ info@aomprofessional.com

Buttock Muscle Strength Testing

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• Hip extension: taiyang
• Gluteus maximus
• Hip external rotation: shaoyang
• Piriformis, quadratus femoris, deep 4 external rotators
• Test w/hip flexed < 90°
• (When hip is flexed > 90°, these muscles internally rotate the hip!)
• Hip abduction: shaoyang
• + External rotation, extension: gluteus medius
• + Internal rotation, flexion: gluteus minimus

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1. Motor neuropathy: delayed contraction, smooth, painless weakness; progresses → flaccid atrophy → paralysis
1. Upper: motor cortex, cerebellum, spinal cord
2. Lower: spinal radiculopathy, peripheral motor neuropathy
2. Hypofunction: stable, mild painless weakness; no progression to atrophy, paralysis.
3. Tendinitis/fasciitis: pain
4. Injured fascicles, trigger points in muscle: pain

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Where & What Pattern or Lesion

Is causing weakness?

Lower motor neuropathy: disc, bone, tumor, soft tissue impingement

3

Signal damaged

Hypo-

function

Tendinitis

Fasciitis

Muscle injury

Nerve signal

Any combination may be present in varying degrees

Hypo-

function

Nerve signal

Upper motor neuropathy: stroke, tumor, injury

Contraction painful

Weak signal

Muscle contraction

Interpreting Findings of Strength Testing

Integrating Ortho-Neuro w/AIM

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Dermatomal Sensory Testing

ETOH swab: light touch & temp sensation

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• Light touch and temperature sensations are the first to decline from nerve injury
• Compare dermatomes on symptomatic leg vs. other leg/asymptomatic region
• Does cotton swab with isopropyl alcohol feel the same?
• Warm or diminished sensation = sensory loss
• Best uses: rapid, sensitive screening for sensory loss
• Limitations: subjective, not quantifiable

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Dermatomal Sensory Testing

For 2-point discrimination sensation

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• Compare dermatomes on symptomatic leg vs. other leg
• What is the minimum distance at which patient can differentiate 1 vs. 2 points of contact?
• < 6 mm = normal
• 6-10 mm = fair
• 11-15 mm = poor
• > 15 mm = very poor
• Anesthetic
• Best uses: quantification of sensory loss
• Limitations: subjective, time-consuming, poor inter-trial variability

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Sensory Function Measurement:

2-point discrimination

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• “Diskriminator” or equivalent tool: fast, easy
• May also use protractor or U-shaped paper clip + mm ruler: cheap, but slower
• Patient must close eyes, give their best guess
• Minimum of 3 trials/dermatome for validity, accuracy
• Normal: able to discriminate 2 vs. 1 point of contact at < 6 mm
• Fair: 6-10 mm
• Poor: 11-15 mm
• Very poor: 15-20 mm
• Anesthetic/ > 20 mm

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2-pt discrimination measuring tools

Lumbar Spine: Deep Tendon Reflex (DTR) Testing

Objective, sensitive, specific…but require interpretation

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• DTRs: normally present & bilaterally symmetrical
• Unilaterally diminished or absent: specific to ipsilateral lower motor neuron lesion (L 3-S 1 radiculopathies)
• Bilaterally diminished:
• DTRs show some genetic variability and decline with age
• May also indicate bilateral lower motor neuron lesions (uncommon)
• Hyperactive, clonus: specific to contralateral upper motor neuron lesion

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Deep Tendon Reflex Scale

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Lumbar Spine: Pathologic Reflex Testing

Objective, sensitive, specific…but requires interpretation

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• Pathologic reflexes:
• Normally absent
• Presence = contralateral upper motor neuron lesion
• Spinal cord
• Brain
• Clonus after rapid passive ankle dorsiflexion
• Positive Babinski sign
• (Normally present in infants 👼)

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Reflex Testing for Lumbar Spine:

Best Uses

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• Purely objective, cannot be voluntarily altered or subjectively mis-reported
• Unlike myotome and dermatome tests, reflexes are not affected by mood, myofascial pain, difficulty with patient compliance, or physiologic sensory loss
• Crucial screen for urgent/serious lower or upper motor neuron injury

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Reflex Testing for Lumbar Spine:

Limitations

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• DTRs show some genetic variation, and decline with age
• Both require some (modest) skill to perform and observe; potential for practitioner error
• Not an assessment of functional capacity; reflexes are not needed for anything
• Neither DTRs nor pathologic reflexes indicate when injury occurred
• Once DTRs are altered, or pathologic reflexes appear, they generally stay the same regardless of chronicity, treatment, etc.

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Signs of Limb N/T/W: Neural, or Vascular?

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Special Ortho-Neuro Exams for Lumbar Spine

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• Valsalva: low sensitivity, but specific for disc injury
• Seated slump (video), more sensitive, but less specific than Valsalva or SLR for lumbar disc
• Straight-leg raise:
• More specific to lumbar discogenic radiculopathy, but less sensitive than Seated Slump
• Can be measured for diagnosis and evaluation
• Shopping cart sign/test:
• Bracing upper body with arms alleviates pain → suspect lumbar spondylolisthesis or significant lumbar instability

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Straight Leg Raise (SLR)

What is provoking pain, where?

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• Pain upon 0-30° of hip flexion: non-anatomical pain (negative test result)
• Apprehension, psychogenic
• 2ndary gain (litigation, etc.)
• Leg pain/tingling below knee at 30-70° of hip flexion: suggests discogenic pain (positive test result). Specificity to disc herniation may be increased by the following:
• Lower leg until pain goes away, then perform neck flexion + ankle dorsiflexion (stretches dura); pain reproduction ⇒ disc
• Symptom reproduction upon raising the asymptomatic leg ⇒ disc
• Reflexive lumbar extension upon pain provocation ⇒ disc
• Pain only in posterior thigh: suggests hamstring strain
• Pain only in buttock: suggests SI joint, gluteal lesion
• Sign of the Buttock (video) test can also exclude gluteal lesion

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Watch video

• Pain in low back only, at > 70° of hip flexion: Facetogenic pain (negative test result)

© Anthony Von der Muhll, L.Ac, DNBAO, FAIPM ☯ info@aomprofessional.com

Valsalva Maneuver/Sign:

Sensitive and Specific for Disc Injury

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• Spinal pain (and any limb symptoms) ↟ on coughing, laughing, sneezing, swallowing, defecating
• Patients may report this sign after lying in bed and coughing during a respiratory tract infection
• Patients may seek to avoid pain by extending spine
• Exam: ask patient to do any of the above, or
• Holding breath and “bearing down” as if constipated and trying hard to defecate
• Increase in intrathecal pressure bulges disc posteriorly
• Provocation of spine pain strongly indicates disc lesion

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Ouch!

Ouch!

Special Ortho-Neuro Exams for Sacroiliac Joint

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• 1-leg standing stork test: flex hip/raise knee as high as possible, hands may be used for balance but not to grab leg
• Normal finding: PSIS stays level or drops slightly
• PSIS elevates on side of dysfunction (may be opposite to symptoms)
• Also watch for:
• Trendelenburg sign: injury to gluteus medius &/or L 4-L 5 motor neuropathy
• Provocation of calf pain, tingling: sciatic compression neuropathy in piriformis, gluteus medius, quadratus femoris
• Generally poor core stability
• Sidelying, anterior, and posterior pelvic/SI joint compression:
• Location of any pain provocation → SI joint sprain, inflammation

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Tinel’s & Compression Exams for Peripheral Neuritis

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• Tinel’s sign: tap firmly (reflex hammer)
• Compression test: press firmly (elbow)
• Target: common compression sites
• (+): pain, numbness tingling in nerve distribution

These tests have low sensitivity and specificity, however they are the only exams short of electrodiagnostic procedures to identify these uncommon conditions.

Sciatica: Ortho-Neuro Signs and Exams

Provocation of pain/tingling in sciatic distribution (calf) upon:

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• Manual strength testing of the piriformis
• Compression of piriformis (with elbow, or in sidelying position)
• Tinel’s test at piriformis
• 1-leg stance (engages piriformis, gluteus medius)
• Stretching of piriformis through leg rotation
• Internally with hip flexed < 90 degrees
• Externally with hip flexed > 90 degrees (“figure 4 stretch”)

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These tests are not very sensitive (ie, many false negatives), but positive findings are specific to compression of the sciatic nerve in the piriformis muscle.

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Palpation of Erector Spinae, Buttock, Iliopsoas Muscles

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• Palpate muscles for atrophy; determine thru manual strength testing if it’s:
• Neurologic: L 3-S 1 radiculopathy; refer to physician
• Disuse d/t pain, sedentary lifestyle
• Palpate muscles and tendons for hypertonicity, taut fibrous bands, trigger points, reproduction of referred pain
• Hypertonicity of erector spinae suggests weak spinal intrinsics and abdominals, spinal joint instability
• Gluteals, piriformis, quadratus femoris, and their attachments: iliac crest, sacrum, greater trochanter
• Psoas proximal attachments to antero-lateral lumbar spine (through abdomen)
• Iliacus proximal attachment to anterior internal rim of ilium
• Iliopsoas distal attachment to lesser trochanter (hip in FABER position)
• (Quadratus lumborum is too deep to palpate reliably except on very thin individuals)

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Palpation of Lumbopelvic Joints and Ligaments

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• Tenderness at ligaments, joint lines: suggests inflammation, laxity
• Supraspinous ligament at intervertebral spaces: suggests underlying disc lesion
• Posterior sacroiliac, iliolumbar, sacrotuberous ligaments; pubic symphysis
• (Facet joints are too deep to palpate reliably, except on very thin patients)

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Objective: Tenderness Scale

Not a direct indicator of functional capacity, but helpful in documentation

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Plain-film X-rays

1st-line study

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• Uses: images bone and any surgical hardware
• Assess/rule-out fracture: spondylolisthesis, compression, traumatic
• A/RO congenital anomalies: spina bifida, extra or fused vertebrae, etc.
• Assess bony abnormalities, degeneration: osteophytes, scoliosis, deformation, loss of disc space
• Assess status of any prior surgical implants/hardware
• May identify masses
• Limitations: does not image soft tissue; findings may not correlate with pain or disability
• Risks: radiation exposure

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Magnetic Resonance Imaging

2nd-line study

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• Uses/indications: image soft-tissue; limb radiating numbness, tingling, weakness
• Assess/rule-out tumor, infection, cysts, edema, inflammation
• A/RO disc pathologies
• A/RO neural compression from tumor, disc, bone
• Surgical failures
• (Diagnostic uncertainty regarding pain generation, and assessment of non-surgical treatment failures are not by themselves indications for MRI)
• Safe, painless, well-tolerated (claustrophobes may need expenesive open MRI
• Limitations:
• Not a study of function
• Correlation with pain is weak: ~50% for spine
• Risks: patients tend to overreact; secondary depression and surgery-seeking behavior are common

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Interpreting Imaging Studies

For Acupuncturists

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• Radiographic interpretation is best left to ordering physicians and radiologists (who usually but do not always agree)
• Clinical interpretation requires skill to guide patient appropriately
• How well do images match/explain symptoms and physical exam?
• Left vs. right?
• Level of spine?
• Does dermatomal pain/numbness, myotomal weakness match the side and levels of neural impingement identified on the images?
• Do the image findings match the patient’s history, onset of pain? (Bone and disc degeneration progress slowly over years and decades.)
• Discussing limitations of imaging in diagnosis and prognosis of pain, disability can help prevent/manage patient anxiety, depression, treatment drop-outs

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Neural Function Studies

Often performed together

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• Electromyelogram: assesses neural activity in muscle(s)
• Nerve conduction velocity: assesses speed and strength of nerve signals from spinal cord to periphery
• Indication/uses: assess limb radiating pain, numbness, tingling, weakness
• A/RO central/physiologic neuromuscular diseases: ALS, multiple sclerosis, Guillain-Barre, muscular dystrophy ec.
• Identify location(s) of nerve damage: spinal cord, nerve roots, plexi, peripheral nerves
• Assess degree, status, progression of neuromuscular dysfunction
• Risks: same as any needle puncture; can be painful

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Thank you for your attention!

For more advanced clinical training in treatment of orthopedic conditions, we invite you to consider our class offerings at:

www.aomprofessional.com

​

Please feel free to contact me:

info@aomprofessional.com

www.aomprofessional.com

1-800-499-1438

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