I. Basic concept of rheumatism and osteoarthritis targeted interventional therapy
At present, the pain department of the Second Hospital of Lanzhou University adopts the formula of special drugs that can control soft tissue inflammation and the unique fixed-point puncture technology, so that the drugs can be accurately intervened into the lesions that need to be treated, in order to achieve the treatment of rheumatism and osteoarthritis inflammation and then achieve the treatment method of relieving soft tissue pain. This method is characterized by the accurate intervention of fine needles into the joints, spinal nerve outlets, spinal canal, fascia and tendon sheath tissues of the whole body, which is characterized by less tissue damage, no neurotoxicity, less pain and precise efficacy.
Rheumatism and osteoarthrosis are chronic pain, mainly including head, neck, shoulder and back pain, hip, sacral, lumbar and leg pain and other extremity joint swelling and pain, and include related symptoms such as headache, dizziness, eye swelling, tinnitus, chest tightness, abdominal pain and dysmenorrhea. The range of disease disciplines it treats includes orthopedics, rheumatology, cardiovascular, gastroenterology, neurology, abdominal surgery, gynecology, quintuplegia, stomatology, and some diseases of traditional Chinese medicine.
In addition to the wide range of treatment, another positive significance of targeted interventional therapy is that it provides a new way of thinking and treatment for chronic pain in the field of combined Chinese and Western medicine by saying goodbye to the heavy reliance on hormones in the local treatment of rheumatism and osteoarthritis.
II. Overview of targeted interventional therapy
(1) The field of targeted interventional therapy
This therapy belongs to the field of integrated medicine and belongs to the scope of clinical therapeutics, with chronic pain and functional disorders of bone diseases, rheumatism and other disciplines as the main treatment objects.
The difference with other soft tissue pain treatment methods is that rheumatology and osteoarthritis targeted intervention therapy emphasizes accurate intervention and precise drug delivery, and does not use hormone therapy at all compared with traditional methods, thus avoiding the possible side effects of hormone, and at the same time, it advocates the analysis and treatment according to pathological principles in diagnostics.
(2) Basic elements of targeted interventional therapy
In the course of its development and clinical application, the method has developed a complete line of thought in the pathology, diagnosis and treatment of many chronic pain conditions.
①Pathology: The central and important role of inflammation in the development and progression of spinal and joint diseases is emphasized.
②Diagnosis: New developments in chronic strain disorders of the spine and joints, such as the significance of spinal microarthritis and joint disorders in cervical spondylosis and thoracolumbar spine pain and the relationship between headache, insomnia, and ophthalmopathy and cervical spondylosis, etc., and soft tissue pain of the extremities with emphasis on the significance of dermal nerve entrapment.
③Treatment: precise injection of drugs into the small joints of the spine, all the joints of the extremities and the entrances and exits of the peripheral nerves is the core of the therapy, and for chronic inflammation of soft tissues, intra-inflammatory lesion administration is advocated.
④Guarantees of efficacy: including the selection and use of injection needles, the position and access of various disease diagnosis and treatment, the determination of efficacy and the required course of treatment, and the treatment of possible negative effects.
⑤ Long-term efficacy: Because it is a direct anti-inflammatory, the long-term efficacy is obvious and confirmed by long-term follow-up data. Because there is no hormone application, there are no side effects such as cartilage destruction, osteonecrosis, tendon rupture and skin pigmentation loss.
(3) The project can provide the following service elements for clinical work.
①Breaking the existing division of disciplines, the implementation of comprehensive treatment for various types of rheumatic and osteoarthritic diseases based on targeted interventional therapy, including manual repositioning, massage, physiotherapy and acupuncture, with surgical treatment when necessary.
② Understand the disease from the perspective of pathology and fully recognize the centrality of aseptic inflammation in the development of rheumatic and osteoarthritic diseases.
(3) Actively develop academic cooperation and academic discussion among clinical disciplines to improve the diagnosis and treatment of difficult clinical conditions.
(4) Treatment scope of targeted interventional therapy.
①Cervical and shoulder pain, mainly cervical spondylosis and frozen shoulder, including their comorbidities such as headache, dizziness, insomnia, eye swelling, tinnitus, nausea, shoulder and back pain and hand numbness.
②Lumbar spine pain, including chronic low back pain and disc herniation.
③Osteoarthritis in various parts.
(④) Chronic strain injury and rheumatic diseases caused by spinal limb joint pain.
⑤All kinds of superficial nerve entrapment syndrome.
(6) Various types of aseptic inflammation of bursa, tendon and fascia.
(7) Plant nerve dysfunction
(5) Characteristics of targeted interventional therapy.
Many people think that targeted interventional therapy is the traditional sense of closure, in fact, there is a clear difference between the two, closure emphasizes the control of inflammation through the blockage of nerve conduction and temporary isolation of inflammatory lesions, while targeted interventional therapy emphasizes the direct injection of anti-inflammatory drugs into the inflammatory lesions to eliminate various types of chronic inflammation of soft tissues and peripheral nerves, that is, through anti-inflammatory and achieve the purpose of analgesia and muscle relaxation.
The technical composition of targeted interventional therapy for bone and joint diseases
Bone and joint disease targeted interventional therapy is not a simple drug plus injection, its efficacy includes diagnostic ideas, interventional techniques and drug ratios, all three are indispensable.
1.Diagnostic thinking
The vast majority of clinical chronic pain is caused by inflammation of the following tissues: arthritis, tendon ligamentitis, fasciitis, spinal nerve entrapment, and autoimmune inflammation, so the focus of treatment is anti-inflammation, and the purpose of analgesia is achieved through anti-inflammation.
(1) Diagnosis of cervical and shoulder disorders
There is a clear trend of increasing incidence of cervical spondylosis in recent years, which may be related to the development of consultation and changes in people’s working style. In addition to the incidence, the youthfulness of the affected population is another characteristic. There are seven types of cervical spondylosis, including cervical, radicular, vertebral artery, sympathetic, spinal, esophageal and mixed. Of these, the cervical and mixed types account for the majority. According to our data, the simple cervical type and the mixed type where the cervical type exists together with other types account for about 85%. The main combined symptoms of these patients are dizziness, migraine, full headache, and shoulder and back pain.
The causes of dizziness are many and cannot be generalized to be related to cervical spondylosis. However, clinically, some patients do have dizziness related to cervical spondylosis. The diagnosis should be cervical vertigo. This diagnosis has two main points: first, there is a basis of cervical spondylosis, including imaging and clinically relevant manifestations, and second, the patient has vertigo and it correlates with the active neck position.
The causes of headache are complex. Vascular factors, neurological factors, endocrine factors and occupational lesions can cause headaches. Cervical spine causes of headache are mainly caused by the occipital major and occipital minor nerves being trapped by the soft tissue of the circumoccipital region. Another factor is irritation of the posterior branch of the cervical 2 and 3 spinal nerves at the articular process. Stimulation and injection of Fengchi acupuncture point can help to relieve the headache. However, for accurate and safe treatment, it may be more appropriate to look for the greater occipital nerve 1 M up from the Fengchi point and the lesser occipital nerve 1 M straight up and inject there. This is because the nerve has multiple sites of entrapment, i.e., there must be an entrance and exit as the nerve passes through different tissue structures. This is where the crico-occipital fascia intersects with the occipital bone and is more likely to produce entrapment. Clinical treatment also confirms the validity of this idea. Pain at the top of the head is treated primarily with the greater occipital nerve, while peri-auricular and temporal pain is treated primarily with the lesser occipital nerve block.
There is another group of headache patients with onset 2-3 days before menstruation, with migraine predominating. The headache is often accompanied by nausea and vomiting, and the headache is relieved only after 2-3 hours of vomiting in some patients. The effect of vasodilators and analgesics is not obvious. The effect is rapid and obvious after blocking the occipital major, occipital minor and cervical 2 and 3 synapses. The incidence of this disorder in women decreases significantly after menopause, and it is considered to be associated with changes in hormone levels in women.
There are many causes of shoulder and back pain. If there is no pain in the neck but only limited shoulder and back pain, suprascapular myositis, infrascapular myositis, subscapular bursitis, thoracic small joint disorder, trapezius, suprascapular and inferior nerve entrapment should be considered. If there is a combination of cervical spondylosis, the pain in the back of the shoulder will be more difficult to distinguish from these diseases. The main point is that the shoulder and back pain caused by cervical spondylosis is mostly diffuse pain, and the local pressure pain in the shoulder is not obvious or diffuse. Of course, it is more common for cervical spondylosis to be combined with these disorders. The focus is on careful physical examination, and it is important to emphasize that when examining the scapular region, the patient must cross his hands and hold them tightly so that the scapula is fully abducted, and start palpating from the scapular raphe point rib by rib, and most of the painful points and inflammatory masses can be palpated. In some patients, the inflammatory mass has obvious sliding and is considered to be subscapularis bursitis. The examination of the trapezius muscle should not only pay attention to its tension, but should focus on palpation of the trapezius muscle at the midpoint of the clavicle in the vertical line. This point is the acupuncture point of the shoulder well, which is the nerve entrance of the paraspinal nerve in this muscle and is often prone to entrapment. Injecting this point and pushing the medicine after finding the touching sensation is clinically effective.
Another factor of neck, shoulder and back pain is not from soft tissue inflammation, but from small joint disorders in the cervical and upper thoracic vertebrae, which are mostly manifested by deviation of the spinous process from the axis or the “S” shape of the spinous process on X-ray orthopantomographs. Patients with joint disorders mostly have complaints of restriction in a particular rotational position, and the diagnosis should not be difficult.
Supraspinous ligamentitis and collateral ligamentitis can also cause neck, shoulder, and back pain. However, the pressure points of ligamentitis are more limited. Interspinous ligamentitis is not easily identified, but pain on posterior extension and pinprick pain in the interspinous ligament may assist in the diagnosis.
Another common condition of neck, shoulder, and back pain is ankylosing spondylitis. It is characterized by significant restriction of neck movement. If analgesics and targeted interventions do not work after 1 course of treatment (6 needles as a course of treatment), in this case, the possibility of ankylosing spondylitis should be carefully examined.
(2) Diagnosis of shoulder and arm pain
When shoulder and arm pain is the main complaint of the patient, the nature, location and function of the upper limbs should be clarified first.
①Nature: Pain in motion is mainly considered as tendonitis (including biceps tendonitis, triceps tendonitis and tennis elbow), arthritis (mostly seen as osteoarthritis, frozen shoulder and wrist disorder), periarthritis and bursitis. Tennis elbow, on the other hand, is more complex and includes lesions such as brachioradialis arthritis, radial osteoarthritis and brachioradialis disorder. And when rest pain is present, osteoporosis, physeal dysfunction, erythema limbosum, arterial embolism, thrombo-occlusive vasculitis and Raynaud’s disease should be considered first.
②Site: widespread pain from the anterior shoulder to the upper extremity should be considered as a possibility of thoracic outlet syndrome. Routine examination of Adson’s sign and Wright’s test is recommended. The syndrome has no clear pressure points in the upper extremities, and the pressure points are mostly at the stops of the superior oblique muscles of the first rib and the corresponding parts of the anterior nodes of the transverse processes of the 5th and 6th cervical vertebrae. In biceps longus headitis, the pain is only in the anterior to the medial aspect of the upper arm, and posterior extension is limited. Periprosthetic shoulder arthritis is characterized by extensive pressure points around the shoulder and varying degrees of impaired motion in all directions of the shoulder joint, predominantly supination and posterior extension. The nature of the pain in shoulder synovitis is mainly soreness and swelling of the shoulder joint, with no pressure points. When the pain and discomfort are located on the posterior side of the upper arm, the posterior border of the deltoid muscle, the stop of the deltoid muscle and the lateral border of the scapula (axillary border) should be checked for pressure points or painful masses. The following conditions should be considered when there is pain during upper arm abduction: subacromial impingement bursitis should be considered when the pressure point is located 1-2M below the acromion, while the pressure point is located at the deltoid stop, which is more likely to be deltoid stopitis. In addition, pain should be present when the shoulder is abducted during subacromial impingement sign.
Pain in the elbow: Osteoarthritis is the first consideration in the elderly, especially in those who were engaged in manual labor when they were young. The focus of pain in the lateral elbow is tennis elbow, and the pressure pain includes the lateral epicondyle and supracondylar crest of the humerus, the brachioradialis joint and the proximal lateral radial periosteum. Posterior elbow pain mostly considers posterior elbow bursitis and elbow arthritis, and medial elbow pain should consider medial humeral epicondylitis. When there is soreness and pain in the elbow joint without clear pressure points, elbow synovitis should be considered. A simple method of examination is to press the thumb of one hand on the lateral humeral radial joint in flexion, and quickly straighten the elbow joint with the other hand, if there is pain, it indicates synovial compression. Another method is to examine the hawk’s fossa in the same way.
Wrist pain: Resting pain suggests increased pressure in the carpal joint and carpal tunnel, consider carpal tunnel syndrome and intracarpal joint infection. Wrist pressure pain suggests inflammation of the wrist synovium, including rheumatoid arthritis (often with swelling and impaired motion), traumatic synovitis of the wrist, and osteoarthritis. The other type of wrist synovitis is more insidious, with no definite pressure pain, and pain only when the wrist joint is stretched excessively, with no other discomfort. The pain in the radial part of the wrist should first be considered as stenosing tenosynovitis of the radial styloid process.
③Temperature: When performing shoulder and upper extremity examination, the patient’s hands and wrists will be touched first. At this time, the temperature of both hands should be compared, and when both sides are cold, the examiner should compare it with his own temperature. The overall significance of a cold affected extremity suggests inadequate blood supply. The common causes of this are the entrapment of the subclavian artery (thoracic outlet syndrome), vegetative nerve dysfunction of the innervated artery and vascular self-pathology, and common tests include the Adson’ and Wright tests. If coupled with oblique muscle pressure, this may suggest the possibility of thoracic outlet syndrome. Cold water stimulation induces pain, suggesting the possibility of Raynaud’s disease. Hot water stimulation induces pain and erythema extremities, suggesting the possibility of erythema extremities pain. If there is a continuous, uniform decrease in limb temperature with cyanosis without external stimulation, cyanosis of the hands and feet should be considered. If the skin cyanosis is reticular mottled cyanosis, reticular cyanosis should be considered. Sudden limb pain with distal pallor, pulselessness and decreased skin temperature are characteristic of arterial embolism. If the skin temperature decreases, the pulse weakens and is accompanied by pain in the distal extremity after exercise, the possibility of thrombotic race vasculitis should be considered.
④ upper extremity motor dysfunction: upper extremity internal rotation and internal retraction dysfunction (positive dorsal palpation test) is most common in biceps longus. The disorder is often accompanied by tendon subluxation condition whose identification is performed by biceps tendon repositioning maneuver. Upper extremity abduction disorders are commonly associated with subacromial bursitis. If the upper extremity movement is impaired in all directions, frozen shoulder is the first disease to be considered. The possibility of gout should be considered when there is a sudden onset of joint dysfunction in the upper extremity with localized redness. In recent years, there has been a significant increase in this condition. Rheumatoid arthritis should be considered first when there is multiple joint dysfunction with pressure pain and morning stiffness. In contrast, the dyskinesia associated with osteoarthritis is relieved only at the beginning of movement and after a few minutes.
(3) Diagnosis of low back and leg pain.
The causes of low back and leg pain are very complex, and it is also the most common and difficult to solve a large class of clinical problems. A careful analysis of low back pain can be essentially broken down into the following four problems: low back pain; lumbosacral hip pain; leg pain; and lumbar and leg pain.
①Lumbar pain. It is a common description of a large group of low back disorders. In most cases, pain is the primary manifestation. However, the chief complaint of some patients is a feeling of soreness or emptiness in the lower back. Sudden onset of low back pain must be considered the possibility of urinary stones induced colic, or even in patients with pelvic inflammatory disease while manifesting as low back pain. Patients with central lumbar disc herniation often present with only low back pain during the initial 1-2 weeks. On physical examination of the lumbar region, percussion pain in the kidney area is a mandatory examination. It is important to assess the mobility of the lumbar spine by applying pressure to the lumbar segment. Complete stiffness should first be considered ankylosing spondylitis and requires further examination. If there is pain on one or both sides of a vertebral segment on compression, it often indicates osteoarthritis. The lumbosacral joints are the most common. Compression pain in the spinous process is most commonly associated with spondylitis or supraspinous ligamentitis. Compression pain in the lumbar 3 transverse process often indicates lumbar 3 transverse process syndrome. The characteristic sign is low back pain when rising from a sedentary low stool. Of course, if there is a combination of pressure pain in the lumbar 2 or 4 transverse processes, it should also be included in the treatment of lumbar 3 transverse process syndrome.
One of the least obvious complaints is the discomfort in the lower back when rising from a sedentary position in the morning or after a long sitting period, which is relieved after activity. Physical examination of such patients often does not show any positive findings. In most cases, the site of the lesion is found during treatment. During a lumbosacral block, if the patient has pain when the tip of the needle is pricked diagonally outward toward the iliopsoas pelvic surface stop of the iliolumbar ligament, this suggests possible iliolumbar ligamentitis.
Another group of patients with complaints of low back pain also had no positive findings in their lumbar region. If a positive finding is found after performing the “4” test, the patient’s low back pain complaint often disappears after intra-articular hip injection therapy is performed on such patients. This suggests that the hip joint lesion may have reflex pain in the lower back.
If low back pain occurs 3-4 hours after sleeping at night and is relieved by getting up and moving around, the possibility of osteoporosis should be considered. Another characteristic of the disease is that there are few positive pressure points throughout the body while complaints of pain or discomfort everywhere.
②Lumbosacral hip pain. Lumbosacral percussion pain often suggests ankylosing spondylitis and osteoarthritis. A positive lumbosacral joint impact test (prone position, sudden palm pressure) often indicates lumbosacral joint instability. The superficial pressure pain often indicates fasciitis, while the deep pressure pain should consider inflammatory lesions of the lumbosacral or sacroiliac joints and lesions of the sacroiliac inter-articular ligaments.
Lumbopelvic discomfort is most commonly associated with supraspinatus neuritis, followed by supratrochlear pain syndrome and pear-shaped muscle syndrome. There are four pressure points of the superior gluteal cutaneous nerve: the nerve is turned up at the iliac crest; the superior gluteal cutaneous nerve is divided into medial, middle and lateral branches on the arc of 3-4 M below the iliac crest, each branch is 2-3 M apart. In supra-rotator pain syndrome, the pain spreads to the lateral hip, posterior hip and ipsilateral lateral thigh, and there are often no positive findings on routine physical examination. If the affected limb is abducted to relax the gluteus medius and iliotibial bundle, there is often significant pain when the other thumb touches the top of the supra-rotor with deep pressure, suggesting a positive result. The condition is essentially a supratrochanteric bursitis. It is important to emphasize that there are two bursae on the rotor: the bursa of the iliotibial bundle with the rotor; and the bursa of the iliotibial bundle with the gluteus medius stop.
(iii) Low back and leg pain. This term has now been completely popularized and the streets are full of low back pain specialists. Of course, the term here refers to low back pain combined with leg pain, not just low back pain or leg pain.
The first thing to do in low back pain is to analyze the nature of the pain, the relationship between attack time and body position, as well as the area involved in the pain, and whether it is combined with weakness of the lower limbs and coldness of the limbs. In patients with complaints of low back pain, routine outpatient examinations including a positive lower extremity straight leg raise test should not be assumed to be due to lumbar disc herniation. In fact, when performing lower limb elevation movements, positive manifestations can occur whenever any of the three nerves of lumbar 4 and 5 sacral 1 are obstructed by pulling or when the sciatic nerve is irritated or when the sacroiliac joint lesion prevents it from moving. In the case of lumbar disc herniation, the nerve that is compressed or irritated is often one of these nerves, so the manifestation in the lower extremity is discomfort or pain in the corresponding innervated area.
There is a tendency for many physicians to base their diagnosis of patients with low back pain on CT or MRI. This tendency has two results: one is the generalization of lumbar disc herniation, which often leads many patients who do not have true clinical lumbar disc herniation into the pain of fear of the disease. The other is to deny the presence of intradiscal pathology when no significant herniation of the disc is seen, despite the clinical presentation resembling a lumbar disc herniation. In fact, radiculitis or other inflammatory manifestations within the spinal canal are typical of this example.
The nature of the lumbar pain is important, and the possibility of osteoporosis should be considered when it decreases after walking and worsens after rest. Pain at the beginning and relief after walking should be considered lumbosacral osteoarthritis.
④ Leg pain. A common problem, divided into two main categories: one is the discomfort of the lower limbs due to joint lesions; the second is the result of various types of soft tissue lesions after stimulating the sensory and vegetative nerves that innervate the lower limbs.
Joint lesions: Inflammation of the hip joint is commonly seen in two categories: joint degeneration and simple synovitis. Among the patients’ complaints, thigh pain is the common language, ranging between above the knee and the groin. The “4” test is helpful in determining hip joint pathology. However, a positive “4” test does not only indicate a hip lesion, but also a possible sacroiliac joint problem. The author’s experience is that when the lower limb is externally rotated in the shape of a “4” to the bed, if there is an obstacle in the first half of the whole movement arc, it indicates a pathology of the hip joint itself; while the second half has a factor of sacroiliac joint pathology, so attention should be paid to differentiation. Knee pain is the most common complaint in lower extremity pain, which is related to the structure of the knee joint, as well as its mobility and easiest strain. The most common knee lesion remains osteoarthritis due to degenerative row.
The exact area of inflammatory lesion should be carefully analyzed for the chief complaint. Pain during walking or pain at the beginning of walking that gradually decreases after a short period of time often suggests the presence of widespread synovitis in the whole knee; pain when walking upstairs but not when walking flat often suggests an inflammatory lesion below the patellar ligament stop at the inferior pole of the patella, with bursitis more common; pain when walking downstairs but not when walking upstairs often suggests an inflammatory lesion at the lateral lateral femoral muscle stop at the superior pole of the patella; sudden pain during walking should be considered a meniscal injury A sudden onset of pain during walking should be considered as a possible meniscal injury; while gradually increasing and more constant pain is clearly associated with synovial entrapment signs.
The cause of anterior knee pain is easier to determine. In the case of knee pain, the most commonly misdiagnosed lesion is the posterior knee. The following lesions may be the cause of posterior knee pain and are often associated with incomplete knee extension.
(i) inflammation of the tendon stops of the medial and lateral heads of the gastrocnemius muscle;
(ii) Gastrocnemius pain syndrome;
③Biceps femoris tendonitis;
④N-string tendon stopping point inflammation;
⑤ Synovitis of the posterior capsule of the knee joint.
Synovitis of the knee is a common pathological process in many knee disorders. The outcome of synovitis often triggers symptoms of entrapment during exercise and thus pain in the patient. In addition to conventional conservative treatment, it is important to determine whether to perform synovectomy for synovitis. The author’s own method of examining the subpatellar fat pad and synovial folds for surgical removal is described here: The patient is placed in a supine position with both lower extremities relaxed and the knee in a flexed position. The examiner holds the patient’s lower calf with one hand and places the thumb of the other hand over the eye of the knee. The fingertip should not be placed in the center of the knee eye, but should touch the inferior pole of the patella, i.e., with the abdomen of the thumb placed in the center of the knee eye to ensure balanced pressure on the fat pad of the anterior knee space toward the joint cavity. The remaining four fingers are placed in the N-fossa and the other hand is used to gradually straighten the knee joint. If there is pain and a soft crepitus under the thumb in the 100-00 range, this indicates subpatellar fat pad hypertrophy with synovial crepitus, suggesting surgery. If pain is present in the hyperextended position, the synovial crease compression is mild and conservative therapy is indicated. There is also the possibility of anterior meniscal horn injury and transverse knee ligament injury.
Pain in the thigh is more common with anterolateral pain and less common with medial pain. The most common causes of anterolateral pain and discomfort are lateral femoral cutaneous neuritis and supratrochlear pain syndrome. The lateral femoral cutaneous nerve exits under the inguinal ligament. If there is no pressure pain here or if there is no improvement after a fixed-point injection, inflammation of the exit of the lumbar 2 and 3 spinal nerves and deep surface lesions of the psoas major should be considered. The pain associated with greater trochanteric pain syndrome ranges from the upper trochanter to the lateral thigh, with some patients complaining of pain up to the lateral aspect of the knee. The common site of pressure pain is posterior to the tip of the greater trochanter. In some patients, however, there is no simple superficial pressure pain despite the corresponding complaints, and a special examination should be performed to confirm the diagnosis.
Here we introduce the examination method we created: the patient lies on his side, with the affected side on top, first press the greater trochanter for tenderness, if the lateral part of the rotor is painful to the touch, it is bursitis of the rotor. If there is no obvious tenderness around it, the examiner’s left thumb presses the upper posterior part of the greater trochanter, the right hand lifts the patient’s lower extremity external booth and instructs complete relaxation, at this time the left thumb presses hard, if there is a point of tenderness, it is positive. With this method, inflammatory lesions in the upper part of the greater trochanter and bursitis between the iliotibial and gluteus medius muscles can be palpated while relaxing the iliotibial and gluteus medius muscles. Common causes of pain in the upper medial thigh include genitofemoral neuritis. The pressure point is at the intersection of the groin and the transverse tangent line of the pubic symphysis. Pressure is applied with the fingertips lightly palpating in the direction of the pubic bone in close proximity to the bone surface often with painful points palpable.
Pain in the medial calf should be considered as a possibility of saphenous neuritis. The pressure point should first be sought between the suture muscle and the thin femoral tendon at the medial femoral condyle near the joint space. Another common pressure point is located at the junction between the posterior border of the medial femoral muscle and the suture muscle at the junction of the middle and lower 1/3 of the thigh. Deep pressure should be applied here to find the painful point. Pain in the lateral calf should first be considered as lateral peroneal dermatomal neuritis and superficial peroneal neuritis, the former mainly innervates the skin sensation in the upper 2/3 of the lateral calf, while the latter innervates the sensation in the lower part of the calf and the back of the foot.