Low back pain is a general term for a class of diseases, referring to a wide range of injuries and diseases that can cause low back pain and leg pain, as the pain is caused by different injuries, so the pain also has its own characteristics and patterns. Analyzing these characteristics and patterns will help to make a correct identification and diagnosis of low back and leg pain. Some problems in the understanding of low back pain Widely used osteophytes to explain the clinical symptoms: in practice, we often see that when we use manipulation on the lumbar spine lesion site to rectify the release, the patient’s symptoms can be immediately relieved or pain elimination, but the imaging examination of hyperplasia is still the same. Could the hyperplasia be eliminated all at once? These phenomena suggest that the pain is not related to the hyperplasia. Since the pain is not caused by hyperplasia, how much practical significance is there in focusing on treating hyperplasia and eliminating bone spurs? The concept of sciatic nerve is not clear: for sciatica, as long as the patient has lower limb pain or limitation of leg lifting, it is rashly diagnosed as sciatica, when we review, analyze and treat many cases of sciatica, we found that the rate of misdiagnosis is as high as 54.1%, and in the misdiagnosed cases, the iliotibial bundle is related to the person who accounted for 93.9%. There are obvious differences between the two in terms of location of the source of the disease, symptom expression, location and range of pain, etc. It is not difficult to identify them with a little comparison. Habit with rheumatism to explain the waist and leg pain: some doctors do not care about the location of the pain, but also do not analyze the characteristics and patterns of pain, will give the patient with rheumatism “hat”. To know, Western medicine and Chinese medicine referred to rheumatism, the concept is not the same. The rheumatism referred to by Western medicine is a kind of perverse reaction caused by bacterial infection, which cannot represent these back and leg pain disorders at all. In Chinese medicine, rheumatism refers to diseases induced by changes in climatic factors such as wind, cold, cold and dampness. Such as some chronic injuries, strain injuries, etc. Although this feature, from the perspective of traditional Chinese medicine can still be called rheumatism, but as mentioned earlier, Chinese medicine on the classification of low back pain is not called rheumatism, low back and leg pain is far more than these diseases, so we can not cover up the “rheumatism”. Regardless of whether the pain and lesions are consistent, then rash diagnosis: some doctors believe that the lateral lower extremity pain can be diagnosed as sciatica, this talkers do not agree. Because the lateral side of the lower limbs should include the lateral side of the large and small legs, and the sciatic nerve is through the thigh after the middle of the calf and innervates the calf, but not through the lateral thigh, thigh pain and how can be counted to the sciatic nerve up to it? Lateral thigh pain is usually caused by injury to the iliotibial bundle. As mentioned earlier the high rate of misdiagnosis of sciatica is easy to understand. Therefore, attention should be paid to the anatomical relationship in the diagnosis, not to be rigidly applied, Zhang Guanzhi. The significance of pain in different directions of the thigh According to the laws of anatomy, the pain in different directions of the thigh, make a judgment is based on evidence, such as the diagnosis of pain in the posterior thigh: the posterior thigh muscle groups are against the lateral biceps femoris and against the medial semitendinosus, which are innervated by the sciatic nerve. Therefore, in the case of posterior thigh pain, the first step is to check whether the flexor muscle group of the femur is normal? There is no history of strain or other injury to the flexor muscle group to clarify whether there is a femoral muscle group injury. The location of the injury of the femoral muscle group is mostly at the junction of the muscle and the muscle belly, the bifurcation of the internal and external sides of the femoral flexor muscle and the attachment area, etc.; muscle belly strains occur from time to time, and the pain point is mostly in the middle, and there is often obvious swelling or hematoma, hard lumps on palpation, tenderness, and so on, and the pain is aggravated by the active and passive muscle contraction or resistance to contraction. If the pain is caused by the nerves, the sciatic nerve or the superior gluteal cutaneous nerve injury should be considered first. Both injuries can be manifested in the waist, buttocks, posterior thigh pain, leg lifting can be limited to varying degrees, but the pain of gluteal epithelial nerve injury is more diffuse, the location is often plausible, vague and uncertain, and only reaches the posterior side of the thigh, but not as good as the calf. Sciatic nerve injury can be found along the sciatic nerve line of pain, the pain is not only manifested in the waist, buttocks, posterior thigh, and the whole calf, especially the lateral calf paresthesia, more common, leg lifting and stretching limited, with pulling pain, tendon reflexes are weakened or disappeared, and in severe cases, it can be seen that the muscle atrophy. Sciatica can be divided into two categories: radicular and dry. Radicular sciatica is mostly due to lumbar disc herniation or degeneration, mostly seen in L4/5 or L5/S1. Dry sciatica can occur throughout the trunk of the nerve, but it is mostly seen in the pudendal muscle, gluteus maximus, minimus, and gluteal fascia when there are chronic damages, therefore, the search for the root cause of sciatica is mainly in the lower lumbar segment and the pudendal muscle. The superior gluteal nerve, on the other hand, should dig for the root cause in the upper lumbar segment. Identification of anterior thigh pain: when the pain in the lower and middle part of the front of the thigh, attention should be paid to the quadriceps injury, in the middle part of the muscle belly is mostly strained, and hard lumps can often be palpated, which is the muscle spasm after muscle strain, blood mass, etc., and there is pressure pain: if the pressure pain is in the lower part of the lower segment, above the patella, it is necessary to pay attention to the strained muscle belly of quadriceps muscle and tendon intersection, or even a rupture injury. Thus, when the quadriceps muscle is contracted or resisted to extend the knee, the pain is intensified, and if there is a rupture, a hollow transverse groove can be seen above the knee, and the quadriceps muscle is obviously contracted upward into a mass. If the pain point appears in the root of the leg, such as in the inguinal ligament below the midpoint of the touch, need to consider the iliopsoas muscle injury, because it is attached to the femoral tuberosity, so can be felt here pressure point, resistance to lifting the leg when the point of increased pain; if the pressure point appears in the anterior superior iliac spine, in addition to consider the broad fascia tensor attachment point injury, should be noted that it is also the attachment point of the suture muscle, the muscle from the anterior superior iliac spine by the front of the femur, diagonally downward, and stops at the medial tibial condyle. This muscle runs from the anterior superior iliac spine through the anterior femur, obliquely inward and downward, ending at the medial tibial condyle. Therefore, it is important to check the attachment points of both ends of this muscle and its course for tenderness, and to check for tenderness when bending the knee and externally rotating the thigh, or when resisting the completion of this maneuver. If there is a positive reaction, it is necessary to consider the suture muscle injury, and if the anterior inferior iliac spine pressure and pain, it is considered to be the head of the rectus femoris muscle attachment area injury. Both of these muscles are innervated by the femoral nerve, if the muscle itself has been ruled out, the upper lumbar segment (L2-4) should be examined to rule out lumbar pathology if it is considered to be caused by the osseous nerve. The significance of medial thigh pain: the medial thigh muscle group is called the adductor muscle, its function is mainly to make the thigh adduction, so if the legs are standing for a long time with the legs spread out strongly pulling the adductor muscle, it can cause pain in the medial thigh, resistance to adduction of the medial thigh pain, which is the pain caused by excessive fatigue or injury to the adductor muscle; resistance to adduction check, such as pain in the pubic bone part of the location and the pubic branch of the pain or even the surface of the surface with roughness and unevenness, it should be noted that it may be the result of the pain. If the pain is located in the pubic bone, and there is pressure pain on the pubic branch or even roughness on the surface of the pubic bone, it should be noted that it may be due to osteitis of the pubic bone caused by chronic injury of the adductor muscle. Because the pubococcygeus muscle is innervated by the femoral nerve and the vastus lateralis muscle is innervated by the sciatic nerve, when there is pain in these two muscles, it is necessary to pay attention to whether there is any lesion of the femoral nerve and the sciatic nerve, and all of the adductors are innervated by the occluder nerve, so it is necessary to pay attention to the examination of the middle lumbar vertebrae (L3-4) to exclude lumbar lesions. Thinking about lateral thigh pain: there is no specific muscle group in the lateral thigh, mainly the iliotibial bundle is here, supporting the lower limb to stand up. If the iliotibial bundle injury pain is mainly in the buttocks, but can be affected along the lateral thigh to the lateral calf, and the lower and middle 1/3 junction of the lateral thigh is the sensitive point of its pressure, so the pain in the lateral thigh is basically due to the injury of the iliotibial bundle. Although the pressure pain at the lower and middle 1/3 junction may sometimes be caused by injury to the lateral head of the quadriceps muscle, as long as there is this concept, it is not difficult to distinguish the two from each other by comparing the direction, scope and function of the two affected. In the case of lateral femoral dermatitis, although there can also be pain in the lateral thigh, it is more predominantly in the upper and middle part of the lateral thigh that there are sensory abnormalities, numbness, and decreased skin sensation. It is important to draw attention to the fact that there is no motor nerve innervation in the lateral thigh, and the sciatic nerve only travels down the back of the thigh and does not pass through the lateral thigh, therefore, when there is pain in the lateral thigh, it should not be thoughtlessly recognized as sciatica. Unfortunately, this basic common sense of misdiagnosis often occurs in clinical practice. As long as one is familiar with the anatomy and is aware of it, it is easy to distinguish it from its location. The origin of posterior lateral thigh distension: sometimes, the location of thigh soreness and distension is not exactly on the side or directly behind, but is located in the posterior lateral side, that is, for the distension of the biceps femoris muscle and pressure, the semitendinosus semimembranosus muscle is not affected, which can’t be explained by the sciatic nerve or by iliotibial bundle injury. This phenomenon is mostly caused by the femoral muscle injury, the general examination position is difficult to find the pain point, should be the healthy side of the lying position, the healthy limb in the lower straightening, the affected limb flexion of the hip and knee, the leg inward, the knee against the bed, so that the greater trochanter of the hip and the sciatic tuberosity as far as possible to pull apart, in the sciatic tuberosity and the great trochanter and a little above the place, that is, the femoral muscle is located, you can check the obvious pressure pain. In this position, manipulation of the quadratus femoris muscle and biceps femoris muscle, can receive immediate results. In this patient, the fifth lumbar vertebrae is often found to be affected or the sacrospinous muscle on that side is damaged and spastic, and if this is treated at the same time, the effect will be faster and more stable. The relationship may be that the quadratus femoris is innervated by a branch of the sacral plexus, and the biceps femoris is innervated by the sciatic nerve, and sacral injuries can affect the stimulation of these nerves, which in turn affects the symptoms of these two muscles. Determination of pain in different areas of the buttocks The buttock muscles are more, but in the low back pain clinic, not all have the same importance, now choose its significance to explore. For the convenience of exploration, we can use the crosshair coordinates to divide the gluteal region into 4 regions from the center, i.e., upper inner, upper outer, lower inner and lower outer regions. Determination of pain in the lower region of the buttocks: pain in the lower part of the buttocks, if its location in the lower outer region of the cross more by the coordinates of the vertical coordinates slightly lateral to the first to consider the possibility of sciatica, first along the posterior side of the thigh, the sciatic nerve line to check the presence or absence of tenderness, pay attention to the pain should be in the posterior side of the thigh (should not appear in the medial or lateral side of the thigh), and the lower limb of the other symptoms with which the match, initially can be used for sciatic nerve If the diagnosis is confirmed, the root cause should be further investigated to determine whether it is radicular or dry, and whether the root cause is in the lumbar vertebrae or in the pyriformis muscle. If the location of the pain is slightly below the outer part, in the inner part of the greater trochanter, it is necessary to pay attention to whether it is a quadriceps injury (for the examination and differentiation method, please refer to the previous section on quadriceps injury). Sometimes the pain point is above the femoral square muscle, it may be a deep small muscle injury, which is rare in the clinic. If the location of pain in the hip joint, especially in the greater trochanter, if it is chronic pain, need to pay attention to the hip with or without chronic injury or inflammation, if the joint activities and rattling sound, pay attention to the popping hip; if the pain caused by acute injury, should pay attention to exclude the femur tibial fracture or hip dislocation, both are post-injury onset of the disease, the greater trochanter upward movement, activity disorders, the former can still be touched locally, the bone friction, the iron drill test is positive, etc., radiographs can be differentiated between the two. In the former case, bone rubbing sound can still be touched locally and iron drill test is positive, etc. X-ray photo can identify and confirm the diagnosis. If the location of pain is in the lower medial region of the buttocks, close to the buttock crease, its relationship with the sciatic tuberosity should be investigated. If the pain is in the sciatic tuberosity, it is necessary to pay attention to whether there are sciatic tuberosity cysts, injuries to the attachment area of the femoral flexor muscle group, or even sciatic tuberosity avulsion fracture (mostly seen in teenagers and children). Common injuries of pain over the buttocks: when the pain is in the upper part of the buttocks near the vertical coordinates, it is necessary to pay attention to whether there is injury to the superior gluteal cutaneous nerve. This nerve injury, its back and leg pain pain is characterized by a more vague discharge of soreness or dull pain, sitting down to the chair surface often suddenly appeared to lose control of the inability to support the chair, fell on the chair, up from the chair, the inability to stand up directly, the need for hand-held in the distal end of the leg or the knee, bend over to lift the buttocks and then to straighten up. Inspection can be in the iliac crest below the midpoint of the external iliac fossa (about 2-5 cm below the iliac crest), for transverse push, to check whether there is vertical downward, about the size of a matchstick, such as the cord, some can be palpable in the subcutaneous, push the can be swung left and right, and some can be palpable, but deeper in the fat layer, the push can not be swung. Although the depth of the two are different, there is the same to the main pain pressure pain, with this symptom and signs of the diagnosis should be undoubtedly. If in the gluteal epithelial nerve slightly below the detection of about the thickness of the finger, from the inner upper zone oblique to the outer lower, pointing to the direction of the greater trochanter muscle bundles, more rigid, tenderness, this is the spasm of the gluteus medius muscle. Injury to the gluteus medius muscle, broad fascia tensor muscle and iliotibial fascia injury is the same as the main cause of lateral thigh pain. The vastus tensor fasciae latae muscle is located in the outermost part of the buttock and can be palpated below the anterior superior iliac spine, and in the case of an injury, a stiff spastic fascicle can also be palpated, which is slightly smaller than that of the gluteus medius muscle. Some people often confuse gluteus medius muscle injury with gluteal epithelial nerve injury, in fact, as long as we note the possibility of injury to each of the two, clinically as long as a slight comparison, the identification is not difficult. In terms of location, the gluteal epithelial nerve is about 2-5 cm below the iliac crest, while the gluteus medius muscle is below the gluteal epithelial nerve; in terms of fiber direction, the gluteal epithelial nerve runs vertically downward from the margin of the iliac crest, while the gluteus medius muscle runs diagonally from the inner upper part of the muscle to the outer lower part of the muscle. If we talk about the size of the fibers, the gluteal epithelial nerve is only the size of a matchstick, and the gluteus medius muscle is the thickness of a finger; the number of epithelial nerves varies from 2-3, and the gluteus medius muscle is only one; the range of symptoms is also different, the gluteal epithelial nerve is radioactive, and vaguely and indeterminately affects the lumbar region, the buttocks, and the posterior side of the thighs (but not the knee), and the spasm of the gluteus medius muscle is the main cause of the iliotibial fascia injuries, and the pain, except for the outer and upper portions of the buttocks, is mainly the outer side of the thighs, or even the outer part of the leg. The pain is mainly lateral to the thigh and even to the lateral calf. According to the above comparison, it is not difficult to differentiate between the two. Since the treatment methods of the two are different, they should be clearly identified to avoid misdiagnosis and wrong treatment, which will affect the therapeutic effect. The pain in the medial edge of the upper inner hip muscle is likely to damage the gluteus medius and pyriformis muscle: the gluteus medius muscle slopes downward from the inner upper, and its medial end is in the upper inner area of the buttocks, and some patients manifested as muscle abdominal pain, then their examination is as mentioned before; some patients are mainly attached to the area of injury, and the location of their pain is in the middle of the upper inner area of the buttocks, so the pressure point is found in this area, so we should pay attention to the gluteus medius muscle injury may be possible. If the pain is below the gluteus medius and slightly medial to the coordinate crossing, the possibility of a pyriformis injury must be noted. Piriformis muscle originates from the front of 2-4 sacral vertebrae, the muscle bundle through the sciatic foramen magnum and out, diagonally outward down to the greater trochanter of the femur, and its injury is the most common cause of dry sciatica. Since this muscle is covered by the gluteus maximus muscle, accurate superficial localization is helpful for definitive diagnosis and accurate treatment. There are different methods for its surface localization: some people advocate that the posterior superior iliac spine and the greater trochanter make a line to indicate the location of the pyriformis muscle, and the practice believes that this line is only the upper edge of the pyriformis muscle; some people advocate that the posterior superior iliac spine and the tip of the coccyx make a line first, and then take the point at the posterior superior iliac spine of the line at 2 centimeters, and then the point and the greater trochanter make a line from this point, and the line that is the center of the pyriformis muscle projected on the surface of the body line. If this line is divided into three equal parts, the inner 1/3 is the beginning of the pear-shaped muscle in the pelvis, the middle 1/3 is the abdominal portion of the muscle after it passes out of the sciatic foramen, and the outer 1/3 is the tendon portion. Therefore, the junction of the inner and middle 1/3 is the exit point of the pyriformis muscle, and the middle 1/3 is the site for examining changes in the pyriformis muscle for injury or disease, and for performing manipulation and other treatments. It should be noted that here in the gluteus maximus muscle often have spasmodic muscle bundles, easy to confuse with the pyriformis muscle, although the two are different, but by the depth of sometimes difficult to distinguish, it is best to touch the inner and middle 1/3 junction, touch the muscle bundles along the muscle bundles to the medial touch. A bone ring can be touched, which is the medial edge of the sciatic foramen magnum, if it is the pyriformis muscle, the muscle bundle will be submerged under this ring and disappear. If the muscle bundle crosses this ring and can be touched on the medial side of the ring, it is the spasticity muscle bundle of the gluteus maximus muscle. In addition, if the pear-shaped muscle injury, in addition to its own pressure and pain, often involving the sciatic nerve, can appear a series of related symptoms, in the posterior superior iliac spine of the upper outer if touching some of the size of different, or bunches, or scattered sliding joints, this is the local fat leaflets herniated into the superficial fascia after the occurrence of swelling, the formation of nodular fat ball, called sacroiliac fat hernia, with local distension, pulling pain and pain, serious cases can be affected to other places. It has localized distension, pulling pain and pressure pain, and may affect other places in severe cases. Clinical often see hip hip chronic soft tissue damage can cause knee pain, which is mainly the closure of the nerve is stimulated or provoked through the saphenous nerve innervation of the knee joint, the complaint of knee pain patients should pay attention to check the ipsilateral hip hip whether there is a disease, in order to prevent misdiagnosis. If the pain is in the medial border of the buttock, it is necessary to pay attention to the injury of the attachment border of the gluteus maximus muscle. In this type of injury, in addition to localized pressure and pain, small fibrous cords and other changes are often palpable. In addition to injury to the gluteus maximus attachment margin, the presence of sacroiliac joint subluxation should also be noted. It can be identified by checking whether the posterior superior iliac spine is symmetrical, “4” test, pelvic compression separation test, etc., and if necessary, X-ray photo examination to confirm the diagnosis. In conclusion, although lower back and leg pain is more complex, but there is still a rule to follow, lumbar disorders can cause lower back and leg pain, and the pain in different parts of the buttocks or legs can also provide us with clues of lumbar disease. By reviewing the anatomy of the buttocks and thighs, it will help us in the prevention and treatment of low back and leg pain.