11: Lower Limb Pain: Hip, Thigh, Knee, Leg, Ankle, and Foot

CHAPTER 11 Lower Limb Pain: Hip, Thigh, Knee, Leg, Ankle, and Foot



INTRODUCTION


Pain and disorders in the hips and lower limbs are, like lower back pain, among the most challenging conditions in acupuncture pain management. As the baby boomer population ages and more middle-aged people are athletically active, more degenerative and traumatic cases are seen in acupuncture clinics. The task of treating pain and other disorders of these regions is challenging for at least two reasons:


1. Just as shoulder and upper limb pain are often associated with neck problems, pain in the lower limb is often related to lower back disorders, which are among the most common health problems.

2. Unlike the upper limbs, the hips and lower limbs bear weight, which makes them more susceptible to degenerative changes. This also makes the healing of injuries more difficult and prolongs the process of restoring normal physical function.

To overcome this difficult clinical challenge and achieve stable and faster results, it is indispensable to have good knowledge of the anatomic and the biomechanic structure of this region as well as some understanding of the pathologic nature of commonly encountered pain and disorders. This chapter will briefly describe the anatomy, physiology, and biomechanics of the hip and lower limb as it is relevant to acupuncture therapy and then discuss the most common hip and lower limb disorders that are seen in clinical practice. Finally, we will discuss the application of our standardized but individualizable protocol to the pain and disorders presented in this chapter.


The lower limbs are built for locomotion, bearing weight, and maintaining body equilibrium. In contrast with the upper limb, the lower limb has a bony junction with the axial skeleton and, unlike the freely movable and non–weight-bearing upper limb, the lower limb has more stability at the cost of reduced mobility. For example, the lateral abduction of the lower limb is restricted by the adductor muscles, while the flexion of the thigh is restrained by the hamstring muscles.


The lower limb consists of four major parts:


• The hip, which connects the femur (thigh bone) of the lower limb to the vertebral column

• The thigh, whose bone, the femur, connects the hip and the knee

• The leg, containing two bones, the tibia (shin bone) and the fibula (splint bone, calf bone), which connect the knee and ankle

• The foot, consisting of tarsus (bones of posterior and middle foot), metatarsus (bones of anterior foot), and phalanges (bones of toes)

From the perspective of acupuncture treatment, lower back problems and disorders of the hip and lower limb are inseparable. For example, ankle or foot pain will change the gait and shift the center of the gravity of the body, which will put more stress on the contralateral hip. When treating an ankle and foot disorder, both hips and the lower back should be examined and treated, as well as the injured ankle and foot.


Common causes of pain and disorders of the hip and lower limbs include degeneration, neurological origins, injuries from sports and daily activities, and inflammation and referral from a distant site, especially the lower back. Other pathologic conditions such as vascular diseases and tumors may cause lower limb pain for which acupuncture can be used only as supplementary or supportive therapy. This chapter addresses only the common causes of those pathologic conditions that are seen in daily acupuncture practice.


It is important to stress again that acupuncture practitioners must treat the whole body, not only the local symptoms. When treating the lower limb, a practitioner must examine the lower back. If there are tender points in the lower back, a practitioner must examine the upper back and the neck. This is why it is so important for an acupuncture practitioner to understand basic anatomy as it relates to acupuncture therapy and why so many chapters in this book emphasize anatomical descriptions from this standpoint.



BASIC ANATOMY OF THE LOWER LIMB: ITS RELATION TO PAIN AND ACUPUNCTURE THERAPY



The Bones of the Lower Limb


The large, irregular hip bone (os coxae) is composed of three bones: ilium, ischium, and pubis. These bones begin to fuse at 15 to 17 years of age and the fusion is complete by age 23. Thus, the hip bone is indistinguishably joined in an adult (Figure 11-1). A cup-shaped socket (named acetabulum, after a shallow cup used in ancient Rome for vinegar) is formed where the three bones fuse. The acetabulum and head of the femur form the hip joint.


image

Figure 11-1 Hip bone and its articular surfaces. Lateral view.


(From Jenkins D: Hollinshead’s functional anatomy of the limbs and back, ed 8, Philadelphia, 2002, WB Saunders, p 264.)


The femur is the longest, strongest, and heaviest bone in the body (Figure 11-2). A person’s height is about four times the length of the femur. The femur consists of a rounded head, neck, and greater and lesser trochanters at the proximal portion of the shaft, and two broadened lateral and medial condyles at the distal portion. The two condyles articulate with the tibia and patella to form the knee joint.


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Figure 11-2 Anterior (A) and posterior (B) views of the femur.


(From Jenkins D: Hollinshead’s functional anatomy of the limbs and back, ed 8, Philadelphia, 2002, WB Saunders, p 269.)


The leg consists of two bones, the tibia (shin bone) and the fibula (splint bone, calf bone). The tibia is the second largest bone in the body and is located on the anteromedial side of the leg. The tibia supports most of the body weight. The proximal end of the tibia is large and its lateral and medial condyles articulate with the corresponding condyles of the femur. The patellar ligament from the thigh muscles inserts into the prominent tibial tuberosity. The distal end of the tibia is small and has articular surfaces for the fibula and talus (Figure 11-3). Here the tibia forms the medial malleolus to stabilize the ankle. The shaft of the tibia is triangular in cross section.


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Figure 11-3 Anterior (A) and posterior (B) views of the right tibia and fibula.


(From Jenkins D: Hollinshead’s functional anatomy of the limbs and back, ed 8, Philadelphia, 2002, WB Saunders, p 329.)


The fibula is a long, pinlike bone (fibula means “pin” in Latin) that articulates with the tibia posterolateral. The fibula serves mainly as an attachment for muscles and gives stability to the ankle joint. The proximal end of the fibula is its head, which has a facet to articulate with the inferior surface of the lateral tibial condyle. The distal end of the fibula is the lateral malleolus, which helps to hold the talus in its socket (see Figure 11-3).


The foot consists of 7 tarsal bones, 5 metatarsal bones, and 14 phalanges (Figure 11-4). Of the seven tarsal bones, only the talus articulates with the leg bones. When treating ankle and foot pain, the practitioner needs to understand the anatomy and biomechanics of the foot to know where to find the symptomatic acupoint(s) (SAs). This chapter will focus only on cases that are commonly seen in acupuncture clinics, such as ankle sprain and plantar fasciitis, and will therefore not describe the complete anatomy and biomechanics of the foot, although readers may consult the available professional literature for more detailed knowledge.


image

Figure 11-4 The bones of the ankle and foot (dorsal view).


(From Jenkins D: Hollinshead’s functional anatomy of the limbs and back, ed 8, Philadelphia, 2002, WB Saunders, p 330.)



Muscles


Muscles are the source of most soft-tissue pain. A knowledge of the anatomy, physiology, and pathology of the muscles and peripheral nerves is vital for achieving optimum therapeutic results. The anatomic description of the muscles below shows that they are all supplied by branches of the peripheral nerves of the lumbosacral plexus. When treating pain in the lower back, the gluteal region, and the lower limb, careful manual palpation of the lower back area from T12 to S4 is always necessary because the paravertebral points from T12 to S4 should be selected for needling together with the SAs in the gluteal and lower limb regions.


Thigh muscles are large and the nerve trunks run deeply below these muscles; therefore only one homeostatic acupoint (HA), H18 iliotibial, is formed on the iliotibial band. However, when treating patients with pain or other disorders of the back, gluteal region, hip, knee, or leg, careful palpation can reveal tender points on the adductor muscles, hamstrings, and anterior leg extensor muscles. These tender points should be located by palpation and properly treated by acupuncture needling.




The Gluteal Muscles


The gluteal region is important for treating pain in the back, hip, and lower limb. Although there are only two HAs—H14 superior cluneal and H16 inferior gluteal—in this region, additional SAs will appear around these two HAs. Practitioners should be very familiar with the bony landmarks and surface markings of this region.


The iliac crest extends from the anterior superior iliac spine to the posterior superior iliac spine. Between the left and right posterior iliac spines is the posterior aspect of the sacrum. The spinous process of L4 vertebra is at the level of the summit of the posterior iliac crest. The spinous process of S2 is just between the left and right posterior superior iliac spine.


The gluteal muscles include (1) the three large glutei (gluteus maximus, medius, and minimus) and (2) four deeper small muscles (piriformis, obturator internus, gemelli, and quadratus femoris) (Figure 11-5). The three large glutei are extensors and abductors of the thigh at the hip joint and they also stabilize the pelvis. The small muscles are lateral rotators of the thigh at the hip joint and stabilize the femoral head in the acetabulum. Table 11-1 shows a summary of the muscles of the gluteal region.


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Figure 11-5 The gluteal muscles.


(From Jenkins D: Hollinshead’s functional anatomy of the limbs and back, ed 8, Philadelphia, 2002, WB Saunders, p 316.)



Table 11-1 The Muscles of the Gluteal Region

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The Thigh Muscles


The large, powerful thigh muscles are organized into three groups: anterior, medial, and posterior. The three groups are separated by fascial intermuscular septa.



The Anterior Thigh Muscles (Flexor Group)


The major muscles of the anterior group are iliopsoas, tensor fasciae latae, sartorius, and quadriceps femoris (Figure 11-6). They are accessible to acupuncture needling. Their anatomic function is summarized in Table 11-2.


image

Figure 11-6 Anterior thigh muscles (flexors).


(From Jenkins D: Hollinshead’s functional anatomy of the limbs and back, ed 8, Philadelphia, 2002, WB Saunders, p 317.)



Table 11-2 The Thigh Muscles

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The Medial Thigh Muscles (Adductor Group)


The medial thigh muscles (the pectineus, adductor longus, adductor brevis, adductor magnus, gracilis, and obturator externus) are adductors of the thigh (Figure 11-7). All of these muscles are supplied by the obturator nerve (L2, L3, and L4) except pectineus, which is supplied by the femoral nerve (L2 and L3). The “hamstring” part of the adductor magnus is supplied by the sciatic nerve (L4).


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Figure 11-7 The adductor muscles of the thigh.


(From Jenkins D: Hollinshead’s functional anatomy of the limbs and back, ed 8, Philadelphia, 2002, WB Saunders, p 318.)



The Posterior Thigh Muscles (The Hamstrings)


Three large muscles (semitendinosus, semimembranosus, and biceps femoris) of the posterior aspect are collectively known as the hamstring muscles (Figure 11-8). These muscles have the same origin on the ischial tuberosity, but the short head of the biceps femoris has an additional origin on the shaft of the femur. These long muscles extend from the hip joint and across the knee joint so they are all extensors of the thigh and flexors of the leg. In addition, they are all supplied by the same sciatic nerve.


image

Figure 11-8 The hamstrings: the flexors of the leg.


(From Jenkins D: Hollinshead’s functional anatomy of the limbs and back, ed 8, Philadelphia, 2002, WB Saunders, p 320.)


Tight hamstring muscles can cause gluteal and back problems because the hamstrings restrict spinal flexion.


The topography of the three groups of thigh muscles is shown in Figure 11-9.


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Figure 11-9 Transverse section through the thigh to show the topography of the three groups of thigh muscles.


(From Gosling J, Harris P, Whitmore I, Willan P: Human anatomy: color atlas and text, ed 4, Edinburgh, 2002, Mosby, p 233.)



Adductor Muscle Strain


Adductor muscle strain is a common muscle problem that is often overlooked by both healthcare practitioners and patients. Ninety percent of patients with lower back or thigh pain have strained adductor muscles.


When treating patients with lower back disorder or pain of the lower limb, adductor muscles should be palpated and their tender acupoints should be needled.



The Leg Muscles


Anatomically and functionally the leg muscles are divided into three compartments by (1) the tibia, the fibula, and the interosseous membrane between them and (2) the anterior and posterior crural intermuscular septa (Figure 11-10): the anterior, lateral, and posterior. The muscles in the same compartment perform similar functions and share the same nerve and blood supply.


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Figure 11-10 Transverse section of the leg to show the three compartments of the leg muscles. Please note that the “small” lateral compartment is surrounded by the fibula and two intermuscular septa.


(From Gosling J, Harris P, Whitmore I, Willan P: Human anatomy: color atlas and text, ed 4, Edinburgh, 2002, Mosby, p 247.)


The anterior compartment is between the tibia and the anterior crural septum. The muscles of this compartment function as extensors of the toes and effect dorsiflexion of the ankle joint (Figure 11-11).


image

Figure 11-11 The anterior muscles of the leg.


(From Jenkins D: Hollinshead’s functional anatomy of the limbs and back, ed 8, Philadelphia, 2002, WB Saunders, p 339.)


The lateral compartment is surrounded by the lateral aspect of the fibula and anterior and posterior crural intermuscular septa. The two muscles in this compartment are responsible for plantar flexion and eversion of the foot (Figure 11-12).


image

Figure 11-12 The lateral muscles of the leg.


(From Jenkins D: Hollinshead’s functional anatomy of the limbs and back, ed 8, Philadelphia, 2002, WB Saunders, p 338.)


The posterior compartment contains both superficial and deep muscles (Figure 11-13). The three powerful superficial calf muscles affect plantar flexion of the foot. These large muscles support and move the weight of the body. Four smaller deep muscles of the posterior compartment act on the knee joint (popliteus) and ankle and foot joints. These four smaller muscles are not important in acupuncture therapy and therefore are not listed in Table 11-3.


image

Figure 11-13 The posterior muscles of the leg.


(From Jenkins D: Hollinshead’s functional anatomy of the limbs and back, ed 8, Philadelphia, 2002, WB Saunders, p 333.)



Table 11-3 The Leg Muscles

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Nerves of Clinical Importance




The Superior Cluneal Nerves


The superior cluneal nerves are branches of the dorsal rami of L1, L2, and L3. They emerge from the deep fascia just superior to the iliac crest and innervate the skin on the superior two thirds of the gluteal region (buttocks). An important homeostatic acupoint, H14 superior cluneal, is formed at the location where the nerves penetrate the deep fascia. Most patients feel tenderness or even pain upon palpation at H14. In patients with chronic lower back or leg pain, the pain may spread over the entire skin area that is supplied by the superior cluneal nerves. In such cases, H14 and adjacent areas should be needled together.



The Inferior Gluteal Nerve


The inferior gluteal nerve branches from the ventral rami of L5, S1, and S2. This nerve leaves the pelvis from the greater sciatic foramen. Accompanying the inferior gluteal artery, the inferior gluteal nerve supplies the gluteus maximus muscle. The motor point, where the inferior gluteal nerve enters the gluteus maximus muscle, is the important HA H16 inferior gluteal. This point is formed deep below the thick gluteus maximus and should be palpated carefully.



The Sciatic Nerve and Its Terminal Branches: the Tibial, Common Fibular (Peroneal), and Sural Nerves


We have discussed this nerve in Chapter 5 and here we emphasize its relation to HAs and pain in the lower limb. The sciatic nerve is the largest nerve in the body. The ventral rami of L4, L5, S1, S2, and S3 converge at the inferior border of the piriformis muscle to form the sciatic nerve (Figure 11-14). Structurally the sciatic nerve consists of two nerves: the tibial and the common fibular (peroneal) nerve. The sciatic nerve leaves the pelvis through the greater sciatic foramen of the hip bone and enters the gluteal region inferior to the piriformis muscle (Figure 11-15

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Jun 11, 2016 | Posted by in BIOCHEMISTRY | Comments Off on 11: Lower Limb Pain: Hip, Thigh, Knee, Leg, Ankle, and Foot

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