We’re discussing actually some case studies in low back pain and how routinely it is so important to check for cluneal nerve entrapments that could be contributing to the patient’s low back pain, or even mimicking it being 100% of the low back pain.
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Hello everyone. And thank you very much for coming to the American Acupuncture Council, our sports acupuncture webinar. We’d like to thank the American Acupuncture Council for sponsoring us with this. I’m here with my friend, colleague and partner in the sports medicine acupuncture certification program. Brian Lau.
Hi, nice to be here again,
Brian and I were discussing just the other day about the upcoming module two low back hip and groin webinar that we’re having in the anatomy pop patient cadaver lab. We’re discussing actually some case studies in low back pain and how routinely it is so important to check for cluneal nerve entrapments that could be contributing to the patient’s low back pain, or even mimicking it being 100% of the low back pain. For example, the superior cluneal nerve entrapment can mimic yarn syndrome pain at the iliac crest, or it could be maybe 30% or 40% of that con contribution to the pain. So something just to routinely check in your cases of low back pain to see if an attraction is contributing to part of it. So I think we could probably just start bouncing right into it. So, Brian, do you want to go ahead and take it away and we’ll just go to the next slide.
Yeah, sure. So, uh, we’ll go, um, pass the title slide here. So into the next slide, and we’re going to start by, um, just giving a quick overview of the clinical nerves. So you have three circles that you see there. Uh, we have the superior cluneal nerve, so that’s that upper circle, uh, that I’m going to cover quite a bit in just a moment. So just for now, yeah. There’s the highlight, uh, showing the superior cluneal nerves now there’s multiple ones. Um, and we’ll, we’ll talk about that in just a moment, but then below that, in that middle circle, we have the middle cluneal nerves. Uh, those mats going to go into a little bit more, we’re both going to discuss some, but, um, he’s going to take that primarily. We’re not going to be discussing the inferior cluneal nerves, that bottom circle, uh, in this particular webinar, just because, um, this one is a little bit more on causes of low back pain and fluid inferior cluneal nerves, or are important.
Maybe another day we’ll cover those, but we’ll focus more superior and middle. Uh, so these nerves are cutaneous. Nerves are sensory nerves. Um, they, uh, then that means they’re going to be primarily innervating the skin. So they’re traveling in the subcutaneous tissue and innovating the skin. Uh, so let’s go ahead and move on and we’ll go right into superior cluneal nerves. So the superior cluneal nerves, uh, come from, they stem from [inaudible] the dorsal ramus. They travel posterior, uh, as they get more inferior penetrate through fibrous tunnels within the thoracolumbar fascia, uh, then they branch over the iliac crest to become subcutaneous where they, uh, innovate the skin and the subcutaneous tissue. Uh, so these are a common site of entrapment. Uh, so this, uh, superior cluneal nerves can becoming trapped in the superficial layer of the thoracolumbar fascia and can contribute to low back and leg pain.
Uh, just the note is that’s a little bit of a shorthand. So when it says that they, they, uh, stem from L one through L three travel posterior, there’s a whole lot of territory, you know, they’re not traveling through empty space at that time period. They’re actually traveling through structures like the, so as they’re traveling sometimes through the quadratus lumborum, but usually between the psoas and the QL, they travel through the para spinal muscles. So there’s a lot of territory, uh, in that region that we might be able to come back to later on in the, in the webinar to differentiate between various types of injuries. Our focus though is going to be on that, uh, area where they Pierce the thoracolumbar fascia, just at the iliac crest region, and then drape over the iliac crest. So maybe more on the other, other areas later, but let’s go with the entrapment site that we’re talking about in this webinar. So that’s the superior cluneal nerves and their site of entrapment.
So in, in terms of, uh, entrapment, there’s a, these are all the superior cluneal nerves, but there’s a middle or medial. Uh, one of those though, you know, the one that’s most medial, uh, then there is a middle or intermediate and then a lateral, uh, superior cluneal nerve. So these are all superior cleaning, the nerves that we’re talking about now, but we’re looking at the multiple nerves. So the medial most the middle and the lateral one, and it’s usually the medial branch that is commonly affected, uh, in terms of, um, becoming and trapped. So they all can be contributors, but this, this medial branch is the one that we’re really, um, gonna focus on, uh, in terms of where it’s, it’s going to become trapped. So, uh, these traveled through a fibrous tunnel, uh, then they go over the iliac crest so they can get in trapped in that fibrous trunk tunnel of the thoracolumbar fascia, or they can get trapped between that and kind of adhering to the iliac crest. So there’s a lot of research out there. You can look into it if you want it to, to check more information about it, but this image really kind of highlights that fibrous tunnel that you can see that those medial branches of the superior cluneal nerves travel through. So it’s just a, just a sort of a fibrous tunnel through the thoracolumbar fascia. All right, so let’s move on next one.
So in a cadaver studies, the researchers found that this medial branch of the superior cluneal nerve was frequently adhered between the fibers tunnel and the thoracolumbar fascia and where the medial branch travels over the iliac crest located just lateral to the PSIS. So there’s a lot of studies on this. Um, why it’s studied in Western literature, uh, is twofold. Uh, they study it of course, because it’s an entrapment site and it can be a pain generator. It’s considered not super common of a pain generator, but it is a pain generator and it’s worth knowing about, uh, that’s one reason that it’s a study. The other reason that it’s studied is when they harvest bone from the iliac crest to use for, um, fusion for lumbar fusions, uh, they want to know, you know, it’s really important that they know where these, uh, cluneal nerves are, so that they don’t damage the cluneal nerves in the process of process of harvesting bone from the iliac crest.
So because of that, there’s a lot of really good research that that kind of gives an average of where these cluneal nerves exit, um, both, you know, the, the medial ones, the intermediate and the lateral ones. So they have it all charted out on various different cadaver studies, measured from the PSIS are measured from the midline. And if we look at this, um, medial branch of the superior cluneal nerve, it’s approximately in the region of Yan, you know, of course they’re measuring it from different criteria. They’re usually usually measuring in millimeters, but the measurement kind of comes to about that same measurement, uh, as Yan, which is three and a half sun from the lower border of L four, just over the iliac crest. So this being a common site of entrapment means that it’s also a contributing factor, or sometimes the factor for Yan syndrome, which is pain at this particular region.
Um, again, we can come back and differentiate this type of pain that’s caused from an entrapment of the superior cluneal nerve versus other things that are in this region. Like the Leo Castelli’s lumborum, which attaches to the iliac crest in that region, or deeper to that, the quadratus lumborum, which attaches to the iliac crest in that region. So being able to differentiate what’s the, the pain generator is important, but in that process of determining what’s the pain generator, we want to make sure that we take into consideration the, uh, the superior cluneal nerves. So those cause pain Ayanna, that pain might radiate down into the buttock region, and you could follow those nerves and see how they drape over the glute medius. And even over the glute Maximus. Matt, do you want to add anything to that kind of just jumped in and covering it, but
That was great. Yeah, that was really good. So, uh, just to reiterate the, the, on, we just published a, an article as well on the sports medicine acupuncture website, and it’s talking about the superior superior cluneal nerve entrapment at the extra point Yon, and also in the Yon region, just something to, for practitioners to consider that there is a cadaver dissection that we did. And we were able to find one of the superior cluneal nerves, which is a difficult dissection to tease out these cutaneous nerves. Um, it’s not just us, that it’s actually in some of the articles, um, that are in the references. Um, they talk about the difficulty of actually trying to tease them out and try to be able to dissect them, to see if they are entrapped or not. Um, Yon syndrome that we call it is also in Western science called iliac crest syndrome is basically the, um, the strain of the soft tissues within that area like Brian was talking about, could be the thoracolumbar fashion, the illiocostalis or the thoracolumbar fascia and the quadratus lumborum.
And this has been treated for thousands of years by acupuncturist, but yet the entrapment side also could be a contributing factor to that. So the patient is complaining of that low back pain. They may also talk about a mild parasthesia you’ll have to dig that out of them. Most people are not going to consider that as a chief complaint. Um, it’s just more of the low back pain in that Yon region. So the entrapment side is something definitely to assess which we’re going to be talking about. The very simple assessment coming up in just a little bit, Brian, should I jump into the next entrapment? Uh, yeah. Yeah.
There’s some other things that we can come back to later on. That’ll be more differentiation. Um, but, uh, just to highlight one real quickly, what you said about why these are so difficult to dissect is that they live in the, at least the process that we’re the part of them that we’re looking for, uh, in terms of where they drape over the iliac crest, those live in the adipose tissue, and you know, this dissection, I mean, this, uh, this image from Netter, they they’re so clear looking. It’s so easy to see, but in dissection and it all looks alike, it’s all the same color. These are little over a millimeter in diameter, so they’re super thin. And just finding them in that adipose can be very challenging and take time to look for. But, um, one highlight from the video that Matt referenced on the blog, um, that in the processing of this video, it’s funny how you listen to things over and over, and you never noticed something. I just noticed today, actually, when I was listening to it, that I say superficial cluneal nerve over and over again, instead of superior cluneal nerve. Um, so, uh, if you listened to that video, if you go to the blog post and you look at that, that dissection video, don’t be confused. It is superficial because we’re looking at it, look, our we’re highlighting and showing it where it would be in the adipose tissue. But I meant to say superior cluneal nerve and not superficial clinical.
Yeah, that’s good. Brian, I think, I think it’s important for people to understand that this is really quite superficial. So if we have the low back, you’ve got the skin, then you’ve got your layer of your subcutaneous tissue. Then it’s just underneath that. So people have been treating the superior and middle cluneal nerve entrapment for a long, long time with techniques with cupping. And guash on with acupuncture. All of those actually have a strong effect on this superficial tissue, which we’ll talk little bit more about Sue
And Matt. It sounds like your chickens are laying eggs in case people are wondering.
Yeah. They just, they, they, they love to interrupt these webinars. They do. All right. I was wondering if you could hear it. All right. So let’s go to the next slide. Thank you. All right. So the middle cluneal nerves, so let’s separate, let’s differentiate this from what Brian was just talking about. The superior cluneal nerves are further broken down to medial, intermediate and lateral. You can see those three nerves as the superior, right? That’s not circled in this particular image. So now, now we’re going to be talking about the middle cluneal nerves that are branches from the [inaudible] dorsal. Ramiah now like the superior cluneal nerves. They also exit through the thoracolumbar fascia. And then the cutaneous area for them to innovate is going to be the lower part of the PSIS medial, buttock and OXA also the coccsyx region. So a patient may be complaining of pain in that area. It could, it could be planning of pain in the SSI joint that at first glance, you’re thinking that it could be a sake really actually problem. Um, but then you further differentiate that possibly the middle cluneal nerves are part of this. And we’ll talk about that. And just a little bit, when we get into our assessment and treatment, let’s just break down the anatomy of it for, for us right now. So let’s go ahead and go to the next slide.
So anatomically here’s an image from Grey’s anatomy, the course of the middle cluneal nerve stems from the sacral nerve roots. So we talked about S one through S3, then it travels posteriorly either under or through the long posterior sacroiliac ligament. Now there’s a number of different references for you guys to be able to check out and through the different anatomy from human to human, the course of the medial cluneal nerve, um, does vary. So sometimes it’s going to be underneath this long posterior sacral ligament, and other times it goes through it. And other times it goes above it with patients that have had the medial cluneal nerve entrapment with the surgeons. What they’re, what they’re saying. And their research is that when the long posterior sacral ligament becomes two tense in certain conditions, it will entrap the medial corneal nerve as it exits from the [inaudible] underneath that ligament, or in some humans, it’ll actually go through that ligament.
So that would be the entrapment site in the ligamentous tissue. However, like we saw in the slide before we saw that, that medial cluneal nerve, as it exits deep in this ligament and then comes superficial cause it’s a cutaneous nerve and it goes through thoracolumbar fascia. So in one of the articles that are in the references, they actually talk about that as being one of the entrapment sites it’s strong and Divya in 1957, they actually talk about how difficult it was to go to find the medial corneal nerves, but they felt that the entrapment side was through that thoracolumbar fascia. And then with further research, I think a decade later is when they actually started seeing the possible trap this side of the long posterior sacral ligament. So there’s two and Travis’ sites for us to be able to consider with the middle cluneal nerves that can mimic or contribute to pain in the SIB joint region. So let’s remember that one.
Hey Matt, can I add something to this, uh, later on, uh, when we talk a little bit more about treatment, it’s worth that noticing the connection between the, um, long posterior sacral, uh, sacroiliac ligament and the sacred tuberous, like a mint, cause that’s all kind of one chain of, of continuous tissue. So the sacred tuberous ligament ligament goes from the issue of tuberosity on the kind of bottom of that image as starting right there and then travels up at an angle towards the sacrum. Um, so we might come back and mention that later. So just, this is a good image to see that. All right, thank you. Um, next slide,
We talked about the neuro travels through the superficial fibers and exits a slightly lateral to you be 32 and 34. So that would be our landmarks. So the entrapment site couldn’t be through that long posterior sacral ligament. That’ll be deep to that region and also through the thoracolumbar fascia as a possibility. All right. So in this very interesting study from, uh, Kono and atta, the middle cluneal nerve is associated with pain involving lower back and buttocks. It can mimic sake, really act joint pain. It creates sciatica likes sensations, which is really quite fascinating. Now, according to our research, the trapping of the middle cluneal nerves is underdiagnosed cause of low back and or lakes symptoms. And if you refer to this research, uh, what they found was in 13% of the cadavers that they dissected, they found that the, uh, middle, middle cluneal nerve was adhered and trapped underneath the long poster sacral ligament.
In fact, they teased out the middle corneal nerves in the middle colonial nerves. If we look at this pin had normal density on one side normal density on the other side, when the attract it was, it was really, really very, very thin. So that patient most likely had low back pain, which was an attribute from the middle cluneal nerve as fascinating. So 13% of the population. So think about how many people are coming into your office with low back pain, like said it’s a good routine thing to check for superior cranial, nerve entrapment, and middle cluneal nerve entrapment on this image. You’ll see, there’s an a, and then there’s a B. And what they did is they measured from the lower border of the PSIS and the posterior, um, the long posterior sacral ligament, which is a mouthful to say where approximately where that attracted is from the lower border of the PSIS. And on average, it was about one centimeter. It was about one centimeter, so that you can see why that entrapment would mimic sacroiliac joint pain because you’re right next door to the lower aspect of the sacroiliac joint. [inaudible]
All right. So Brian, we’ll go ahead and jump into this one together. I’ll start it off. So the Cardinal symptom of chronic low back pain with, or without legs symptoms, you guys, so this remember that it doesn’t always have to be a chief complaint of parasthesia, but it’s a good thing to ask if somebody talks about a little bit of numbness or tingling and they may not even be aware of it because it can be so subtle, um, into the butt off region or maybe down the leg. I’ve of course, if it’s going down the leg, we have to rule out a disc problem with the many different nerve tension test for sciatica. Um, common aggravating activities are going to be walking rising from sitting, standing flection and extension. So a lot of functional examinations are going to be important with this. Uh, patients often find that pushing above the iliac crest with their hand relieves symptoms of the superior cluneal entrapment. So that kind of body language you want to watch for, you can ask the person if they find that if they put pressure on their low back and they push down a little bit, if that helps, that would be a sign as a possible nerve entrapment.
Yeah. They’re kind of decompressing it themselves, right? Yeah,
Exactly, exactly. They’re decompressing and try to open up the, uh, Travis’ side. I mean, people can have this for years because it may be just low back pain of a two or a three, and then sometimes it gets really bad to a four or five. And how many people do you know that just don’t get treated with their low back pain thinking that it’s just an aging thing. So this is something for us to consider when that patient comes in. They’ve had it for chronic low back pain for years, definitely check for these nerve Travis’ sites. In addition to the other things that could be occurring, it could be sacroiliac joint problem. It could end up being a Yon syndrome where there’s a strain within that soft tissues. And we’ll talk about that a little bit more when we get into posture, which I think is in a few more slides, Brian, you want to take it from here?
Let me just, uh, dimension the, uh, leg pain aspects. And, and you can tell me if I’m correct on this map. And my understanding with that, first of all, the cluneal nerves, if you go back to those images, do travel through the gluteal region. Uh, they’re superficial at that point, but they’re traveling in the adipose to, in route to the skin, uh, over glute max glute medius, depending on which, uh, which ones we’re looking at. Um, but the leg symptoms, uh, from my understanding, I think is more of a sensitization and, and a common innervation for other nerves that are traveling peripheral nerves that are traveling down to the legs. So if it’s very, um, severe entrapment, then that can start to irritate the other, other structures in that same innovation zone and, and cause pain in the legs. That’s my understanding of it. Does that match, match your, your, um, understanding of that, the leg symptom, uh, component of it?
Yeah. Cause it makes sense. I mean, it shares the same sciatic nerve distribution of being L four down to S3. Yeah.
Yeah. And especially the middle cluneal nerves, which have a lot of, uh, innovation of the legs. Yeah. So, um, looking at, uh, uh, pelvic imbalances, if there’s an elevated ilium, uh, anterior tilt, uh, is, is often associated too with it because of the shortening that can happen in the thoracolumbar fascia with that, of course a posterior tilt is going to kind of overstretch that, um, that same structure. So it wouldn’t be unheard of to have a posterior tilt of the pelvis, but those are the things to really note and notice with, um, with, uh, uh, cluneal nerve entrapment, regardless if we’re talking about the superior or the middle colonial nerves, just because those, uh, postural imbalances and we’ll look at an image for this to kind of highlight it. Those are gonna put extra tension on, on the ligaments, the, the, uh, posterior, uh, sacred iliac ligament that we’re talking about, the long posterior sacral ligament, um, but also the thoracolumbar fascia and how that tension patterns are then going to relate to a propensity to entrap the nerve.
So when we get to an image on that, we can highlight some of those aspects. Uh, as we both mentioned, this could be the cause, you know, this could be what, uh, is the, the, the main pain generator for a patient. Um, it could be like number one, but you know, it also can be just a component of a series of things that are kind of coalescing in the same area, and that can cause pain. So it doesn’t have to be an all or none type of type of thing. Like Matt mentioned, I think 20 or 30% of it might be coming from the clinical nerve irritation and entrapment. So it’s worth checking for, uh, do you want to talk about assessment mat
With it? I think the next slide we can jump into and kind of get into a little bit more. Yeah, there we go.
Yeah. So here we have that image of somebody with an elevated ilium. So you can look at and see that the person has an elevation on the left. So sometimes we call it a left, elevated ilium. Sometimes we refer to that as a right tilt of the pelvis because the whole pelvic structure is tilting to the right. The top of it’s kind of pointing to the right, but the left side is high. And that’s the main thing to notice. So with that, there’s going to be a lot of shortening and things like the quadratus lumborum iliacus Talis lumborum, those are all, uh, kind of intimately associated with the thoracolumbar fascia. Um, so that’s gonna, uh, tend to, uh, correlate with more of a propensity for entrapment of the, um, cluneal nerves. I would tend to see it more often, see it on the side of the elevation, but again, just those changes are going to change the tension patterns on both sides. Really. So the fact that that, that the tension patterns are changed and disrupting the, uh, the, uh, uh, normal sort of, uh, even balance, uh, in the pelvic and low back region that, that elevation of the Lem could really be a big factor for, for people. Um, of course it’s not the only one.
Yeah. So at the takeaway with this, I believe is to make sure that you are addressing the pelvic imbalances, which will then help with the soft tissue imbalances that are in trapping the cluneal nerves, as well as causing a sick really act joint problems or Yon syndrome, or the other many other causes of low back pain, something of which that we spent a heck of a lot of time in module, two, trying to be able to teach people how to be able to balance these. Because when you think about it, you want to balance that dantien your center of gravity. And then by balancing that pelvic curdle that changes the balance above, and it changes the balance. Yeah.
Now this particular patient, uh, I can’t tell looking at them, especially from the back, uh, if there’s an anterior or posterior tilt, um, sometimes visually you can see that it’s a little easier to get in and palpate, uh, to, to, um, feel landmarks like the PSA. I S N a S I S and look, we have a particular protocol we teach to measure that that’s a little bit more accurate than just glancing. Same with pelvic rotation. That’s a somewhat of a visual assessment, but it’s all, it’s really more of a palpatory assessment, but this particular model, you can definitely see the elevation of the Lem. Cool.
All right. So then now the second to last bullet, did we cover? Yes. So, so the third to last bullet where it says cluneal nerve and trauma can be a contributing factor along with other causes of low back and leg pain. Absolutely. So when you’re diagnosing what is causing that person’s low back and leg pain simply, and this is the assessment. One of the assessments is simply taking your index finger or your middle finger, and just tap firmly, firmly, right over the area of Jalya where the superior cluneal nerves could be in tract. It’s like a tunnel sign. Alright, just tap very thoroughly all around that region, even onto the PSIS, where the traffic could happen, then move down level with you be 32 and you’d be 34, do the same type of tapping. What you’re looking for is the patient have any pain with that is a reproducing, the pain that they’re complaining about, is it reproducing any of the parasthesia that they know about, or maybe they don’t about it? Like if you’re, if you are tapping on there and it’s causing that, parasthesia consider that the nerves are entrapped and they are contributing to part of the clinical picture here. Brian was anything.
Yeah. Even before that, you might not have gotten to the point where you, you think about doing a tunnel sign there, but you’re just palpating. You’re kind of going through the process of figuring out where the cause of the low back pain is and trying to diagnose what the, what the condition is. And you go to palpate, maybe you think it’s an SSI joint, um, uh, it’s SSI, joint pain, and you go to palpate that PSIS region. And even with superficial pressure, you know, you barely, you’re definitely not pressing past the subcutaneous tissue into the deeper muscular structures, but when you start getting that superficial, uh, pain, that’s a little bit more pain than you’d expect at such a superficial level. That’s if I haven’t already been considering cluneal nerve entrapment, that’s a, that’s a point at which I’m definitely starting to think about it because it’s, uh, it’s, they’re, they’re cutaneous nerves. So you don’t have to press particularly hard to elicit pain if they’re irritated and then going from there to the tapping for a Tinel sign might be a consideration that’s, especially the case with the superior ones, you know, with the, the middle ones, the, the entrapment can be a little deeper if it’s at that, uh, ligaments. So that may or may not be quite the case, but if it’s irritated, uh, uh, at a periphery from that entrapment site, you still might get that elicit that, uh, very superficial pain.
All right. Should we go into a couple of needle techniques we could use? Yeah. So these are some images from the sports medicine acupuncture textbook on the left-hand side, you’ll see four arrows. Those are different vectors angles that we’ll use to palpate to affect the, um, iliac joint region. So the needle is going to actually be going into ligamentous tissue and the deep [inaudible], but let’s talk about the arrow that’s on the very bottom. Now that particular direction there, if you remember that direction is going to be very, very close to where the entrapment site of the middle cluneal nerve in the long post of your sacral ligament would be. So you could take your finger underneath that. PSIS approximately one centimeter go directly anterior, and then push upward toward that PSIS but deep angle it toward the sacroiliac joint. Now that’s really very, very tender and maybe even causes some parasthesia again.
Then you could be able to consider an entrapment site, and that would be a needle angle that we could choose. So going in with a three inch needle, or maybe a two-inch needle going into that Oscher point that we just diagnosed through palpation stimulating. Now, what you can do as well is to rotate the tissue around the needle. So turn the needle 180 degrees, 300 6720 degrees in one direction, as long as the patient’s. Okay. And then gently just pull up to loosen up that tissue with the idea, the intention of opening the area of the entrapment site. Of course, always to patient comfort. Uh, patients usually really liked that area because a deep, deep massage really doesn’t get to it, but that acupuncture needle can get to that region. So that’s one needle technique that you can use, but remember, that’s just one spot and this area is associated with the urinary bladder primary channel, and also the sinew channel.
So remember to link points that will address this region. So your adjacent and your distal points as well. Now you’ve got the images on the middle here on this slide and also in the lower right. That’s going to be looking at Yon. So the finger, you can see the middle fingers pointing right toward where that superior cluneal nerve can be entrapped. So that’s really quite tender. You can kneel that with your three inch needle. Um, the lower right-hand side is going to be kneeling in that level. And then as we discussed in the smack program, and this was Brian’s finding that this particular level is going to be more about the urinary bladder, send your channel, and if it would happen to be deeper, it’d be more about deliver channel Brian. You want to take it away? Uh,
Yeah. So this is another one that that needle technique by itself, uh, is great. And, um, I think what Matt was alluding to was if we’re at superficial, uh, pressing into Yon, we might, we’d be pressing into the iliacus Dallas, uh, muscle, which is also a potential, uh, site of pain in and of itself. But, uh, that could be putting excess tension into the thoracolumbar fascia. Um, and that would be more online with this new channel associated with the urinary bladder. So we might link it with, I don’t know, biceps, remoras, motor point, maybe beat channel points. We could try distal points and then go back and palpate that area and see if it reduces pain. If we go a little bit lateral sink in and go deep back to that same point. And we were at the quadratus lumborum attachment quadratus lumborum is on the myofascial plane that is continuous with the iliacus and into the abductors.
So it’s part of the liver send your channel. Uh, liver five would be my go-to point for that, but again, you can try different points and see if, uh, if that helps reduce pain at that site. Um, those, those are, those could potentially be vectors for the muscle pain, but those would also be associated with tension in that region. Um, when I, when I think that there’s, um, cluneal nerve entrapment, sometimes I do one vector like that, uh, just as being shown and I’ll do another vector above and trying to actually touch the iliac crest, kind of like two needles meeting at the same point and do it just what Matt mentioned with the middle Glendale nerve, where I’ll, I’ll, I’ll twist the needle to comfort to get the needle stuck purposely. You know, if you let it sit for awhile, it’ll, it’ll be able to come out, but you want to be able to get it a little bit, uh, wrapped around the tissue so that I can pull both of those needles in opposite directions. You know, one superior the other lateral to help decompress and open that area up. Maybe even a couple needles in, in that, uh, that region might be useful that way, but that would be by patient comfort. And you have to keep in communication with your patient.
Chinese needles are usually the best for that. Some of the, um, the Japanese or Korean Neil’s needles that are coded doesn’t wrap the tissue as well. So, um, our favorite needles for that is watchtowers. And you get the, watch us from LASA RMS. That’s good. Um, we’re about to show you. We’ll be,
Uh, Matt, since I let’s go back just for a second, since we’re mentioning, we both mentioned that, uh, usually you let the needle sit for 10 minutes or however long you’re going to have the treatment. They come right out after that time, but it’s always good to note which way you’re rotating the needle in case there is an issue and you have to D rotate it. Do you want to remember, oh, I did a clockwise. I needed to D rotate a counter-clockwise. So just, uh, to make a note of that is, is useful.
One more thing for me now is that after that needle technique, now this is not just an allopathic needle technique. This is going to be a needle technique for decompressing, that nerve entrapment in the region that you leave with that we’ll be communicating with all of the rest of the needles that you’re using during that treatment. So just to be clear, we’re not going in and doing the different needle techniques and then taking the needles out. That’s actually part of the treatment it’s going to be communicating with the channel systems. Just want to make sure that that was clear, uh, before we go to the next one. So we’re going to have two videos right now. These are some myofascial release techniques that are really very useful to use after the needle techniques. These techniques are going to be taught in the assessment of treatment of the channel sinews module two coming up in September. So these are just two of the, uh, mini techniques that we’re going to be teaching in that weekend class. Um, very useful for, uh, low back pain. And also in particular, these nerve entrapments. Brian, can we just go for it? Yeah, sure.
So this is a very simple technique just to spread and, and descend the tissue or the erector spinae as part of the urinary bladder sinew channel. A couple of considerations though, is as we’re spreading down the urinary bladder line, when we get to the iliac crest, we have a couple options. If the patient has an elevated ilium, may hike your Liam up. We might work a long, the iliac crest to be able to descend that tissue, but also to help, uh, push the helium down. In addition to that, a posterior tilt moving from medial to lateral will help sort of put the tissue back into a place. That’ll take them into an anterior tilt. So either posterior tilt or ilium elevation, I can take that tissue then to, from a medial to lateral position, they have an anterior tilt. I might gently come over the ilium, just being sure not to push into the bone and then descend down through the fascia over the sacrum. We’re going to find a good starting place somewhere around the inferior angle of the scapula. I want to be careful not to dig my elbow into the spine, but I’m going to be pretty close to the Lima, but the bulk of the pressure is going to be along the urinary bladder line sink in, and then slowly spreading downward [inaudible]
Patient movement. They can just gently take a nice deep breath and breathe in to the pressure
And exhale [inaudible].
And again, when I get closer to the OEM, that’s when I need to make a decision based on my assessment to either spread along the top of the iliac crest, going medial to lateral or in this case, I think I’m going to be careful not to dig my elbow into the bone. And I’m just going to continue downward to take the pelvis or influence the pelvis into a posterior tilt. Yeah. I can have the patients slowly talk to the pelvis under and relax one more time and track the glitch. Just try to slowly, just a little bit tuck under. Yeah, there you go. And that feels like a good place to exit.
Okay. It’s a very nice technique, especially after Neely needling in that area and helps reduce any kind of needle soreness. And then we have another one coming up, which is in particular really great for the sacrum and middle cluneal nerve. Brian, do I say anything before we jump into it? Nope. I
Think it’s about to start anyways. Or maybe that’s that play? Yeah, I think the video will describe it pretty well.
So it will be well working on the attachments of the glute Maximus, especially the sacral attachments and just that spreading and moving kind of softening the attachments along the sacrum. Very nice technique. Uh, we can adapt the technique to somebody who has a posterior and anterior tilt. This model. We have an anterior tilt, but I’m an exaggerate. The anterior tilt. You can imagine with that, that it’s going to be much more effective if I move that tissue away from the sacrum. Yes. But also downward to help encourage more. Posteriority tip the pelvis. Conversely, if somebody has posterior telecon tuck your pelvis under. Yeah. And in that case, you know, if you were working in that same direction, it’s going to encourage them more into a posterior tilt in the RDR. So it would make more sense to come from a different angle and help lift the tissue to help encourage more anteriority to the pelvis.
So we can adapt that general direction. But in both cases, you’re moving the tissue away from the sacrum, either away and down kind of lateral and down or lateral and up. So we’ll start with lateral and downward. I’m going to set a little bit out at the edge of the table. My side is towards her, so I can gently let my body sink into the tissue, using the elbow. Also a little bit of the proximal, although I’m going to go right to the sacral attachments, think perpendicular and then spread slightly lateral just to distract the tissue away from the sacrum, an inferior. I might have the patient gently and slowly tuck the pelvis under just the small movements, adequate good and relax, move slightly downward, get another area of the tissue sink in, talk under and move. That movement that you’re doing is going to help them talk the pelvis under relax [inaudible] and slowly, gently talk under
So in some instances you might, especially with an anterior tilt, you might add to the technique I put in the patient into sort of a crawl position. And you can see in this position, that’s going to encourage even more of a posterior tilt of the pelvis. So I can do similar technique here. Again, similar technique with them in this position. And the position itself is going to encourage more of a posterior tilt
And I might hold a little longer in this particular position.
Okay. That was great. So with that crawl position, you could see that the long posterior sacral ligament will then be slackened because the attachment sites were brought together closer. The PSIS went into a posterior tilt and his Brian’s elbow was right there. Pretty much level with S two S3 S four region. So what a great technique for sacred iliac joint problems, as well as if you are suspecting any kind of, of middle cluneal nerve entrapment, Brian, anything you want to say before we do our conclusions?
No, I think, uh, I think we’re, we’re good. Um, just the fall assessment really to differentiate what’s causing the pain. Is this a contributor or is this really a sacred iliac joint problem or is this a facet joint problem? Um, thoracolumbar junction syndrome for me is one that’s really tricky to differentiate between just because of those nerves can also be involved in thoracolumbar junction syndrome, but they’re involved, uh, not as they exit the thoracolumbar fascia, but they’re involved, uh, in route to, to that region. So those are, those are a little trickier to differentiate, but looking at all, differentiation for all of those really ruled out which one is, or, you know, figure out which one is really the pain generator is important.
Yeah. A thorough differential diagnosis. Yeah. With through sports medicine assessment, and also through TCM, which is something that we do in sports medicine, acupuncture certification program. So you guys, if you like our education, please come join us at www.sportsmedicineacupuncture.com. You can also reach out to Patricia, which is, uh, through email AQI sport firstname.lastname@example.org. Um, I believe that’s going to be wrapping it up for us. You guys thank you so much for staying the extra time. I know that these are only supposed to be a half an hour, so thanks for the extra time and also come back next week. Cause we have Chen Yen coming in. Who’s going to be discussing a lot of great things. So, uh, Brian, it’s always a pleasure. Thank you so much. We want to thank the American Acupuncture Council for having us. Thanks for much you guys. And we’ll see you again soon. Yeah. Have a great day, everyone. All right. Bye