H11 Lateral Medial Popliteal

Dorn Spinal Therapy

Spine Healing Therapy

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The H11 lateral popliteal ARP is located on the lateral side of the tendon of the semitendinosus muscle, or on the medial side of the tendon of the biceps femoris. The sensitivity of these points can be evident in most patients on the lateral side, some on the medial side, or on both sides.

The innervation of these points is unclear, but it may be related to the innervation of the origin of the medial or lateral head of the gastrocnemius. These points are sensitive in 93% of the author's patients and may appear laterally or medially or on both sides, in which case they are still treated as one ARP. In patients with back or sciatic problems, this ARP is definitely sensitive. The author suggests directing a 4-cm-long needle perpendicularly at this point. Alternatively, the needle can be tilted slightly toward the midline of the popliteal fossa.

Superior gluteal artery, Superficial branch

Gluteus maximus

Inferior gluteal nerve Inferior gluteal artery

Internal pudendal artery; vein

Posterior cutaneous nerve of thigh

Sciatic nerve

Muscular branches (tibial nerve) Biceps femoris, long head

Semitendinosus

Semimembranosus

Popliteal vein Popliteal artery Tibial nerve

Medial sural cutaneous nerve

Inferior gluteal nerve Inferior gluteal artery

Internal pudendal artery; vein

Posterior cutaneous nerve of thigh

Adductor Magnus Dry Needling

Lateral sural cutaneous nerve

Sciatic nerve

Small saphenous vein -

Figure 8-23 The inferior gluteal nerve, which innervates the gluteus maximus muscle. The iliotibial tract is innervated by cutaneous branches from the sciatic nerve. The popliteal acu-reflex point appears on the popliteal fossa, and the actual innervation is unclear.

Gluteus medius Piriformis Gemellus superior Obturatorius internus Gemellus inferior

Ascending branch (medial circumflex femoral artery)

Superficial branch (medial circumflex femoral artery)

Quadratus femoris Deep branch

(medial circumflex femoral artery) Perforating artery Adductor magnus

Perforating arteries

Biceps femoris, long head Biceps femoris, short head

Common fibular nerve

Lateral sural cutaneous nerve

Small saphenous vein -

Figure 8-23 The inferior gluteal nerve, which innervates the gluteus maximus muscle. The iliotibial tract is innervated by cutaneous branches from the sciatic nerve. The popliteal acu-reflex point appears on the popliteal fossa, and the actual innervation is unclear.

Many patients may feel a tingling sensation moving along the peroneal nerve down to the ankle when this point is needled.

H4 Saphenous (Cutaneous)

The H4 saphenous point is easily found on the medial side of the knee below the medial condyle of the tibia (Fig. 8-24). This point is sensitive in almost every patient.

The H4 saphenous point is formed right at the site where the saphenous nerve emerges from the deep fascia. The saphenous nerve is a cutaneous branch of the femoral nerve that descends through the femoral triangle. It accompanies the femoral artery and vein, and its branches supply innervation to the skin and fascia of the anterior and medial surfaces of the knee and leg as far as the medial malleolus.

The femoral nerve, from which the saphenous nerve branches, is the largest branch of the lumbar nerve plexus (arising from L2 to L4). The femoral nerve forms in the abdomen and enters the lower limb through the pelvis to the midpoint of the inguinal ligament. After passing distally in the femoral triangle, the femoral nerve divides into several terminal branches to supply innervation to the hip and knee joints and to the skin on the anteromedial side of the leg.

Dry Needling Medial Forearm

Medial marginal vein

Figure 8-24 The saphenous nerve, a cutaneous branch from the femoral nerve.

Perforating vein

Medial cutaneous nerve of leg (saphenous nerve)

(Arcuate vein of posterior leg)

Deep fascia of leg

Medial cutaneous nerve of leg (saphenous nerve)

Superficial fibular nerve

Medial dorsal cutaneous nerve

Intermediate dorsal cutaneous nerve

Infrapatellar branch (saphenous nerve)

Saphenous nerve

Great saphenous

Medial marginal vein

Figure 8-24 The saphenous nerve, a cutaneous branch from the femoral nerve.

Like the H1 deep radial ARP on the forearm, the H4 saphenous ARP is useful both for treatment and evaluation of health. As homeostasis declines, sensitivity develops gradually along the saphenous nerve distally from the H4 saphenous point. Thus the saphenous nerve provides quantitative information about healing potential and treatment prognosis. Information from both the H4 saphenous ARP and the H1 deep radial ARP constitutes the basis for quantitative evaluation of healing potential.

H24 Common Fibular (Peroneal)

The H24 common fibular ARP is just anteroinferior to the head of the fibula (Fig. 8-25). The common fib-ular nerve is one of the two terminal branches of the sciatic nerve. The finger-sized sciatic nerve, the largest nerve in the body, is formed by the ventral rami of L4 to S3. It leaves the pelvis through the greater sciatic foramen and runs inferiolaterally deep to the gluteus maximus. As it descends in the midline of the thigh, this nerve is overlapped posteriorly by the adjacent margins of the biceps femoris and semimembrano-

sus muscles. In the lower third of the thigh, it divides into the tibial and common fibular nerves.

The common fibular nerve enters the popliteal fossa along the medial border of the biceps muscle. It leaves the fossa by crossing superficially the lateral head of the gastrocnemius muscle. It then passes behind the head of the fibula, winds laterally around the neck of the bone, pierces the peroneus longus muscle, and divides into two terminal nerves: the superficial and deep fibular nerves. The H24 common fibular point is formed at the branching site.

This ARP is innervated by a terminal branch from the sciatic nerve; therefore it is needled to treat symptoms related to the lower back and sciatic nerve. Like the deep radial nerve and the saphen-ous nerve, the common fibular nerve has a linear course down the leg medial to the fibular bone. As the body's homeostasis declines, other sensitive points appear along the common fibular nerve distal from the H24 common fibular point.

H10 Sural (Cutaneous)

This ARP is located around the middle of the posterior aspect of the leg, between the two heads of the gastrocnemius muscle (Fig. 8-26). As mentioned previously, the sciatic nerve contains two nerves: the common fibular nerve and the tibial nerve. These two nerves separate before they enter the popliteal fossa. In the popliteal fossa, the common fibular nerve branches into the lateral sural nerve, and the tibial nerve branches into the medial sural nerve. These two branches descend and unite between the two heads of the gastrocnemius muscle to form the sural nerve. The sural nerve pierces the deep fascia around the middle of the posterior leg where the ARP is formed. The sural nerve is then joined by the fibular communicating branch of the common fibular nerve.

The sural nerve supplies the skin on the lateral and posterior part of the inferior one third of the leg. It enters the foot posterior to the lateral malleo-lus and supplies the skin along the lateral margin of the foot and the lateral side of the fifth digit.

H6 Tibial (Cutaneous)

This ARP is located on the medial aspect of the leg, about 6 to 8 cm above the medial malleolus. The tibial nerve is the larger terminal branch of the

Superior lateral genicular artery

Inferior lateral genicular artery

Common fibular nerve Fibularis [peroneus] longus

Extensor digitorum longus Anterior tibial recurrent artery Deep fibular nerve Superficial fibular nerve Fibularis [peroneus] longus

Extensor digitorum longus

Superficial fibular nerve Fibularis [peroneus] brevis Extensor digitorum longus Fibular artery, perforating branch Lateral malleolar network Anterior lateral malleolar artery

Extensor digitorum brevis

Fibularis [peroneus] tertius, tendon

Superior medial genicular artery

Genicular anastomosis Patellar ligament Anterior tibial nerve

Tibialis anterior

Deep fibular nerve

Extensor hallucis longus

Inferior extensor retinaculum Deep fibular nerve Dorsalis pedis artery

Dorsal digital nerves of foot

Dorsal metatarsal arteries Figure 8-25 The common fibular nerve, a branch from the sciatic nerve.

sciatic nerve (L4 to S3). The tibial nerve descends through the middle of the popliteal fossa, straight down the median plane of the calf and deep to the soleus muscle, and supplies all muscles in the posterior compartment of the leg. In addition, the tibial nerve gives off a cutaneous branch to form the sural nerve (described in previous section). The tibial nerve comes close to the medial skin about 6 to 8 cm above the medial malleolus. This is where the very important H6 tibial ARP is formed. From this point, the tibial nerve courses down and passes deep to the flexor retinaculum between the medial mal-leolus and calcaneus. Then the tibial nerve divides into the medial and lateral plantar nerves and the calcaneal branches, which supply the skin of the sole and heel (Fig. 8-27).

The H6 tibial ARP is sensitive in almost every patient. This point is very superficial in patients with thin leg muscles. For more effective needling in those patients, a 4-cm-long needle can be tilted downward to make better contact between the needle and tissues.

Greater saphenous vein

Saphenous nerve

Medial cutaneous nerve of leg (saphenous nerve)

Smallsaphenous vein

Medial cutaneous nerve of leg c (saphenous nerve)

Small saphenous vein

Medial cutaneous nerve of leg c (saphenous nerve)

Perforating Cutaneous Nerve

Figure 8-26 The sural nerve, a cutaneous branch from the sciatic nerve.

Small saphenous vein

Lateral sural cutaneous nerve (common fibular nerve)

Perforating vein* Medial sural cutaneous nerve (tibial nerve) Sural communicating branch Sural nerve

Deep fascia of leg

Lateral marginal vein Dorsal venous arch of foot

Dorsal venous network of foot , Lateral dorsal cutaneous nerve (sural nerve)

Figure 8-26 The sural nerve, a cutaneous branch from the sciatic nerve.

H5 Deep Fibular (Peroneal) (Cutaneous)

This ARP is located about 2 cm proximal to the web between the first and second toes. It appears sensitive in almost every patient.

As mentioned in the discussion of the H24 common fibular point, the deep fibular nerve is one of the two terminal branches of the common fibular nerve. The deep fibular nerve descends down the leg and gives off branches to the arteries, the ankle joint, and other articulations. This nerve becomes cutaneous approximately 2 cm proximal to the web between the first and second toes, where the ARP is formed (Fig. 8-28).

CUTANEOUS ACU-REFLEX POINTS OF THE TORSO

Every spinal nerve divides into two primary rami: posterior (dorsal) and anterior (ventral). The anterior primary ramus gives off two branches:

the lateral cutaneous and the anterior cutaneous nerves. Each cutaneous nerve separates into two end branches to supply side and anterior parts of the same dermatome. Thus lateral ARPs and anterior ARPs are formed at each spinal nerve from T2 to T12 (Fig. 8-29).

HOMEOSTATIC ACU-REFLEX POINTS FORMED BY THE POSTERIOR RAMI OF THE SPINAL NERVES

All facial ARPs are formed on the cranial nerves, and all body ARPs are associated with the spinal nerves. Once the spinal nerve leaves the intervertebral foramen, it divides into two major branches: the anterior primary ramus and the posterior primary ramus.

The skin and muscles of the back are supplied in a segmental manner by the posterior rami of the 33 pairs of spinal nerves, 8 from cervical vertebrae (C1 to C8), 12 from thoracic vertebrae (T1 to T12), 5 from lumbar vertebrae (L1 to L5), 4 from sacral vertebrae (S1 to S4), and 4 (or 3 in some cases) from the coccygeal bones. The coccygeal spinal nerves are very small and are needled only in treating pain in the coccygeal region.

The posterior rami of C1, C6, C7, C8, L4, and L5 supply innervation to deep muscles but not to the skin. The posterior ramus of C2 ascends over the back of the head and supplies the skin of the scalp, and a very important ARP is formed there.

The posterior rami run downward and laterally and innervate a band of skin at a lower level than the intervertebral foramen from which they emerge. This can be understood from the scheme of dermatomes of the back. Skin nerve supply overlaps considerably.

As described, the posterior primary ramus of a spinal nerve goes to the back and divides into two terminal branches: the medial branch and the lateral branch. In the thoracic region, the medial branch supplies the skin and the lateral branch supplies the muscles, whereas in the lumbar area, the medial branch supplies muscles and the lateral branch supplies the skin. The posterior primary ramus also sends small branches to innervate the joints of the spine.

Popliteal artery Popliteal vein

Inferior medial genicular artery

Popliteal artery Soleus

Posterior tibial artery Tibial nerve

Tibialis posterior

Flexor digitorum longus^

Posterior tibial artery

Tibial nerve Tibialis posterior, tendon Medial malleolus Flexor retinaculum ^

Popliteal artery Popliteal vein

Inferior medial genicular artery

Popliteal artery Soleus

Posterior tibial artery Tibial nerve

Dry Needling Tibialis Posterior

Common fibular nerve --Tibial nerve

Soleus Fibular artery

Flexor hallucis longus

Lateral malleolus Superior fibular [peroneal] retinaculum

Calcaneal tendon

Figure 8-27 The tibial nerve, a branch from the sciatic nerve.

Common fibular nerve --Tibial nerve

Soleus Fibular artery

Flexor hallucis longus

Lateral malleolus Superior fibular [peroneal] retinaculum

Calcaneal tendon

Figure 8-27 The tibial nerve, a branch from the sciatic nerve.

Superficial fibular nerve

Inferior extensor retinaculum

Lateral malleolus Medial dorsal cutaneous nerve Intermediate dorsal cutaneous nerve Small saphenous vein

Lateral dorsal cutaneous nerve

Lateral marginal vein

Dorsal venosus arch of foot

Superficial fibular nerve

Inferior extensor retinaculum

Lateral dorsal cutaneous nerve

Lateral marginal vein

Dorsal venosus arch of foot

Medial Sural Cutaneous Nerve

Saphenous nerve Medial sural cutaneous (tibial nerve) Greater saphenous vein

Medial malleolus

Greater saphenous vein Saphenous nerve

Medial marginal vein Perforating vein

Deep fibular nerve, dorsal digital nerves of foot

Dorsal digital nerves of foot Figure 8-28 The deep fibular nerve, a branch from the common fibular nerve.

Saphenous nerve Medial sural cutaneous (tibial nerve) Greater saphenous vein

Medial malleolus

Greater saphenous vein Saphenous nerve

Medial marginal vein Perforating vein

Deep fibular nerve, dorsal digital nerves of foot

Dorsal digital veins

Dorsal digital nerves of foot Figure 8-28 The deep fibular nerve, a branch from the common fibular nerve.

Third occipital^ nerve (C3)

Greater occipital nerve (C2) Suboccipital nerve (C1) Vertebral artery Lesser occipital nerve (cervical plexus) Great auricular nerve (cervical plexus)

Longissimus capitis Levator scapulae

Serratus posterior superior Multifidi

Thoracic nerves, medial and lateral posterior branches Iliocostalis thoracis

Longissimus thoracis Serratus posterior inferior Posterior branch (T12) Latissimus dorsi External oblique

Lumbar triangle; iliohypogastric nerve

Iliac crest

Posterior branch (T12)

Superior clunial nerves

Greater occipital nerve (C2); occipital artery; vein Great auricular nerve (cervical plexus) Posterior branch (C6) Posterior branch (C7) HF5/ / , Posterior branch (C8) ^////Posterior branch (T1)

Lateral supraclavicular nerve (cervical plexus) Deltoid

Inferior lateral cutaneous nerve of arm Radial nerve;

profunda brachii artery; (vein)

Posterior cutaneous nerve of arm brachii, long head Intercostobrachial nerve Axillary nerve; posterior circumflex humeal artery; vein Teres major Circumflex scapular artery; vein Teres minor Infraspinatus Rhomboid major Latissimus dorsi

(Subcutaneous bursa of posterior superior iliac spine) (Subcutaneous sacral bursa)

(Subcutaneous coccygeal bursa)

Third occipital^ nerve (C3)

Dry Needling For Radial Nerve

(Subcutaneous coccygeal bursa)

Posterior branch (S3) N Posterior branch (S4)

Figure 8-29 Spinal cutaneous nerves of the back.

Gluteus maximus -

Posterior branch (S3) N Posterior branch (S4)

Figure 8-29 Spinal cutaneous nerves of the back.

The posterior rami of the spinal nerve form the paravertebral ARPs. Sometimes paravertebral ARPs are physiologically different from both symptomatic and homeostatic points. The author selects and needles symptomatic and homeostatic ARPs because they are pathologically sensitive. Paravertebral ARPs are selected and needled because they are located close to the nerve roots of the symptomatic ARPs. Paravertebral ARPs are not necessarily sensitive during the needling session. In other words, both paravertebral ARPs and symptomatic ARPs are innervated by the spinal nerve fibers and share the same segmental organization. The stimulation of the paravertebral ARPs by needling will desensitize symptomatic ARPs through the physiologic segmental reflex. The relief of core muscle stress has also been shown to help the neuromuscular coordination of the limbs.

There is clinical evidence that very successful results have been obtained by needling only para-vertebral ARPs in patients with complex regional pain syndrome.

To locate the paravertebral ARPs, the author starts with palpation of the midline (the spinous processes). The precise location of the ARPs is not critical because of overlapping innervation of the cutaneous segmentation of the spinal nerves, but locating a point at the same level as the spinous process of the corresponding vertebra is preferable because this point may be closer to the primary ramus of the spinal nerve. Both sides of the spine are needled to ensure that muscles on both sides are relaxed, which helps realign the vertebral joints and provides enough stimulation to the nerve endings. The points to be needled are usually 2 to 3 cm (about 1 inch) from the midline.

There are five primary homeostatic ARPs on the back.

H7 Greater Occipital (Cutaneous)

This ARP is located at the base of the occipital region, 2 or 3 cm from the midline (see Fig. 8-30). This ARP can be located easily because it is sensitive in more than 95% of the author's patients. The dorsal rami of the C2 spinal nerve form the greater occipital nerve. This nerve emerges between the posterior arch of the atlas (C1) and the lamina of the axis (C2), below the small inferior oblique muscle of the head. The greater occipital nerve surfaces to supply the skin of the occipital region and back of the skull (Fig. 8-30). The H7 greater occipital ARP is frequently used because many symptoms can be traced to problems of the neck, which are discussed in detail in later chapters. For effective treatment, the author usually uses 34-gauge (0.22-mm diameter) needles. The depth varies from 2 to 5 cm, depending on the thickness of a patient's neck tissues.

H20 Spinous Process of T7 (Cutaneous)

This ARP is located right on the spinous process of T7. This point is sensitive in 80% of the author's patients. The tissues of this ARP are innervated mainly by small branches from the posterior primary ramus of the seventh thoracic spinal nerve.

Two methods can be used to locate this ARP. The first method is to palpate the spinous process of C7, which is the most prominent process at the base of the neck. From C7, the practitioner can palpate down to T7. The second method is faster: This ARP is level with the inferior angle of the scapula, and so the practitioner can locate the scapula and its inferior angle first (Fig. 8-31).

It is still not clear neuroanatomically why this ARP becomes more sensitive than most other body points. T7, located at the lower edge of the scapula, may serve as a mechanical pivot between upper and lower thoracic spine. Because of the scapula, the intervertebral joints from T1 to T6 are less bend-able. As a mechanical pivot, T7 is more vulnerable to mechanical wear. In addition, the center of the gravity of the head and shoulder girdle, including the upper limbs, is located just in front of T7, which makes it an important point of stress in maintaining posture.

Another possible reason why the spinous process of T7 can become sensitized earlier than other spinous processes is that the center of gravity of the upper limb and head is located just anterior to the body of the vertebra T7. This may create physical

Greater occipital nerve Semispinalis capitis Obliquus capitis superior Rectus capitis posterior major

Vertebral artery, atlantic part

Suboccipital nerve Obliquus capitis inferior Posterior branch (C2) Third occipital nerve

Cervical plexus

Dry Needling For Occipital Neuralgia

Obliquus capitis inferior Vertebral artery, cervical part Rectus capitis posterior major

Interspinales cervicis

Figure 8-30 The greater occipital nerve.

Third occipital nerve

Rectus capitis posterior minor Temporal bone, mastoid process Suboccipital nerve Atlas, posterior arch

Obliquus capitis inferior Vertebral artery, cervical part Rectus capitis posterior major

Interspinales cervicis

Figure 8-30 The greater occipital nerve.

Scapula <

Vertebra prominens Rib I

Superior angle Acromion-

scapula

Medial _ border Inferior angle

Iliac crest Posterior superior iliac spine Posterior inferior iliac spine

Iliac crest Posterior superior iliac spine Posterior inferior iliac spine

Posterior Vertebral Column

Vertebral column (cervical part)

Vertebral column (thoracic part)

Vertebral column (lumbar part)

Sacrum

[sacral vertebrae I-V] Coccyx

[coccygeal vertebrae I—IV]

Figure 8-31 Skeletal markers for the H20 spinous process point of T7 and the H15 posterior cutaneous point of L2.

Vertebral column (cervical part)

Vertebral column (thoracic part)

Vertebral column (lumbar part)

Sacrum

[sacral vertebrae I-V] Coccyx

[coccygeal vertebrae I—IV]

Figure 8-31 Skeletal markers for the H20 spinous process point of T7 and the H15 posterior cutaneous point of L2.

stress on the T7 level inasmuch as the muscles and ligaments have to maintain the postural balance of the upper part of the spine.

For needling this point, the author inserts a 5-cm-long needle diagonally into the ligament between the spinous processes of T7 and T8 until resistance is felt.

From T1 to T9, the spinous process of T7 is always the first point to become sensitive. The second sensitive spinous process is usually T5. As homeostasis declines, more sensitive points appear from T1 to T9. Thus the number of sensitive spinous processes from T1 to T9 provides quantitative information about the level of a person's homeostasis. Manual palpation of the spinous processes from T1 to T9 should be included in routine practice to estimate the healing potential of the patient.

H21 Posterior Cutaneous of T6 (Cutaneous)

This ARP is located about 3 cm laterally from the spinous process of C6. It is sensitive in 80% of the author's patients. This ARP is supplied by the cutaneous and medial branches of the posterior primary ramus of the T6 spinal nerve.

A 2.5-cm-long needle is tilted toward the mid-line and inserted to a depth of about 2 cm.

H15 Posterior Cutaneous of L2 (Cutaneous)

This ARP is sensitive in 90% of the author's patients. For most people, this ARP lies on the lateral border of the lower back muscle (erector spinae), at a level on the narrowest part of the waist. In patients with much subcutaneous fat, a practitioner can palpate the lowest edges of the rib cage on both sides and draw an imaginary line between them. This ARP lies on the crossing point of this line and the lateral border of the erector spinae muscle. An experienced practitioner can easily locate the spinous process of L2 and find this ARP very quickly by palpating the erector spinae muscle in the lumbar region.

This ARP is supplied by the cutaneous branch of the primary posterior ramus of L2 (see Fig. 8-31). Each posterior primary ramus gives off two terminal branches: the medial and the lateral. In the thoracic region, the medial branch is cutaneous and the lateral branch is muscular. In the lumbar region, the medial branch is muscular and lateral branch is cutaneous. Thus, in the lumbar region, palpation is important for locating the actual sensitive spot.

This point is extremely sensitive, especially in patients with lower back, leg, and gynecologic problems. A 4- to 5-cm-long needle is inserted, slightly tilted toward the midline. The depth of insertion varies from 3 to 5 cm.

H22 Posterior Cutaneous of L5 (Cutaneous)

To locate this point, it is better to locate the H15 posterior cutaneous ARP of L2 or the spinous process of L2, or both, first and then palpate down to locate the spinous processes of L4 and L5. This ARP is located about 3 cm from the spinous process of L5, right on the bulge of the erector spinae muscle. In some people, this point is closer to L4; in others, it is closer to L5. This point is innervated by the muscular branch of the posterior primary ramus of the spinal nerve of L5.

This is an important ARP in the treatment of lower back pain. The needling methods are the same as for the H15 posterior cutaneous ARP of L2, but the needle should be inserted perpendicularly downward.

H14 Superior Cluneal (Cutaneous)

This point is located at the highest point of the iliac crest. The iliac crest is palpated first in order to locate this ARP, which is sensitive in 90% of the patients. The lateral branches of the posterior primary rami of the first three lumbar nerves unite to form the superior cluneal nerves. The superior cluneal nerves take an oblique downward course to the buttock region and emerge from the deep fascia just superior to the iliac crest. These nerves supply the skin on the superior two thirds of the buttock (Fig. 8-32).

A 5- to 7-cm-long needle is inserted perpendicularly or downward just superior to the iliac crest. In case of severe lower back and leg pain, a large area around the iliac crest may be sensitive and painful, and three to five needles can be used. Some needles may be directed inferiorly into the gluteus medius muscle, which is attached to the external surface of the ilium.

SYMPTOMATIC ACU-REFLEX POINTS AND THEIR IDENTIFICATION IN EACH CASE

Needling homeostatic ARPs creates general stimulation, which improves physiologic and mechanical coordination and restores homeostasis. This restoration of homeostasis is nonspecific; in other words, the improvement in physiologic coordination is the same in every case regardless of the specific pathologic process. The specific pathologic process sensitizes a specific part of the body, and the ARPs related to that condition become sensitive. Thus homeostatic ARPs themselves are very often involved and become symptomatic. For example, the low back homeostatic H15, H14, H22, and H16 ARPs are always sensitive in patients with lower back pain. In these cases, homeostatic ARPs are also symptomatic ARPs.

The author needles local sensitive ARPs to desensitize them because these sensitized points usually are related to or generate pain. To understand the nature of symptomatic ARPs, practitioners need to understand the organization of a segment of the spinal cord. The body of a sensory neuron is housed in the dorsal (posterior) root ganglion, which is outside the spinal cord. This sensory neuron sends an axon (the peripheral nerve fiber) to the skin or muscle, or both, and to a dendrite centrally to the spinal cord gray matter.

The spinal cord gray matter contains different neurons and is divided into three parts: the dorsal (posterior) horn, the lateral horn, and the ventral

Superior clunial nerves (L1-L3) Medial clunial nerves (S1-S3)

(Gluteal fascia)

Inferior clunial nerves (posterior cutaneous nerve of thigh) Posterior cutaneous nerve of thigh

Tibial nerve

Semitendinosus Adductor hiatus

Gracilis Semimembranosus Popliteal artery Sartorius Popliteal vein Superior medial genicular artery Muscular branches (tibial nerve) Gastrocnemius, medial head

Gluteus Maximus Fiber

Gluteus maximus

Sciatic nerve

Perforating artery Biceps femoris, long head

Perforating arteries Common fibular nerve

Lateral sural cutaneous nerve Medial sural cutaneous nerve

Sural nerve Gastrocnemius, lateral head

Figure 8-32 Superior cluneal nerves (L1 to L3).

Gluteus maximus

Sciatic nerve

Perforating artery Biceps femoris, long head

Perforating arteries Common fibular nerve

Lateral sural cutaneous nerve Medial sural cutaneous nerve

Sural nerve Gastrocnemius, lateral head

Figure 8-32 Superior cluneal nerves (L1 to L3).

(anterior) horn. The neurons in the dorsal (posterior) horn connect with the dendrites from the sensory neuron of the dorsal root ganglion.

The dorsal horn neurons may inhibit, facilitate, or perform the relay of the sensory signals to the lateral horn and the ventral horn or to other segments of the spinal cord and to the brain. The processed signals from the dorsal horn neurons modulate the physiologic activities of the neurons of the lateral horn and the ventral horn.

The lateral horn neurons control the autonomic physiologic activities of internal organs, blood vessels, and glands. The ventral horn neurons are motor neurons, which control muscle activity.

The brain centers, after being activated by ascending signals from sensory neurons, may send signals to the segment to affect spinal cord neurons. Therefore the signals from the sensory nerve fibers influence lateral horn neurons, ventral horn neurons, other spinal segments, and the brain.

The lateral horn neurons regulate the autonomic activity of the organ systems (Fig. 8-33), blood vessels, joints, muscles, and skin. For example, the skin may become pale and cold as a result of vasoconstriction (constriction of the blood vessels). A muscle may show a diminished ability to stretch because of trophic changes caused by low blood circulation. Lack of sufficient blood circulation means low supplies of nutrition and oxygen to the joints. As a result of trophic changes of the ligaments, the joints will have a restricted range of motion.

The motor ventral horn controls muscle movement. It is important to keep in mind that the sensitized sensory fibers will in turn sensitize the motor neurons, which will cause muscle shortening or stiffness. The shortened muscles on the back can lead to blocked vertebral joints, resulting in stiffness of the neck and back, or to injuries to other shortened skeletal muscles and restrict the power of normal movement.

VIII

Gelatinous substance

Gelatinous substance

VIII

Intermediolateral nucleus

Anterior column, anterior horn

Marginal nucleus Posterior column, posterior horn

Posterior thoracic nucleus

Intermediate column, lateral horn

Intermediolateral nucleus

Anterior column, anterior horn

Nuclei

(Intermediate periaqueductal grey substantce)

Figure 8-33 Organization of the spinal cord. The neurons of the lateral horn regulate the autonomic physiologic activities.

Every sensitive ARP contains sensitized sensory nerve fibers. If the sensitivity of the sensory nerve increases for an extended period of time, the sensitized nerve will sensitize the neurons in the lateral horn and anterior horn of the spinal cord in a retrograde direction. As a result of this retrograde sensitization from peripheral nerves, the anatomy, physiologic activities, and biochemical profile of the spinal cord will become abnormal.

This spinal sensitization causes increased sympathetic activity, which affects the motor nerves and the postganglionic nerves. This process leads to vasoconstriction and muscle tension. Once this vicious circle is established, the local nerve fibers become more sensitive, affect more nerve fibers and other soft tissues, and finally cause the local tissues to react abnormally to mechanical, thermal, and chemical stimuli.

This peripheral pathologic phenomenon is known as hyperalgesia (pain) or hyperesthesia (discomfort). Local points are rendered sensitive by the acute onset of diseases or injuries or by chronic diseases. The disease- and injury-related sensitive points are defined as symptomatic, segmental, or local ARPs according to their physiologic nature. For example, injuries of the upper limb, such as tennis elbow or carpal tunnel syndrome, create sensitive points on the upper limb. These points are called symptomatic points if the symptoms of the injuries are discussed.

These sensitive points of the upper limb can be traced, through the pathway of their peripheral nerve, to spinal segments C5 to T1. These same points are called segmental points if the emphasis is on their neural origin in spinal segments.

The appearance of symptomatic points is a very individual process because no two patients are identical in terms of body types, genetic makeup, medical history, onset of injury or illness, lifestyle, or tolerance of needling. The appearance of symptomatic points in each case is thus a unique process.

How, then, does a practitioner locate the symptomatic points in each patient? To decide which symptomatic ARPs should be needled in current treatment, a practitioner needs to obtain the patient's medical history, especially data from medical examinations (including laboratory tests and imaging studies) and information about all the injuries sustained by the patient and related events. If the case is suitable for acupuncture therapy, visual examination should be performed first.

The first data are collected from the patient's description of the complaint and from the medical history. Then the physical data should be considered. The undressed patient stands in a relaxed way so that the practitioner can check posture, three-dimensional muscle balance, and spine structure. Such visual data may help reveal symptomatic points. Subsequently, the practitioner should perform a thorough examination of the body by manual palpation to see whether the self-presented data match the visual data. This process enables a practitioner to determine the following:

1. What structures are involved in the injury or are related to the symptoms

2. Where the symptomatic points are located

3. The physical and psychologic status of the patient (some patients are psychologically or physically less tolerant of needling)

4. The possible outcome of treatment

It is not clinically difficult to relate particular symptomatic points to their corresponding spinal segments. The reason is simple. Symptoms may vary from one case to another, but each symptom is related to spinal nerves of one or two portions of the spinal cord. The spinal cord can be divided into five portions: cervical (C1 to C7), upper back (C7 to T7), middle back (T5 to L2), lower back (T12 -L5), and sacral (L5 to S4). (Because the innervation of neighboring spinal areas always overlaps, there is some overlapping between these portions.) Cervical paravertebral points should be selected when any head or face problems are addressed. In the treatment of any upper limb problems, the paravertebral points of C5 and T1 should be needled. Lumber and sacral paravertebral points should be considered in in the treatment of any problems associated with lower back and lower limbs, including lower back pain and gynecologic, urinary, and large intestine problems. The paravertebral points of the neck and upper back should be needled to improve symptoms related to muscle balance and posture, heart disease, respiratory symptoms such as cough, asthma, and blood pressure. Stomach, small intestine, and gall bladder functions are related to the spinal segments of the middle back. For each treatment, two to seven points on each side of the spine may be needled. The number of paravertebral points selected depends on the severity of the symptoms and on the body's physical or pathologic tolerance of needling.

PRINCIPLES OF USING SPINAL SEGMENTATION IN ACUPUNCTURE THERAPY

The innervation of skin, muscles, bones, and even viscera is segmented in terms of spinal nerves. By understanding the basic principles of this spinal segmentation, the practitioner can select the proper paravertebral ARPs to match particular symptomatic ARPs.

HOW TO SELECT PARAVERTEBRAL ACU-REFLEX POINTS

The principles of selecting the paravertebral ARPs to match the symptomatic ARPs according to spinal segmentation are described in the following sections. In most cases, these principles are simple and obvious. For example, for symptoms of the upper limb, paravertebral ARPs from C4 to T1 are needled. For lower limb disorders, paraverte-bral ARPs along L2 to S3 are needled. Paravertebral ARPs along T1 to T7 are needled for problems of the upper back and chest, and paravertebral ARPs from T8 to L1 are needled for problems of the abdominal region.

Segmentation of the Body Structure

The following description of body segmentation is aimed to help practitioners to relate symptomatic and segmental points to their corresponding spinal segments. For purposes of clinical acupuncture, the precise segment is not critical because the innervated field of one spinal nerve overlaps with the innervated fields of both neighboring spinal nerves.

The segmental innervations of the skin, muscles, viscera, and bones are referred to as der-matome, myotome, viscerotome, and sclerotome, respectively. The description of the segmentation of the neural supply is intended simply as an aid to understanding the segmental relationship between local points and their corresponding spinal segmentation.

Segmental Innervation of the Skin: Dermatomes

In the trunk, cutaneous segmentation is arranged in regular bands from T2 to L1 (Fig. 8-34).

A few body marks can help practitioners remember the dermatomes: T2 is at the sternal angle, T10 at the level of the umbilicus, and L1 in the region of the groin. As mentioned previously, there is

Dry Needling For Radial Nerve

Nerves

Ophthalmic nerve Maxillary nerve ■fj .-Mandibular nerve 'Jf ^Greater auricular nerve (C2, C3)

Transverse cervical nerve (C2, C3) Supraclavicular nerve (C3, C4) T2 nerve

Upper lateral cutaneous nerve of arm (C5, C6) T3 nerve T4 nerve T5 nerve T6 nerve T7 nerve T8 nerve

Lower lateral cutaneous nerve of arm (C5, C6) Medial cutaneous nerve of arm (C8, T1) T9 nerve T10 nerve T11 nerve

Subcostal nerve (T12)

Posterior cutaneous nerve of forearm (C5, C6, C7, C8) Lateral cutaneous nerve of forearm (C5, C6) Iliohypogastric nerve L1 Ilioinguinal nerve L1 ^"^Superficial branch of radial nerve (C6, C7, C8) Femoral branches of genitofemoral nerve L1 Median nerve (C6, C7, C8)

Lateral femoral cutaneous nerve (L2, L3) Medial and intermediate femoral cutaneous nerves (L2, L3, L4) Obturator nerve (L2, L3, L4) Saphenous nerve (L2, L3, L4) Lateral cutaneous nerve of calf (L4, L5, S1)

---Superfical peroneal nerve (L4, L5, S1)

Deep peroneal nerve (L5)

Figure 8-34 Adult dermatome pattern. A, Anterior view. B, Posterior view.

Nerves

Greater occipital nerve (C2) -Greater auricular nerve (C2, C3)^\^ Lesser occipital nerve (C2) Supraclavicular nerve (C3, C4) Dorsal rami (C3, C4, C5) T2 nerve T3 nerve T4 nerve

Upper lateral cutaneous nerve of arm (C5, C6)-

T5 nerve T6 nerve T7 nerve T8 nerve T9 nerve

Medial cutaneous nerve of arm (C8, T1) Posterior cutaneous nerve of forearm (C5, C6, C7, C8)

T10 nerve T11 nerve T12 nerve Subcostal nerve (T12) ^ Medial cutaneous nerve of forearm (C8, T1)— Iliohypogastric nerve (L1) Dorsal rami (L1, L2, L3)

Dermatomes

Lateral cutaneous nerve of forearm (C5, C6)'V Ulnar nerve (C8, 11/ Median nerve (C6, C7, C8)

Dorsal rami (S1, S2, S3).—— Lateral cutaneous nerve of thigh (L2, L3) Posterior cutaneous nerve of thigh, (S1, S2, S3) Lateral cutaneous nerve of calf (L4, L5, S1)

Sural nerve (S1) Saphenous nerve (L3, L4) Medial calcaneal branches of tibial nerve (S1) Superfical peroneal nerve (L4, L5,

Dermatomes

Lateral cutaneous nerve of forearm (C5, C6)'V Ulnar nerve (C8, 11/ Median nerve (C6, C7, C8)

Sural nerve (S1) Saphenous nerve (L3, L4) Medial calcaneal branches of tibial nerve (S1) Superfical peroneal nerve (L4, L5,

Dry Needling Posterior Tibialis

considerable overlap between neighboring der-matomes of the trunk. For clinical simplicity and efficacy, it is therefore important to treat both the affected dermatomes and the neighboring der-matomes. For example, if postherpetic neuralgia is associated with T5 and T6, the dermatomes from T4 to T7 should be needled together, including par-avertebral ARPs from T4 to T7.

Segmental Innervation of the Musculature: Myotomes

The innervation of muscles of the trunk has a strictly segmental pattern from T1 to L1. The posterior rami supply the thoracic and lumbar muscles (spinal extensors), and their anterior rami innervate the intercostal muscles, abdominal flank muscles, and the rectus abdominis muscle in a regular segmental manner.

The segmental pattern of the muscles in the limbs is more functionally arranged. The groups of muscles that act for similar primary functions are often innervated by adjacent spinal nerves. For example, elbow flexor muscles are innervated by C5 and C6, whereas the elbow extensor muscles are innervated by C7 and C8.

For clinical practicality and efficacy, acupuncture practitioners do not need to remember which single muscle is supplied by which single segmental nerve, but they do need to know what portion of the segments are related to the particular muscles. For example, elbow flexors are innervated by C5 and C6, and extensors by C7 and C8. When any elbow pain or even any upper limb problems are treated, practitioners simply needle paravertebral ARPs from C4 to T1. Table 8-5, designed for clinical practicality, lists segmental innervation of muscles. More details of myotomes may be found in textbooks of neuroanatomy.

Segmental Innervation of the Skeletal System: Sclerotomes

Some patients seek acupuncture therapy for pain felt in the bones. One common example is the pain on the shin bone (tibia). Recognizing segmental supply by the spinal nerves (Table 8-6) helps prac-

TABLE 8-5

Segmental Innervation of Muscles

Musculature of the Body Region

Segments of the Spinal Cord

Face Neck

Upper limb (including shoulder) Lower limb (including hip) Trunk:

Diaphragm

Other trunk and abdominal muscles

Cranial nerves Cervical plexus C1-C4 C5-T1

T12-S3

C1-C5

Regular segmental pattern from C5 to S2

titioners select the proper paravertebral ARPs for needling. The principle of using sclerotomes is very similar to that of myotomes.

Segmental Innervation of the Internal Organs: Viscerotome

Some patients may complain of pain related to an internal organ such as the kidney or gall bladder. These patients should be referred to internists. However, the knowledge of segmental innervation of internal organs helps practitioners needle the correct paravertebral ARPs to relieve pain or muscle spasm of the internal organs.

Figure 8-35 shows that most important internal organs are innervated by both cervical and thoracic spinal nerves (including kidneys). Thus

TABLE 8-6

Segmental Innervation of the Skeletal System

TABLE 8-6

Segmental Innervation of the Skeletal System

Bones of the Body

Segments of the Spinal

Region

Cord

Cervical vertebrae

C1-C8

Upper limb (including

C4-T1

shoulder)

Lower limb (including hip)

T12-S3

Trunk

Costae

Regulär pattern from T1

to T12

Thoracic and lumbar

Regulär segmental

vertebrae

pattern from T1 to L5

Trigeminal nerve

Segmental symptoms

Trigeminal nerve

Trunk

OOOOOOOOHH h-Hh-HHHHHHH-l _J_J_J_JC0 G0G0G0G0

Vagus nerve

Heart

Lungs

Spleen

Stomach _

Duodenum

Pancreas

Liver/gall bladder

Kidney

Bladder

Uterus

Figure 8-35 Segmentation of the internal organs.

it is important to needle the cervical paravertebral ARPs when treating disorders of these organs.

SUMMARY

Changes in homeostasis, chronic diseases, and acute injuries convert latent ARPs into passive ARPs. There are three types of ARPs: symptomatic, homeostatic, and paravertebral. From a pathophysiologic viewpoint, two types of ARP are considered: symptomatic and homeostatic. As homeostasis declines, homeostatic ARPs appear nonsegmentally all over the body in a predictable pattern and sequence. Symptomatic ARPs are segmentally associated with external injuries or internal diseases. The third type, para-vertebral ARPs, helps balance the activities of the autonomic nervous system. For effective treatments, the three types of ARP should be properly combined.

The 24 homeostatic ARPs are used to treat all symptoms because needling these points improves homeostasis. All the other homeostatic ARPs may develop in some patterns related to these 24 homeostatic ARPs. When practitioners know the locations of the 24 homeostatic ARPs, they are able to predict where to find other homeostatic ARPs in which needling is necessary for the particular treatment.

Symptomatic ARPs are used to treat specific symptoms. Their appearance is usually local and segmental and less predictable. A practitioner should carefully palpate the patient's body to locate these points for each treatment.

Paravertebral ARPs should be selected to facilitate the therapeutic efficacy of the symptomatic ARPs that are being used. The paravertebral ARPs and symptomatic ARPs should be innervated by the spinal nerves of the same spinal segments.

In pain, acute symptoms sensitize only peripheral neurons, whereas chronic diseases sensitize both peripheral and central neurons. Acute symptoms can be easily desensitized with a few local treatments. Chronic diseases necessitate more holistic treatment to desensitize both peripheral and central neurons; in such cases, the pain symptoms are likely to reappear as a result of resensitization, even after some improvement is achieved.

Table 8-7 is a summary of the peripheral nerves and their muscular innervation.

Summary of Peripheral Nerves, Muscles, and Nerve Roots in the Upper and Lower Extremities*

Nerve

Muscle Innervated

Function of the Muscle

Origin of Nerve

Spinal accessory nerve

Trapezius

Elevates shoulder and arm; fixes

XI, C3, C4

scapula

Phrenic nerve

Diaphragm

Inspiration

C3, C4, C5

Dorsal scapular nerve

Rhomboid

Draws scapula up and in

C4, C5, C6

Levator scapulae

Elevates scapula

C3, C4, C5

Long thoracic nerve

Serratus anterior

Fixes scapula on arm raise

C5, C6, C7

Lateral pectoral nerve

Pectoralis major

Pulls shoulder forward

C5, C6

(clavicular head)

Medial pectoral nerve

Pectoralis major

Adducts and medially rotates

C6, C7, C8, T1

(sternal head)

arm

Pectoralis minor

Depresses scapula and pulls

C6, C7, C8

shoulder forward

Suprascapular nerve

Supraspinatus

Abducts humerus from 0 to

C5, C6

15 degrees

Infraspinatus

Externally rotates humerus

C5, C6

Subscapular nerve

Subscapularis

Internally rotates humerus

C5, C6

Teres major

Adducts and internally rotates

C5, C6

humerus

Thoracodorsal nerve

Latissimus dorsi

Adducts and internally rotates

C6, C7, C8

humerus

Axillary nerve

Teres minor

Adducts and internally rotates

C5, C6

humerus

Deltoid

Adducts humerus beyond

C5, C6

15 degrees

Musculocutaneous nerve

Biceps brachii

Flexes and supinates arm and

C5, C6

forearm

Brachialis

Flexes forearm

C5, C6

Radial nerve

Triceps

Extends forearm

C6, C7, C8

Brachioradialis

Flexes forearm

C5, C6

Extensor carpi radialis

Extend wrist; abduct hand

C5, C6

(longus and brevis)

Posterior interosseus nerve

Supinator

Supinates forearm

C6, C7

(branch of radial nerve)

Extensor carpi ulnaris

Extends wrist; adducts hand

C7, C8

Extensor digitorum

Extends digits

C7, C8

(communis)

Extensor digiti quinti

Extends digit 5

C7, C8

Abductor pollicis longus

Abducts thumb in plane of

C7, C8

palm

Extensor pollicis (longus

Extends thumb

C7, C8

and brevis)

Extensor indicis proprius

Extends digit 5

C7, C8

*Boldface indicates the clinically important nerve root related to the primary acu-reflex points

*Boldface indicates the clinically important nerve root related to the primary acu-reflex points

Summary of Peripheral Nerves, Muscles and Nerve Roots in the Upper and Lower Extremities*—Cont'd

Nerve

Muscle Innervated

Function of the Muscle

Origin of Nerve

Median nerve

Pronator teres

Pronates and flexes forearm

C6, C7

Flexor carpi radialis

Flexes wrist; abducts hand

C6, C7

Palmaris longus

Flexes wrist

C7, C8, T1

Flexor digitorum superficialis

Flexes metacarpophalangeal and proximal interphalangeal joints

C7, C8, T1

Lumbrical (I, II)

For digits 2 and 3, flex metacarpo-phalangeal joints; extend other joints

C8, T1

Opponens pollicis

Flexes and opposes thumb

C8, T1

Abductor pollicis brevis

Abducts thumb perpendicular to plane of palm

C8, T1

Flexor pollicis brevis

Flexes first phalanx of thumb

C8, T1

(superficial head)

Anterior interosseous nerve

Flexor digitorum profundus

Flexes digits 2 and 3

C7, C8

(branch of median nerve)

(digits 2 and 3)

Flexor pollicis longus

Flexes distal phalanx of thumb

C7, C8

Pronator quadratus

Pronates forearm

C7, C8

Ulnar nerve

Flexor carpi ulnaris

Flexes wrist; adducts hand

C7, C8, T1

Flexor digitorum profundus

Flexes digits 4 and 5

C7, C8

(digits 4 and 5)

Lumbrical (III, IV)

For digits 4 and 5, ilex metacarpo-phalangeal joints; extend other joints

C8, T1

Palmar interossei

Adduct fingers; flex metacarpopha-langeal joints; extend other joints

C8, T1

Dorsal interossei

Abduct fingers; flex metacarpopha-langeal joints; extend other joints

C8, T1

Flexor pollicis brevis (deep

Flexes and adducts thumb

C8, T1

head)

Adductor pollicis

Adducts thumb

C8, T1

Muscles of hypothenar

eminence

Opponens digiti brevis

Internally rotates digit 5

C8, T1

Abductor digiti minimi

Abducts digit 5

C8, T1

Flexor digiti minimi

Flexes digit 5 at metacarpophalan-geal joint

C8, T1

Superior gluteal nerve

Gluteus medius

Abducts and medially rotates thigh

L4, L5, S1

Gluteus minimus

Abducts and medially rotates thigh

L4, L5, S1

Tensor fasciae latae

Abducts and medially rotates thigh

L4, L5, S1

Inferior gluteal nerve

Gluteus maximus

Extends, abducts, and laterally rotates thigh; extends lower trunk

L5, S1, S2

Obturator nerve

Obturator externus

Adducts and outwardly rotates leg

L2, L3, L4

Adductor longus

Adducts thigh

L2, L3, L4

Adductor magnus

Adducts thigh

L2, L3, L4

Adductor brevis

Adducts thigh

L2, L3, L4

Gracilis

Adducts thigh

(Continued)

Summary of Peripheral Nerves, Muscles and Nerve Roots in the Upper and Lower Extremities*—Cont'd

Nerve

Muscle Innervated

Function of the Muscle

Origin of Nerve

Femoral nerve

Iliopsoas

Iliacus

Flexes leg at hip

L2, L3, L4

Psoas

Flexes leg at hip

L2, L3, L4

Quadriceps femoris

Rectus femoris

Extends leg at knee; flexes hip

L2, L3, L4

Vastus lateralis

Extends leg at knee

L2, L3, L4

Vastus intermedius

Extends leg at knee

L2, L3, L4

Vastus medialis

Extends leg at knee

L2, L3, L4

Pectineus

Adducts thigh

L2, L3, L4

Sartorius

Inwardly rotates leg; flexes hip and knee

L2, L3, L4

Sciatic nerve

Adductor magnus Hamstring muscles

Adducts thigh

L4, L5, S1

Semitendinosus

Flexes knee; medially rotates thigh; extends hip

L5, S1, S2

Semimembranosus

Flexes knee; medially rotates thigh; extends hip

L5, S1, S2

Biceps femoris

Flexes knee; extends hip

L5, S1, S2

Tibial nerve (branch of

Triceps surae muscles

sciatic nerve)

Gastrocnemius

Plantarflexes foot

S1, S2

Soleus

Plantarflexes foot

S1, S2

Popliteus nerve

Tibialis posterior

Plantarflexes and inverts foot

L4, L5

Plantaris

Spreads, brings together, and flexes proximal phalanges

L4, L5, S1

Flexor digitorum longus

Flexes distal phalanges; aids plantar flexion

L5, S1, S2

Flexor hallucis longus

Flexes great toes; aids plantar flexion

L5, S1, S2

Small foot muscles

Cups sole

S1, S2

Superficial peroneal (fibular)

Peroneus longus

Plantarflexes and everts foot

L5, S1

nerve (branch of sciatic

Peroneus brevis

Plantarfle

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