Peripheral Impingement: Fibular Head and Lumbosacral Angle

by Sheldon C. Yao, DO

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    00:01 So when you have compression of the nerve roots, sometimes that could cause muscle weakness.

    00:05 So, compression of the S1 nerve root which innervates your Achilles can sometimes cause a foot drop.

    00:14 This could also be mimicked by compression of the common fibular nerve.

    00:17 So, you could have central compression of the nerve in the nerve root at the spine due to disc herniations.

    00:24 But you have to differentiate that from possible peripheral impingement.

    00:27 So if we have peripheral impingement of the common fibular nerve at the fibular head, where you could have the fibula positioned more posteriorly because that nerve lies right posterior to the fibular head, that could lead to compression of the nerve causing a possible foot drop.

    00:44 So it mimics the same.

    00:45 So when you have certain findings, you also then have to differentiate between the central cause versus the peripheral cause of nerve injury.

    00:54 So some pearls to think about if we have lumbar disc degeneration and herniations.

    01:00 Not all disc herniations have to be symptomatic.

    01:04 In fact, 95% of those in the younger population may totally be asymptomatic.

    01:12 Nerve root symptoms are typically on one side.

    01:15 So if you have a herniated disc, it's very rare to have bilateral symptoms.

    01:19 In fact if you do have a bilateral or saddle innervation issues then you have to think about compression of the nerve roots, the cauda equina syndrome which is a surgical emergency So usually if you see a nerve symptoms, it's usually gonna be at one side only, usually not both sides.

    01:39 You definitely have to correlate what you're finding with what the patient is explaining in terms of duration of symptoms, history of trauma, history of injury and also correlate that with what's found via imaging.

    01:55 Disc herniations again is only just one reason for nerve impingement.

    01:58 There could be many different causes of nerve impingements such as muscle spasms.

    02:04 You could have piriformis syndrome where the sciatic nerve is compressesd by a spasmed piriformis muscle.

    02:11 So don't think that every single nerve issue is because of disc herniations.

    02:17 And not everything that radiates down the leg is due to just a nerve root.

    02:22 As we mentioned before, piriformis syndrome or other compressions such as the common peroneal nerve from the fibular head.

    02:28 Some pitfalls in evaluation when you're evaluating the lumbar spine, If someone comes in and they're severly injured, you don't want to make them do the works.

    02:38 So you don't want them to do any sort of active range of motion.

    02:41 Sometimes if you have suspicion to think that there is a fracture or some sort of injury in the area, you don't want to induce too much flexion or extension, especially if someone has severe osteoporosis or some sort of fracture.

    02:57 You always want to take an X-ray first in that case and make sure you rule those things out.

    03:02 If you don't perform an adequate orthopedic or neurological exam, you may miss some of the signs and symptoms that may come along with nerve root issues or orthopedic issues.

    03:11 And not performing a structural exam, tying in all the key structural findings of somatic dysfunctions that could tie in to lower back pain and similar presentations.

    03:21 One of the things that could help in the evaluation of low back pain is to take an X-ray and if you take an x-ray from the lateral view to take a look at the lumbosacral angle or also called the Ferguson angle.

    03:33 What this angle does is that it gives you approximate amount of lumbar lordosis and potential indication of whether or not there is an issue contributing to the low back pain.

    03:47 So, this angle is formed where you draw a line between the inclination of the sacrum to a horizontal line, usually it's like 25 to 35 degrees.

    03:57 If you have an angle greater than that, that's usually due to increased stress at the lumbosaccral joint.

    04:02 Again, increase in lordosis if you have ptosis where you have weakness of the anterior abdominal muscles or just obessity or pregnancy at times will increase that lumbar Ferguson angle.

    04:15 That lumbosacral angle also has a big part to do with the muscles and muscle tightness in our back.

    04:23 And so, there are certain muscles in our body that tend to be more spasmed and tight with overuse.

    04:32 And there are certain muscles in our body that tends to get more weak and inhibited.

    04:36 And so, around our pelvis, we have our erector spinae muscles in the back and our hip flexors, the ilipsoas and rectus femoris.

    04:46 These muscles going from the back to the frontier tend to become tighter when spasmed.

    04:52 Whereas our abdominal muscles and our gluteus muscles in the back here tend to become inhibited and weaker with stress.

    05:01 And so you could see how this kinda creates a cross and so they call this the "lower cross syndrome" where our muscles in our back and our hip flexors become tight and our abdominal muscles and our gluteal muscles become weaker leading to increased Ferguson angle.

    05:18 The anterior abdominal muscles here play a big part in supporting our lower back.

    05:23 And so we talked about having a core or cylinder surrounding our lumbar spine and so weakness of this abdominal muscles or transversalis can play a part in lower back pain also and is usually a key part in actual recovery to have the patients try to strengthen their abdominal muscles and if needed, to lose weight to decrease some of the strain at that area.

    05:49 So when evaluating lower back pain, causes and issues, there are some key things that can aid you with diagnosing the causes of lower back pain.

    06:00 So if patient comes in and they're complaining of increased pain with walking and twisting, that could be musculoskeletal, some sort of strain.

    06:07 If a patient says that their pain decreases with sitting, or if you bend towards where that actually increases a lot when they're standing up straight or trying to lay flat in bed, then we have to think about possible psoas syndrome or psoas muscle spasm.

    06:22 If they complain of increased pain with sitting or lumbar flexion, you have to think about possible disc herniation especially if the pain is shooting and more unilateral than bilateral.

    06:37 Increased pain with lumbar extension- this might be more of a facet joint issue cause you're closing the joint, and if the joint is inflammed, that could make the pain worse.

    06:48 Additional considerations to think about other things that contribute to pain lower back pain include posture, muscle weakness, sacrum or pelvic or lower extremity dysfunctions Having a leg-neck discrepancy is gonna cause uneveness at the pelvis which lead to side bending in the lumbar spine to compensate.

    07:09 And there's definitely certain things that could cause low back pain that's non-mechanical.

    07:14 Pain that is worse at night or doesn't really get any better with movement or positioning, you do have to think about possible tumors.

    07:25 Tumors from the prostate, especially it spread to bone really rapidlly.

    07:31 And also, lower back pain and stiffness that's worse really in the morning, tends to be more rheumatological.

    07:38 If you have pain associated with fever or chills, that might also be infection or a bone infection.

    About the Lecture

    The lecture Peripheral Impingement: Fibular Head and Lumbosacral Angle by Sheldon C. Yao, DO is from the course Osteopathic Diagnosis of the Lumbar Region. It contains the following chapters:

    • Peripheral Impingement – Fibular Head
    • Lumbar Spine – Pitfalls in Evaluation
    • Lumbosacral (Ferguson`s) Angle

    Included Quiz Questions

    1. Posterior
    2. Anterior
    3. Lateral
    4. Medial
    5. Anterolateral
    1. Ferguson's or Lumbosacral angle
    2. Angle of His
    3. Ranke angle
    4. Angle of Louis
    5. Fick angle
    1. Lateral upright view
    2. Anteroposterior view
    3. Posteroanterior view
    4. Lateral supine view
    5. Oblique view
    1. 35 degrees
    2. 45 degrees
    3. 40 degrees
    4. 25 degrees
    5. 20 degrees

    Author of lecture Peripheral Impingement: Fibular Head and Lumbosacral Angle

     Sheldon C. Yao, DO

    Sheldon C. Yao, DO

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