Case 1｜Acute Right Thoracolumbar Pain: From Sharp Back Pain to Cough Pain — A Four-Tier Diagnostic Pathway

① Case Background

A 46-year-old female developed sudden, severe right thoracolumbar pain one week ago while bending forward to pick up an item in the kitchen.
The pain extended from the right costal margin down to the iliac crest. The patient described it as “right lower back and flank pain.”

Typical features:

• Pain significantly worsened with coughing, sneezing, or deep breathing

• Pain increased with thoracolumbar movement

② Four-Tier Clinical Reasoning

🔵 Tier 1: Symptom-Level Interpretation — The Trap of “Muscle Strain”

At first glance, this appears to be a typical “acute back strain” scenario:

• Sudden onset after bending

• Localized tenderness

• Patient feels she “twisted her back”

Thus, many clinicians and patients naturally assume:

muscle strain / muscle spasm / soft-tissue injury

However, this explanation fails to answer key questions:

• Why does coughing, sneezing, or deep breathing immediately worsen the pain?

A muscle strain alone does not produce sharp, cough-induced pain.

👉 Staying only at the muscular level easily leads to diagnostic misdirection.

🟡 Tier 2: Functional / Neurological Interpretation — This Is Nerve Root Irritation

Clinically, the question should shift from “Where does it hurt?” to
“When does it hurt the most?”

Three hallmark symptoms stand out:

• Coughing pain

• Sneezing pain

• Deep-breathing pain

These strongly suggest nerve root irritation.

Physical examinations further confirmed this:

• Hyperalgesia in the right T10–T12 dermatomes

• Paraspinal tenderness at T10–T12, with referred pain to the patient’s symptomatic region

Together, these findings point to:

Intercostal neuralgia / thoracic nerve root irritation

This is no longer a muscular issue.
👉 The nervous system is signaling distress.

This tier marks the shift from “muscle thinking” to “neurogenic thinking.”

🟠 Tier 3: Structural / Mechanistic Interpretation — What Is Irritating the Nerve Root?

After confirming nerve root involvement, the next essential question is:

“Why is the nerve root irritated?”

Several examination clues provided the answer:

• Distinct paraspinal tenderness at T10–T12

• Restricted mobility in the same segments

• Immediate reduction in cough pain after facet joint mobilization

These findings strongly support:

Thoracic facet joint dysfunction / capsular entrapment → irritation of the corresponding nerve root → intercostal neuralgia

The diagnosis thus progresses from “what hurts” to
👉 “what mechanism is creating the pain.”

🔴 Tier 4: Deep Structural Interpretation — Why Did Facet Dysfunction Occur?

The deeper question is not
“Which joint is misaligned?”
but rather:

“Why is this patient prone to facet joint locking?”

Common underlying contributors include:

• Prolonged sitting and forward-bending postures → thoracolumbar stiffness / flat-back posture

• Mild scoliosis or asymmetric spinal loading

• Insufficient core stability

• The thoracolumbar junction’s inherent nature: low stability + limited mobility

In such a structural environment,
even a simple forward-bending movement can trigger facet locking → nerve root irritation → acute sharp back pain, cough-induced pain, and abdominal radiation.

This tier reminds us:
The acute episode is the result; long-standing structural imbalance is the true cause.

③ Treatment Strategy

The management approach is straightforward:

1. Remove the source of nerve root irritation

• Mobilize the thoracolumbar facet joints

• Release tissues potentially impinging or tethering the nerve root

2. Reduce protective muscular guarding

• Acupuncture or manual techniques to relax hypertonic muscles

• Interrupt the protective spasm cycle

3. Restore normal joint mobility

• Guide the patient through gentle flexion, extension, and side-bending

• Reestablish proper joint biomechanics

After one treatment, the patient’s severe pain significantly reduced, and coughing no longer triggered sharp pain, confirming that the nerve root irritation was relieved.

④ Key Clinical Insight

Back pain should not be evaluated only by “where it hurts.”
Once coughing pain appears, nerve root irritation must be considered.
Following the pathway of neurogenic pain leads to identifying facet dysfunction, spinal imbalance, and deeper structural contributors.

Case 2｜Left Testicular Pain: A Psoas Chain–Induced Neural Traction Trap

① Case Background

The patient is a Kiwi male.
He has experienced left testicular discomfort for approximately 13 years, with significant worsening over the past two years.

Main symptoms:

• Dull ache and aching sensation in the left testicle

• A feeling of scrotal heaviness or “dragging”

• Mild discomfort in the left inguinal region

• Standing or prolonged walking aggravates symptoms

• Lying down relieves symptoms

• NSAIDs (ibuprofen, Voltaren) provide relief

• Antibiotics have no effect

He was previously severely obese (around 130 kg) and later lost nearly 50 kg through surgery and fat-reduction procedures.
His current weight is around 90 kg.

The patient believed his symptoms might be related to a vasectomy he underwent when younger or possibly to varicocele.

One week ago, after receiving treatment at my clinic, he happily reported that he experienced several days without any pain, confirming that our diagnostic direction was correct.

② Four-Level Thinking Analysis

🔵 Level 1: Symptom Layer — Is “testicular pain” really coming from the testicle?

Typical testicular pain is often misattributed to:

• Epididymitis

• Varicocele

• Post-vasectomy pain syndrome

However, this case presents several contradictions:

• No tenderness of the testicle itself

• No redness, swelling, or warmth

• Antibiotics completely ineffective

• NSAIDs effective

• Significant improvement after a single structural treatment

All of these suggest:
👉 The problem is NOT within the testicle itself.

🟡 Level 2: Functional / Neural Layer — A classic pattern of neural traction pain

The clinical triad:

• Dull ache

• Dragging sensation

• Mild inguinal discomfort

strongly suggests genitofemoral nerve traction pain.

Symptom behavior:

• More activity → worse

• Rest / lying down → relief

• NSAIDs effective

• Antibiotics ineffective

This pattern indicates:
👉 Pain arises from neural tension and traction, not infection.

🟠 Level 3: Structural / Mechanistic Layer — The psoas muscle is the true source

Three key clinical findings:

**① Deep abdominal palpation of the psoas showed:

Hypertrophy, hardness, and pain rated 6/10 on the affected side (vs 1–2/10 on the healthy side)**
→ Indicates long-term psoas tension and inflammatory thickening.

② Positive Thomas Test

→ Clear evidence of psoas shortening.

③ Audible snapping during hip flexion/extension (“snapping psoas”)

→ A classic sign of abnormal tendon glide.

These structural abnormalities create a clear chain:

Psoas hypertrophy and tightness
⬇
Traction on L1–L2 nerve roots
⬇
Irritation of the genitofemoral nerve
⬇
Manifestation as “pseudo testicular pain”

👉 The pain originates from the psoas chain, not the testicle.

🔴 Level 4: Deep Structural Layer — Obesity, rapid weight loss, and collapse of mechanical chains

This is the most critical layer in this case.

The patient had long-standing severe obesity (~130 kg).
During obesity:

• Excess abdominal mass

• Chronic anterior pelvic tilt

• Psoas overactivation to stabilize the spine

• Gradual development of chronic hypertrophy and shortening

Then he underwent rapid weight loss of nearly 50 kg.

Deep mechanical consequences of rapid weight loss:

1) The psoas, already chronically hypertrophied, does NOT regain normal elasticity simply because weight decreases

Muscle architecture remains shortened and tight.

2) Trunk stability decreases abruptly

With reduced abdominal mass,
the psoas must take on even more stabilizing work
→ continuous over-tightening
→ increased neural traction

3) Neural structures become more exposed and sensitive

Soft-tissue buffering decreases after weight loss
→ the genitofemoral nerve becomes more vulnerable to traction
→ symptoms worsen

This explains why symptoms have intensified over the past two years, forming a classic pattern of:

Obesity → chronic psoas overload
⬇
Hypertrophy + shortening
⬇
Rapid weight loss → instability
⬇
Increased neural traction
⬇
Pseudo testicular pain

③ Treatment Strategy

Goal: Release the psoas chain traction on the genitofemoral nerve.

Key steps:

1) Deep psoas release (the most critical step)

• Abdominal deep-pressure technique

• Needling into the psoas access points

• Improve tendon glide and reduce muscle tone

2) L1–L2 facet mobilization

Reduce nerve-root tension.

3) Gentle release at the inguinal nerve-exit zone

Assist in reducing neural traction.

4) Establish psoas relaxation and hip-extension training

Shift the psoas from a “compensatory pattern” back to a functional pattern.

After a single treatment session, symptoms improved dramatically, repeatedly confirming the correctness of the diagnostic chain.

④ Clinical Insight

Many cases of “testicular pain” do NOT originate from the testicle itself,
but from neural traction caused by the psoas chain.
Understanding structural chains is the key to eliminating the pain.