Shi Yangshan, a Master of Traditional Chinese Medicine, is the fourth-generation inheritor of the Shi's Traumatology School and a chief physician at the Huangpu District Central Hospital in Shanghai. He is clinically skilled in treating low back and leg pain. Shi Yangshan uses the modified Shi's Phlegm-Dispelling and Collateral-Unblocking Decoction to treat various types of low back and leg pain, achieving good therapeutic results. The following introduces Shi's experience in diagnosing and treating low back and leg pain for the benefit of colleagues.

There are many causes of low back and leg pain. Modern medical research has found that conditions such as lumbar disc herniation, lumbar spondylolisthesis, and piriformis muscle spasm can all cause varying degrees of low back and leg pain symptoms. Traditional Chinese Medicine (TCM) introduced the concept of low back pain as early as in the "Huangdi Neijing" (The Yellow Emperor's Inner Canon). The "Suwen·Ci Yaotong" (Plain Questions·Treatise on Needling for Low Back Pain) states, "The Hengluo vessel causes low back pain, making it impossible to bend forward or backward; when leaning backward, one fears falling, and it is caused by lifting heavy objects that injure the waist." It also says, "The Rouli vessel causes low back pain, making it impossible to cough; coughing causes tendons to contract and tighten." The "Yixue Xinyu" (Medical Insights) also notes, "Low back pain with stiffness and tension, radiating to the legs and feet." The above indicates that this condition can be caused by trauma, with symptoms including low back pain combined with lower limb pain, which worsens with coughing. This is essentially similar to the symptoms of sciatica described in Western medicine, and in TCM, it is referred to as "low back and leg pain" or "low back pain extending to the knees."

Treatment Based on Pathogenesis

Shi Yangshan has considerable expertise in diagnosing and treating this condition. He believes that the Shi family's theories of "concomitant pathogens" and "phlegm-stasis" were specifically developed to address such complex situations. Regarding "concomitant pathogens," Shi Yangshan states: "Any condition that is not the primary disease, regardless of whether it occurs before or after, and coexists with the primary disease for a period, is called a concomitant pathogen." Although concomitant pathogens may be completely unrelated to the primary disease, they often interact with and exacerbate it. Therefore, the treatment of concomitant pathogens should not be overlooked.

Furthermore, Shi Yangshan believes that when a disease lingers and fails to heal over a long period, it inevitably gives rise to phlegm-dampness and blood stasis. He holds that after chronic injuries or strain, disharmony of qi and blood often leads to phlegm-dampness congealing and stagnating in the meridians. As noted in *Ren Zhai Zhi Zhi*: "When qi and blood are harmonious and the meridians are unobstructed, phlegm dissipates and disappears. When the qi vessels are blocked and the orifices are congested, phlegm accumulates and appears." When a disease lingers and fails to heal over time, blood stasis inevitably develops. The mutual obstruction of phlegm and stasis makes pain difficult to resolve. Therefore, in the treatment of low back and leg pain, the Shi family prioritizes addressing "phlegm-stasis" and regulating "concomitant pathogens."

Simultaneously, Shi Yangshan also points out that in clinical practice, such diseases primarily manifest with pain or numbness along two main meridian pathways. The first type of pain radiates along the Foot Taiyang Bladder Meridian. As stated in *Ling Shu · Meridians*: "The Bladder Foot Taiyang Meridian... its straight pathway enters from the vertex to connect with the brain... alongside the spine reaching the lumbar region, entering along the paravertebral muscles, connecting with the kidney, and pertaining to the bladder. Its branch descends from the lumbar region, alongside the spine, passing through the buttock, and entering the popliteal fossa. Another branch separates from the shoulder blade on both sides, descends alongside the spine internally, passes through the hip joint, follows the lateral aspect of the thigh posteriorly, and converges in the popliteal fossa. From there, it descends through the calf muscle, emerges posterior to the external malleolus, follows the lateral aspect of the foot to the lateral side of the little toe." This is thus termed the Taiyang type. The second type of pain follows the course of the Foot Shaoyang Gallbladder Meridian. *Ling Shu · Meridians* states: "The Gallbladder Foot Shaoyang Meridian... its straight pathway descends from the supraclavicular fossa to the axilla, follows the chest, passes the hypochondrium, and converges at the hip joint. It then descends along the lateral aspect of the thigh, emerges lateral to the knee, descends anterior to the fibula, directly down to the end of the fibula, emerges anterior to the external malleolus, follows the dorsum of the foot, and enters between the fourth and fifth toes. Its branch separates from the dorsum of the foot, enters between the big toe and the second toe, follows the web between the first and second metatarsal bones, emerges at its tip, and connects around the nail, emerging at the 'three hairs'." This is called the Shaoyang type. If phlegm-stasis obstructs these two meridians, the symptoms of the disease manifest.

For the Taiyang type in treatment, Shi Yangshan employs the modified Zhutan Tongluo Decoction (composed of Arctii Fructus, Bombyx Batryticatus, Tribuli Fructus, Angelicae Pubescentis Radix, Gentianae Macrophyllae Radix, Angelicae Dahuricae Radix, Pinelliae Rhizoma, and Mori Ramulus). For cases presenting with cold syndrome, Guizhi (Cinnamomi Ramulus) and Paofuzi (Aconiti Lateralis Radix Praeparata) are added in appropriate amounts, drawing inspiration from the Guizhi Decoction. For cases presenting with heat syndrome, Gegen (Puerariae Lobatae Radix) and Shigao (Gypsum Fibrosum) are added in appropriate amounts, drawing inspiration from the Gegen Decoction.

For the Shaoyang type in treatment, Shi Yangshan also employs the modified Zhutan Tongluo Decoction. For cases presenting with cold syndrome, Wuzhuyu (Evodiae Fructus) and Mugua (Chaenomelis Fructus) are added, drawing inspiration from the Wuzhuyu Decoction. For cases presenting with heat syndrome, Chaihu (Bupleuri Radix) and Baishao (Paeoniae Radix Alba) are added, drawing inspiration from the Xiao Chaihu Decoction.

Typical Medical Cases

● Case One

Tang, male, 46 years old at the time. Presented with "recurrent right-sided low back and leg pain for 1 year, aggravated for 2 weeks." The patient was diagnosed with lumbar disc herniation one year ago. During this period, he received medication treatment with intermittent recurrences. Two weeks ago, after catching a cold, his symptoms worsened, with numbness in the right lower limb, restlessness, and inability to sleep at night. Various medications were ineffective, so he sought consultation based on reputation.

The patient's pain radiates along the Foot-Taiyang Bladder Meridian. He is unable to bend forward, backward, or turn sideways, experiences aversion to cold, has a bland taste in the mouth without thirst, a dark tongue with a white, greasy coating, and a wiry pulse. This pattern belongs to phlegm and blood stasis obstructing the collaterals, compounded by contraction of cold-dampness. The primary disease and the concurrent pathogenic factors interact and cause trouble. The prescription is based on the modified Zhutan Tongluo Tang (Phlegm-Expelling Collateral-Unblocking Decoction): Arctii Fructus (牛蒡子) 9g, Bombyx Batryticatus (僵蚕) 9g, Sinapis Albae Semen (白芥子) 9g, stir-fried Pheretima (炙地龙) 9g, Euphorbiae Helioscopiae Herba (泽漆) 12g, processed Arisaematis Rhizoma (制南星) 9g, Caraganæ Sinicæ Radix (金雀根) 30g, Angelicae Sinensis Radix (当归) 12g, Cyathulae Radix (川牛膝) 12g, stir-fried Glycyrrhizae Radix et Rhizoma (炙甘草) 6g, prepared Aconiti Lateralis Radix Praeparata (炮附子) 12g, Cinnamomi Ramulus (桂枝) 12g, Atractylodis Macrocephalae Rhizoma (白术) 15g, Scorpio (全蝎) 6g, Scolopendra (蜈蚣) 6g, Zingiberis Rhizoma Recens (生姜) 5 slices. 7 doses. After taking the medication for one week, the patient reported being able to sleep peacefully at night, with reduced numbness, but walking was still difficult. Treatment continued with modifications of the previous formula. After one month, the low back and leg pain was completely cured.

● Case Record Two

Zhu, female, 30 years old at the time. Presented with "recurrent left-sided low back and leg pain for over half a year." She had a history of lumbar trauma many years ago. She received treatments such as acupuncture and traction for over half a year, during which the pain recurred intermittently and never completely resolved, so she came for consultation.

The patient experiences dry mouth with slight bitterness, irritability, restlessness, occasional stabbing pain in the lower back radiating along the gallbladder meridian of the foot Shaoyang, cramping pain in the calf with limited flexion and extension, a red tongue with scant saliva, a thin, yellow, greasy coating, and a wiry, rapid pulse. This indicates unresolved old traumatic blood stasis in the lower back, stagnant heat in the liver and gallbladder transforming into fire, which scorches fluids into phlegm, leading to phlegm and blood stasis obstructing the collaterals. Therefore, the modified Zhutan Tongluo Decoction was prescribed: Arctii Fructus 9g, Bombyx Batryticatus 9g, Sinapis Semen 9g, Pheretima Aspergillum (processed) 9g, Eupolyphaga seu Steleophaga (processed) 9g, Trachelospermi Caulis 12g, Arisaema cum Bile (processed) 9g, Fritillariae Thunbergii Bulbus 15g, Salviae Miltiorrhizae Radix et Rhizoma 15g, Angelicae Sinensis Radix 12g, Cyathulae Radix 12g, Glycyrrhizae Radix et Rhizoma (raw) 6g, Bupleuri Radix 15g, Scutellariae Radix 9g, Bambusae Caulis in Taeniam 12g, Paeoniae Radix Alba 12g. Seven doses. The patient was advised to maintain a light diet and regulate emotions. Symptoms improved after taking the medication, and as the formula was effective, it was continued unchanged. The patient recovered substantially after one month.

Note: Shi Yangshan pointed out that the above two cases represent the Taiyang type and Shaoyang type, which are relatively common in clinical practice. However, there are several other types of low back and leg pain that, although less common, are equally noteworthy. The author lists them here for readers to differentiate.

● Medical Case Three

Li, female, 29 years old. Presented with "low back and leg soreness and pain for two weeks." She reported that two weeks prior, her lower back was exposed to cold while sleeping, after which she developed soreness and pain in the lower back and legs, along with muscle cramps. An external hospital CT scan indicated: L5-S1 intervertebral disc herniation posteriorly, accompanied by spinal canal stenosis. The patient feared surgery and sought consultation because anti-inflammatory and analgesic tablets were ineffective.

The patient typically experiences aversion to cold, cold limbs, lethargy and fatigue, pale lips and tongue, and a deep, weak pulse. With no clear meridian symptoms to follow, Shi Yangshan pondered for a long time and considered the patient to have deficiency of both yin and yang as well as qi and blood. He prescribed a modified version of the classical formula Shaoyao Gancao Fuzi Tang: White Peony Root (Paeonia lactiflora) 30g, Honey-fried Licorice Root (Glycyrrhiza uralensis) 30g, Prepared Aconite Lateral Root (Aconitum carmichaelii) 15g, Astragalus Root (Astragalus membranaceus) 30g, Chinese Angelica Root (Angelica sinensis) 12g, Twotooth Achyranthes Root (Achyranthes bidentata) 15g. Seven doses. After taking the formula continuously for two weeks, the pain was relieved. Subsequently, it was changed to Shi's Tiaozhong Baoyuan Tang for recuperation and consolidation.

● Medical Case Four

Patient Wang, male, 59 years old at the time. Presented with "soreness and pain in the right lower back and leg, difficulty walking for 3 months," with no obvious precipitating cause, and worsening difficulty walking. The patient had undergone treatments such as medication and traction without effect, and thus came for consultation.

The patient had a flushed face, dry mouth with a bitter taste, spontaneous sweating and night sweats, normal appetite, normal bowel and urinary functions, soreness and pain in the lower back and leg, restlessness whether lying down or standing, a red tongue with a yellow, greasy coating, and a wiry, large pulse. The patient complained of soreness and pain along the entire leg, with no clear meridian pattern to follow. The syndrome was thus differentiated as downward infusion of damp-heat. The prescription was formulated as Zhutan Tongluo Tang with added Gypsum Fibrosum (Gypsum), Talcum (Talc), Kudzu Root (Pueraria lobata), and Cork Tree Bark (Phellodendron chinense). The patient was advised to avoid spicy foods, alcohol, and rich foods.

Note: Shi Yangshan believes that in the diagnosis and treatment of lumbar and leg pain, one must avoid preconceptions and hasty medication. Although the Zhutan Tongluo Decoction has proven efficacy, it cannot cure all conditions. Only by understanding the norm and adapting to changes, applying syndrome differentiation and treatment, and flexibly modifying prescriptions can the immense power of traditional Chinese medicine be fully realized.