腰痛证，旧有五辨∶一曰阳虚不足，少阴肾衰。二曰风痹、风寒、湿着腰痛。三曰劳役
伤肾。四曰坠堕损伤。五曰寝卧湿地。虽其大约如此，然而犹未悉也。盖此证有表里虚实寒
热之异，知斯六者庶乎尽矣，而治之亦无难也。
一、腰痛证，凡悠悠戚戚，屡发不已者，肾之虚也。遇阴雨或久坐，痛而重者，湿也。
遇诸寒而痛，或喜暖而恶寒者，寒也。遇诸热而痛，及喜寒而恶热者，热也。郁怒而痛者，
气之滞也。忧愁思虑而痛者，气之虚也。劳动即痛者，肝肾之衰也。当辨其所因而治之。
一、腰为肾之府，肾与膀胱为表里，故在经则属太阳，在脏则属肾气，而又为冲任督带
之要会。所以凡病腰痛者，多由真阴之不足，最宜以培补肾气为主。其有实邪而为腰痛者，
亦不过十中之二三耳。
一、腰痛之虚证，十居八九，但察其既无表邪，又无湿热，而或以年衰，或以劳苦，或
以酒色斫丧，或七情忧郁所致者，则悉属真阴虚证。凡虚证之候，形色必清白而或见黎
黑，脉息必和缓而或见细微，或以行立不支而卧息少可，或以疲倦无力而劳动益甚。凡积而
渐至者皆不足，暴而痛甚者多有余，内伤禀赋者皆不足，外感邪实者多有余，故治者当辨其
所因。凡肾水真阴亏损，精血衰少而痛者，宜当归地黄饮，及左归丸、右归丸为最。若病稍
轻，或痛不甚，虚不甚者，如青娥丸、煨肾散、补髓丹、二至丸、通气散之类，俱可择用。
一、腰痛之表证，凡风寒湿滞之邪，伤于太阳、少阴之经者皆是也。若风寒在经，其证
必有寒热，其脉必见紧数，其来必骤，其痛必拘急兼酸，而多连脊背，此当辨其阴阳，治从
解散。凡阳证多热者，宜一柴胡饮，或正柴胡饮之类主之；若阴证多寒者，宜二柴胡饮、五
积散之类主之。其有未尽，当于伤寒门辨治。
一、湿滞在经而腰痛者，或以雨水，或以湿衣，或以坐卧湿地。凡湿气自外而入者，总
皆表证之属，宜不换金正气散、平胃散之类主之。若湿而兼虚者，宜独活寄生汤主之。若湿
滞腰痛而小水不利者，宜胃苓汤，或五苓散加苍术主之。若风湿相兼，一身尽痛者，宜羌活
胜湿汤主之。若湿而兼热者，宜当归拈痛汤、苍术汤之类主之。若湿而兼寒者，宜《济生》
术附汤、五积散之类主之。
一、腰痛有寒热证，寒证有二，热证亦有二。凡外感之寒，治宜温散如前，或用热物熨
之亦可。若内伤阳虚之寒，治宜温补如前。热有二证。若肝肾阴虚、水亏火盛者，治当滋阴
降火，宜滋阴八味煎，或用四物汤加黄柏、知母、黄芩、栀子之属主之。若邪火蓄结腰肾，
而本无虚损者，必痛极，必烦热，或大渴引饮，或二便热涩不通，当直攻其火，宜大厘清饮
加减主之。
一、跌扑伤而腰痛者，此伤在筋骨，而血脉凝滞也，宜四物汤加桃仁、红花、牛膝、肉
桂、玄胡、乳香、没药之类主之。若血逆之甚而大便闭结不通者，宜《元戎》四物汤主之，
或外以酒糟、葱、姜捣烂罨之，其效尤速。
一、丹溪云∶诸腰痛不可用参补气，补气则疼愈甚；亦不可峻用寒凉，得寒则闭遏而痛
甚。此言皆未当也。盖凡劳伤虚损而阳不足者，多有气虚之证，何为参不可用？又如火聚下
焦，痛极而不可忍者，速宜清火，何为寒凉不可用？但虚中挟实不宜用参者有之，虽有火而
热不甚，不宜过用寒凉者亦有之，若谓概不可用，岂其然乎？余尝治一董翁者，年逾六旬，
资禀素壮，因好饮火酒，以致湿热聚于太阳，忽病腰痛不可忍，至求自尽，其甚可知。余为
诊之，则六脉洪滑之甚，且小水不通而膀胱胀急，遂以大厘清饮倍加黄柏、龙胆草，一剂而
小水顿通，小水通而腰痛如失。若用丹溪之言，鲜不误矣，是以不可执也。（新按）
一、妇人以胎气、经水损阴为甚，故尤多腰痛脚酸之病，宜当归地黄饮主之。
腰痛证，过去有五种辨析：一是阳气虚弱不足，少阴肾气衰退。二是风痹、风寒、湿邪留着导致的腰痛。三是劳累过度损伤肾脏。四是坠落跌打造成的损伤。五是睡卧在潮湿之地。虽然大体情况如此，然而还不够详尽。因为此病证有表里、虚实、寒热之不同，知晓这六个方面，大概就全面了，而治疗也就没有困难了。
一、腰痛证，凡是悠悠然不适、隐隐作痛，屡次发作不能痊愈的，是肾气虚损。遇到阴雨天气或久坐后，疼痛且伴有沉重感的，是湿邪。遇到各种寒冷刺激而疼痛，或者喜欢温暖而厌恶寒冷的，是寒邪。遇到各种炎热刺激而疼痛，以及喜欢清凉而厌恶炎热的，是热邪。因郁怒而引发疼痛的，是气机阻滞。因忧愁思虑而引发疼痛的，是气虚。劳动后即感疼痛的，是肝肾衰败。应当辨别其病因进行治疗。
一、腰部是肾的外府，肾与膀胱互为表里，所以在经络层面属于太阳经，在脏腑层面属于肾气，同时也是冲脉、任脉、督脉、带脉的重要交会之处。所以凡是患有腰痛的人，大多由于真阴不足，最适宜以培补肾气为主。那些因为有实邪而导致腰痛的，也不过是十人中二三人罢了。
一、腰痛中的虚证，占十分之八九。只要观察确认既无表邪，又无湿热，而是因为年老体衰，或因劳苦，或因酒色过度耗损，或因七情忧郁所致的，都属于真阴虚证。大凡虚证的征候，面色形体必定清亮洁白或略带黎黑，脉象气息必定和缓或见细微，或者站立行走支撑不住而躺下休息稍可缓解，或者疲倦无力而劳动后症状加重。凡是积累渐至的都属于不足，突然发作且疼痛剧烈的多属于有余（实证），内伤禀赋不足的都属于不足，外感邪气盛实的多属于有余，所以治疗者应当辨别其病因。凡是肾水真阴亏损，精血衰少而致痛的，适宜用当归地黄饮，以及左归丸、右归丸最为恰当。如果病情稍轻，或疼痛不剧烈，虚损不严重的，如青娥丸、煨肾散、补髓丹、二至丸、通气散之类，都可以酌情选用。
一、腰痛中的表证，凡是风寒湿滞等邪气，侵袭太阳经、少阴经的都是。如果风寒在经络中，其证候必定有恶寒发热，脉象必定见紧数，发病必定突然，疼痛必定拘急兼有酸痛，且多牵连脊背，这应当辨别其阴阳属性，治疗从解散邪气入手。大凡阳证多热的，适宜用一柴胡饮，或正柴胡饮之类主治；若阴证多寒的，适宜用二柴胡饮、五积散之类主治。其中还有未尽的情况，应当在伤寒门类中辨别治疗。
一、湿气滞留经络而致腰痛，可能是因为雨水淋身，或者穿着湿衣，或者坐卧湿地。凡是湿气从外部侵入的，总都属于表证范畴，适宜用不换金正气散、平胃散之类主治。如果湿邪兼有虚损的，适宜用独活寄生汤主治。如果湿滞腰痛且小便不利的，适宜用胃苓汤，或五苓散加苍术主治。如果风湿相兼，全身都疼痛的，适宜用羌活胜湿汤主治。如果湿邪兼有热邪的，适宜用当归拈痛汤、苍术汤之类主治。如果湿邪兼有寒邪的，适宜用《济生》术附汤、五积散之类主治。
一、腰痛有寒证和热证，寒证有两种，热证也有两种。凡是外感寒邪，治疗适宜温散如前所述，或用热物熨烫也可以。如果是内伤阳虚导致的寒证，治疗适宜温补如前所述。热证有两种。如果是肝肾阴虚、水亏火盛的，治疗应当滋阴降火，适宜用滋阴八味煎，或用四物汤加黄柏、知母、黄芩、栀子之类的药物主治。如果是邪火蓄结于腰肾，而原本没有虚损的，必定疼痛剧烈，必定烦热，或者大渴引饮，或者大小便热涩不通，应当直接攻伐其火邪，适宜用大厘清饮加减主治。
一、跌扑损伤导致的腰痛，这是伤在筋骨，导致血脉凝滞，适宜用四物汤加桃仁、红花、牛膝、肉桂、玄胡、乳香、没药之类的药物主治。如果血逆严重且大便闭结不通的，适宜用《元戎》四物汤主治，或者外用酒糟、葱、姜捣烂敷贴，效果尤其迅速。
一、朱丹溪说：各种腰痛不可用人参补气，补气则疼痛更加严重；也不可用峻猛的寒凉药，得寒则闭塞遏阻而疼痛更甚。这些话都不恰当。大凡劳伤虚损而阳气不足的，多有气虚的证候，为何人参不可用？又有如火聚在下焦，疼痛剧烈无法忍受的，速宜清火，为何寒凉药不可用？只是虚证中夹杂实邪不宜用人参的确实存在，虽然有火但热势不盛，不宜过用寒凉药的也确实存在，如果说一概不可用，难道是这样吗？我曾经治疗一位董姓老人，年过六十，体质素来强壮，因为喜好饮用烈性酒，导致湿热聚集于太阳经，忽然患病腰痛无法忍受，甚至求死，其严重程度可想而知。我为他诊脉，六脉洪滑非常严重，且小便不通而膀胱胀急，于是用大厘清饮加倍加入黄柏、龙胆草，一剂药后小便顿时通畅，小便通利而腰痛消失。如果采用丹溪的说法，很少有不误事的，所以不可固执己见。（新按）
Lumbago syndrome was traditionally differentiated into five categories: first, deficiency of Yang Qi and decline of the Shaoyin Kidney; second, lumbago caused by Wind-Bi, Wind-Cold, or Dampness retention; third, kidney injury due to overexertion; fourth, trauma from falls or blows; fifth, sleeping on damp ground. Although these cover the general scope, they are not exhaustive. This condition varies by Exterior/Interior (Biao-Li), Deficiency/Excess (Xu-Shi), and Cold/Heat (Han-Re). Understanding these six aspects allows for comprehensive diagnosis and treatment without difficulty.
First, regarding lumbago: if the pain is lingering and aching, recurring frequently without resolution, it indicates Kidney Deficiency. If pain worsens with heavy sensation during rainy weather or prolonged sitting, it indicates Dampness. If pain occurs upon exposure to cold or is relieved by warmth and aggravated by cold, it indicates Cold. If pain occurs upon exposure to heat or is relieved by coolness and aggravated by heat, it indicates Heat. Pain triggered by anger and frustration indicates Qi Stagnation. Pain triggered by worry and overthinking indicates Qi Deficiency. Pain induced immediately after labor indicates Decline of the Liver and Kidney. Treatment must be based on identifying the specific cause.
Second, the waist is the mansion of the Kidney. The Kidney and Bladder are exterior-interior pairs. Thus, in the meridians, it belongs to the Taiyang (Greater Yang) channel; in the zang-fu organs, it relates to Kidney Qi; and it is also a crucial convergence point for the Chong, Ren, Du, and Dai vessels. Therefore, most cases of lumbago stem from insufficiency of True Yin (Zhen Yin), and treatment should primarily focus on nourishing and tonifying Kidney Qi. Cases where lumbago is caused by Excess pathogens account for only two or three out of ten.
Third, Deficiency-type lumbago accounts for eight or nine out of ten cases. Provided there are no Exterior pathogens and no Damp-Heat, such cases—whether due to advanced age, hard labor, excessive sexual activity or alcohol consumption, or emotional depression—are all classified as True Yin Deficiency. Signs of Deficiency syndromes include a complexion that is clear and white or slightly dark/black, a pulse that is harmonious and slow or fine and minute, inability to stand or walk supported while lying down provides relief, fatigue and weakness exacerbated by activity. Conditions developing gradually are always Deficiency; sudden onset with severe pain is mostly Excess. Internal injuries and constitutional weakness are Deficiency; external pathogenic excess is Excess. Physicians must distinguish the etiology. For pain due to depletion of Kidney Water and True Yin, with decline of Essence and Blood, Danggui Dihuang Yin (Angelica and Rehmannia Decoction) is most appropriate, followed by Zuogui Wan (Left Restoring Pill) and Yougui Wan (Right Restoring Pill). For milder cases or less severe deficiency, Qing'e Wan, Weishen San, Busui Dan, Erzhi Wan, and Tongqi San may be selected.
Fourth, Exterior-type lumbago involves pathogenic factors such as Wind, Cold, and Dampness stagnating in the Taiyang and Shaoyin meridians. If Wind-Cold resides in the meridians, symptoms include aversion to cold and fever, the pulse is tight and rapid, onset is sudden, pain is spasmodic with soreness, and often radiates to the back. Differentiate between Yin and Yang syndromes and treat by dispersing the pathogen. For Yang syndromes with more heat, Yichaihu Yin (Single Bupleurum Decoction) or Zhengchaihu Yin (Regular Bupleurum Decoction) are indicated. For Yin syndromes with more cold, Erchaohu Yin (Double Bupleurum Decoction) or Wuji San (Five Accumulations Powder) are indicated. Remaining complexities should be addressed within the context of Cold Damage (Shanghan) differentiation.
Fifth, lumbago caused by Dampness stagnation in the meridians results from rain exposure, wet clothing, or sitting/lying on damp ground. External invasion of Dampness belongs to the Exterior category, treated with Buhuanjin Zhengqi San (Golden Change Upright Qi Powder) or Pingwei San (Stomach-Pacifying Powder). If Dampness is combined with Deficiency, Duhuo Jisheng Tang (Angelica Pubescens and Poria Decoction) is indicated. If Damp-stagnation lumbago is accompanied by difficult urination, Weiling Tang or Wuling San (Five Ling Powder) plus Cangzhu (Atractylodis Rhizoma) are indicated. If Wind-Dampness combines causing whole-body pain, Qianghuo Shengshi Tang (Notopterygium and Humulus Decoction) is indicated. If Dampness combines with Heat, Danggui Niantong Tang (Angelica and Ligusticum Decoction) or Cangzhu Tang are indicated. If Dampness combines with Cold, Jiasheng Zhufu Tang (from *Ji Sheng Fang*) or Wuji San are indicated.
Sixth, lumbago presents with Cold and Heat syndromes; there are two types of Cold and two types of Heat. External Cold is treated with warming dispersion as described above, or hot compresses. Internal Cold due to Yang Deficiency is treated with warming tonification as described above. Regarding Heat: if caused by Liver-Kidney Yin Deficiency with water deficiency and fire hyperactivity, treatment requires nourishing Yin and descending Fire using Ziyin Bawei Jian (Eight-Ingredient Yin-Nourishing Decoction) or Siwu Tang (Four Substances Decoction) plus Huangbai (Phellodendri Cortex), Zhimu (Anemarrhenae Rhizoma), Huangqin (Scutellariae Radix), and Zhizi (Gardeniae Fructus). If Fire Pathogens accumulate in the lumbar region and kidneys without underlying deficiency, pain is extreme, accompanied by irritability and heat, intense thirst, or hot/difficult urination and defecation. Directly attack the Fire using Dalì Qingyin (Great Purification Decoction) with modifications.
Seventh, lumbago from traumatic injury involves damage to sinews and bones with blood stasis. Treat with Siwu Tang (Four Substances Decoction) plus Taoren (Persicae Semen), Honghua (Carthami Flos), Niuxi (Achyranthis Bidentatae Radix), Rougui (Cinnamomi Cortex), Yuanhu (Corydalis Rhizoma), Ruxiang (Olibanum), and Moyao (Myrrha). If blood rebellion is severe with constipation, Yuanrong Siwu Tang (Siwu Tang from *Yuanrong*) is indicated. External application of fermented rice wine lees, scallions, and ginger mashed together accelerates recovery.
Eighth, Zhu Danxi stated: "For all lumbago, Ginseng should not be used to tonify Qi, as this worsens pain; harsh Cold-Cooling herbs should not be used, as Cold causes obstruction and worsens pain." These statements are inappropriate. In cases of labor-induced deficiency with Yang insufficiency, Qi Deficiency signs are common; why is Ginseng contraindicated? If Fire accumulates in the Lower Jiao causing unbearable pain, clearing Fire urgently is necessary; why are Cold-Cooling herbs contraindicated? It is true that Deficiency with夹杂 (intermixed) Excess may preclude Ginseng use, and mild Heat may preclude excessive Cold-Cooling use. However, claiming absolute contraindication is incorrect. I once treated an elderly Mr. Dong, over sixty years old, constitutionally robust, who consumed strong liquor, leading to Damp-Heat accumulation in the Taiyang meridian. He suffered excruciating lumbago, even contemplating suicide. His six pulses were extremely surging and slippery, with urinary retention and bladder distension. I prescribed Dalì Qingyin with doubled Huangbai and Longdancao (Gentianae Radix). After one dose, urination resumed, and lumbago vanished. Adhering strictly to Danxi’s advice would have led to error. One must not be dogmatic. (New Commentary)
Ninth, women suffer significant Yin loss due to pregnancy and menstruation, making them particularly prone to lumbago and sore legs. Danggui Dihuang Yin (Angelica and Rehmannia Decoction) is indicated.