Monday, December 21, 2015

The Diaphragm and the Liver Sinew Channel, Part 2


Fig 1: Typical posture often seen with
Liver Qi Stagnation. Image courtesy
Matt Callison, L.Ac.
In the last post we outlined the basic anatomy associated with the Liver sinew channel. If you have not yet read it, you might want to start with that post. In this post, we will discuss a common postural dysfunction associated with the Liver sinew channel, and we will look at common orthopedic conditions associated with this. Finally, we will discuss some treatment options. Keep in mind that many of these treatments are best learned in a class setting and that much of the discussion here will be alluding to these techniques. Others will be relatively straight forward and easily adaptable in your practice, however.

Dysfunction is observed when the Liver sinew channel (which is more posterior than the Spleen sinew previously discussed) is short and the ribcage is closer to the pelvis in the back than in the front, compressing the posterior diaphragm. This compression prevents the diaphragm from being able to descend effectively; patients often must rely more on the accessory breathing muscles, such as the scalenes, which often become tight and restricted. These patients often exhibit chest or paradoxical breathing. Many of them have the typical Liver Qi Stagnation posture seen in Fig. 1. This posture presents with a very straight, rigid spine and an anterior tilt to the pelvis. The chest is often held up in a military-style posture and the patient looks as if they are unable to exhale fully. This posture, along with several others, were presented and discussed by Matt Callison, L.Ac. at the Pacific Symposium in 2011, where he presented research which correlated Zangfu disharmony as described in Traditional Chinese Medicine with common postural patterns. (This was discussed in a previous post.)


Figure 2: Palpation of the QL at Yaoyan. Image courtesy
of Matt Callison, L.Ac. from his soon to be released book
Sports Medicine Acupuncture.
Many of these patients present with Yaoyan syndrome (often referred to as Iliac Crest Syndrome in Western circles). This presents with pain at Yaoyan. Yaoyan is level with the lower border of L4 and, depending on whether you palpate slightly more medial or lateral, will be more reactive at either the iliocostalis (the most lateral muscle of the erector spinae group) or the quadratus lumborum (QL) attachment at the iliac crest. When there is pain with palpation of the QL, I frequently find LIV-5 to be very sensitive to palpation, also. Needling LIV-5 and obtaining Daqi often reduces the pain at the QL with palpation by about 50%.




Another frequent pain condition which is seen with this posture is thoracic outlet syndrome (TOS) which involves an entrapment of the brachial plexus either between the anterior and middle scalenes, between the clavicle and ribcage, or between the pectoralis minor and the ribcage. In this posture, the scalenes and pectoralis minor are short and holding the ribcage too rigidly up (creating a very wooden spine). I associate these muscles with the Lung sinew channel, but see this as a way that excessive Liver energy can affect the channels associated with the Lung. These patients often have a paradoxical breathing pattern where they pull the abdomen in during the inhale and lift the chest. This uses accessory breathing muscles and they should be elevating the upper ribs, but with the restricted movement in the diaphragm, they have to work overtime; thus they become tight and rigid and can then compress neural structures.


Fig. 3: Brachial plexus entrapment on the left side 1) between the ribcage and clavicle, 2) between the anterior and middle scalene, and 3) under the pectoralis minor. I include the scalenes and pec. minor in the Lung sinew channel. They are listed here as Liver Qi Stagnation and the posture shown above is a common contributor of TOS.



Fig. 4: Anterior pelvic tilt.
Since an anterior tilt of the pelvis is involved with the posture in Fig. 1, it is important to address this when treating many pain patterns, especially if they are chronic. In the Sports Medicine Acupuncture Certification program run by AcuSport Seminar Series, we teach a particular needle technique at LIV-4 (paired with GB 39.5) as treatment for an anterior pelvic tilt. This is used on the most anterior side and could be part of the treatment of many back conditions such as radiculopathy, facet syndrome, and SI joint dysfunction; it can also be used with treatments for TOS and other problems. This point combination and needle technique was developed by Matt Callison through his understanding of channel theory and then refined with trial and error. I interpret LIV-4 as softening the psoas and helping relax and lengthen this muscle, which is such a strong contributor to an anterior pelvic tilt. It is mentioned here to highlight the relationship of the Liver sinew channel to the psoas major, which is heavily involved with an anterior tilt of the pelvis. 


In addition to acupuncture to distal points, direct needling of motor points to muscles such as the QL, scalenes, pectoralis minor, and other related structures can help improve alignment. Also tuina is indicated. I utilize myofascial release extensively in my practice and it can be very helpful in releasing tight fascia and allowing the body to find a more healthful balance. In Sports Medicine Acupuncture and in the KMI training, Simone Lindner teaches a very useful myofascial release technique to the lateral raphe (a fascial structure which then separates to becomes the anterior and posterior layer of the thoracolumbar fascia). This structure is at the edge of the QL; the technique involves working with a seated patient and, using this fascial structure as leverage, lifting their ribcage out and away from their pelvis in the back. Also addressing the front of the diaphragm is useful as it is pulled up. Accessing this fascia under the costal margin and bringing it down will free the breath and soften the Liver channel.

Other sinew channels have a strong relationship to the diaphragm, either directly or indirectly, and can be explored at another time. Most notably, the Pericardium sinew channel influences it via its relationship with the serratus anterior, another muscle which can act as a clamp and restrict proper expansion of the thorax. Needling SP-21 or other points which correlate with motor points of this muscle will increase the Lung pulse, for instance. The Lung sinew channel relates to the pectoralis minor and the scalenes (both discussed in this post) and has a strong relationship to the diaphragm in that these muscles are accessory breathing muscles and, when restricted, can greatly limit breathing. The Yang sinew channels also include many structures such as the abdominals and pectoral muscles that can limit expansion of the breath. Therefore, the diaphragm, with its relationship to effortless and healthful breathing, is one of those pivotal structures for vibrant health.

Note: Tom Myers has an interesting discussion on this fascial plane which I am categorizing as part of the Liver sinew channel. His post can be found here; however, it is not written from a TCM or Chinese medicine prospective.

Monday, December 14, 2015

The Diaphragm and the Liver Sinew Channel, Part 1

Image modified from
Toldt's Atlas of Anatomy.
Labels added to highlight
Liver sinew channel
In the last post we discussed how the Spleen sinew channel connected to the anterior aspects of the diaphragm; we looked at dysfunctional patterns associated with this sinew channel and how this relates to breathing and posture. 

This post will look at the Liver sinew channel and the posterior aspects of the diaphragm. This connection is mediated through both the quadratus lumborum and psoas muscles as their fascia blends with that of the diaphragm. This occurs at the 12th rib for the QL and the superior portion of the psoas. 

Before getting to the diaphragm, let's look at the Liver sinew channel in the thigh and work up to its connection at the posterior diaphragm. There are two prominent fascial septa in the medial thigh; an anterior septum which separates the quadriceps from the adductors, and a posterior septum which separates the adductors (primarily adductor magnus) from the hamstrings.

The anterior septum is associated with the Liver sinew channel and links the more anterior adductors such as adductor longus, adductor brevis, and pectineus with the distal iliopsoas tendon.

While the iliacus and psoas muscles (which together make up the iliopsoas) have a common attachment distally, each muscle takes a different, though similar, pathway as it moves proximally. 


Posterior Abdominal Wall, from Netter's Atlas of Anatomy.
Labels added to highlight Liver sinew channel.
The iliacus portion attaches to the iliac fossa on the medial ilium. Its proximal portion at the iliac crest connects to the distal portion of the quadratus lumborum (QL). This places the QL on a direct fascial plane with the adductors and iliacus and makes it a much more Yin muscle in terms of depth and fascial connection. 

Other authors usually assign the QL to Yang channels, most often the Gallbladder, but occasionally the Urinary Bladder. Legge. Maciocia, and Kendall place it in the Gallbladder sinew channel. Whitfield Reaves has some interesting commentary in his book based on his struggles with this muscle and its channel relationships. He deems it too lateral to be easily assigned to the Urinary Bladder and too medial for the Gallbladder channel (he does not refer to the sinew channels, specifically). All of this is understandable, based on where it would be palpated and needled. 

However, I have become convinced that it more properly belongs in the Liver channel, based on the fascial plane it exists on; functional relationships it has with the Gallbladder sinew channel muscles such as the gluteus medius and minimus (this will be a future topic); and my own findings of consistent reactivity of LIV-5 to QL pain at Yaoyan (its iliac crest attachment), Pigen (its 12th rib attachment), or in the midbelly at its motor point (this will be discussed more in part 2 of this post).  

To continue with the fascial connection, the QL attaches to the inferior portion of the 12th rib, while a portion of the diaphragm attaches to the superior portion of this rib. However, the fascia between these attachments is continuous. This fascial connection can be illustrated with the scenario of an actress who has her 12th rib removed (an actual cosmetic procedure, used to reduce waist size). Neither the QL nor the diaphragm needs to be cut surgically. The 12th rib is cut away and the periosteum (containing both the QL and diaphragm attachments) is teased away from the rib. The rib is then removed and the QL-periosteum-diaphragm is kept intact.

The psoas has a more direct pathway, covering the same basic territory as the QL-iliac muscle to blend with the fascia of the posterior portion of the diaphragm at its proximal end.

In Sports Medicine Acupuncture®, we look at the cases where the too-tight diaphragm can impinge on and inhibit the psoas. This inhibition of the psoas destabilizes the back and leads to pain, which often comes on when the breathing is challenged during exercise. Matt Callison teaches a technique he developed to assess for this, and he treats it with a particular needle technique at ST-20. This assessment and technique is better left to in class training, but it is interesting that ST-20 descends both Stomach Qi (not surprising for an ST channel point in this region), but also descends rebellious Lung Qi. Could this be considered a case of Metal overacting on Wood, as breathing restrictions are inhibiting the proper firing of a Liver sinew channel muscle?

Image from Deadman's
A Manual of Acupuncture
To briefly restate the anatomy: this sinew channel follows the anterior septum of the thigh up the medial leg. This would include a series of fascially linked structures such as the adductor longus, the adductor brevis, the pectineus, and the distal iliopsoas. This would then branch at the iliopsoas, with one portion linking the psoas to the posterior diaphragm and another branch linking the iliacus to the QL to the posterior diaphragm. Note that classically the Liver sinew channel ends at the groin. However, I feel, for reasons described above and in future posts, that a strong argument exists for extending it up to the diaphragm.

In the next post we will look more thoroughly at dysfunctional patterns associated with the Liver sinew channel and its connection to the diaphragm. We will explore various postural changes that can be observed (as we did with the Spleen sinew channel) and we will explore various pain patterns that arise. 



Tuesday, December 8, 2015

The Diaphragm and the Spleen Sinew Channel

Fig.1: Diaphragm, Anterior and Superior view, from
Grant's Atlas of Anatomy.
This is Part One of a post that will explore the sinew channels and their relationship to the respiratory diaphragm. This post will highlight the Spleen sinew channel (and will also discuss the Chongmai). The next post will highlight the Liver sinew channel. 

The respiratory diaphragm is a large, complex and extremely influential muscle. Its unrestrained movement is essential for proper breathing. This involves not only freedom in the muscle itself for it to ascend and descend, but also freedom in related structures which, when restricted, can act as a clamp and prevent expansion of the abdomen and thorax. Structures such as the the abdominal muscles, pectoral muscles, serratus anterior, and certain cervical muscles are among those that can be particular detrimental to breathing when they are restricted. In addition, the visceral organs move with each breath, so freedom in the diaphragm requires good circulation and unrestrained mobility in the organs for proper response to the diaphragmatic movement. Cervical pain, low back pain, thoracic outlet syndrome, and hypochondriac and rib joint pain are just some of the many conditions that can occur with poor breathing due to dysfunction associated with the diaphragm.

From a Traditional Chinese Medicine standpoint, the ascending and descending of the diaphragm is important as it regulates the ascending of Spleen Qi and descending of Stomach Qi. Vietnamese educator and Classical Chinese medicine scholar Nguyen Van Nghi described the acupuncture point BL-17 from this standpoint, indicating that the reason it was both the Back Shu of the diaphragm and such an influential point of blood production was tied to the fact that it regulated the upward and downward  movement of the diaphragm, thus regulating the upward and downward movement of the Spleen-Stomach Qi mechanism, both being so integral to the production of blood.

This and the next post will look at the relationship of the sinew channels to the diaphragm, especially those of the Spleen and Liver sinew channels. I have been exploring the sinew channels for about 15 years, first as a taiji and qigong practitioner, then as structural integration practitioner (the body of work that includes Rolfing) and then as an acupuncturist. I was not thinking about these directly as sinew channels when I practiced structural integration, but was very influenced by Tom Myers' development of Anatomy Trains as these seem to relate to the 'tendons' we referred to in our 'tendon changing' exercises in taiji and qigong practice. As I transitioned into acupuncture, I noticed a lack of description of these sinew channels and have been working to develop these more thoroughly. I feel there is enormous potential in having a more detailed anatomical knowledge of them, and in using this specificity of detail to inform clinical decisions.

Much of this material is influenced by my practice first in structural integration and then in acupuncture, specifically through my work with Matt Callison and Sports Medicine Acupuncture®. This information is condensed from a lecture I have been giving in the certification program for Sports Medicine Acupuncture®. This primarily explores the sinew channels from the perspective of fascial planes, how these channels relate (internally-externally, six division, midday-midnight, five elements), and how they communicate proprioceptively through the fascia.

Fig 2: Cross section above the umbilicus which highlights the fascia anterior
and posterior to the rectus abdominis. This fascia is associated with the
Stomach and Spleen sinew channels.
The first sinew channel to explore relating to the diaphragm is the that of the Spleen. Actually, it might be better to consider this as a pair involving the Stomach and the Spleen. As in much of Chinese medicine, the physiology of the Stomach and the Spleen sinew channels are very tied together. Often internally-externally related sinew channels have an agonist-antagonist relationship when looking at how they balance a particular joint complex. With the Spleen and Stomach sinew channels, they work much more together. We will look at the anatomy of these channels in relationship to the torso in this post.

The fascia associated with the rectus abdominis muscle is particularly relevant to these channels. The fascia of the external obliques travels anterior to this musclel the fascia of the internal obliques bifurcates, half of it travels anterior, half posterior. The transverse abdominis travels completely posterior to the rectus abdominis. Note: this changes below a structure called the arcuate line, which is roughly in the region of Ren-6, at which point the rectus abdominis becomes deep to all of this fascia and continues to connect to the pelvic floor.



Fig. 3: Image from www.brucelee.com.
The fascia which travels anterior to the rectus abdominis (that of the external obliques and part of the internal obliques) comprises the abdominal portion of the Stomach sinew channel. Following this fascia superiorly reveals that the anterior fascial layer is continuous with the fascia anterior to the ribcage, especially the sternalis fascia. This fascia then connects with that of the sternal head of the sternocleidomastoid muscle (SCM). When this layer is short and tight, the abdomen is often very flat and possibly bowed concave, the sternum is pulled down, and the head is pulled forward. The build of a boxer comes to mind, but I am including an image of Bruce Lee as this is so apparent on him. The tension in the abdominal muscles hasthe capacity to prevent adequate expansion of the abdomen during an inhale and can limit a full breath. 

Fig. 4: Spleen Sinew Channel image from Deadman's
A Manual of Acupuncture.
The posterior abdominal fascia has a different trajectory, and is continuous with the costal margin attachments of the diaphragm at the inner surface of the anterior ribcage. From here, one could follow the diaphragm around to its connection to the lumbar spine. This connection is called the crus (feet) of the diaphragm and connects this muscle to the lumbar spine at L1 and L2 (Fig. 1). This would describe the Spleen sinew channel as seen in Fig. 4. 

However, one could also follow the diaphragm up to the central tendon (Fig. 1). The pericardium attaches to the central tendon on its superior surface. The pericardium is in the same fascial layer which comprises the hyoid muscles. This plane (posterior abdominal fascia-diaphragm-pericardium-hyoids) could be considered part of the sphere of influence described by the Chongmai and accessed through SP-4 (Fig. 5). Also included in this layer is the transversis thoracic muscle, an interesting muscle on the posterior surface of the ribcage that shares a similar trajectory to the portion of the Chongmai that disperses in the chest (Fig. 5). For all practical purposes, I consider the Spleen sinew channel to follow this upward trajectory in addition to the attachments at the lumbar spine. And, not surprisingly, SP-4 (paired with PC-6) is a powerful point combination to affect this region.

Fig. 5: Chongmai from
Deadman's A Manual of
Acupuncture.
When this layer is restricted, the abdomen is bowed convex and is distended (not unexpected in Spleen Qi deficiency, for instance). Also the solar plexus region is collapsed inward. Often, there is an appearance of someone being punched directly in the solar plexus. Simone Lindner, my fellow faculty member in the Sports Medicine Acupuncture Certification program and a senior instructor with KMI (the program that teaches Anatomy Trains and Kinesis Myofascial Integration), often states that when she sees this pattern, she wonders if, at some influential point in their development, this person had 'their breath taken away'. This could be physical through some direct trauma or emotional. But it is usually pretty deeply seated in their physiology. And, more important to the discussion, it obviously restricts breathing. Patients who present with this pattern generally take very shallow breaths into the belly, with very minimal movement expanding into the chest. It appears that these patients cannot take a full expansive inhale, and are stuck on the exhale portion of the breath. Fig. 6 highlights this, notably the bowing of the abdomen, the collapse of the chest and the general restriction of the ability to take an inhale expanding into the chest.






Fig. 6: Image courtesy
Matt Callison / Sports
Medicine Acupuncture
Used with permission
Releasing this posterior rectus abdominis fascia usually is rewarded with a profound release of the breathing and marked improvement in the ability to take a full inhale. This can be released manually by starting at the Spleen channel and insinuating fingers behind the rectus abdominis to reach the Kidney channel and waiting for a release. The fascia can also be lifted or dropped depending on the need. Acupuncture needles can instead be used following the same trajectory as the fingers. Upon the release of this layer, the breath is able to move from the abdomen into the chest, allowing for a full expansion in the chest.

In the Sports Medicine Acupuncture Certification program (in 2016 it will be in Chicago), we cover vertebral fixations and their treatment with mobilization techniques, specific needle techniques at Huatuojiaji points and use of extraordinary vessel points. Fixation at specific levels (certain midback and cervical regions) which are treated with SP-4, PC-6 are understood better by thoroughly comprehending the anatomy explained above. And the treatments described in this post can supplement the treatments explored more thoroughly in these classes.

Before moving on to the Liver sinew channel in the next post, it might be useful to note that the abdominal obliques do travel around the body to the lumbar region, and their fascia blends in with the thoracolumbar fascia and attaches to the spine. This accounts for the Stomach sinew channel attaching to the spine (Figures 7 and 8). This layer also needs to be open and free for a full expansive breath.










Fig. 7: Abdominal and Thoracolumbar Fascial Layers
from John Hull Grundy's Human Structure and Shape.


Fig. 8: Stomach Sinew Chanel from Deadman's
A Manual of Acupuncture.



























Friday, December 4, 2015

Two Blogs: One for Professionals, One for Patients

Starting in the Fall of 2015 I committed myself to regular blog posting. I had two primary things in mind for this. First, I wanted to provide educational information for my patients and the public. Second, I wanted to provide educational material for practitioners of Traditional Chinese Medicine, especially those interested in working more with sports injuries and orthopedic conditions.

For the first goal, I wanted to provide information that would help educate the public, primarily related to my area of expertise which is sports injuries and orthopedic conditions. And, I wanted to give some insight into how acupuncture, manual therapy, herbal medicine and other things practiced as part of Traditional Chinese Medicine can help prevent, improve and manage these conditions.

For the second goal, that of writing for professionals, my plan was to take material from lectures I have given in Manhattan and San Diego with the Sports Medicine Acupuncture Certification program run by AcuSport. This material is on the sinew channels, secondary channels in the meridian system described in Chinese medicine, and is derived from work I have been doing first as a Structural Integration practitioner and then as an Acupuncture Physician. The blog posts are the first step in a process that will lead to a book. The steps for me include producing lecture notes, writing blog posts, refining much of this information for published articles, and then further refining this for a published book.

Since these two goals are somewhat hard to synchronize in a blog, I have made the decision to have two separate blogs. One will be for patients and the public. This will be found at idealbalanceacupuncture.blogspot.com. The second will be for professionals and will explore the sinew channels in much more anatomical detail. This will be found at drbrianlau.blogspot.com. These two blogs will be linked so that those interested in both can move back and forth between them.

Monday, November 30, 2015

Direct Needling of the Masseter and Pterygoids

In the last blogpost, I discussed the muscles of mastication with an emphasis on the masseter and the pterygoids. Also, the channel relationships were discussed, including a look at the Large Intestine sinew channel and its possible trajectory traversing the pterygoids.

In this post, we will explore ways in which these muscles of mastication can be influenced with an acupuncture needle directly. Some of these techniques are very straightforward and will be in the range of techniques that are taught in school, though I often find that the actual anatomy is not emphasized. So, it will be useful to look at the specific anatomy associated with common acupuncture points.

Other techniques might be beyond the skill set taught in school and I advise you to use your own judgment when using these, as they involve deeper needling and a more precise understanding of anatomy.

First and foremost, in the last blog post we discussed certain Stomach channel points and their relationship to the masseter muscle. These were ST-5, ST-6 and ST-7. Depending on the source you look at, the masseter has two or three layers of muscle fibers. I described three layers in the last post, a superficial, an intermediate, and a deep layer. I locate ST-5 just anterior to the superficial fibers of the masseter and just superior to the angle of the mandible. The superficial fibers create a very palpable border and the intermediate fibers are less distinct at ST-5. However, a palpable taut band of the masseter is usually apparent if you crossfiber it in an anterior-posterior direction. And you can feel that this band is still anterior to the much more obvious superficial fibers. So, needling ST-5 perpendicularly directly into this taut band will access a common trigger point in this region, one that often refers to the eyebrow and can be a contributing factor to headaches that project pain to the eye region. Another possible needle method would be to thread from ST-5 to ST-6 which would crossfiber the masseter.

ST-6 would be in the belly of the masseter and is another common pain generator, often referring into the teeth, especially the lower teeth. This can be needled at ST-6. The needle direction is mostly perpendicular. Palpation with the finger first can fine tune needle direction, and I often find a slight medial direction slightly angled to ST-4 often elicits the strongest sensation.


ST-7 has the ability to address two muscles depending on depth and angle. It can address the deep fibers of the masseter and a common trigger point with referral to the ear. However, deeper needling can access the lateral pterygoids. The lateral pterygoids refer pain to the ear and to the upper teeth or maxillary sinus region. Pain from the lateral pterygoids can contribute to TMJ disorder and can be a contributing factor to sinus pain.

Dr. Janet Travell, MD describes injection at a region consistent with ST-7 (she does not reference specific acupuncture points, however) for both the medial and lateral pterygoids, but she keeps the patient's mouth in an open position by having a cork between the upper and lower teeth. This is especially necessary for the medial pterygoids. While this is an appropriate method for accessing the medial pterygoids, this would be much more valid if there were not needle retention. She is describing injection, so there would obviously not be needle retention in this case. If however, the plan was to retain the needle, there is another method for accessing the medial pterygoids and that is from an inferior direction by coming below the ramus of the mandible to the medial surface. If you palpate with your finger or thumb, you will feel a space. Your finger is much too large to get deep enough to reach the medial pterygoid, but you might be able to feel the lower attachment and you might note that this is very sore, especially if you have jaw issues.

A 1.5 (40mm) can be used to reach the medial pterygoids from this inferior direction below the angle of the mandible. The direction will be superior in the same direction as your finger would push to reach the inferior attachment of the medial pterygoids and the needle will cross fiber the muscle and will elicit a strong Qi sensation.


Another muscle of mastication which should be assessed when working with TMJ disorder, muscle tension headaches and other related disorders would be the temporalis muscles. The temporalis muscle differs from the masseter and pterygoids, in that it is more in the distribution of the Gallbladder channel. This muscle will be discussed in another post.

Tuesday, November 10, 2015

The Masseter and Pterygoids and their Channel Relationships

The masseter muscle is one of the muscles of mastication (chewing) and is frequently involved with TMJ pain, but also headaches and other less considered symptoms.  The masseter consists of a superficial, intermediate, and deep layer. All three are on the lateral surface of the mandible and can be palpated directly. The superficial and intermediate layer (considered together) attach from the anterior two thirds of the zygomatic arch to the angle and inferior portion of the ramus of the mandible. The deep layer attaches from the posterior one-third of the zygomatic arch to the superior portion of the ramus of the mandible. Both layers are accessible with an acupuncture needle and several stomach channel points directly traverse this muscle (Fig. 1). The medial pterygoids attach to the angle of the mandible on the medial surface and then attaches to the medial surface of the lateral pterygoid plate of the sphenoid bone. The lateral pterygoids attach to the lateral surface of the pterygoid plate and then to the condyloid process of the mandible (Fig. 3). This blog entry will explore the pain patterns, symptoms, and channel relationships of the muscles of mastication with a primary influence on the masseter and the pterygoids.

Fig. 1: The Masseter in reference to ST-5 - ST-7
Fig 2: Masseter TrPs. Image from Travell and Simons'
Myofascial Pain and Dysfunction: A Trigger
Point Manual

















When considering the pain pattern of the masseter muscle, it is best to look at the superficial, intermediate, and deep layer separately. Trigger points in the superficial and intermediate layer refers pain to the lower jaw, teeth and gums and to the maxilla. Trigger points with these referrals usually develop in the region of ST-6. In addition, trigger points might develop in the ST-5 (and posterior to ST-5) region which can refer in an arc across the temple and over the eyebrow. This referral can be a significant contributing factor to headaches, especially when other cervical muscles are referring pain to an overlapping area. This is often seen with a head forward posture as discussed in a previous blog post. In addition to pain, trigger points in the superficial layer of the masseter can cause tooth sensitivity to stimuli such as hot and cold.

The deep layer of the masseter can develop trigger points which can refer to the cheek and TMJ, but often radiate pain deep into the ear. The ear referral is specifically caused by trigger points near the attachment at the zygomatic arch in the region of ST-7. This deep ear referral can be a cause of tinnitus which is usually unilateral, but the masseter can be dysfunctional on both sides, so it can also be bilateral. When bilateral, the patient might report that one side is worse than the other. If the masseter is causing tinnitus, the symptoms will often be aggravated or alleviated with opening the mouth wide as this will stretch the masseter.

As mentioned above, several Stomach channel points (ST-5 – ST-7) directly affect the masseter and can be used as local points. Distal Stomach channel points also can be effective for softening the masseter. ST-44 can be an effective point and looking at actions and indications in Deadman's A Manual of Acupuncture reveals many of the same symptoms described by Travell and Simons in Myofascial Pain and Dysfunction: A Trigger Point Manual. Notably pain in the teeth, pain in the eye, pain in the face, and tinnitus are all indication listed in Deadman for ST-44 which are consistent with trigger point referrals and symptoms of the masseter.  Personally, I find ST-44 a very useful point when there is exquisite sensitivity with palpation at ST-43. Often I will find this on the same side as the symptoms and it will not be as sensitive on the other side nor at similar regions such as LIV-3 or in the other metacarpal spaces. If ST-43 is not sensitive, sometimes ST-40 is very sensitive and feels bruised to the patient, in which case I include this point.

In addition to the Stomach channel, the Large Intestine is frequently used for symptoms associated with dysfunction of the masseter. LI-4 is used by many practitioners and is often combined with ST-44 for tinnitus associated with the masseter, toothpain, and frontal headaches.

However, consideration of LI-6 becomes more interesting. LI-6 is the Luo-Connecting point of the Large Intestine channel and it is at this point that the Luo-Connecting channel separates from the primary channel. The Luo-Connecting channel travels up the arm and, at the angle of the mandible, branches to the ear and to the teeth. Looking at the picture in Deadman (Fig. 5) or the classical description does not indicate depth. It is my opinion that the Luo-Connecting channel does not travel on the lateral surface of the mandible, but on the medial surface. This part of the mandible is really only accessible to palpation with a gloved hand inside the mouth. The muscles that you would be palpating inside the mouth on the medial surface would be the medial and lateral pterygoids. 

Fig. 3: Lateral and Medial Pterygoids. Image from
Netter's Atlas of Anatomy
A couple of interesting things about referrals and symptoms of the pterygoids are worth considering to help bring life to LI-6. First off, the medial pterygoid refers pain deep to the ear and to the throat. This can interfere with swallowing and can contribute to soreness in the throat. In addition, this muscle has an interesting relationship to the tensor veli palatini muscle which, when you yawn or open your mouth, pulls the eustachian tube open and allows drainage and pressure normalization of the middle ear. Tightness of the medial pterygoid can block this function and be a major contributor to ear stuffiness (barohypoacusis) and can contribute to otitis media.

Looking at LI-6 shows indications for dry throat and throat pain. Also, deafness is an indication and this indication is listed as one of the excess conditions in the Great Compendium or Acupuncture and Moxibustion. Many would agree that true deafness is unlikely to be successfully treated with acupuncture, but ear stuffiness and diminished hearing associated with it could potentially be treated, and it is possible that LI-6, via softening and releasing the medial pterygoid muscle, could potentially allow for better drainage and health of the middle ear.

The lateral pterygoids has a very interesting pain referral pattern that first made me consider the connection to the Large Intestine Luo-Connection channel. Notice the similarity between the pain referral as depicted by Travell and Simons and trajectory of the Luo-Connecting Channel (Figs. 4 and 5). In addition, tinnitus and rhinitis are commonly associated with lateral pterygoid dysfunction and these are both indication of LI-6.

Fig. 4: Lateral pterygoid TrP referral pattern.
Image from Travell and Simons' Myofascial
Pain and Dysfunction: A Trigger Point Manual


Fig 5: Large Intestine Luo-Connecting Channel
Image from Peter Deadman's A Manual of Acupuncture


























I will often palpate LI-6 when I am working with TMJ dysfunction or any symptoms associated with restriction in the muscles discussed (ear stuffiness or tinnitus that is associated with these muscles, for instance) and include it when it is painful to palpation. When LI-6 is painful to palpation, I find that it is about 50% of the time on the ipsilateral side and 50% of the time on the contralateral side, so it is worth palpating bilaterally. This is not surprising since both the Large Intestine primary and sinew channel cross to the opposite side of the body. I often needle this point by threading the needle parallel to the proximal edge of the abbductor pollicus longus muscle which produces a Qi sensation that travel towards LI-4.


Fig 6: Large Intestine Sinew Channel
Image from Peter Deadman's
A Manual of Acupuncture
For a final thought, since so much muscle anatomy was explored, it is useful to look at the Large Intestine sinew channel. This channel binds at the nose. Much like the Luo-Connecting channel, I believe that this involves the pterygoids which ‘bind’ at the lateral pterygoid plate of the sphenoid bone (Figs. 3 and 6). Much of the Large Intestine sinew channel is more superficial than this, but I believe that the upper portion includes the scalenes and the pterygoids which are on the same myofascial layer. Actually, this portion of the sinew channel is really more obviously on the same myofascial layer as the Lung sinew channel which includes muscles such as the pectoralis minor. LI-6 has an effect on this layer for this very reason, in my opinion, as it is affecting a more Lung sinew channel layer that happens to be part of the Large Intestine sinew channel.


Note: In the next entry we will discuss some local needle techniques for the pterygoids.

Sunday, October 25, 2015

Head Forward Posture: Part 3: Relationship to Zangfu Disharmony

Fig. 1: Upper Cross Syndrome
In the last blog post, I wrote about a common postural disparity called Upper Cross Syndrome (UCS) which involves a head-forward posture and scapular protraction. Upper Cross Syndrome is a muscle imbalance which includes a combination of overactive, shortened muscles and inhibited, lengthened muscles. We can visualize this by looking at a person from the side and picturing an X overlaying the body as illustrated in Fig. 1; one leg of the X indicates the overactive muscles (the posterior cervical extensors and pectoralis muscles) and another indicates the inhibited muscles (the lower and middle trapezius and rhomboids and the anterior cervical flexors).

Also discussed in this post was the sinew channels (jingjin) involved in UCS. Specifically, the Lung and Large Intestine sinew channels were seen to work in a coordinated fashion to balance the scapula and were involved with imbalance as seen in scapular protraction. In protraction, the muscles of the Lung sinew channel (pectoralis minor) were short and overactive while the muscles of the Large Intestine sinew channel (the middle and lower trapezius) were inhibited.

The Kidney and Urinary Bladder sinew channels work together to balance the cervical spine in relationship to flexion and extension. In a head forward posture, the muscles of the Urinary Bladder sinew channel (comprising the cervical extensors such as the splenius cervicis and capitis) were overactive while the muscles of the Kidney sinew channel (comprising the deep cervical flexors such as the longus colli and capitis) were inhibited.

So, in terms of the sinew channels, the structures involved with UCS are Lung/Large Intestine and Kidney/Urinary Bladder. Interestingly, the zangfu pattern commonly seen with UCS parallels this, as seen in a study done by Matt Callison, M.S., L.Ac. Callison presented the finding of this study at the Pacific Symposium in November of 2011. He took a sample size of 150 (this has now grown to over 250) and had them fill out a questionnaire which included common questions asked as part of the examination methods in TCM. In addition, postural assessment was performed revealing five basic postural patterns. These are seen in Fig 2 below.

Fig 2: Image courtesy of Matt Callison and used with permission. Type I indicates the Zang pattern associated with UCS. Other postures and their respective sinew channel relationships will be explored in other posts. 

Matching the results from the questionnaire revealed trends that allowed a comparison between these five common postural disparities and common Zangfu diagnoses. Relevant to this discussion, respondents with UCS as seen in the first image in Fig 2 gave answers that would be consistent with Spleen, Lung and Kidney deficiency. Observing this posture, one can see the compression of the lungs which affects breathing, but also the middle jiao is compressed and there is a bowing of the abdomen. Kidney deficiency manifests with a reduction in tone of the stabilizing muscles of the spine, especially the cervical spine in UCS. Note: UCS involves the Lung and Kidney sinew channels and their respective internally and externally related channels. UCS describes a Western muscle imbalance, first discussed by Vladamir Janda. It is only describing the relationship of the shoulder girdle and the head/cervical balance. In practice, I see the Spleen sinew channel involved, as it incorporates the deep abdominal fascia which, when restricted, can contribute to a bowing of the abdomen.

The question that often arises is that of chronology. Which came first: the posture or the pattern? In my opinion, this is a somewhat unimportant question; it is more useful simply to understand that structure and function are related. One affects the other. Possibly there is no answer to this question, as dysfunction occurs differently for everyone. Some may have zangfu dysfunction, which affects the channels and collaterals and leads to a change in the posture. Others may have a job or other circumstance that affects the posture and, due to the strain on the internal organs, leads to zangfu disharmony.

What is more important to consider is that addressing the posture can impact the health of the zangfu. This will reinforce and broaden treatment with distal points in an acupuncture session, and with herbs, diet, and lifestyle changes.

Saturday, October 10, 2015

Head Forward Posture: Part 2 - Upper Cross Syndrome and the Sinew Channel

In the last post I discussed how a head-forward posture can, due to the additional load on the posterior cervical region, contribute to several injuries and orthopedic disorders. In this post, I will discuss a common relationship that a head-forward posture has with the shoulder girdle. The sinew channel relationship to this imbalance will also be discussed with the emphasis on the importance of assessing and treating this common pattern with acupuncture, tuina, and corrective exercises. In the next post, we will look at how this postural pattern relates to zangfu disharmony. Acupuncturists can greatly improve their results by recognizing and addressing this common postural imbalance when treating a wide range of conditions.

Upper cross syndrome describes a common postural pattern first discussed by Vladamir Janda, a Czech physician. Janda described this common upper body muscle imbalance as an X with one leg of the X consisting of a group of overactive (locked-short)* muscles and the other consisting of a group of inhibited (locked-long) muscles. This common pattern is seen with a head-forward posture and scapular protraction. 
*Note: locked-long and locked-short is terminology used by Thomas Myers and also employed by Sports Medicine Acupuncture. The tendency is for practitioners to think that inhibited muscles will feel soft and weak on palpation and that overactive muscles will feel ‘tight’. The reality is that there is often tension in both and they are both locked, one in a lengthened position, the other in a shortened. For practitioners of Chinese medicine, it might be helpful to consider the terms 'deficient' and 'excess.'

The muscles that contribute to this imbalance are listed below and grouped according to the overactive, locked-short leg of the X and the inhibited, locked-long leg of the X:

  • Overactive: Pectoral muscles, posterior cervical extensors, levator scapula, upper trapezius
  •  Inhibited: Lower and middle trapezius, anterior cervical flexors

Pectoralis minor, highlighted in red, pulls in and down in the front. Lower and middle trapezius (and rhomboids), highlighted in blue, pulls in and down in the back. When maintaining a balanced tone, this stabilizes and balances the shoulder girdle. The common muscle imbalance seen is for the pectoralis minor (red) to be overactive and the middle and lower traps (blue) to be inhibited.

The pectoralis minor is particularly important in its influence on scapular protraction as it has direct attachments to the scapula at the coracoid process. From the coracoid process, the pectoralis minor has an attachment to the 3rd, 4th, and 5th ribs. The fibers attaching to the 3rd rib have a relatively more horizontal fiber direction compared to the more vertical 5th rib attachment. This line of pull creates a medial rotation of the scapula, while the 5th rib attachment creates more of an anterior tilt. Scapular protraction often has components of both of these when the pectoralis minor is short.

The lower and middle trapezius, highlighted in blue, balancing
the pull of the pectoralis minor, highlighted in red. 
Balancing this line of pull is the lower and middle trapezius and the rhomboids. The lower trapezius balances the downward pull of the pectoralis minor while both the middle trapezius and rhomboids counter the movement of the scapula away from the midline. Both the lower and middle trapezius and the rhomboids have a tendency to become inhibited and fail to properly resist the pectoralis minor.








From A Manual of Acupuncture, by Peter Deadman. Notice
the connection of the LI sinew channel to the thoracic spine.
For acupuncturists, it can be very informative to review the pathway for the Large Intestine and Lung sinew channels. The Large Intestine sinew channel expands the influence of the primary channel as it attaches to the thoracic spine. I believe this to include a continuous sequence of muscles and fascial structures which start with the first dorsal interosseus muscle (accessible at LI-3 and LI-4) and continuing up the arm to connect, via the middle and lower trapezius, to the thoracic spine. The Lung sinew channel begins at the thenar muscles and continues up the arm to connect, via the pectoralis minor, to the ribs.

What this means is that the internally-externally related Lung and Large Intestine sinew channels work together to balance the shoulder girdle on the ribcage. When there is an imbalance between these two related channels, this is frequently seen with scapular protraction.

However, upper cross syndrome also describes cervical muscle imbalance. This includes the overactive cervical extensors on the posterior neck and the inhibited cervical flexors on the anterior neck. These can also be seen as an imbalance between internally-externally related sinew channels. The Urinary Bladder sinew channel includes the posterior cervical muscles, while the Kidney sinew channel includes the deep anterior cervical muscles such as the longus colli and longus capitis.

Even the pectoralis major can be seen to have a connection to the Urinary Bladder sinew channel. Through the thoracolumbar fascia, the Urinary Bladder sinew channel has a branch that I interpret as the latissimus dorsi. The latissimus dorsi attaches to the medial lip of the bicipital groove, in very close proximity to the attachment of the pectoralis major. However, classically the sinew channels are said to converge, and I believe the pectoralis major to be also part of the Heart sinew channel, so it is a region where the Urinary Bladder and Heart sinew channels converge.

BL-60 Kunlun, from A Manual of Acupuncture, by Peter Deadman
Also, there is a branch that attaches to the shoulder and connects with another area of convergence, the lower trapezius (this time converging with the LI sinew channel). In my view, both of these branches of the Urinary Bladder sinew channel (lats and lower traps) help explain how excessive pathological Yang can rise and contribute to tension manifesting in excess (overactivity) in the neck, shoulders and chest. It is helpful to review commentary about BL-60 Kunlun and understand that this point ‘Clears heat and lowers excess’. In addition it ‘pacifies wind and leads down excess’. This involves Liver disharmony with pathological Yang rising up the Urinary Bladder channel. This rising Yang often contributes to occipital headaches, neck pain, and shoulder pain. BL-10 Kunlun treats the manifestations of this rising Yang, often in combinations with SI-3 Houxi. Being a Jing-River point, it is an excellent point to relax the sinews, in this case associated with the Urinary Bladder sinew channel.

BL-60 Kunlun is a useful distal point to treat the rising Yang activity which contributes to the imbalance discussed with UCS, but in order to fully take patients out of this dysfunctional pattern, it is necessary to treat locally. Acupuncture to motor points of the affected muscles (both inhibited and overactive) is a great strategy to reset dysfunctional muscle spindles and balance the internally-externally related channels. In addition, tuina/myofascial release and corrective exercises help increase the therapeutic results.

UCS, therefore, offers fantastic insight into the coordinated balance between the sinew channels and common patterns of dysfunction that occur between internally-externally related channels. The Lung-Large Intestine sinew channels work together to balance the shoulder girdle, while the Urinary Bladder-Kidney sinew channels work together to balance the cervical spine.

Thursday, October 1, 2015

Head Forward Posture: Part 1

One of the most common postural disparities I see is a head-forward posture. In The Physiology of Joints, Volume III, French surgeon and anatomist Adalbert I. Kapandji states that for every inch the head goes forward it gains an additional ten pounds of weight in terms of strain on the posterior neck and upper back muscles. The average weight of the head is about 4.5-5 kg (10-11 pounds) and, in a balanced posture, it is supported evenly amid the muscles of the neck. With a head-forward posture, this balanced support is disrupted, and the posterior neck and upper back muscles then become increasingly more overloaded (and painful) with every additional degree of head-forward posture. With the head an inch forward (neutral is considered as consisting of the ear aligning over the acromion process which is the highest point of the shoulder) this means that the posterior neck and upper back muscles have to support about 20 pounds of weight all day. At 2 inches forward, this becomes about 30 pounds. With Americans spending more and more time behind the wheel, in front of computer screens, glued to cell phones and tablets, and performing other activities which lend themselves to this already common posture, it is not surprising that we frequently see so many problems attributed to this posture.

This is the first post of a three-part article about the implications of the head-forward posture. Part One (today’s post) discusses some common pain syndromes to which it contributes. Part Two will discuss the relationship of this imbalance to the shoulder girdle and will look at the sinew channel relationships. These two parts will be useful for patients and those suffering from the painful conditions described below; they will also be useful for acupuncturists who want to understand how improving posture can improve treatment results.

Part Three will explore the relationship of this imbalance to the zangfu (primary organ systems discussed in TCM). This will be largely for the benefit of practitioners of acupuncture, tuina and other modalities used in Traditional Chinese Medicine. 

The following are common complaints that involve a head-forward posture:

Generalized neck pain and shoulder pain caused from muscle overuse: As stated above, for every inch the head moves forward, it gains an additional 10 pounds of weight in terms of strain on the posterior neck and upper back muscles. What this means is that the muscles of the posterior cervical spine are working overtime, day in and day out, and for a prolonged time. It is just a matter of time before they start to cry out for some attention and that usually comes in the form of aches and pain. Specifically, the upper trapezius, levator scapula, and splenius cervicis are frequent muscular contributors to neck discomfort; they not only produce pain, but reduce range of motion and can contribute to stiffness, including stiffness which makes it difficult to turn the neck. Generally, restriction in the upper trapezius manifests in reduced range of motion and discomfort towards the end of the range of motion when looking in the opposite direction, while restriction in the levator scapula often causes pain when looking to the same direction. However, sometimes all three of these muscles can become spasmed, making it very difficult to turn the neck in any direction without considerable pain.

And it is not just the muscles which are involved with neck pain from a head-forward posture. The strain in the posterior neck from the additional load signals fibroblasts to produce more extracellular matrix to support this area. Fibroblasts are specialized cells that produce the building blocks of fibrous connective tissue, such as collagen fibers and a sticky, syrupy substance called proteoglycans (a protein-carbohydrate based molecular structure). Prolonged strain (such as years of bracing against the extra weight of having the head forward) stimulates production of this extra material which can be easily felt as dense, ropy, fibrous bands in the upper back and neck region. It is the body’s attempt to add more support to a region that has additional demands placed on it. Local massage, acupuncture, or other treatments applied directly to the painful tissue may temporarily help make this dense, stagnant tissue feel better, but the posture as a whole needs to be addressed if there is to be any hope of long-lasting relief.


Cervical facet joint referral patterns.
Image from: Osteoarthritis of the Spine:
The Facet Joints, Gellhorn, A.C. et al
Nature Reviews Rheumatology 9, April 2013
Facet joint syndrome: This involves a degeneration of the vertebral facet joints, which is usually secondary to degeneration of the intervertebral discs. Cervical disc degeneration is usually exaggerated whenever there is long term hypomobility (limited movement) of cervical spine. While the outer part of the intervertebral disc has a blood supply, the inner part does not and requires nutrition and fluids via diffusion from the outside. So, with any limited movement patterns that persist for a long time, the discs suffer. As one of my tai chi instructor states, “Motion is Lotion,” and this is definitely true for the spine. In addition to the discs, the synovial, freely moveable (at least they should be) joints of the spine can become degenerative and lead to pain, which can affect the neck but can also refer to the head and, even more commonly, between the shoulder blades. This is a commonly overlooked source of pain and patients with a head-forward posture are much more predisposed to it.

Facets joints are the synovial joints between adjacent vertebrae. They can become degenerative and painful with osteoarthritis of the spine. In a head forward posture, the upper cervical facets are often in a closed position while the lower facets are in an open unstable position. Both situations can aggravate the joints and lead to referred pain. This image is from Kapandji's Physiology of Joints.


Splenius capitis (close to GB-20) and splenius cervicis
(at extrapoint Bailao) TrP referral patterns.
Image from Travell and Simons' Myofascial Pain and
Dyfunction: A Trigger Point Manual.
Tension headaches: With cervical (neck) flexion and capital (head) extension, the posterior cervical muscles are in a shortened position, especially the muscles referred to as the suboccipitals. These four deep upper cervical muscles are very common causes of referred pain into the head, contributing to tension headaches. With the movement of the head forward, the eyes would be looking toward the ground if not for these muscles tightening to lift the head, placing the occiput into an extended position relative to the top of the cervical spine. Other muscles, such as the upper trapezius, splenius capitis, splenius cervicis, and sternocleidomastoid (SCM) are also negatively impacted and common contributors to tension headaches.


Nerve impingements and entrapments: Since disc health is affected by head-forward posture, it can play a role in spinal nerve impingement.  In addition, thoracic outlet syndrome (another type of entrapment of neural structures) is often seen with a head-forward posture. Both of these can radiate pain into the upper extremities and be causes of pain in the arms, elbows, forearms or hands.
Thoracic outlet syndrome involves an entrapment of the brachial plexus, which is the bundle of nerves that exit from the neck and travel to the arms. The brachial plexus can be entrapped as it travels between the anterior and middle scalene muscles (two anterior neck muscles which are shortened in a forward-head posture), between the clavicle and ribcage, and between the pectoralis minor muscle and the ribcage. The head-forward posture is often a contributing factor to all of these, especially as the entire shoulder girdle is involved (more on this in the next post).

Jaw tension: a head-forward posture places the mandible (lower jaw bone) in a position which stresses and tightens the muscles of the jaw. The position of the head places anterior neck muscles such as the suprahyoids and infrahyoids in an overstretched position. These muscles attach to the mandible and pull down on the lower jaw bone. The muscles of mastication (chewing), such as the masseter, reflexively tighten to hold the jaw close. They then develop trigger points which put pressure on the temporomandibular joint (TMJ).

Shoulder and other problems: Part 2 of this post will discuss the relationship of the balance of the cervical spine to the shoulder girdle. Because these are so intimately tied to each other, shoulder dysfunction such as supraspinatus tendinopathy, bicipital tenosynovitis, infraspinatus and subscapularis myostrain, and other conditions are often made worse by the strain of a head-forward posture. As we explore the sinew channel relationship described in Chinese medicine, this neck-shoulder girdle relationship will become even more apparent.

Image from Startle as a Paradigm 
for Malposture, by Pierce, F. et al 
Perceptual and Motor Skills, 1964
A)     Patient standing upright
B)      Door closes loudly and 
startles patient. Notice the 
shortening along the front 
of the body 
In addition to shoulder dysfunction, head-forward posture can contribute to other problems elsewhere in the body. This could become a very complex analysis, so I will not give a complete list. However, I will mention some interesting research that explored hamstring flexibility in relation to the suboccipital muscles (which extend the joint between the occiput and top of the cervical spine). This research measured hamstring flexibility and then split the subjects into two groups. Members of one group performed hamstring stretches; members of the other performed stretching to the suboccipital muscles. Surprisingly, the group that received stretching for the suboccipitals alone had a greater increase in hamstring flexibility (13%) than the group receiving hamstring stretches alone (9%). The reason likely has to do with the high concentration of muscle spindles present in the suboccipital muscles and, due to this, the fact that they have such a strong influence on tone throughout the musculature of the back, especially at the hip joint. Consider what happens when someone is startled, and the typical startle response observed. The firing of the suboccipitals might be reflexively tied to the firing of the hamstrings which assists in extending the hip joint. This, along with the shortening in the front of the body, would effectively protect the vulnerable organs.

For acupuncturists, it is worth reexamining the Urinary Bladder sinew channel and noting that it does bind to the occiput, and, therefore would include the suboccipital muscles. Looking for a head-forward posture and addressing shortened suboccipitals would be a worthwhile strategy, not only when treating local dysfunction, but with any strain pattern affecting the Urinary Bladder sinew channel. Addressing this pattern would help focus the selection of effective points to treat according to the principle of “selecting points above to treat below.”