Tuesday, September 1, 2015

Perspectives on Acupuncture Point BL-58

Feiyang BL-58 is an acupuncture point on the Urinary Bladder channel. It is on the posteriolateral portion of the leg. In A Manual of Acupuncture, Peter Deadman locates this point on the lower leg, 7 cun directly superior to Kunlun BL-60, lateral to and approximately 1 cun inferior to Chengshan BL-57. This places the point about halfway up the leg (a bit inferior to this) and posterior to the peroneal muscles. BL-58 is the Luo-connection point of the Urinary Bladder channel. Deadman lists its actions as:
Fig. 1: BL-58 at the myotendinus
junction of the gastrocnemius. Note 
the deeper soleus which is more visible 
in fig. 2 as the gastrocnemius is removed.
  • Harmonise the upper and lower
  • Expel wind from the taiyang channel
  • Treat hemorrhoids
  •  Activate the channel and alleviate pain

The indications of this point relate to these actions, particularly:
  • Harmonize the upper and lower: Many indications are listed involving the head and neck and symptoms associated with the sense organs such as the eyes. These include things such as headaches and dizziness, visual dizziness, and pain in the neck and occiput.
  • Expel wind from the taiyang channel: Indications include lumbar pain, heaviness of the body with inability to sit or stand, difficulty walking, sciatica, and inability to flex and extend the toes.
  • Activate the channel and alleviate pain: This also incorporates many of the indications above.


Fig.2 BL-58 with the muscle
belly of the more superficial
gastrocnemius removed.
This illustrates the location at
the belly of the deeper soleus.
I would like to give a few interesting perspectives on this acupuncture point, in order to explain some of its action. These perspectives are derived from the work of five primary sources, in order of reference below: 1) the late Dr. Janet Travell, M.D., author of Myofascial Pain and Dysfunction: The Trigger Point Manual; 2) Andrew Nuget-Head, director of the Association for Traditional Studies; 3) My colleague Matt Callison, L.Ac, M.A., director of Acusport Seminar Series; 4) Luigi Stecco, Italian physiotherapist and anatomist; and 5) my own lectures with the Sports Medicine Acupuncture Certification Program, exploring the sinew channels (Jingjin) described in the meridian system and how they relate to anatomical regions of the body.

Fig. 3: TrP 3 as described
by Travell, and its referral
to the SI joint region.
Anatomically, this point is at the lateral portion of the myotendinous junction of the gastrocnemius muscle, and in the belly of the deeper soleus muscle (fig. 1 and 2). This point is in a region of a particular soleus trigger point that Dr. Travell describes as referring pain to the sacroiliac joint region (fig. 3). Pain in the region of the sacroiliac joint can have many causes, sacroiliac joint dysfunction being a primary one. But she describes cases where trigger points in the soleus at the region (corresponding to BL-58) can be a contributing factor. I have used this point often with sacroiliac joint dysfunction and have seen many instances where it referred to the sacroiliac joint. Actually, when I use this point to treat sacroiliac joint problems, I will often try to propagate sensation to the joint.

This discussion of Dr. Travell’s trigger point referral patterns leads me to the next reference, Andrew Nuget-Head. I have not yet had the opportunity to work with Andrew (though I hope to in the near future), but have had the good fortune to discuss much of his work with Sean McCann, L.Ac., a good friend of mine who studies and works closely with him in his clinic. Much of their training focuses on the importance of needle manipulation to propagate sensation to the desired place (creating a warming sensation in the abdomen for cold in the Stomach by manipulating ST-36, for instance). While a major skill set taught is how to properly propagate sensation, and the explanation is that this can be accomplished at just about any point, the reality is that certain points are much easier to work with in this way and yield better clinical results for the task at hand. Deadman’s A Manual of Acupuncture offers a tremendous range of points for things such as lumbar pain. While all of these points might be useful to a skilled practitioner, the challenge is to discern which will be the best and easiest to use for the ‘flavor’ of lumbar pain presented by a particular patient. I feel that the particular ‘flavor’ of lumbar pain for BL-58 is the treatment of pain associated with sacroiliac dysfunction, and this is consistent with the general natural tendency of referral of the point when it is reactive.

With the pain referral in mind, it is useful to explore some of the indications associated with BL-58 listed above. One sees sciatica, inability to sit or stand, difficulty walking. All of these are consistent with pain that can be experienced with sacroiliac joint dysfunction.

Matt Callison describes vertebral facet fixations and their impact on particular muscle weakness. He finds that certain muscles will test bilaterally weak in manual muscle testing when there are corresponding vertebral facet fixations in particular regions. In the presence of sacroiliac joint fixation, the cervical extensors will test weak when testing the left and the right side individually. Releasing the fixation will turn the weak muscles back on and they will test strong when performing manual muscle tests after treatment. (In Sports Medicine Acupuncture, we teach particular Extraordinary Vessel pairs, local needle techniques, and joint mobilization techniques to accomplish this.)

With this relationship between the sacroiliac joint and the cervical extensors, one can again explore the indications for BL-58 and see the action of harmonizing the upper and lower with indications present such as pain in the neck and occiput, dizziness, etc.

Note that BL-58 is not one of the Extraordinary points taught by Matt Callison for sacroiliac joint fixation. The combination of GB-41/SJ-5 and specific local needle technique associated with the sacroiliac joint, along with joint mobilization, is taught within Sports Medicine Acupuncture® classes. GB-41/SJ-5, via its relationship with the Daimai, has effect on different sinew channels and, therefore, affects sacroiliac balance in a different way than do points affecting the Urinary Bladder and Kidney sinew channel (remember that BL-58 is the Luo-connecting point—more on this in a bit). But additional points are added to expand the therapeutic outcome, such as BL-58; this is not commonly used to affect the cervical spine, and I personally rarely use it for this, but I list the description above to illustrate the relationship between the sacroiliac joint and the posterior cervical extensors and tie the anatomy into the classical indications of BL-58.

Luigi Stecco describes how fascial linkages between muscles are a peripheral source of proprioceptive communication for the nervous system. What this means is that muscles have many more ‘attachment’ sites than are listed and shown in anatomy books. About 30% of the muscle force is transmitted through cross-links to other muscles via these myofascial fuzz fibers.

Through careful anatomical study, Stecco has proposed that much of this crosslinkage is used as a way for the muscles of the body to communicate via tension with each other and coordinate movement, especially between agonists and antagonists. He describes something he calls a myofascial unit which describes a particular relationship between monoarticular muscles (muscles that cross only one joint, the soleus in this case) and biarticular muscles (muscles that cross two joints, the gastrocnemius in this case), and attachments between these and their antagonists. He proposes that movements of joints in particular directions are coordinated by what he refers to as centers of coordination. These centers of coordination are areas where the monoarticular muscles and biarticular muscles share a fascial connection which help direct and coordinate the muscle action via tension acting on muscle spindles. If the fascia becomes densified in these centers of coordination, this can disrupt proprioception and can lead to pain and dysfunction.

Fig. 4: Image
illustration of cc 
for ankle movement from 
Fascial Manipulation
for Musculoskeletal Pain,
by Luigi Stecco
BL-58 corresponds to one of these centers of coordination and it is a region where, as he describes it, the myofascial vectors of the gastrocnemius and soleus converge. This is a myofascial union, between the more superficial gastrocnemius and the deeper soleus. These structures and their movements are organized via their fascia within a sequence of myofascial tissue that travels up the back of the leg.

This leads to the work I have been doing: relating the sinew channels more clearly to actual anatomical structures. In Sports Medicine Acupuncture Certification, I describe the sinew channels from a precise anatomical perspective. For the Urinary Bladder and Kidney sinew channel, I describe myofascial connections in the posterior leg and thigh. In particular I outline the gastrocnemius connections to the hamstrings, particularly to the biceps femoris and semitendinosus and into the sacrotuberous ligament which connects to the posterior sacrum. I ascribe this to the Urinary Bladder sinew channel. There is another deeper myofascial connection which includes the soleus attaching to the semimembranosus and adductor magnus and into the pelvic floor muscles which connect to the anterior sacrum. I ascribe this to the Kidney sinew channel. Therefore sacroiliac movement, at least relating to the flexion/extension aspects (called nutation and counternutation) is moderated by the balance (or dysfunction due to imbalance) between the Urinary Bladder and Kidney Sinew channels.

It is interesting to see that BL-58, a Luo-connecting point, is indeed a point at an influential union between the gastrocnemius and soleus. Needling this point affects a region of proprioceptive communication between a Urinary Bladder sinew channel muscle and a Kidney sinew channel muscle. These two sinew channels strongly influence mobility at the sacroiliac region. Known trigger points described by Dr. Travell refer pain to the sacroiliac joint. Indications of this point can certainly be interpreted as sacroiliac joint dysfunction. Actions of this point include the expulsion of wind, a pathogenic factor that causes rigidity. Anyone who has diagnosed sacroiliac joint dysfunction would agree that there is a notable amount of rigidity that is associated with this syndrome. When properly diagnosed, BL-58 is a useful point in treatment, especially when it propagates sensation to the sacroiliac joint.

I have been working with the sinew channels in one capacity or another since 1998, first with my taiji and qigong practice (where we refer to them as tendons and discuss tendon-changing exercises); then through study of structural integration and especially the Anatomy Trains developed by Tom Myers and currently taught in Sports Medicine Acupuncture by Simone Lindner; and next through my own research as I became a faculty member in the Sports Medicine Acupuncture Certification program, especially with the opportunity to closely analyze fresh cadaver specimens. My study of the sinew channels is a work in progress and I am currently engaged in quite a lot of research into various sources (Stecco, Tom Myers and his Anatomy Trains; the descriptions from the Ling Shu and David Legge’s interpretation of these descriptions; Travell’s groundbreaking work; acupuncture sources such as Deadman’s A Manual of Acupuncture, and other sources), while testing these ideas in clinic to see if they predictably produce results. This will likely be a lifelong process. While I feel there is a strong basis for what I describe above, it is subject to change as more clinical data is presented by other practitioners.

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