Monday, January 22, 2018

The Anatomy of LIV 5 Ligou

LIV-5 (ligou) is the luo-connecting point of the Liver channel. It is 5 cun above the prominence of the medial malleolus and lies between the tibia and the triceps surae (gastrocnemius and soleus muscles). I would like to discuss some of the specific anatomy of this point, which will help both with point location (where exactly is this point and what is the target tissue you are aiming for) and with understanding some of its indications, specifically back and groin pain. This will help determine when you would use this point for greatest effectiveness for these indications.

A couple of the many indications of this point include groin (and genital) pain and low back pain. For low back pain, Deadman, author of A Manual of Acupuncture, lists “inflexibility of the back with inability to turn.” Wang Ju Yi, author of Applied Channel Theory, discusses this point and further states: "because of the commonly seen relationship of the musculature of the groin to the low back, this point can be helpful in treating lumbar pain, especially when there is also tenderness at the point."

Why would both groin pain and low back pain be treated by this point? Moreover, for patients who present with low back pain, when is LIV-5 indicated? And why might there be a relationship to both back and groin pain in these cases?

First off, let's explore the anatomy and target tissue of LIV 5 and a related acupuncture point, SP 6 sanyinjiao. The anatomy involves the interaction of two muscles which are directly posterior to the tibia for most of their length: the tibialis posterior and the flexor digitorum longus (FDL). These muscles are each part of a separate jingjin or sinew channel. The tibialis posterior is a muscle of the Spleen jingjin, while the flexor digitorum longus is on the Liver jingjin. Finally, the soleus, part of the Kidney jingjin, will play a part in understanding SP 6 sanyinjiao, a point where we can see in the anatomy a place where the three yin channels cross.

Fig. 1: Posterior
compartment with
tib. posterior
(highlighted) and FDL.
Gastrocnemius and
soleus removed.
Image modified from
Gray's Anatomy
Deadman places LIV 5 and SP 6 at interesting anatomical locations. The tibialis posterior muscle travels lateral to the FDL for most of its length. But, at the distal tibia, it crosses anterior to the FDL to become the most medial muscle (Fig. 1). It then becomes the most anterior muscle to pass behind the medial malleolus. Some might recall the mnemonic 'Tom, Dick, And Very Nervous Harry' which alludes to Tibialis posterior, flexor Digitorum longus, posterior tibial Artery and Vein, tibial Nerve, and flexor Hallucis longus; this is the order in which these structures pass behind the medial malleolus.

The tibialis posterior muscle (SP jingjin) crosses the FDL (LIV jingjinapproximately 3 cun above the medial malleolus. Proximal to this, the soleus (KID jingjin) is thicker and covers the medial leg, but starts to taper and become thinner, more tendinous and more posterior as it approaches the Achilles tendon. So, this location at SP-6 sanyinjiao is a place where the three yin channels, or at least their associated channel sinews, can be seen to literally cross. This crossing leaves an indentation, and needling SP 6 would advance the needle towards the tibialis posterior muscle and its associated fascia (Fig. 2).

Because of the crossing of the tibialis posterior muscle at SP 6, the flexor digitorum longus (LIV jingjin) is pushed slightly posterior, which alters its position and creates another indentation approximately 5 cun proximal to the medial malleolus at the location of LIV 5 (Fig. 2). Advancing the needle at LIV 5 penetrates this muscle and/or its associated fascia. The most predictable results, especially if you are trying to sedate, are accomplished with an oblique needle angle pointing distally and against the channel. The needle would be directed towards the posterior surface of the tibia; a sensation usually travels down the channel, with an occasional fasciculation observed in the FDL muscle, and a slight observable toe flexion occurring as the muscle is stimulated.

Fig. 2: Cadaver image of medial leg, gastrocnemius removed. Image shows tibialis posterior traveling anterior to FDL and emerging at SP 6. LIV 5 is also illustrated. 

Fig. 3: Liver jingjin from adductors through
the iliacus and quadratus lumborum to the
posterior diaphragm.
Following the Liver sinew channel along its course helps connect some of the actions of this point. The Liver sinew channel includes many of the adductor muscle group (adductor longus, brevis, gracilis, and pectineus); the iliopsoas; and, in my opinion, the quadratus lumborum, which is on the same fascial plane as the adductors and the iliacus muscle (Fig. 3). Although the QL is palpated at the low back (Fig. 4), it is a deep muscle which has connections to the iliacus below and the diaphragm above. It is really a yin muscle in terms of depth, and it is on a direct line from the adductors through the iliacus to the posterior attachments of the diaphragm.

Pain at the quadratus lumborum, especially its iliac attachment which is at the extra point yaoyan, can cause moderate to severe back pain which is often worse with turning. The pain can radiate to the groin. Shortening and contraction of the QL can elevate the ilium at that side. With an elevated ilium, both the quadratus lumborum and the adductors are in a shortened position, and may both present with pain.

Fig. 4: Palpation of yaoyan. Top
image shows palpation of the superficial
vector, which is at the iliocostalis
 muscle. Bottom  image shows palpation of
the deep vector, which is at the quadratus
lumborum deep to the iliocostalis.
Image courtesy Matt Callison /
Sports Medicine Acupuncture
When there is palpable pain at the QL attachment at yaoyan, LIV 5 becomes hypersensitive. Due to the tension in the sinew channel, LIV 5 is often much easier to find, as it has a more defined and palpable indentation. Proper needling of LIV 5 when there is pain at the QL attachment at yaoyan will reduce this pain by fifty percent. Try this: if you have successfully diagnosed that there is pain at yaoyan*, palpate yaoyan and ask for a pain level from the patient on a scale of 1-10 (Fig. 4, bottom image - deep vector). Then needle LIV 5, obtain qi, and return to yaoyan for palpation. Again, ask the patient to quantify the pain level. I find that it frequently reduces by about fifty percent. However, I do not find that this pain reduction will hold once the needle is removed unless you successfully needle the quadratus lumborum at yaoyan to further reduce contraction into this muscle. 

Needling of reactive motor points in related muscles such as the gluteus medius and minimus greatly increases therapeutic outcome. These muscles are part of the Gallbladder jingjin, and are usually inhibited and locked-long as part of dysfunction with the quadratus lumborum (which is often overactive and locked-short). Local, adjacent, and distal needling is a very effective strategy when pain is diagnosed at yaoyan.
Points to consider are:

  • yaoyan (deep vector)*
  • gluteus medius and minimus motor points
  • a host-guest point combination (source-luo) which includes LIV 5 (luo-connecting point of the Liver channel) and GB 40 (yuan-source point of Gallbladder channel)
  • Dijia, usually on the contralateral side. This extra point is the motor point of the levator scapula, a muscle on the Small Intestine sinew channel. It frequently becomes dysfunctional along with QL. When the QL shortens and elevates the ilium, usually the levator scapula shortens and elevates the scapula on the contralateral side. This is a midday-midnight channel relationship involving LIV and SI
  • other points for any internal disharmony (back-shu points, other channel points). 

This produces a balanced TCM treatment with sustained results.

*Yaoyan is located approximately 3.5 cun lateral to the lower border of L4. It is at the iliac crest of one of two muscles: the iliocostalis lumborum, which is superficial, and the quadratus lumborum, which is deep. For the above discussion, LIV 5 reduces pain when there is pain at the deep vector which is at the iliac crest attachment of the quadratus lumborum. 

Sunday, January 7, 2018

Sinew Channels and the Architecture of the Carpal Tunnel

Fig. 1: Cross section of carpal tunnel
The carpal tunnel is created by the concave shape of the volar (palmar side) surface of the carpal bone which makes up the floor of the carpal tunnel, and the thick, fibrous flexor retinaculum which makes up the roof (Fig.1). This structure is like a bow, with the carpal bones forming the body of the bow and the retinaculum forming the bowstring. If the bow becomes too flat and looses its concavity, the tunnel becomes narrowed and the neurovascular structures passing through this tunnel can become entrapped (particularly the median nerve).

Proper shape of this bow-like structure is influenced by the Pericardium and Sanjiao sinew channels. Both of these sinew channels include the finger and thumb flexors and extensors (P – flexors, SJ – extensors) and the forearm pronators and supinators (P – pronators, SJ – supinators). How these muscles interact affect the relationship of the radius and ulna which, in turn, affects the shape of the tunnel.

Fig. 2: Pronator quadratus on the
volar side of forearm.
Imagine that you are typing with the wrist extended and the forearm pronated. The extension of the wrist tends to flatten the carpal tunnel and rolls the ulna and radius away from the volar side of the arm. The pronator quadratus muscle, located at the distal portion of the forearm, is uniquely positioned to pull the radius and ulna in the opposite direction, rolling them towards the volar side and maintaining the integrity of the tunnel (Fig. 2). If this muscle becomes inhibited, it fails to maintain the proper relationship between the two bones, and the carpal tunnel loses its depth leading to a compression of the median nerve and a greater possibility of paresthesia in the median nerve distribution of the palm and fingers.

Many acupuncturists use a threading technique through the flexor retinaculum at P-7. This technique is effective in creating space in the carpal tunnel. An additional technique, developed by Matt Callison and taught in the Sports Medicine Acupuncture Certification program, addresses the inhibited pronator quadratus muscle. This is done if it is determined that the pronator quadratus is indeed inhibited. The needling technique for the motor point of this muscle, which will help to wake it back up and bring it back into the neurological loop, is a bit tricky as the motor point lies directly deep to the median nerve at P-6. So, one can't simply drive the needle deep into P-6 to reach it without risking damage to the median nerve. This technique is best discussed and demonstrated in a class setting. It is a very effective technique and can improve clinical results because of its strong action on the pronator quadratus, so that it can have a profound effect on the relationship of the radius and ulna, and can add integrity to the carpal tunnel.

Fig. 3: An old-fashion pup tents which is a tensegrity structure. The
tension from the guy wires give the structure integrity, much like the
shape of the carpal tunnel is given integrity by the balanced pull of
the pericardium and sanjiao sinew channels.
An analogy to consider for proper balance and integrity of the carpal tunnels is an old-fashioned pup tent. These tents require a balanced tension in the guy wires to stabilize the shape of the tent (Fig. 3). This balanced tension creates an open space inside the tent. If the guy wire tension is unbalanced, one side is too short and tight and the other too slack, the tent will lose its shape and sag. This is very much the same with the open shape of the carpal tunnel, and it is the muscles of the pericardium and san jiao sinew channels that create a balancing pull to maintain the integrity of the tunnel. Imbalance between these channels will lead to a less than optimal shape and increase the chance of compression of the structures traveling through the tunnel. So it is important to look for imbalances between these two channels and treat accordingly.