Saturday, May 12, 2018

Assessment and Treatment of the Channel Sinews: Pes Planus

Fig. 1: A technique referenced below which can be used for pes planus 

Last Fall, Matt Callison and I put together a presentation for the Pacific Symposium in San Diego, CA. We presented on pes planus, a condition where the foot rolls into excessive pronation during weight bearing due to a collapse of the medial arch.

In the presentation, we discussed assessment and treatment of pes planus and discussed some common injuries associated with it. The role the channel sinews (jingjin) play in proper support of the medial arch and how imbalances can contribute to pes planus was emphasized. This month, Matt Callison will be expanding on this presentation for the keynote presentation at the Sports Acupuncture Alliance. I won't be able to make this event, but thought I would write a bit of an intro for those attending. You can consider this a study guide.

For those not able to attend, you can get a small flavor of the class and start to play with some of the information. If you are interested in expanding on this, it is taught in the Sports Medicine Acupuncture Certification starting in San Diego, June 19-24. For the European audience, you can check out a 2-day version of the class in Kilchberg, Switerland on November 17-18.

Fig. 2 Pronation includes dorsiflexion, eversion, and abduction;
supination includes plantarflexion, inversion, and adduction.
During gait, the foot is in supination at heel strike. After heel strike and as the weight travels into the foot, it transitions into pronation as it absorbs the body's weight (Fig. 2).

Normal pronation causes an increase in tension (a good thing, in this case) as the elastic myofascial structures in the foot are lengthened. The result of this is an elastic recoil which helps propel the weight off the foot and back into supination.

Fig. 3
In pes planus, the foot over-pronates and cannot recover into supination for adequate push-off from the big toe (Fig. 3).

Due to the altered mechanics in the foot and into the leg, pes planus sets a person up for a host of potential injuries such as plantar faciosis, Morton's neuroma, tibialis posterior tendinopathy, tarsal tunnel syndrome, Achilles tendinopathy, shin splints, medial knee injuries and injuries into the low back and hip. Clinicians working with these conditions will achieve far better results if they help correct pes planus, thus reducing the mechanical strain that led to the injury.

For the acupuncturist, it is important to understand the channel relationships associated with pes planus. This can be facilitated by looking at the muscles and other fascial structures which support the medial arch and understanding which channel sinew they are part of. The two main channel sinews which support the medial arch are the Spleen and the Kidney. The relevant anatomy is below:

Fig. 4: Yellow line is tibialis
posterior (medial side) &
anterior (lateral side) - SP&ST;
blue line is peroneus longus
and brevis - UB;
black line is soleus and
abductor hallucis - KID.
  • Spleen jingjin - tibialis posterior, flexor hallucis brevis
  • Kidney jingjin - soleus, plantar fascia (main portion), abductor hallucis
The Stomach jingjin is also involved. A relevant structure is the tibialis anterior which also helps support the medial arch.

In pes planus these structure fail to lift the medial arch, they are inhibited and become over-lengthened as the foot overpronates. The qi of these structures is dropped and needs to be lifted.

In pes planus as the Spleen and Kidney jingjin fails to lift and support the medial arch, other structures become excessively shortened. These structures are part of the Urinary Bladder jingjin and include:
  • Urinary Bladder  jingjin - gastrocnemius, peroneus longus and peroneus brevis, adductor digiti minimi, plantar fascia (lateral band)
In pes planus the Urinary Bladder jingjin is locked-short and is pulling excessively up. The qi of these structures excessively lifts and needs to be dropped and lengthened.

A technique that we teach in SMAC and Matt will be teaching at the Sports Acupuncture Alliance involves needling motor points of the involved structure and lifting, dropping, or lengthening the channel sinew. This is an advanced technique and can best be taught in a class setting. There is a sample in the image at the top of this blog post which involves lengthening the lateral band of the plantar fascia, a myofascial structure which becomes short and tight in pes planus.

Sunday, May 6, 2018

The Stomach and Spleen Qi Palpated in the Quadriceps

Fig. 1: A myofascial release technique to lengthen and move the vastus lateralis (lateral quadriceps) inferior. This is particularly useful when the vastus lateralis is excessively pulling upward on the patella, causing it to track improperly. If this tissue, which is part of the ST sinew channel, is palpated and felt to be very restricted and it feels as if it is pulling excessively upward, it might be useful to ask if there are other rebellious ST qi signs.
Note: this manual technique is particularly useful after acupuncture including use of the extra point xinfutu which is the vastus lateralis motor point, located 1-2 cun lateral from ST 32 (futu) with 0.5-1 inch needle depth.

One very interesting and quite useful observation when working with the musculoskeletal system is that the qi of the organs can be observed and palpated in the channels system. Of course, being part of the channels system, this includes the sinew channels. A very clear example of this is seen when working to balance the patella.

Fig. 2: Patella resected to see the
femoral groove. 
The patella tracks in the femoral groove (Fig. 2). The patella is a sesamoid bone. These 'sesame seed like' bones are enveloped in tendon, and it is the quadriceps tendon that surrounds the patella on its way to the tibial tuberosity. Two muscles out of this group are particularly important for balanced tracking of the patella: the vastus medialis and the vastus lateralis.

The vastus lateralis is part of the Stomach jingjin and the vastus medialis is part of the Spleen jingjin. These muscles blend in with the lateral retinaculum and medial retinaculum of the patella respectively, and through this pull have a strong influence on the tracking of the patella. It is frequently the case that the vastus lateralis is overactive and pulls excessively upward on the lateral portion of the patella while the vastus medialis is inhibited and fails to lift the medial edge. The patella becomes pulled lateral and frequently has a medial tilt (the top points medial). This can be assessed by observing that the lateral edge frequently does not lift adequately and that the patella does not rotate away from the medial tilt (Fig. 3).

Fig. 3: Assessment of the patella with a relaxed and extended knee. The patella can be rotated to see range and ease of movements and the medial and lateral edge can be lifted to assess ease of motion. When the vastus lateralis is overactive and the lateral retinaculum is excessively tight, it is typical to observe difficulty rotating the patella laterally and difficulty lifting the lateral edge.

With your next patient who has chondromalacia patella or patellofemoral syndrome, do a mobility test on the patella and palpate the vastus medialis and vastus lateralis. These muscles can be a window into not only the function of the patella, but the function of the zangfu. Recall that in TCM the Stomach qi descends while the Spleen qi ascends. One of the functions of the Spleen is to lift. When you are palpating the vastus lateralis (ST jingjin), feel whether it is excessively tight and pulling on the patella through the lateral retinaculum. For the vastus medialis (SP jingjin), feel whether it lacks tone and is failing to lift the medial edge of the patella through the medial retinaculum. This can help understand how these muscles are involved with patellar tracking issues, but can also guide questioning to see if there are signs of internal disharmony such as rebellious Stomach qi and/or Spleen qi deficiency. If the vastus lateralis is excessively pulling upwards, you might find rebellious Stomach qi signs. If the vastus medialis lacks tone, you might find Spleen qi deficiency signs. The observation found with palpation can help guide questioning and/or can put information from you TCM assessment into context.