Monday, May 6, 2019

Futu (ST 32) and the Extrapoint Xinfutu for Low Back Pain

Fig 1: ST Jingjin Thigh and Torso
Anterior View (L image) and Posterior View (R image)
image modified from image created with zygote body,
information © Brian Lau

At the end of last year, I was a guest on the excellent Qiological podcast hosted by Michael Max. We discussed the channel sinews and how they relate to structure and function. The podcast is below, or you can check it out here.

On the notes page of this podcast is a nice clinical tip regarding a branch of the Stomach channel sinews which links to the low back. Many practitioners have noticed this branch when looking at illustrations of the channel sinews in books such as Peter Deadman's A Manual of Acupuncture. Furthermore, many practitioners have noticed indications of Stomach channel points which have indications for low back pain. Specifically, ST 31 - ST 34 have indications for lumbar pain.

ST 31 happens to be the motor point for the rectus femoris, the only quadriceps muscle that attaches to the innominate bone (it attaches to the AIIS). Shortness in this muscle will pull excessively on the innominate bone and contribute to an anterior tilt of the pelvis and excessive lordosis of the spine. This is an obvious biomechanical explanation for why this specific point would help with lumbar pain, as reducing tension in the rectus femoris would affect pelvic and lumbar mechanics. This would be especially helpful for patients with pain in the lumbar facet joints (facet syndrome), as these joints would be jammed together when the patient has an anterior pelvic tilt.

The points ST 34 - ST 32, however, require a different explanation for their impact on the low back. These points would not be on the rectus femoris; they would have a greater influence on the vastus lateralis muscle. This muscle does not attach to the innominate bone, so tension in this muscle would not directly affect pelvic and lumbar mechanics. Understanding how this muscle affects the lumbar region requires a different explanation. The explanation will require an review of the Stomach channel sinews. Fortunately, it will provide some relevant diagnostic information that you can use in clinic.

The Stomach channel sinews mostly follow the Stomach primary channel. However, there is a branch that connects to the lumbar spine.  Here is a quote from Chapter 13 of the Lingshu, translated by the Vietnamese scholar Nguyen Van Nghi: "The Zu Yangming (St) Jing Jin begins at the extremity of the third toe, inserts in the ankle joint, climbs obliquely along the fibula and inserts in the lateral surface of the knee, goes vertically to the hip joint where Huantiao (GB 30) is located, runs along the false ribs, and ends at the spinal column." The remainder of the ST channel sinews is then described to complete the entry for the Stomach. This follows the primary channel.

What anatomy could this be describing? A few highlights are helpful. First, this branch is more lateral than the remainder of the Stomach channel sinews on the thigh (the portion which follows the primary channel), and it goes to the hip joint (where GB 30 is located). If you look at the vastus lateralis muscle, you will notice that it goes very lateral; it actually attaches to the posterior portion of the femur at the linea aspera. This attachment comes very close to the femoral attachment of the gluteus maximus on the gluteal tuberosity. The fascia of each of these muscles merges and creates a fascial continuity. If you press on GB 30, you are pressing on the gluteus maximus, so this connects the Stomach channel sinews to GB 30 as described above.

The gluteus maximus then has a fascial continuity with the thoracolumbar fascia (TLF), a thick aponeurotic structure in the lumbar region which attaches to the lumbar spine. The TFL is a bit complex and multilayered. The gluteus maximus blends with the superficial layer of the TLF. There are 3 layers of the TLF. A layer wraps over the erector spinae muscles (this is the layer that the gluteus maximus blends in with), another layer wraps deep to the erector spinae, and a third layer wraps deep to the quadratus lumborum.

Fig 2: Image of the TLF and the lateral raphe, from
an excellent article written by Warren Hammer, DC
In Sports Medicine Acupuncture®, we palpate the TLF a number of ways. One way is to palpate the lateral raphe, which is a region where the multiple fascial layers meet before separating into the 3 layers described above (Figs. 1 and 2). You can think of it as a fascial seam or meeting point. This fascial seam is a meeting place of forces coming from several directions. It can be palpated most easily at the level of L3 with the fingers following the lateral border of the iliocostalis and following the edge of the muscle with the fingers pointed slightly medial towards the navel. Just past this muscle, you will run into the fascial wall of the lateral raphe. Medial to this, the fascial layers will differentiate into the 3 layers describes.

For patients with significant tension at both the lateral raphe and at the vastus lateralis, palpate the lateral raphe and ask the patient to report the pain with palpation on a scale of 1-10. You can then needle one of the Stomach channel points such as ST 32 (futu) to see if it reduces tension in the TLF and reduces pain. However, you might consider using the motor point of the vastus lateralis instead; this is located at the extrapoint xinfutu which is found 1-2 cun lateral to ST 32. This point will have a stronger effect on the vastus lateralis muscle.

Locate xinfutu, the MP of the vastus lateralis, needle this to the depth of 0.5-1 cun, obtain deqi, and return to palpate the lateral raphe. Frequently, the patient will report a reduction of pain by 50% or greater.

This is easiest to do with the patient supine, and palpation of the lateral raphe will require you to reach under the patient. But it will give you immediate feedback that you have reduced tension on the TLF from at least one vector, that of the Stomach channel sinews following up the vastus lateralis and gluteus maximus to the TLF. Other forces can also tension the TLF, such as the abdominals, the latissimus dorsi and the muscles of the lumbar spine. These need to be looked at separately and can be left to another discussion. The takeaway for now is to consider reducing tension in the vastus lateralis for patients with low back pain if their lateral quadriceps are very rigid. This will add to your clinical effectiveness when treating low back pain.

Sunday, November 18, 2018

Sports Medicine Acupuncture® Fall 2018

Flexor carpi ulnaris manual muscle test,
a useful test for medial epicondylitis.
I have had a very busy Fall, and have not been able to post here lately. However, I did just finish a blog post for the Sports Medicine Acupuncture® blog. The link is below; the post includes a video of a recent Sports Medicine Acupuncture dissection highlighting the Heart sinew channel. Check it out! The title is Medial Epicondylitis and the Heart Channel Sinews.

September kicked off Module 2 of the Sports Medicine Acupuncture Certification (SMAC) in San Diego, CA. Updates and upgrades are an ongoing feature of the SMAC program, and in this Module we debuted a new class: "Assessment and Treatment of the Channel Sinews (Jingjin): Low Back, Hip and Groin." I will share some info from this class in an upcoming blog post and  the upcoming classes for the Lower Extremities (Module 3) and Head, Neck & Upper Extremities (Module 4).

A picture I took with four practitioners who live near me in Tampa, FL. It is alwasy great to meet new people in SMAC, but is especially an honor to work with practitioners who I am already friends with!

After the September SMAC class, Sports Medicine Acupuncture® hosted a 5-day dissection class in Boulder, CO at the Laboratories of Anatomical Enlightenment. In this 5-day class, participants, including myself, worked in teams of 6, each with their own cadaver specimen. As in all Sports Medicine Acupuncture dissections, these specimens are non-chemically treated cadavers, which offers a superior experience for holistic practice as it keeps the fascia intact and you get a much better view of the real tissue quality. All acupuncturists should take the opportunity to do dissection such as this; there really is no substitute for it. I will share some specific experiences from this event soon, and we will be hosting another program, probably a 4-day, sometime in the Spring. Check the SMA page for updates.

After the Boulder dissection class, it was back to San Diego for the completion of SMAC Module 2: Low Back, Hip and Groin. The two remaining classes were Assessment and Treatment of Low Back, Hip and Groin injuries, and Postural Assessment and Corrective Exercises (PACE).That wraps it up for Module 2, and we will start back up with Module 3 in the new year.

In the first week of November, I attended a 5-day taiji and qigong workshop at the new International center of the Taoist Tai Chi Society. I won't go into detail about this workshop here, but I will say that my taiji and qigong practice (which I started in 1998) was the first experience I had with the channel sinews. In my practice, we discuss certain 'tendon changing and marrow-washing' exercises. These 'tendons' may run all the way up the body. Obviously, these are not what Western anatomists refer to as tendons, but are, instead, myofascial planes of tissue that fit the template of how I discuss the channel sinews. This practice was the foundation which led to my ongoing exploration of the channel sinews.

Finally, on November 14th, I was privileged to be a guest on the terrific podcast, "Qiological", hosted by Michael Max. This was a panel discussion on myofascial trigger points, orthopedic acupuncture, and dry needling; but also on channel theory, language, and continual learning. The panel included Michael Max, my friends and colleagues Josh Lerner and Fernando Bernall, and myself. This was a fascinating discussion and I am looking forward to its release on Qiological. It will likely be released early for subscribers. I recommend subscribing, not just to listen early, but as a great way to support the efforts that build and grow our profession; this podcast and its growing community are part of those fantastic resources!

Tuesday, July 31, 2018

Assessment and Treatment of the Gallbladder Channel Sinew

This yoga pose (Parivrttha Janu Śirsāsana - revolved head of the knee pose) features rotation and movement of the ribcage, especially highlighting the lower ribcage and its ability to move in relationship to the pelvis. This movement is moderated by the Gallbladder sinew channel. Image of Tricia Amheiser used with permission,

This will be the first in a series of posts looking at the channel sinews (jingjin) and their role in normal (and dysfunctional) movement of the pelvis, hip, and low back. This first post will explore the Gallbladder sinew channel and its role in both stability and movement between the pelvis and ribcage. These functions are necessary for balanced movement in the low back and hip region, and failure of this channel to perform these functions can be a cause, or at least a significant contributor, to pain of the low back and hip.

This post will specifically highlight the role of the movement between the ribcage and the pelvis, and also the pelvis and the sacroiliac joint. The reader is encouraged to visit a recent post on the Sports Medicine Acupuncture blog written by Matt Callison, L.Ac on the assessment and treatment of sacroiliac joint pain with acupuncture and Chinese medicine. For the most in-depth information on treating sacroiliac joint pain for the TCM practitioner, I recommend the upcoming Sports Medicine Acupuncture Certification classes which will cover this and other conditions affecting the low back and hip.

There is a video below which demonstrates a myofascial release technique for the Gallbladder sinew channel. This technique helps free the ribcage from the pelvis and can be used to round out a comprehensive treatment plan for sacroiliac joint pain, lumbar facet syndrome, and many other pain patterns of the low back and hip.

Fig 1:
Venus with the Apple, 1813-1816.
Contrapposto, or counterpoise, in visual arts refers to the pose of a figure with the weight on one leg and the various tilts, shifts and rotations of the pelvis, ribcage, shoulder girdle, neck and head that arise from it. While this is a bit of an exaggerated pose, many patients will exhibit some of these tilts, shifts and rotations. This will be evident in their normal standing posture and as they move, as an imbalance can be observed with the swaying, rocking and turning of the body.

Fig. 2
The myofascia of the Gallbladder sinew channel greatly influences this balance between the left and the right sides of the body, as it provides lateral stability to the body segments (such as the pelvis), but  also allows movement between body segments (such as between the ribcage and the pelvis). In Sports Medicine Acupuncture® we include the following myofascial structures in the Gallbladder sinew channel:

  • Iliotibial band
  • Tensor fascia lata
  • Gluteus medius, minimus, maximus
  • External obliques and internal oblique
  • Serratus anterior and pectoralis minor
  • Upper trapezius

Note: this is not a complete list, and some of these muscles are shared in other channels.

In particular, the hip abductors such as the gluteus medius and minimus need to stabilize the pelvis on the weight-bearing leg so that the ilium does not excessively rise and the pelvis does not excessively shift laterally. The weight of the body as it is supported on one leg would drive the ilium on that side superior and away from the midline (think of the 'sway' seen when a model walks on a runway). Look again at the statue in Fig. 1 and note the failure of the gluteus medius and minimus on the right to stabilize the lateral pelvis. The hip abductors would be locked-long and the femur is adducted.

Fig 3: Gluteus medius and minimus manual muscle test. The practitioner pushes the patient's hip into adduction while the patient engages the hip abductors to resist. The practitioner is looking for a locking of the hip indicating that the gluteus medius and minimus are strong. Image courtesy Matt Callison/Sports Medicine Acupuncture

This supportive function of the Gallbladder sinew channel can be assessed with a gluteus medius and minimus manual muscle test (Fig. 3), examining the portion of this channel which stabilizes the pelvis on the lateral side and prevents excessive upward and outward movement of the pelvis during weight bearing. This resistive muscle test assesses the ability of these muscles to respond to added force applied to them, which demonstrates how they respond as weight is transferred into the leg during the weight-bearing phase of gait. This and other MMTs are taught in Sports Medicine Acupuncture Certification; they are a valuable assessment for muscle function and, therefore, sinew channel function and health.

Fig. 4
While there needs to be stability in the Gallbladder sinew channel, it also needs to allow expansion so that the ribcage can move away from the pelvis. This occurs in movements such as walking, reaching, standing up from a seated position, and climbing stairs. The ability of the ribcage to move away from the pelvis is controlled and stabilized by the internal obliques; this allows for expansion without an excessive flaring of the ribs, You can observe the loss of this function when you see patients excessively bend the torso from side to side as they walk (not enough movement) or patients with excessively flared lower ribs (not enough stability). 

The ability of the pelvis to move away from the ribcage can be assessed as follows (Fig. 4): The patient stands with one leg forward and one back, with the weight initially on the back leg. As they stand up on the front leg, they reach forward and up with the opposite hand (shoulder flexion to 120 degrees). As they reach, you visually observe and/or feel whether the ribcage is able to move away from the pelvis without excessively leaning back (posteriorly tilting the ribcage) and compressing the lumbar region. You can also observe whether the scapula is able move away from the ribcage. In other words: is there expansion along the channel, allowing for differentiated movement?

It is not uncommon for one or both sides to have restrictions in this part of the Gallbladder sinew channel, binding the ribcage to the pelvis and/or binding the scapula to the ribcage. The abdominal obliques and the latissimus dorsi, part of the Gallbladder sinew channel, need to be supple and flexible to allow this independent, yet connected, movement of the body segments. See below for a myofascial release technique to free the ribcage from the pelvis. This can be done after acupuncture treatment.

Fig. 5: Cat Cow, image courtesy
Matt Callison/Sports Medicine Acupuncture
Observe as the ribcage moves with the pelvis: notice that it tends to move in a particular way. As the ilium goes into posterior tilt, the lower portion of the ribcage follows the inclination of the pelvis and moves posterior, causing the entire ribcage to tilt anterior (Fig. 5, top image). As the ilium goes into anterior tilt, the lower portion of the ribcage follows the inclination of the pelvis and moves anterior, causing the entire ribcage to tilt posterior (Fig. 5, bottom image).

This related movement of the ribs and ilium is normal, but fascial shortening and/or muscle inhibition can occur and prevent it from moving freely. Such restrictions might fix the lower ribcage in a position where it is held anterior or posterior. This could be a bilateral imbalance, or it might be different on the left and the right side. This twisting from side to side is frequently seen with sacroiliac joint pain. Why? The twisting in the lower ribcage (one side anterior, the other posterior) is a response to a twisting in the two ilia of the pelvis (one side anterior tilted, the other posterior tilted); the sacrum will also rotate in response to the twist between the two ilia. This means that there is a relationship between the holding patterns of the ilia, the sacroiliac joints, and the two sides of the ribcage. Unwinding one has an effect on the others.

Fig. 6
Let's state that again in a bit more detail, first highlighting the pelvic movement.The left and right ilia should be able to move in a contralateral motion, for example in walking and running. As one leg goes into hip flexion, the corresponding ilium rotates posteriorly. As the other leg goes into hip extension, the other ilium rotates anteriorly. This is vital for the health of the right and left sacroiliac joints, which move in conjunction with this contralateral motion of the ilia.

It is frequently the case that movement is easier in one direction than in the other. For instance, maybe the runner in Fig. 7 moves very easily as she swings her left leg back (left ilium rotates anterior as it follows the hip extension, right ilium rotates posterior as it follows the hip flexion), but less easily and with reduced range of motion as she swings her right leg back (right hip extension and left hip flexion). If this were the case, her left ilium would probably be anteriorly tilted and her right posteriorly tilted. This is sometimes referred to as pelvic torsion or a twisted pelvis. The sacroiliac joint is part of this twist and will often become painful on one side.
Fig. 7

The lower ribcage tends to follow the pelvis. The more anterior the ilium tilts, the more anterior the lower ribcage moves, and the more posterior the ilium tilts, the more posterior the lower ribcage moves. For the runner, it may be that the right lower ribcage moves back more easily (following the right arm swing) and the left lower ribcage moves forward more easily (following the left arm swing), but these sides do not move well when the position reverses.

Let's revisit the assessment illustrated in Fig. 4, which looks at the ability of the ribcage to move away from the pelvis. The left image below (Fig. 8) shows assessment of the ability of the ribcage to move away from the pelvis and the lower ribs to move forward. The one on the right shows assessment of whether the ribcage can roll back into line with the pelvis. Both are important movements.

With sacroiliac joint pain, the goal is often to balance the left and right sides. With acupuncture, corrective exercises and manual therapy, you would address the level of restriction at the sacroiliac joint, balance the pelvis (especially if there was a twist), and balance the ribcage (especially if there was a twist). The technique in the video below is just one part of this, and it would mobilize the ribcage away from the pelvis. To complete the treatment, one would work with any zangfu disharmony or other TCM patterns.

Fig. 8: The ribcage moves away and flares out on the left. The ribcage has difficulty rolling back on the right.
One last thought on the relationship of this channel to the organ network: as TCM practitioners know, the sinew channels do not attach to the zangfu. Nevertheless, there is a relationship of this sinew channel to the Gallbladder organ and its related yin organ, the Liver. Consider the movement we have been discussing regarding the lower ribcage movement. This forward and backward movement matches the mobility of the liver organ (and the gallbladder, which is structurally bound to the liver), which also rolls backward and forward as part of its movement (referred to as inspir and exspir). Freeing any stuck areas in the lower ribcage would allow these organs to have the freedom to move within their range of motion, something that is very important for their health. Conversely, if these organs are under duress, they will often become stuck and will limit the range of motion of the lower ribcage. Treating any signs of Liver or Gallbladder disharmony will help with the health of these organs; it will also make the manual technique below much easier to do and allow its effects to be longer lasting.