Saturday, September 26, 2015

Asymmetrical Pelvic Tilts

The following is a summary of an article by Rolfer and Educator Robert Schleip. I am summarizing here so as to describe it in terms of acupuncture and sinew channel relationships, and to relate it to what is taught in Sports Medicine Acupuncture®.

Schleip discusses and gives strategies for a pelvic torsion which involves one ilium which is in an anterior tilt relative to the other, which is in a relative posterior tilt. Specifically he discusses how this relates to the acetabulum and the sacroiliac joint and how this relationship informs understanding of sacral base elevation. This pattern is a frequent finding in sacroiliac joint dysfunction and could also be seen in facet syndrome, Yaoyan pain and a host of other conditions affecting the low back and hip.

Regardless of whether an ilium goes into an anterior or posterior tilt, the distance remains the same between the acetabulum and the sacroiliac joint. However, the vertical distance increases on the anterior tilted side and decreases on the posterior tilted side. The vertical distance is described in reference to two horizontal lines, one through the acetabulum and the other through the sacroiliac joint. In an anterior tilt, the sacral base moves anterior and superior, increasing the distance between the horizontal lines. This effectively raises the sacral base. The opposite is true on the posteriorly tilted side. The sacroiliac joint moves posterior and inferior, decreasing the distance between the two horizontal lines and effectively lowering the sacral base.
Fig 1: Neutral Ilium.
Notice the length between the
horizontal lines, and notice the
length of the line between the
acetabulum and the SI joint.
Fig 2: Anterior Tilted Ilium.
Notice that the line between acetabulum
and SI joint is the same, but the vertical
distance between the two horizontal
lines has increased.

The sacral base is assessed at the dimples which are just medial to the PSIS. If this pelvic torsion was the only postural disparity in the body, an elevated sacral base would be observed on the anteriorly tilted side. This all assumes that the heads of the left and right femur are at an equal level. But there are many situations that will cause either a functional or a structural leg length discrepancy. A structural leg length discrepancy would be based on bone length (femur or tibia) and would be either congenital or occur as a result from trauma. A functional leg length discrepancy would include various muscle imbalances which effectively shorten a leg. Things such as foot over-pronation, rotations in the tibiotalar joint compressing the ankle, and rotations in the tibiofemoral joint compression of the knee, medial shifts of the knee, etc., are all possible things that could reduce length in the leg and lower the femoral head relative to the other side.

Again, imagine that the leg length discrepancy (regardless if it was functional or structural) was the only postural disparity. The side with the higher femoral head would also be the side with the more elevated sacral base in this case. But what if the body, in an attempt to create a level sacral base compensated by going into a posterior tilt on the elevated side? This would lower the sacral base on this side and help to balance the base of the spine, which would be advantageous to this person both in terms of spinal function and comfort.

If the right ilium were to go into an anterior tilt
and the left were to go into a posterior tilt, this
would raise the sacral base on the right side.
If the right leg were longer (structurally or functionally)
the left ilium could go into a posterior tilt to lower the
sacral base as a compensation.

In Sports Medicine Acupuncture, we discuss various postural disparities and describe ways to measure and record these. Treatment with acupuncture, manual therapy, and corrective exercises is derived from these observations. We describe an elevated ilium as being a transverse plane deviation. This means that this deviation would move away from a transverse plane. We also describe this asymmetrical pelvis (one side anteriorly tilted, the other posteriorly tilted) as a transverse plane deviation even if it does not involve an elevated ilium. This would be an exception to the rule, as it does not move away from a transverse plane. However, based on the discussion above, whenever there are asymmetrical tilts of the ilium, there is movement away from the transverse plane, at least based on the sacral base's relationship to the legs and spine. This is true even if there does not appear to be an elevation on one side or the other, as this would involve some compensation, likely based on leg length.

When there are asymmetrical ilium tilts and/or left or right pelvic tilts (right or left elevated ilium), we use acupuncture points on the Gallbladder and Liver channels to affect the Gallbladder and Liver sinew channels. This reduces tone on structures such as the iliopsoas and adductors in addition to more lateral structures such as the ITB and gluteal muscles, and the abdominal obliques. In particular, we use motor points on the muscles of the Gallbladder and Liver sinew channels, and we use various distal point combinations on the Gallbladder and Liver primary channels.

The pelvis is a supremely important structure in terms of its influence on the entire body, and it is vital for it to be in a balanced position to allow qi to move efficiently through the channels. It is also important to relate the legs to the pelvis and the pelvis to the spine by correcting disparities in these structures by balancing yin and yang. This can be accomplished by addressing overactive (excess) muscles and inhibited (deficient) muscles to improve structural support in the legs and balance the pelvis in relationship.

Schleip gives some interesting commentary regarding when to address this pelvic asymmetry and when to see it as an intelligent compensation and leave it alone. His general statement is that when the sacral base is higher on the anterior tilted side, you would likely want to work with unwinding this pattern. If the sacral base was higher on the posterior tilted side, you would consider seeing this as an intelligent compensation and unwinding it might further reduce balance in the spine. He comments that the reality is that gravity is a very effective therapist, and that unwinding the pelvis in the second situation would more than likely only be temporary as the body would return to the torsion to balance the base of the spine.

I agree with Schleip, though I would like to add a couple of things. He is discussing using myofascial release techniques and also mentions work by chiropractors and osteopaths. Forcefully manipulating a segment of the body to fit some outside idea of what is considered ideal can sometimes be a disservice to a patient. In this case, forcing the pelvic tilts to be balanced when they are effectively leveling the sacral base could effectively unbalance the base of the spine. However, addressing muscle imbalances with an acupuncture needle by needling things such as motor points and distal points and then using corrective exercises in a balanced way can correct the underlying muscle imbalances and allow the body to find a natural balance. This will often balance the tilts. If the pelvic torsion is compensating for something such as a structurally longer leg*, it will likely not change the anterior and posterior tilts as they are there for a reason. However, it will reduce the fixation of the segment and improve movement possibilities which will reduce pain and improve performance.

This should be the ultimate goal, and practitioners who look at the structure should remember that this is done because structure and function are so related. If the structure can not change, but the function improves, then this is a successful intervention. The key is to address what you see, improve function, but don't get too dogmatic about forcing a patient's structure to comply to some ideological standard. Some people have normal, naturally occurring asymmetries or regions which are compensating in a useful way to a congenital deformity.

* For a functionally longer leg, correcting imbalances affecting the major joints (such as the ankle, knee and hip) will return length as it will start to unwind this structure. In this case, you could expect to see a much more lasting change in the pelvis, as it has a stable support below.

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Thursday, September 24, 2015

The Four Pillars of Traditional Chinese Medicine

While many of my posts are written for acupuncturists and manual therapists, the following is a description of the major treatments used in Traditional Chinese Medicine. It is written for patients.

Traditional Chinese Medicine (TCM) is a comprehensive medical system from China. While many people are aware of acupuncture, TCM actually incorporates four major avenues or treatment. These are known as “the four pillars” of TCM, and they are: acupuncture; Chinese herbal medicine and dietary therapy; Tuina, which incorporates medical massage and manipulation; and exercise and movement therapy. Your trained Doctor of Oriental Medicine will evaluate your case and prescribe one or several of these treatments depending on what is needed.

Acupuncture involves the use of very thin, single-use, sterilized needles inserted in various locations to regulate body processes. In the West, acupuncture is most often used for pain relief, for which it is very effective. But this is not the full scope of comprehensive acupuncture treatment; it is actually appropriate in a wide range of illnesses. Click here to see a complete list from the World Health Organization of the over 40 diseases acupuncture is listed to treat.

Chinese herbal medicine is based on a vast array of medicinal formulas, which are therapeutically balanced combinations of herbs used to treat patterns of medical disharmony. TCM looks for clinical signs and symptoms of these patterns and then prescribe specific herbal medicinal formulas to treat these patterns. TCM pattern differentiation and treatment with herbal medicinals can offer a safe and effective natural treatment for illness or can complement your treatment prescribed by your Western MD, in some cases possibly enabling your Western pharmaceutical prescription to be reduced, or helping deal with side effects. 

In addition to the prescription of herbal medicinals, dietary recommendations can also be used as part of the treatment. This can include general assistance with weight loss or maintenance, or specific food choices and preparations designed to help you manage an existing condition. 

Tuina is a Chinese system of clinical massage and joint mobilization. Tuina is derived from two words; tui meaning to “to push” and na meaning “to lift and squeeze”. Tuina uses light, moderate, or deep pressure to mobilize the body’s structures and joints and restore normal movement. It is primarily used for musculoskeletal conditions, but it can also be employed for other condition such as respiratory or digestive problems. Generally, tuina focuses on particular regions such as the neck, back, legs, etc., and resembles more clinical styles of Western deep tissue massage therapy. Click here to see a previous post about tuina.

Finally, Therapeutic Exercises are often prescribed in China to help treat illness and to maintain and improve health. In particular, tai chi (taiji) and qigong are therapeutic forms of exercise that improve flexibility, circulation and general wellbeing. 

When looking for a practitioner of Traditional Chinese Medicine, it is important to understand that many practitioners focus mostly on one or maybe two of these ‘pillars’ listed above, usually based on a practitioner’s specialization. Practitioners focusing on internal medicine might use herbs more extensively while those treating musculoskeletal pain might be inclined to use tuina more. In my clinical practice, I specialize in the treatment of sports injuries and orthopedic pain conditions. So, I primarily focus on acupuncture, tuina, and corrective exercises to facilitate rehabilitation from injury, and to correct muscle imbalances that contribute to pain conditions. When I prescribe herbal medicine, it is usually a formula (balanced combinations of herbs) to help with the particular pain or injury. Such herbal formulas may help with trauma; they may address how the body deals with inflammation, or they may regulate the nervous system to reduce overcontraction and tightness in the muscles. The herbs basically support the treatment, while the acupuncture, tuina and therapeutic exercise prescription specifically target the region of pain and return normal movement to the body. 

Another practitioner who specializes in internal medicine might rely much more on herbs, and their acupuncture treatment might be more supplemental. It is important for patients to know what to look for when seeking a practitioner, as not all have equal training and not all have experience that will make them effective in treating all medical problems.

Most TCM practitioners do use these four pillars, but there is no need to be dogmatic about using only techniques that originated in historical China. If a modern or Western-developed treatment protocol is appropriate and compatible with TCM principles, it can be integrated into a Four Pillars-based treatment plan. For instance, to reduce inflammation, I might prescribe a classical herbal formula, but I might also prescribe fish oil supplementation. Also, I frequently use manual massage techniques and mobilization of joints, but much of my training comes from Western bodywork systems such as myofascial release and structural integration (I am certified in both of these via the CORE Institute). On an even deeper level, my acupuncture treatments rely heavily on Western anatomy and Sports Medicine principles. These techniques are taught in AcuSport Seminar Series and the Sports Medicine Acupuncture Certification Program, on whose faculty I serve. My point is that as Chinese medicine becomes more global, it can include insight from many other viewpoints, especially Western medicine, but the heart of the medicine will continue to focus on these four basic pillars of treatment which are designed to return the body to a balanced state of health.

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Tuesday, September 15, 2015

Sanyinjiao (SP-6) - Three Yin Crossing

 SP-6 is widely known as a point where the three yin channels of the leg cross. Therefore it is a place where the three leg yin channels (Spleen, Liver, and Kidney) can be simultaneously influenced. Most commonly, this is used to influence these channels to influence the production of Blood, since, according to Traditional Chinese Medicine, all three of these channels/organs contribute to Blood production.
Fig 2: The deep posterior
compartment, including the
tibialis posterior. The
soleus has been removed to
reveal the deeper structures

Fig. 1: Soleus muscle.
The more superficial
gastrocnemius muscle
has been removed.
There is an intriguing anatomical consideration of SP-6 which I have been interested in recently, and was able to confirm this past week while preparing a cadaver specimen for the Sports Medicine Acupuncture Certification Lower Extremity Module. The Anatomy, Palpation and Cadaver Lab portion of the lower extremity module was Thursday and Friday of this past week (9/10/15 and 9/11/15) and, since dissection was a part of this class, I was able to closely observe the region of SP-6 and confirm my suspicion, which is discussed below.

When teaching the Spleen sinew channel, I include the tibialis posterior muscle as
part of a series of myofascially linked structures connecting the medial arch to the knee and thigh. Tibialis posterior is the middle muscle of the deep posterior compartment. The placement of the muscles behind the tibia from medial to lateral is as follows: flexor digitorum longus - tibialis posterior - flexor hallucis longus. Therefore, if you were to insinuate your fingers under the tibia in the region of SP-7 or SP-8, you would encounter the flexor digitorum. If you were able to continue, you would contact the tibialis posterior and then the flexor hallucis longus. Inferior to this, the tibialis posterior then crosses under (anterior to) the flexor digitorum longus and, by the time it passes behind the medial malleolus, it is the most anterior of the deep posterior compartment muscles (recall the mnemonic 'Tom, Dick and Harry' to remember the order of the tendons at the medial malleolus).

Fig 3: Deep posterior compartment
tendons as they pass posterior to the
medial malleolus. These are (in
order) tib posterior, flexor digitorum
longus, flexor hallucis longus
SP-6 is the region at which the tibialis posterior emerges from under the flexor digitorum longus to become the most medial muscle. Flexor digitorum longus is part of the Liver sinew channels. In addition, this region is very close to the soleus muscle at this level. I include the soleus as part of the Kidney sinew channel.

Therefore, SP-6 is at an anatomical location where there is a literal crossing of the three yin sinew channels. This accounts for the usefulness of SP-6 as a distal point for knee pain. This is especially the case when the knee pain has a component of disruption of the musculature of the Spleen sinew channel and can include conditions such as chondromalacia patella, patellofemoral syndrome, and pes anserine tendinopathy.

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Monday, September 7, 2015

Research Review from a Sinew Channel Perspective: The Anatomy of the Posterior Aspect of the Knee | The Journal of Bone & Joint Surgery

The Anatomy of the Posterior Aspect of the Knee | The Journal of Bone & Joint Surgery

The link above contains an abstract discussing anatomical research on the posterior knee. This research will be listed and discussed as a component in a class I will be teaching in San Diego, CA as part of the Sports Medicine Acupuncture Certification Program. This week will be class one and two for Module Four - The Lower Extremities, and the discussion will be part of my lectures based on the Anatomy of the Sinew Channels.

The research discusses the complexity of this structure and emphasizes eight fascial expansions off the main semimembranosus (one of the medial hamstring muscles) tendon (fig. 1). These include:

Fig. 1
  • A lateral expansion to the oblique popliteal ligament which is the largest posterior knee structure. This expansion had two attachments: 1) to the meniscofemoral portion of the posterolateral joint capsule and, 2) to the tibia, along the lateral border of the posterior cruciate ligament.
  • An anterior arm which connects to the medial collateral ligament;
  • A distal expansion which crosses over (posterior to) the popliteus.
A couple of things are important to note about this that can give some insight into the channel system, particularly the sinew channels. First off, it is useful to notice how fascially connected the semimembranosus is to the ligamentous and fibrocartilage structures of the knee. Fascial expansions connect to the MCL, PCL, and lateral meniscus (since the MCL attaches to the medial meniscus, this could be considered in addition). Considering that the Kidneys are associated with the knee, I feel this is a strong argument for the semimembranosus to be considered as part of the Kidney Sinew Channel.

Fig. 3:
removed, illus.
Fig. 2:
intact, illus.
Actually, I see the Kidney sinew channel comprising the semimembranosus and the 'fourth hamstring' which consists of the fascially connected biceps femoris short head and the middle fibers of the adductor magnus. This 'fourth hamstring' is discussed both by Dr. Janet Travell, MD in her book Myofascial Pain and Dysfunction: The Trigger Point Manual, and by Thomas Myers in his book Anatomy Train: Myofascial Meridians for Manual and Movement Therapists. This is depicted in fig. 3 to the right which is contrasted with the image containing the biceps femoris long head and semitendinosus in fig 2, to the left. The superficial hamstrings (semitendinosus and biceps femoris long head) both blend in with the sacrotuberous ligament which links these structures with the posterior ligaments of the sacroiliac joint. These more superficial hamstrings connecting to the posterior ligaments are logically ascribed to the Urinary Bladder sinew channel.

The semimembranosus and 'fourth hamstring' have more fascial connections to the pelvic floor which connects to the anterior ligaments of the sacroiliac joint and are ascribed, as discussed above, to the Kidney sinew channel. See my previous blog post on BL-58, the Luo-connecting point of the Urinary Bladder channel for more thoughts on these two sinew channels.

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Thursday, September 3, 2015

Article Review: Understanding the IT band | Harvard Gazette

Link: Understanding the IT band | Harvard Gazette

Fig. 1, From Netter's
Atlas of Anatomy
Linked above is an article that summarizes some interesting research about the elastic qualities of the iliotibial band (IT band or ITB). This fascial structure connects the lateral hip with the lateral knee. The gluteus maximus attaches directly into the IT band, as does the tensor fascia lata (TFL) muscle. This structure can be involved with many pain patterns, including IT band friction syndrome, about which I posted recently. This post will explore the content of the Harvard Gazette article through the perspective of the Stomach and Gallbladder sinew channels.

Fig. 2, From Netter's
Atlas of Anatomy
The research shows that the IT band stores and releases elastic energy during walking or running, which makes these activities more efficient. Running, in particular, was shown to take advantage of this elastic recoil. The 'recycled energy' gained from elastic recoil is due to the fact that the IT band connects to the front of the pelvis through the TFL attachment (ASIS and anterior iliac crest) and the back of the pelvis through the gluteus maximus (primarily the sacral attachments and PSIS) (fig. 1). During extension, the anterior line of ITB through the TFL to the front of the pelvis is stretched, and the energy being released propels the limb forward. The posterior line of the ITB through the gluteus maximus to the posterior pelvis is then stretched as the limb is flexed, thus building tension and storing energy to assist with extension. A pretty remarkable system of energy storage and conservation is therefore created and used!

For acupuncturists, especially Sports Medicine Acupuncturists like me, there is an opportunity to examine this dynamic with respect to the sinew channels. I believe this involves the Gallbladder sinew channel and the Stomach sinew channel (or at least a branch of the Stomach sinew channel).

Fig 3: Gallbladder Sinew Channel
from A Manual of Acupuncture, by
Peter Deadman
Gallbladder Sinew Channel: This involves the attachments of the extensor digitorum longus into the ITB, which, in my clinical experience, communicates primarily with the gluteus maximus attachment (fig. 2 and 3). One might also consider the peroneus longus, but I feel this is more properly assigned to a branch of the Urinary Bladder sinew channel which connects into the biceps femoris and affects sacroiliac joint balance during gait. But that is beyond the scope of this discussion (see fig. 5).

Fig 4: Stomach Sinew Channel
from A Manual of Acupuncture
Stomach Sinew Channel: This involves the attachment of the tibialis anterior into the ITB which, in my clinical experience, communicates primarily with the TFL. Note that the ST sinew channel does involve the tibialis anterior and anterior crural fascia attaching into the quadriceps (mainly rectus femoris and vastus lateralis). But I believe the ITB-TFL connection to be a branch of the ST sinew channel (fig. 2 and 4), as depicted in Deadman's A Manual of Acupuncture and described in the Ling Shu: "A branch goes along the leg bone and joins the Leg Shaoyang..." (translation from Jingjin, by David Legge).

Fig. 5: Urinary Bladder sinew
channel From A Manual of Acupuncture.
Note the side branch on the leg, which I 
interpret as the peroneus longus; 
this connects to the biceps femoris 
and is not part of this discussion.

So, proper balance and efficiency in walking and running is partially achieved through the relationship of the Stomach sinew channel and the Gallbladder sinew channel. This gives new insight into Zusanli ST-36 (Leg Three Miles) which is one of two motor points of the tibialis anterior. The TFL is very often overactive, as seen in Ober's test. Could needling the motor point of the tibialis anterior at ST-36 allow for better range of motion through this tibialis anterior-ITB-TFL connection, allowing for better extension and creating more stored energy? It sounds like classical thought was on to something in stating "that stimulating Zusanli ST-36 would enable a person to walk a further three li, even when exhausted." (from A Manual of Acupuncture).

I encourage you to check out the original article; there is a great animation to visualize the elastic recoil I mentioned.

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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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