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.

Wednesday, June 27, 2018

Neck and Rhomboid Pain

I am the author of the blog post on neck and rhomboid pain featured at the Sports Medicine Acupuncture page. Here is the link.

The post discusses dorsal scapular nerve entrapment which is a common cause of neck and periscapular pain. The post also discusses the relationship of this condition to the Large Intestine sinew channel.

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.

Saturday, April 7, 2018

Injection and the Sinew Channels

Tomorrow I am a guest instructor with Christina Captain's excellent injection certification in Sarasota, FL. I have taught this class for several years. Below is a description of what I will be teaching, and what my philosophy is when using injection and when teaching.

First, I think that it is fantastic that some states have injection in the scope of practice for acupuncturists, as Florida does. It is a worthwhile endeavor for the state professional organizations to work towards expanding the scope to include injections in the states that do not have this. However, I don't think that acupuncture physicians should get too allopathic when using injection. We have this wonderful and extremely advanced channel system that is easy to lose sight of when we are all of a sudden using a hypodermic needle, especially when treating musculoskeletal pain and injury.

When I teach as part of this injection certification in Florida, I am there as a guest instructor from the Sports Medicine Acupuncture Certification program (SMAC). As a guest instructor, I am teaching injection for musculoskeletal pain, sports injuries, and other orthopedic conditions. So, much of what I teach is very influenced by what is taught in SMAC.

In SMAC, we do not teach injection. Very few states have this in the scope of practice and this is an international program. We teach how to assess and treat orthopedic conditions and how to integrate these treatments with Traditional Chinese Medicine (TCM) to build a comprehensive treatment protocol. These treatments build on what acupuncturists already know. For instance, is this an excess or deficient pattern? Does the person have Blood deficiency, Spleen Qi deficiency and Dampness, Kidney Yin deficiency? All of the elements that make our medicine so powerful are included and highlighted. Added to this is a comprehensive ability to assess specific musculoskeletal injuries while understand the muscle imbalances that contribute to these injuries. This means that we teach how to diagnose the specific injury and assess the imbalances in the sinew channel (jingjin) that contribute to the injury and prevent proper healing.

Treatments include the following local, adjacent and distal approach:
  1. Specific, advanced needle techniques for the condition.
  2. Treatment to balance the sinew channels which entails balancing overactive (excess) muscles  and inhibited (deficient) muscles. This includes acupuncture to the motor points of the muscles involved and to distal points along the channel that these muscles are a part of.
  3. Myofascial release techniques to support the treatment and increase the therapeutic outcome.
  4. Prescription of corrective exercises to support the treatment and correct muscle imbalances and postural disparities. 
In my mind, nothing changes when using injection. I can use injection as part of the local treatment. Often, I will be using the same local, injury specific technique. These techniques were developed by the founder of SMAC, Matt Callison, and are extremely effective with an acupuncture needle and can easily be adapted for injection. Added to this will be placing a homeopathic injectable solution (I use Heel products such as Traumeel and Zeel) at the site of injury which, depending on the injectable,  can help reduce inflammation, reduce irritation of a joint, nerve or muscle, and stimulate lymphatic circulation.

However, I still want to use acupuncture, myofascial release techniques and corrective exercises to balance the sinew channels and I still want to treat any zangfu imbalances that present with the patient. What I do not want to do, and what I want to encourage acupuncturists adding injection to their treatments not to do, is simply to inject the local tissue that is affected and lose sight of the comprehensive, holistic, and advanced nature of our medicine.

Tuesday, April 3, 2018

The Ligaments and The Kidney

Here is a post written by Matt Callison and featured on the Sports Medicine Acupuncture blog. It is an excerpt from his soon to be released book, Sports Medicine Acupuncture. The suggestion is that the ligaments really belong under the influence of the Kidneys in TCM as part of their correspondence with bone, not the Liver.

Wednesday, March 7, 2018

Yaoyan and the Channel Sinews

Above is a link for a blog post I wrote which is on the Sports Medicine Acupuncture®
 website. This post describes the two vectors for needling the extra point yaoyan, the common ashi points found in two separate muscles palpated and needled at these vectors, and the two different channel sinews (jingjin) these muscles would be on.

This information is essential for linking local and distal acupuncture points to achieve the best clinical outcome.

Monday, February 26, 2018

Day 1 of a 5 Day Dissection Course

I just finished day 1 of a 5 day dissection course led by Todd Garcia. I am working alongside many of my sports medicine acupuncture® colleagues. I will post some discoveries from the class soon. This type of experience is such a fantastic way to see and explore the channels of Chinese medicine!

Thursday, February 15, 2018

KID 10 (yingu) and the Posterior Knee

KID 10 (yingu) is a very interesting point in relationship to the knee and knee injury and pain. It contains some fascinating anatomy that might not be apparent on first glance. 

Peter Deadman, in A Manual of Acupuncture, describes the location thus: “At the medial end of the popliteal crease, between the semitendinosus and semimebranosus tendons.” Claudia Focks, author of Atlas of Acupuncture, has a similar description: “At the medial end of the popliteal crease, between the tendons of the semimembranosus and semitendinosus muscles, on the level of the knee joint space.”

I find these descriptions a bit confusing, as they don't completely match what we find in palpation. In a way, it might be more accurate to say that KID 10 is between the semimembranosus and another part of the semimembranosus. If you press into the space between the semitendinosus and the semimebranosus tendon, you might be able to feel a very thin, but palpable band. This band will definitely contract when the knee is flexed, verifying that it is a hamstring.

In this illustration, the semitendinosus tendon has been
removed. It would be lateral (to the right of)
semimebranosus (SM). I think KID 10 is about
where the label for 'Coronary attachment' is in
the above illustration.
What hamstring muscle is between the semimembranosus and semitendinosus tendon, you might ask? Look at most anatomy books and you won't find one. The answer is that this band is a fibrous expansion of the semimembranosus tendon which blends into the oblique popliteal ligament (a major structure of the posterior joint capsule). I think KID 10 is between the main body of the semimembranosus and this lateral expansion. If you advance into this space, you will affect the fascia of the fibrous expansions of the semimembranosus.

Press slowly and gently into this space and you will frequently elicit a referral deep into the knee joint and into the medial tibia. Needling into this would contact this proprioceptive rich fascia which blends with the posterior capsule of the knee. These expansions also have connections to the medial meniscus and the medial collateral ligament (see 'anterior arm' in the image to the left).

If you press or needle lateral to this expansion, in other words, between it and the semitendinosus, you miss this fascia altogether. 

This is a somewhat challenging area to palpate. When palpating, stay very close to the lateral border of the main tendon of the semimembranosus and you will slide between it and this fascial expansion. Having the knee flexed helps with palpation.

In addition to KID 10, and when presented with medial knee pain and/or problems with the posterior knee capsule, you might consider treating the motor points of two muscles of the Kidney sinew channel: semimembranosus and popliteus. As can be seen in the image above, these muscles are very connected to this important fascia that stabilizes and supports the posterior and medial knee. Obviously, there is a lot more assessment that would be required to build a treatment plan, but these suggestions would frequently be applicable for MCL injury, medial meniscus injury, weakness of the posterior joint capsule, and medial knee pain referred from semimembranosus.

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.