Friday, June 7, 2019

Treatment of the Kidney Sinew Channel for Injuries Associated with the Urinary Bladder Sinew Channel

Fig. 1: This myofascial release technique on the posterior intermuscular septum of the thigh (the fascial septum between the adductor magnus and the medial hamstings) is taught in the Assessment and Treatment of the Channel Sinews class in Sports Medicine Acupuncture Certification. It is a technique that could be used to treat the Kidney channel as discussed in this post.

I authored this month's SMA (Sports Medicine Acupuncture®) blog post, which is on assessment and treatment of the channel sinews for posterior and medial knee pain. It focuses common injuries associated with the Urinary Bladder and Kidney channel sinews (jingjin), including upper gastrocnemius strain, hamstring tenosynovitis (both of these are associated with the UB jingjin), and MCL injury (associated with the KID jingjin). Check it out.

At the end of the post, I discuss how treatment of the channel associated with the injury does not always yield lasting results. Obviously, acupuncturists know this. We have many channel relationships that help guide our clinical decision making. Sometimes we treat the channel that is associated with an injury; sometimes we treat the internal-external pair; sometimes we treat based on six divisions; sometimes we use midday-midnight correspondences; and sometimes our decision-making can be even more complex. The channel system is very interdependent and it is not always as simple as treatment including local, adjacent, and distal points where all of these are on the same channel.

In the SMA blog post, I gave an example of treatment of upper gastrocnemius strain and/or hamstring tenosynovitis (UB jingjin) when there is a loss of integrity of specific ligaments associated with the KID jingjin. In these cases, the gastrocnemius and hamstrings will need to make up for the loss of stability in the knee due to the loss of integrity of the ligaments. To get lasting results in this case, one must address the Kidney channel. There are many ways that one can accomplish this and I don't want to get into treatment in this post. Regardless of whether you are using acupuncture, regenerative injection techniques, manual therapy, or other tools, communicating with the Kidney channel will keep the UB structures from having to overwork as they attempt to stabilize the knee.

Fig. 2

There is another example that didn't get explored in the SMA blog post for space reasons. It has to do with the relationship of the UB and the KID jingjin and their associated myofascial structures, the hamstrings and the adductor magnus. The hamstrings are associated with the UB jingjin and the KID jingjin. The two superficial hamstrings (the biceps femoris long head and the semitendinosus) are part of the UB jingjin while the semimembranosus is part of the KID jingjin (Fig. 2). 

Fig. 3: The semimembranosus removed on the right
to reveal the '4th hamstring'.
There is also a '4th hamstring' which is comprised of the biceps femoris short head and the adductor magnus (Fig. 3). The adductor magnus is not technically a hamstring, but the middle fibers are fascially connected with the biceps femoris short head and this pair can be considered as a 4th hamstring. This '4th hamstring' is discussed both by Tom Myers in his book Anatomy Trains: Myofascial Meridians for Manual and Movement Therapists, and by Janet Travell in her book Myofascial Pain and Dysfunction: The Trigger Point Manual.

To recap, there are two pairs of hamstrings; a superficial pair (biceps femoris long head and semitendinosus; both associated with the UB jingjin), and a deep pair (semimembranosus and biceps short head/adductor magnus; both associated with the KID jingjin). The video below explores the anatomy of these two channels in the foot, ankle, leg and thigh.

Back to the topic of this post; how one channel can influence another and how an injury associated with one channel might require treatment to a related channel. The hamstrings get their blood supply from perforating arteries which branch off of the deep femoral artery (femoral artery profunda), which itself is a branch off of the femoral artery. The name 'perforating arteries' implies that they perforate something, which they do. They perforate the adductor magnus on their way to the hamstrings (Fig. 4). If the adductor magnus is short and tight, this could definitely restrict blood flow to the hamstrings. If you have a patient that comes in with chronic hamstring problems, maybe it is worth assessing and treating the adductor magnus. You will be assessing and treating the KID jingjin to help with any work you do with the UB jingjin. The image at the top of this post shows a myofascial release technique which frees obstructions in the posterior intermuscular septum of the thigh (between the adductor magnus and the medial hamstrings)

Fig 4: Gray's Anatomy illustration showing perforating arteries perforating the adductor magnus on their way to the hamstrings. Hamstrings are not shown in this illustration so that the arteries can be seen.

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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.

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