Reflections from the Cadaver Lab: Week 2 Day 4

Reflecting on my fourth day of week two teaching the 2022 Cadaver Lab.

Each year I teach this cadaver lab, I plan on posting some reflections at the end of each day. I did pretty well this year, posting for days 1-4 of the first week. And then I got off track. This is for two reasons. 1) Dissection lab is very tiring both mentally, but also physically. One is standing the entire day and working over a table, accounting for the physical aspect, but it is also mentally tiring due to the sustained concentration. This is especially true when you are teaching. 2) There is really so much to highlight that at the end of the day it almost makes it too difficult to remember what I was planning to post when I get home. This is made worse by point number one.

Day 4 is the same as last week. It is the day that evisceration occurs and the organs are studied. It is not only this, however. The dissection continues into deeper layers of the anterior neck and extremities so that you can follow myoneurovascular structures from the neck and into both the thoracic cavity but also the upper extremities and you can follow myoneurovascular from the abdominal cavity into the lower extremities. Day 4 is really the culmination of the week up to this point.

Here are some reflections:

1. There are many things I teach to acupuncturists regarding the channel sinews (jingjin) and their myofascial connections. Reflection of the biceps brachii is a great example of this. With the biceps reflected, you get a great view of the coracobrachialis and the brachialis. The brachialis has two myofascial connections. On the lateral side of the humerus, it has a clear myofascial connection to the deltoids, especially the anterior fibers. Following this path highlights the a deep branch of the Lung sinew channel. However, the brachialis also has a clear myofascial connection to the coracobrachialis which highlights the Pericardium sinew channel. This connection is great in anatomy texts, but much more obvious on a fresh tissue dissection when you can put tension into these myofascial planes. Visually it is apparent, but the tactile portion helps solidify the understanding when considering how injury can affect this plane.


2. The IT band is really a fascinating structure when you do dissection. It is really almost abstract because, to view this structure, you have to remove the fascia lata (the deep fascia of the thigh) while retaining the IT band. This means you cut an artificial line on the anterior and posterior border and remove the fascia lata off up to this line you created. There is a guideline regarding where you make this line and that is the TFL muscle. The ITB does have some variability in tension from specimen to specimen, but nothing like what you feel when you palpate patient's lateral thighs. There is far more variation with patients. So, all of these tight IT bands really has more to do with the baseline tension in the TFL and/or the underlying vastus lateralis. I think the vastus lateralis is the more likely thing practitioners are palpating. When reflecting the IT band, you follow under the TFL to the ASIS to reflect both together. You have to find the fascial plane between the TFL and the underlying gluteus medius when doing this. It is hard to differentiate. Which is also the case when you palpate and needle these structures on patients. I think many times, clinicians are sensing the gluteus medius and advancing the needle to this muscle when they think they are treating the TFL.


3. The plantar foot is organized in layers which can be followed in dissection. The superficial layer has the plantar fascia which has a very clear connection to the underlying flexor digitorum brevis, but it also has a clear connection to the adductor hallucis. This is the layer of the Kidney sinew channel. The next layer involves has the flexor digitorum longus, quadratus plantae, and lumbricals. This is the layer of the Liver sinew channel. The final layer includes the tibialis posterior, flexor hallucis and adductor hallucis. This is the layer of the Spleen sinew channel. These layers are well depicted in Netter and other anatomy atlases because the plantar foot is so clearly organized this way in dissection. The channels would follow would also be associated with this order.


4. I saw a pretty odd anomaly of the psoas major. I will look a bit closer and try to describe tomorrow.

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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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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, http://iy-sp.com/s-p

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.

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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.

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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!

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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.

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