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.

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The Spleen and Stomach Sinew Channels and Patellar Tracking

From Grant's Atlas of Anatomy,
showing patellar surface where the
patella tracks during knee movement.

Internally-externally related sinew channels often function together to stabilize major joints and allow for balanced mobility of these joints. In some respects, they can have an agonist-antagonist functional relationship across these major joints. Patellar tracking and the Spleen and Stomach sinew channel provides an excellent example of this phenomenon.

In many ways these two sinew channels, not unlike their respective primary channels and organs, work more in unison compared to other internally-externally related sinew channels. These channels contain the quadriceps; the Spleen sinew channel including the vastus medialis (medial quadriceps) and the Stomach sinew channel including the rectus femoris and vastus lateralis (lateral quadriceps). These work together to perform knee extension.

Image from: http://smartrad.blogspot.com/2012/04/patellofemoral-pain-syndrome.html
Patient was a 40 year-old man with bilateral knee pain. Examination revealed tight lateral restraint.
A tight lateral restraint indicates a tight lateral retinaculum which fails to allow proper medial patellar glide and tilt. Note the excessive lateral pull on the patella.

So, how is it that these separate sinew channels balance the patellofemoral joint? To understand this, it is useful to look at the tensional pull the vastus lateralis and vastus medialis have on the patella. When looking at basic muscle anatomy texts, one sees that the quadriceps tendon wraps around the patella and then attaches to the tibial tuberosity. Actually it is called the patellar ligament from the patella to the tibia as it connects bone to bone, but it is the same structure as the quadriceps tendon. .

The vastus lateralis muscle blends in with the lateral retinaculum and the vastus medialis blends in with the medial retinaculum and both exert a pull on the patella. In balance, this influences the tracking of the patella in the femoral groove. Often, the vastus lateralis becomes overactive and the vastus medialis becomes inhibited, contributing to an excessive line of pull in a lateral direction. This is referred to as patellofemoral syndrome. It contributes to early degenerative changes in the cartilage of the patella, femur and/or tibia. Looking from a sinew channel perspective, this condition can be seen as a disorder between the Spleen and Stomach sinew channels.

Simultaneous stimulation of xinfutu (upper left) and
baichongwo (lower right).

Treatment with acupuncture can consist of specific release techniques of the lateral retinaculum and specific local needling for the patellar pain. But the muscle firing can be directly affected by needling the motor point of the vastus lateralis which is at the extra point xinfutu, and needling the motor point of the vastus medialis which is at the extra point baichongwo. Getting Qi in both and stimulating these points at the same time can help balance the firing of these two important muscles related to the tracking of the patella.

In addition, SP-6 and ST-36 can be added. The vastus lateralis and lateral retinaculum blend in with the fascia of the tibialis anterior. ST-36 is the motor point of this muscle and will help with the release of the Stomach sinew channel. SP-6 is a good distal point to assist with the ‘tonification’ of the vastus medialis. It has an interesting anatomical aspect that is discuss in a previous blog post called Sanyinjiao (SP-6)–Three Yin Crossing.

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