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.

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.

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The Fascial Slings of the Foot and the Balance of the Arches, Part 2

Part 1 of this post introduced the fascial sling which connects at the plantar portion of the medial arch. It includes the tibialis anterior and peroneus longus muscles. The tibialis posterior can also be included in this sling, and the last post looked at how the tibialis anterior (part of the Stomach sinew channel) and the tibialis posterior (part of the Spleen sinew channel) can function synergistically to lift the medial arch. It was discussed that the healthy T&T function of the Spleen-Stomach can help nourish these muscles and that a drop of the medial arch can be seen as part of the Spleen's holding or lifting function. See the previous post for this discussion.

This post will look at the main part of this fascial sling, the tibialis anterior - peroneus longus. This convergence of the Stomach and Urinary bladder sinew channels has a more agonist-antagonist relationship, and working to balance these muscles/channels is key to proper balance in the arches of the foot.

Fig. 1

The peroneus longus (aka the fibularis longus) attaches from the head and proximal portion of the fibula. It traverses the lateral portion of the fibula, passes posterior to the lateral malleolus, travels just superior to UB-62, and crosses under the cuboid bone in the peroneal canal which is created superiorly by the cuboid sulcus and inferiorly by the long plantar ligament. It reaches the medial cuneiform and base of the 1st metatarsal which is its distal attachment. This is the same attachment site as the tibialis anterior, and they connect to one another through the joint capsules of these bones. When it contracts, the peroneus longus creates plantar flexion at the ankle, which pulls on the lateral arch and everts the foot. When it is overactive, it can contribute to foot overpronation by pulling up on the lateral arch and dropping the medial arch.

Fig. 2: Note the lateral branch of the UB
sinew channel which travels behind the lateral
malleolus. Image is from Deadman's
A Manual of Acupuncture.

The peroneus longus is part of the lateral branch of the Urinary Bladder sinew channel (Fig. 2). This muscle has a very strong fascial connection into the biceps femoris (lateral hamstring). For more on this connection, see this past post. This muscle acts as an antagonist to the tibialis anterior muscle (part of the ST sinew channel), which performs dorsiflexion at the ankle and inverts the foot at the subtalar joint.

Fig. 3

Fig. 4

Many agonist-antagonist muscle imbalances are seen between the Stomach (Earth) and Urinary Bladder (Water) sinew channels. Examples include the quadriceps (ST) - hamstrings (UB) and rectus abdominis (ST) - erector spinae (UB). The relationship between the tibialis anterior (ST) and the peroneus longus (UB) is another example.

When the peroneus longus is locked-short and the tibialis anterior is locked long, the foot will be pulled into eversion (Fig.4). Alternately, when the tibialis anterior is locked-short and the peroneus longus is locked-long, the foot will be pulled into inversion.

Treatment can include needling the most reactive tibialis anterior motor point; ST-36 is often the most reactive, but the extra point lanweixue M-LE-13 is also a motor point. And the peroneus longus MP (approximately 1 cun inferior to the fibular head) can also be needled.

There are some more specific advanced techniques that Matt Callison and I will demonstrate at the Pacific Symposium this coming Fall 2017, involving an acupuncture fascial release that helps pull down the lifted UB sinew channel for foot overpronation. This is a bit tricky to discuss in a blog post, but stay tuned for more information in the future.

The next and final post in this series will follow the sinew channels up to the hip and explore how pelvic imbalances can influence foot overpronation.

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