The Diaphragm and the Liver Sinew Channel, Part 2

Fig 1: Typical posture often seen with
Liver Qi Stagnation. Image courtesy
Matt Callison, L.Ac.

In the last post we outlined the basic anatomy associated with the Liver sinew channel. If you have not yet read it, you might want to start with that post. In this post, we will discuss a common postural dysfunction associated with the Liver sinew channel, and we will look at common orthopedic conditions associated with this. Finally, we will discuss some treatment options. Keep in mind that many of these treatments are best learned in a class setting and that much of the discussion here will be alluding to these techniques. Others will be relatively straight forward and easily adaptable in your practice, however.

Dysfunction is observed when the Liver sinew channel (which is more posterior than the Spleen sinew previously discussed) is short and the ribcage is closer to the pelvis in the back than in the front, compressing the posterior diaphragm. This compression prevents the diaphragm from being able to descend effectively; patients often must rely more on the accessory breathing muscles, such as the scalenes, which often become tight and restricted. These patients often exhibit chest or paradoxical breathing. Many of them have the typical Liver Qi Stagnation posture seen in Fig. 1. This posture presents with a very straight, rigid spine and an anterior tilt to the pelvis. The chest is often held up in a military-style posture and the patient looks as if they are unable to exhale fully. This posture, along with several others, were presented and discussed by Matt Callison, L.Ac. at the Pacific Symposium in 2011, where he presented research which correlated Zangfu disharmony as described in Traditional Chinese Medicine with common postural patterns. (This was discussed in a previous post.)

Figure 2: Palpation of the QL at Yaoyan. Image courtesy
of Matt Callison, L.Ac. from his soon to be released book
Sports Medicine Acupuncture.

Many of these patients present with Yaoyan syndrome (often referred to as Iliac Crest Syndrome in Western circles). This presents with pain at Yaoyan. Yaoyan is level with the lower border of L4 and, depending on whether you palpate slightly more medial or lateral, will be more reactive at either the iliocostalis (the most lateral muscle of the erector spinae group) or the quadratus lumborum (QL) attachment at the iliac crest. When there is pain with palpation of the QL, I frequently find LIV-5 to be very sensitive to palpation, also. Needling LIV-5 and obtaining Daqi often reduces the pain at the QL with palpation by about 50%.




Another frequent pain condition which is seen with this posture is thoracic outlet syndrome (TOS) which involves an entrapment of the brachial plexus either between the anterior and middle scalenes, between the clavicle and ribcage, or between the pectoralis minor and the ribcage. In this posture, the scalenes and pectoralis minor are short and holding the ribcage too rigidly up (creating a very wooden spine). I associate these muscles with the Lung sinew channel, but see this as a way that excessive Liver energy can affect the channels associated with the Lung. These patients often have a paradoxical breathing pattern where they pull the abdomen in during the inhale and lift the chest. This uses accessory breathing muscles and they should be elevating the upper ribs, but with the restricted movement in the diaphragm, they have to work overtime; thus they become tight and rigid and can then compress neural structures.

Fig. 3: Brachial plexus entrapment on the left side 1) between the ribcage and clavicle, 2) between the anterior and middle scalene, and 3) under the pectoralis minor. I include the scalenes and pec. minor in the Lung sinew channel. They are listed here as Liver Qi Stagnation and the posture shown above is a common contributor of TOS.

Fig. 4: Anterior pelvic tilt.

Since an anterior tilt of the pelvis is involved with the posture in Fig. 1, it is important to address this when treating many pain patterns, especially if they are chronic. In the Sports Medicine Acupuncture Certification program run by AcuSport Seminar Series, we teach a particular needle technique at LIV-4 (paired with GB 39.5) as treatment for an anterior pelvic tilt. This is used on the most anterior side and could be part of the treatment of many back conditions such as radiculopathy, facet syndrome, and SI joint dysfunction; it can also be used with treatments for TOS and other problems. This point combination and needle technique was developed by Matt Callison through his understanding of channel theory and then refined with trial and error. I interpret LIV-4 as softening the psoas and helping relax and lengthen this muscle, which is such a strong contributor to an anterior pelvic tilt. It is mentioned here to highlight the relationship of the Liver sinew channel to the psoas major, which is heavily involved with an anterior tilt of the pelvis. 

In addition to acupuncture to distal points, direct needling of motor points to muscles such as the QL, scalenes, pectoralis minor, and other related structures can help improve alignment. Also tuina is indicated. I utilize myofascial release extensively in my practice and it can be very helpful in releasing tight fascia and allowing the body to find a more healthful balance. In Sports Medicine Acupuncture and in the KMI training, Simone Lindner teaches a very useful myofascial release technique to the lateral raphe (a fascial structure which then separates to becomes the anterior and posterior layer of the thoracolumbar fascia). This structure is at the edge of the QL; the technique involves working with a seated patient and, using this fascial structure as leverage, lifting their ribcage out and away from their pelvis in the back. Also addressing the front of the diaphragm is useful as it is pulled up. Accessing this fascia under the costal margin and bringing it down will free the breath and soften the Liver channel.

Other sinew channels have a strong relationship to the diaphragm, either directly or indirectly, and can be explored at another time. Most notably, the Pericardium sinew channel influences it via its relationship with the serratus anterior, another muscle which can act as a clamp and restrict proper expansion of the thorax. Needling SP-21 or other points which correlate with motor points of this muscle will increase the Lung pulse, for instance. The Lung sinew channel relates to the pectoralis minor and the scalenes (both discussed in this post) and has a strong relationship to the diaphragm in that these muscles are accessory breathing muscles and, when restricted, can greatly limit breathing. The Yang sinew channels also include many structures such as the abdominals and pectoral muscles that can limit expansion of the breath. Therefore, the diaphragm, with its relationship to effortless and healthful breathing, is one of those pivotal structures for vibrant health.

Note: Tom Myers has an interesting discussion on this fascial plane which I am categorizing as part of the Liver sinew channel. His post can be found here; however, it is not written from a TCM or Chinese medicine prospective.

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The Diaphragm and the Liver Sinew Channel, Part 1

Image modified from

Toldt's Atlas of Anatomy.

Labels added to highlight

Liver sinew channel

In the last post we discussed how the Spleen sinew channel connected to the anterior aspects of the diaphragm; we looked at dysfunctional patterns associated with this sinew channel and how this relates to breathing and posture. 

This post will look at the Liver sinew channel and the posterior aspects of the diaphragm. This connection is mediated through both the quadratus lumborum and psoas muscles as their fascia blends with that of the diaphragm. This occurs at the 12^th rib for the QL and the superior portion of the psoas. 

Before getting to the diaphragm, let's look at the Liver sinew channel in the thigh and work up to its connection at the posterior diaphragm. There are two prominent fascial septa in the medial thigh; an anterior septum which separates the quadriceps from the adductors, and a posterior septum which separates the adductors (primarily adductor magnus) from the hamstrings.

The anterior septum is associated with the Liver sinew channel and links the more anterior adductors such as adductor longus, adductor brevis, and pectineus with the distal iliopsoas tendon.

While the iliacus and psoas muscles (which together make up the iliopsoas) have a common attachment distally, each muscle takes a different, though similar, pathway as it moves proximally. 

Posterior Abdominal Wall, from Netter's Atlas of Anatomy.
Labels added to highlight Liver sinew channel.

The iliacus portion attaches to the iliac fossa on the medial ilium. Its proximal portion at the iliac crest connects to the distal portion of the quadratus lumborum (QL). This places the QL on a direct fascial plane with the adductors and iliacus and makes it a much more Yin muscle in terms of depth and fascial connection. 

Other authors usually assign the QL to Yang channels, most often the Gallbladder, but occasionally the Urinary Bladder. Legge. Maciocia, and Kendall place it in the Gallbladder sinew channel. Whitfield Reaves has some interesting commentary in his book based on his struggles with this muscle and its channel relationships. He deems it too lateral to be easily assigned to the Urinary Bladder and too medial for the Gallbladder channel (he does not refer to the sinew channels, specifically). All of this is understandable, based on where it would be palpated and needled. 

However, I have become convinced that it more properly belongs in the Liver channel, based on the fascial plane it exists on; functional relationships it has with the Gallbladder sinew channel muscles such as the gluteus medius and minimus (this will be a future topic); and my own findings of consistent reactivity of LIV-5 to QL pain at Yaoyan (its iliac crest attachment), Pigen (its 12th rib attachment), or in the midbelly at its motor point (this will be discussed more in part 2 of this post).  

To continue with the fascial connection, the QL attaches to the inferior portion of the 12th rib, while a portion of the diaphragm attaches to the superior portion of this rib. However, the fascia between these attachments is continuous. This fascial connection can be illustrated with the scenario of an actress who has her 12^th rib removed (an actual cosmetic procedure, used to reduce waist size). Neither the QL nor the diaphragm needs to be cut surgically. The 12^th rib is cut away and the periosteum (containing both the QL and diaphragm attachments) is teased away from the rib. The rib is then removed and the QL-periosteum-diaphragm is kept intact.

The psoas has a more direct pathway, covering the same basic territory as the QL-iliac muscle to blend with the fascia of the posterior portion of the diaphragm at its proximal end.

In Sports Medicine Acupuncture®, we look at the cases where the too-tight diaphragm can impinge on and inhibit the psoas. This inhibition of the psoas destabilizes the back and leads to pain, which often comes on when the breathing is challenged during exercise. Matt Callison teaches a technique he developed to assess for this, and he treats it with a particular needle technique at ST-20. This assessment and technique is better left to in class training, but it is interesting that ST-20 descends both Stomach Qi (not surprising for an ST channel point in this region), but also descends rebellious Lung Qi. Could this be considered a case of Metal overacting on Wood, as breathing restrictions are inhibiting the proper firing of a Liver sinew channel muscle?

Image from Deadman's
A Manual of Acupuncture

To briefly restate the anatomy: this sinew channel follows the anterior septum of the thigh up the medial leg. This would include a series of fascially linked structures such as the adductor longus, the adductor brevis, the pectineus, and the distal iliopsoas. This would then branch at the iliopsoas, with one portion linking the psoas to the posterior diaphragm and another branch linking the iliacus to the QL to the posterior diaphragm. Note that classically the Liver sinew channel ends at the groin. However, I feel, for reasons described above and in future posts, that a strong argument exists for extending it up to the diaphragm.

In the next post we will look more thoroughly at dysfunctional patterns associated with the Liver sinew channel and its connection to the diaphragm. We will explore various postural changes that can be observed (as we did with the Spleen sinew channel) and we will explore various pain patterns that arise. 

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