Scapular Training for the UB and the GB Jingjin

Scapular training is an essential component of bodyweight calisthenics training and qigong training. Not only do you want proper scapular stabilization when you are hanging or reaching overhead, but the scapulae need to have controlled movement to increase power with things like pulling exercises. The scapular movement also needs to coordinate with other muscles for efficient whole body movement. Let's look at this coordinated movement in relationship to the the Urinary Bladder and the Gallbladder channel sinews (jingjin).

UB Jingjin: Superficial Branch.
Deep Branch includes
spinal erectors.

A simple pull up serves as an example of the movement pattern of the UB jingjin. The lower trapezius and the latissimus dorsi both depress the scapulae and this motion occurs with other muscles of the back such as the erector spinae. If you are bringing the chest to the bar, this is especially apparent. Another example would be taiji when in mountain climbers stance. The chest would be up and there is a coordinated activation of the Urinary Bladder jingjin which activates the scapular depressors, spinal erectors and gluteus maximus.

GB Jingjin

Other pulling exercises would highlight the movement pattern of the GB jingjin. The same scapular muscles would be activated, but they would coordinate this activity along with the obliques and the hip abductors. The human flag would be a great example (see video below for an example). Also movements that would involve rotation such as swinging from monkey bars would require pulling motions engaging the scapular depressors along with trunk rotation activating the obliques. 

So these same muscles can be part of a global movement pattern of different channels. And injury of these muscles could be associated with different channels. Local treatment may involve motor entry points (MEP) and/or myofascial trigger points (MTrP) of these same muscles, but how you link this local treatment can change depending on the channel involvement. Check out the video I did to explore this dynamic.

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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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Yaoyan and the Channel Sinews

www.sportsmedicineacupuncture.com/yaoyan-channel-sinews

Above is a link for a blog post I wrote which is on the Sports Medicine Acupuncture®
 website. This post describes the two vectors for needling the extra point yaoyan, the common ashi points found in two separate muscles palpated and needled at these vectors, and the two different channel sinews (jingjin) these muscles would be on.

This information is essential for linking local and distal acupuncture points to achieve the best clinical outcome.

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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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The Gluteus Maximus and Converging Sinew Channels

Fig. 1: Image from Functional Atlas of the Human
Fascial System by Carla Stecco

This image (Fig. 1)  is from the excellent book, Functional Atlas of the Human Fascial System, by Carla Stecco. In Manhattan two years ago, during the Sports Medicine Acupuncture Certification (SMAC) program, Matt Callison and I were preparing a fresh tissue cadaver specimen for the Anatomy/Palpation/Cadaver lab for Module 3, which addresses the lower back and hip. In this specimen, we observed an interesting fascial expansion which extended from the deep fibers of the gluteus maximus and connected to the hamstrings and sacrotuberous ligament (STL). This was in the region of BL-36. We saw this as confirmation that the gluteus maximus was part of the Urinary Bladder sinew channel.

Fig. 2: Image from
A Manual of Acupuncture
by Peter Deadman

Maybe this seems like an obvious sinew channel in which to place this muscle, but consider that the gluteus maximus also attaches to the iliotibial band (ITB) which is on the lateral leg. Also, this muscle matches the topography described in the Lingshu, which mentions that the Gallbladder sinew channel has a branch that attaches to the sacrum (Fig. 2 and 3). Both of these vectors of pull are discussed in Stecco's book and seen in Fig. 1. The black line (ITB - gluteus maximus - sacrum) describes the GB sinew channel. The red line (hamstrings - gluteus maximus - STL - thoracolumbar fascia and erector spinae) describes the BL sinew channel. So, the gluteus maximus is an example of where two sinew channels converge. Like the primary channels, this kind of convergence is something that occurs with some regularity.

Fig. 3: Image from
An Atlas of Human
Anatomy for
Students and
Physicians by
Carl Toldt

A few clinically useful things can be taken from this:

1) The gluteus maximus MP can be added to treatments that affect the GB sinew channel. These include trochanteric bursitis, iliotibial band friction syndrome, and asymmetrical pelvic tilts (contributing to a host of potential problems). Treatment can include GB distal points.

2) The gluteus maximus MP can be added to treatments that affect the BL sinew channel. These include hamstring and gluteus maximus strain, hamstring tendinopathy, coccydynia, sacroiliac joint problems, and erector spinae strain. Treatment can include BL distal points. 

3) The gluteus maximus MP has an empirical use, which is that it reduces tension in the upper cervical muscles. This is an example of treating below to affect above on the same channel. 

4) The gluteus maximus MP can be considered as a distal point when treating restriction and pain in the pectoralis muscle. The pectoralis major is on the Heart sinew channel, so this can be considered a midday-midnight (GB-HE) treatment. And, there is a branch of the BL sinew channel which also travels through the pectoralis major via the  thoracolumbar fascia - latissimus dorsi - pectoralis major - SCM branch seen in Fig 4. It is not imperative that you know which channel relationship you are affecting, and this topic can be taken up another time. 

5) Lastly, the gluteus maximus becomes bilaterally weak when there are upper cervical vertebral fixations. This is harder to explain easily; I can refer you to an article I wrote that was in the Illinois Association of Acupuncture and Oriental Medicine Newsletter (The Illinois Acupuncturist) and will be in the upcoming Florida State Oriental Medical Association newsletter. This is also posted on my blog and you can click here to see it. 

Basically, I see this problem as an interaction of the Urinary Bladder sinew channel and the Spleen and Stomach sinew channels, and an example of Earth overacting on Water. These sinew channels have an agonist/antagonist relationship. The Stomach and Spleen sinew channels become bound, which restricts the anterior portion of the diaphragm and the deep anterior myofascia (abdominals below, transversus thoracic and hyoids above). This causes tension in key regions of the spine and can lead to vertebral fixations. Certain muscles on the BL sinew channel then become bilaterally weak (the gluteus maximus in the case of upper cervical fixations). In Sports Medicine Acupuncture, we treat upper cervical fixations by using vertebral mobilization techniques for the affected vertebrae, needling SP-4/P-6 (which affects the deep holding pattern) and needling the MP of the gluteus maximus. 

Fig. 4: Image from A Manual of Acupuncture by Peter Deadman

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Kunlun BL-60, the Urinary Bladder Sinew Channel, and Muscle Tension Headaches

“Kunlun BL-60 is the fire point of the taiyang Bladder channel and an important point to clear and descend excess wind, fire and yang from the upper part of the body.” So states Deadman in the commentary for this point in A Manual of Acupuncture. He goes on: “The principle 'for disease of the head select [points from] the feet' applies well to the point. Kunlun BL-60 is able to clear heat and lead down excess yang from the head in cases of headache, heat in the head, redness, pain and swelling of the eyes, bursting eye pain, nosebleed and toothache, and to extinguish wind from the head in cases of epilepsy and lockjaw.”

What I would like to consider in this post is the actions of this point on muscle tension headaches, specifically on reducing tension in a group of muscles that often become dysfunctional together as part of this pattern of tension headaches. These muscles individually refer pain to the posterior neck and occiput, the temple region, and the region of the orbit of the eye. Collectively, their referral patterns overlap and can create a composite pattern of pain that many of our patients describe when they come in for treatment. These muscles are the trapezius muscles (primarily the upper fibers but also the lower fibers can contribute to headaches), the suboccipital muscles, the sternocleidomastoid (SCM), and the temporalis muscle.

Fig. 1: TrP pain referrals of the upper trapezius, the suboccipital muscles, the SCM (sternal head), the temporalis, and the SCM (clavicular head). Image from Myofascial Pain and Dysfunction: The Trigger Point Manual by Janet Travell and David Simons.

Fig. 2: Urinary Bladder sinew channel image from
A Manual of Acupuncture, by Peter Deadman

What unifies these muscles from a channel theory perspective is the Urinary Bladder sinew channel. An uprising of Yang, and a flaring of Fire and stirring of Wind, often with disharmony in the Liver network, manifests as contraction in the muscles listed above. These muscles are all part of the Urinary Bladder sinew channel. This channel unites these muscles together in a type of disharmony that causes muscle tension headaches.

The sinew channel would indeed include the suboccipitals along with the chain of myofascial tissue, creating a myofascial meridian, and rising up the back of the body (Fig. 4). This is an obvious muscle to include in any channel description involving the trajectory of the Urinary Bladder channel. And this myofascial meridian also includes the thoracolumbar fascia, the thick aponeurotic structure in the lumbar region. But, other structures attaching to the thoracolumbar fascia explain several branches of this sinew channel. This includes the latissimus dorsi and the lower fibers of the trapezius (Fig. 3). The latissimus dorsi has obvious fascial connections to the pectoralis major which, in turn, connects with the SCM. The trapezius, accounting for the LI-15 and GB-21 binding regions depicted by Deadman and discussed in the Lingshu, blends in with the fascia of the scalp and connects to the temporalis muscle. Excess Yang rises up and all of these muscles become dysfunctional and contribute to the building pain many people feel throughout the day. It can also contribute to the typical guarding posture that is seen with increased stress which is referred to as upper cross syndrome (a posture with a forward head and protraction of the scapula).

Fig.3: Image modified from Netter's Atlas of Human Anatomy. Sinew Channel interpretations by the author, Brian Lau, AP, C.SMA

Fig. 4: A dissection of the Superficial Back Line from Anatomy Trains. This image includes, from left to right, the plantar fascia, the fascia of the periosteum of the calcaneus, the Achilles tendon, the gastrocnemius and soleus, the hamstrings, the sacrotuberous ligament and posterior sacral ligaments, the erector spinae and suboccipitals, and the galea aponeurotica or the fascia of the skull. This is very similar to the myofascial of the main branch of the the Urinary Bladder sinew channel.

According to A Manual of Acupuncture, actions of BL-60 include:

• Clears heat and lowers yang
• Pacifies wind and leads down excess
• Activates the entire Bladder channel and alleviates pain
• Relaxes the sinews and strengthens the lumbar spine
• Promotes labor
  
  

This point, frequently combined with SI-3, serves as a great distal point to treat muscle tension headaches. This should be combined with proper needling of the motor points of the involved muscles and with treatment of the root of the disharmony (BL-60 treats the manifestation of Yang rising, so the practitioner should look to the pattern of excess and deficiency present with the patient, also). Many of the motor points of the muscles involved coincide with points that many acupuncturists already use, but the techniques and depth required to reach and affect muscle spindle relationships in the muscles is not always adequately preformed. The motor points are briefly described, but this type of information is best left to a classroom discussion. I will be teaching a foundation course in Sports Medicine Acupuncture for the neck and shoulder in Manhattan and in the Tampa Bay area in the new year (dates to be determined soon). For other classes and for Sports Medicine Acupuncture Certification (SMAC), you can look at the schedule on the SMA website.

• Upper trapezius – motor point 2 is GB-21; the muscle can be grasped and held away from the rib cage, and it can be needled from SJ-15 with the needle pointed up (away from the pleura) towards GB-21. Motor point 1 is about halfway between SI-15 and -16 and is needled (with the patient supine) through the anterior edge of the muscle from anterior to posterior and with a slightly upward direction. This is through the fibers in the region where the muscle turns from being horizontal to more vertical as it ascends the neck.
• 

  Suboccipitals – accessed from GB-20. Deadman describes palpation with the finger angled towards the nose (this goes into the suboccipital triangle), the finger angled towards the contralateral eye (this accesses the rectus capitis posterior major), or the finger angled towards Yintang (this angles the needle towards the attachments of muscles such as the trapezius to the occiput). We discuss some other needle angles and depth in Sports Medicine Acupuncture classes, but there are safety issues with the vertebral artery that makes a classroom setting much better for this discussion. 
• SCM – both heads can be needled from ST-9. However, it is imperative that the needle direction is lateral and that the needle ascends through the muscle of the SCM and does not travel medial to the muscle towards the carotid artery. Note: this is a different technique than ST-9 describe in A Manual of Acupuncture which discusses needling between the carotid and the thyroid cartilage. SJ-16, though not a motor point, is another reactive point that affects the clavicular head of the SCM. Palpate for the most reactive region and angle slightly anterior into the muscle.
• Another motor point to consider is the piriformis motor point. This point is halfway between BL-54 and BL-53. It is an empirical motor point and it eases pain in the BL-10 region (describing the method of treating below to affect above). And it can also reduce tension in the pectoralis minor (a midday-midnight [zi wu liu zhu] relationship) and assist in opening the chest and correcting the typical upper cross syndrome seen).
• Note: these motor points are listed in Motor Point Index - An Acupuncturist's Guide to Locating and Treating Motor Points.

It is worth noting that the sinew channels converge and that many of the muscles discussed are part of other channels and can be addressed via distal points on other channels. The trapezius, for instance, is a muscle where the Large Intestine, Sanjiao, and Gallbladder sinew channels also converge. There are many other instances where you would consider Shaoyang or Yangming point combinations for other type of disharmonies affecting this muscles; points such as GB-39 and LI-10 come to mind. The above discussion was specifically about a series of muscles related to muscle tension headaches and their dysfunction, which can be seen as a disharmony affecting the Urinary Bladder sinew channel.

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