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.

---

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.

---