Medial knee pain treatment using secondary vessels

by Robert Hayden

(n.b.: this article originally appeared in the North American Journal of Oriental Medicine) Introduction I was very interested to read the article in the last issue of NAJOM (#19) by Ms. Katano and Mr. Kuroiwa regarding trigger point therapy for medial knee pain. I am grateful for their clinical insights and I always believe that studying different viewpoints regarding treatment makes one a stronger practitioner. As far as my own practice goes, I am enamored of Channel theory and am constantly seeking ways to integrate classical concepts into a modern acupuncture practice. So I present a related but somewhat different rationale in treating medial knee pain. During my ve years in practice I have employed a couple of successful strategies in treating this problem. These are not treatments which were shown me directly by any teacher, rather they are adaptations of my own which I picked up from a variety of sources, mostly written. Both of them involve secondary vessels to some extent. Early on in my practice, I was forced to treat without needles due to the restrictions on non-physician acupuncture (these laws have since changed and my state, Illinois, licenses acupuncturists ). While I used a variety of methods, I became very interested in magnet therapy, especially as a way to treat acupuncture points. One of the few books around at the time was Matsumoto and Birch's Extraordinary Vessels (Paradigm Publications, 1986), which became the basis for much of my use of magnets. The treatment I used was based on the knee treatment of Osamu Ito that is described on pages 157-182 of that book. I'm certain that the way I used it is a vast oversimplication of the method used by Mr Ito (or Ms Matsumoto, for that matter), but the results were very encouraging and I still use the treatment from time to time. The method is this: North and South magnets of about 800 gauss are placed on

master/coupled points of the Extraordinary Vessels, and stronger magnets of about 3000 gauss are placed on the affected knee. The differentiation in EV pairs is very simple. For pressure pain on the medial side of the knee, K6/LU7 are used, for medial ST35, SP4/P6 are used, and for lateral ST35, GB41/TB5 are used. In all cases SI3/UB62 is used as well. For Yang vessel pairs the hand gets the north magnet, for Yin vessel pairs the foot gets the north magnet. Next, the north 3000 gauss magnet is placed at the site of the pressure pain used to diagnose the EV pairs, and the south 3000 gauss magnet is placed on another point (usually I would place it on the opposite side of the knee). Retain the magnets for 15-20 minutes. For best results, I would hook up the magnets on the knee to an electroacupuncture machine with the stimulation set to just the threshold of sensation. Alleviation of pain and inammation was often very rapid. More recently the method I use is a combination of meridian therapy with extraordinary vessel and channel sinew treatments. In Toyohari, the treatment of medial knee pain led Mr Miyawaki and Mr Fukushima to extend the Extraordinary Vessel point couplings to include a new pair: LV3 and HT5. Generally these will be treated with copper and zinc needles (PM shin) or pellets, and/or moxibustion. I was shown this method by Miyawaki sensei himself and I still do use it. However I never quite got the results I was looking for, and so I was forced to look elsewhere. I got some ideas for treatment from a few different places, two of them articles in NAJOM. In one(#10), Mr Masakazu Ikeda mentions using moxibustion at LV1 for muscle cramps due to Liver Excess. In another (#12), Mr Hiromi Matsumoto mentions one of his favorite techniques, burning grains of direct moxa at the insertion of a retained needle. In addition, the use of moxibustion combined with motion conceived by Yoshio Manaka has been inspiring along these lines as well. These inuences put together became the basis for the cases described in this article, which seem to me to be Channel Sinew treatments. Channel Sinews are described in Ling Shu 13. The basic pathology is hyper- or hypo-tonicity of the sinews, caused by cold and heat respectively, along the course of the Main Channel. I had already been taught a system of treatment for Channel

Sinews by my teacher in acupuncture school, John Pirog. This is his simplied version of a method developed by the great Vietnamese acupuncturist Nguyen Van Nghi. In this method, one needs to differentiate between excess and deciency in the Main Channels and their corresponding Channel Sinews. If one is excess, the other will be decient. The method then calls for local supercial treatment of indurations along the affected channel sinew combined with distal treatment of the affected main channel on a selected acupuncture point. See Pirog, The Practical Application of Meridian Style Acupuncture, Pacic View Press, 1996, pp 219-239) Ling Shu 13 mentions that the technique for treating Channel Sinews is a "re needle" or "heated needle", and that the technique should be quick. Some acupuncturists, for instance Yoshio Manaka (Yoshio Manaka, Chasing the Dragon's Tail, Paradigm Publications, 1995, pp 183-203), would use a thick needle heated red-hot over a ame and insert very quickly and supercially. As effective as this might be, I would think it rather frightening to some patients. I have in the past used a similar technique with a Tiger Warmer to some effect. Another technique recommended by Manaka is direct moxibustion, which I prefer. I am also fond of the technique spoken of by Mr Matsumoto, namely direct moxa combined with needling, which is a somewhat stronger stimulus than moxibustion alone. In an interpretation by Mr Ikeda, kyuutoushin is used for Cold in the Channel Sinews (ReiSu Handobukku, Ido no Nippon 1980, p108), which I'm sure works very well, however it is impractical in my clinic where the smoke must be kept to a minimum. Kyuutoushin also lacks the characteristic "zing" of tiny direct moxa, which seems to effectively release the contractile tissue. The channel sinews all begin at the jing-well point and run centripetally up the limbs to the head and trunk. They are said by some to bind at the Jing-River points. To me these two points become prime targets in any musculoskeletal treatment. The Liver Channel Sinew connects with all of the other channel sinews according to Ling Shu 13, therefore, LV1 becomes a very useful point in treating musculoskeletal disorders. I have used moxibustion on this point to treat spasm almost anywhere in the body. With these concepts in mind, I would like to discuss briey two recent cases from my practice which illustrates some variations on this approach.

Case #1 Male, 72 years old, semi-retired Main complaint is pain and stiffness on the medial aspect of the right thigh and knee. The pain is secondary to a gunshot wound suffered at the end of the Second World War. There is a scar from the entry wound at the location of LV8, and one from the exit wound about 4 cm inferior to the medial side of the popliteal fossa. The stiffness is primarily in the sartorius muscle of the right thigh. He walks with a cane, and his left foot turns outward about 30 degrees during locomotion in order to compensate for the restriction in his right leg. The abnormal stress on his left foot has caused some deformity of the bone structure in the medial side of the foot, primarily in the talus and navicular bones. The right thigh itself has quite a bit of blood stasis, in other words, the skin is dusky looking and somewhat dry, with general hardening of the tissues underneath. His abdomen is soft and lacking in tone overall, and his pulse is somewhat wiry, the kidney position feels weak and secondarily the liver is weak. He seems to be energetic, and his voice is deep and somewhat booming. He complains of frequent urination, and is being treated for prostate problems and hypertension. In addition, he is under the care of a naprapath (practitioner specializing in soft tissue manipulation). Treatment initially was complaint-centered, with a simple root treatment of Kidney deciency and some trigger-point needling along the sartorius muscle with #2 30mm needles. Moxibustion with stick moxa was added. Some inadvertant bloodletting occurred during the rst treatment in which the blood was thick and dark. Progress was quite slow, however. After 6 treatments I initiated moxibustion rst with kyuutenshi (moxa shields) and then using Junji Mizutani's mini-cautery method. In both cases, however, results seemed to be less than satisfactory. I began to add some liniment (Dr Shir's Liniment from Spring Wind Company) in the area where I had done the moxibustion. After a time, I decided to combine root treatment with needles and direct moxa at indurated points, and direct moxibustion at LV1, LV4, SP10. After that, direct moxibustion was applied to the Stomach and Gallbladder channels on the anterolateral aspect of the leg. Finally, the liniment was applied to selected points along the channel sinews. The result was the rst pain-free treatment yet.

However, the stiffness still remains, and while it is easier to loosen up the leg and stop the pain with the channel sinew treament, the chronicity of the problem suggests a deeper treatment, and so I have begun to include kikei treatments as well. Looking closer at his abdomen, there is some right rectus tension and weakness subumbilically. So I added H5/LV3 (extended kikei treatment according to Miyawaki, as indicated by the presence of medial knee pain and right rectus tension) and K6/LU7 (classically indicated for tension along the medial aspect of the leg). He has indicated that he is able to exercise longer now with reduced pain, though he still has a long way to go as the complaint is quite old and recalcitrant. Recently I have been combining the moxibustion with exercise similar to Sotai, and this seems to loosen the muscles much more effectively. I nd the point in his range of motion where the muscle "catches" (usually between 40-60 degrees) and bolster the knee to that point and have him straighten his leg and hold as I ignite the moxa, and have him release as I snuff out the moxa. I do this at two or three points three times each, near the proximal end of the sartorius. I cannot really claim any signicant victory in the handling of this case, as the results are not as dramatic as I had hoped. However, the course of treatment has forced me to do some research and modify my protocol, which is how one grows as a clinician. Case #2 Male, 56 years old His chief complaint is generalized myalgias and arthralgias due to physical factors. He is a police ofcer and martial artist. He also trains police dogs as a private business. He is six feet tall and weighs 290 lbs. He originally came for treament of lumbar pain for which he was self-treating with magnets and liniment. His knee pain was secondary. Both knees had been operated on, and the left knee has extensive scarring. He says he has no cartilage remaining in the left knee. Pulse was big and ooding or slippery. He has some irritable bowel symptoms (primarily loose stools with some abdominal pain). His work is very stressful physically and mentally. Originally I treated him for Liver deciency, but later switched to Spleen

deciency primary with Liver deciency secondary. The back pain was fairly easy to treat, and as it improved the complaint focused more on the knees. In addition, he had some pain in the rst toe of his right foot secondary to an old trauma. Examination of the knees revealed scarring at both medial ST35. Pressure pain was primarily on the Liver channel on the right knee and the Spleen channel on the left. The left knee in particular had a gritty feeling along the inferomedial aspect of the patella. At rst I did a sort of standard acupuncture knee treatment, bilateral ST35 and Heding, with #2 stainless needles. The ST35 in particular was very painful when needled, and the results were unsatisfactory. I had considered using the magnetic treatment described earlier but decided against it due to the fact that he had been self-treaing with magnets and there was no result. I decided to use less needling and more moxa, beginning with LV1 and SP1 bilaterally (I had already been using moxibustion on his right big toe for his pain there). Left SP5 and right LV4 were needled for the root treatment. Then painful points around the medial knee were treated with direct moxibustion, the right knee primarily between LV7 and LV9, the left knee between SP9 and SP10. This treatment was able to stop the pain almost completely in his right knee, though the left knee still had some residual pain. The following treatment I added two 3mm hinaishin at some very tender points along the inferomedial aspect of the left knee, which helped sugnicantly. The following visit he reported no pain all week. Conclusion The treatment of chronic pain is no simple feat; we as acupuncturists are reminded of this every day in our practices. I nd it both humbling and reassuring to reect on the wealth of knowledge contained in classical texts. It is humbling in that there is no end to study, and that I as an acupuncturist have only begun to lightly scratch the surface of available material, and reassuring in that the answers to most if not all of the challenges presented in the clinic are already laid out for us in some form, and all it takes is study and imagination to update the information into usable form for ourselves.