Poney Chiang: [00:01:10] Hi! Good afternoon! Welcome to today’s show. My name is Poney Chiang. I’m based in Toronto, Canada. I’m a researcher, practitioner, and educator
in acupuncture. I’d like to first begin by thanking the American
Acupuncture Council (https://acupuncturecouncil.com) for the opportunity to share my research with
you. Poney Chiang: Today my topic is entitled “Secrets
of the Three Sisters (Spleen-6).” The reason why I entitled this presentation
“Three Sisters” is because Spleen-6 in Chinese is called San Yin Jiao, which translates
to “Three Yin Crossing.” Yin is the feminine, hence the idea of the
Three Sisters. The image that you’re seeing on my title slide
is a painting by Renaissance master Raphael, and this is his version of the Three Graces. Poney Chiang: The learning objective for today
is to introduce you to a portion of the lower leg called the deep posterior compartment
and its relationship to Spleen-6. I’d like to share with you some of my thoughts
about the anatomy of the Channel Sinew system, and finally, talk to you about this understanding
of the anatomy of this region can be used clinically by changing the angles that we
use to needle Spleen-6 and what different results we can expect. Finally, I will end with some food for thought
on the possible neuroanatomical mechanisms for Spleen-6 amazing functions and indications. Poney Chiang: To begin with, you’re looking
at a cross-sectional image of the lower leg. The white bone over here is the tibia, and
this bone over here is the fibula. In purple, these three muscles, the Digitorum
Longus, Tibialis Posterior, and Flexor Hallucis Longus, comprise what is known as the deep
posterior compartment. So if there’s a deep posterior compartment,
there must be a superficial posterior compartment, and those are represented by the orange muscles,
the soleus and gastro. So imagine your calves, but beyond the gastro
and the soleus is the very deep muscle in your calves. Poney Chiang: Now let’s take a look at a slightly
different angle. This is the posterior to anterior view taken
from “Gray’s Anatomy.” And in this picture, the gastrocnemius muscle
and soleus muscle have been cut away. To review, very conveniently for us in a pre-colored
fashion, Flexor Digitorum Longus on the left, Tibialis Posterior, and then lastly, Flexor
Hallucis Longus on the very right over here. So I would just like you to take your time
to familiarize yourself with this image and get a sense of the medial to lateral relationship
of these muscles. That is to say Flexor Digitorum Longus is
relatively more medial and Flexor Hallucis Longus is more lateral, whereas Tibialis Posterior
is somewhere in between. Poney Chiang: In Western medical school or
Western anatomy, they have a convenient mnemonic called Tom, Dick, and Nervous Harry. The “T” in Tom refers to Tibialis Posterior,
the “D” in Dick refers to the “D” in Flexor Digitorum Longus, and the “N”
in Nervous … sometimes they have a version called “Bloody, Nervous Harry” … the
“Bloody” refers to the tibial artery in red over here, the “N” for Nervous in
yellow, and lastly the “H” in Harry refers to the “H” in Flexor Hallucis Longus. This mnemonic helps you remember the anterior
to posterior order of the tendons that make up the deep posterior compartment muscles
at the vicinity of the medial ankle. Poney Chiang: Now all that was a little introduction
to familiarize yourself with what’s going on the Spleen 6 region when we’re palpating
and needling this point. In this little preview of a figure from an
upcoming book, you can see that Spleen-6 sits on Muscle B, and if you look to follow the
legend at the bottom, Muscle B refers to the Flexor Digitorum Longus. But very close to Muscle B is another muscle
over here, and there’s another muscle behind it, and those are the three muscles, the deep
posterior compartment that we’ve just been talking about. And what you did not see on the earlier slide
is that that nerve that may have been the “Bloody, Nervous Harry” part, the “Nervous”
part of the mnemonic continues down and [inaudible 00:05:56] actually the bottom of the foot
and subsequently becomes what is called the medial and lateral plantar nerves. Poney Chiang: Now let’s do a little bit of
quick review of the Channel Sinew system because if we’re talking about the compartment muscles,
muscles and myofascia are very close to the traditional Chinese concept of Sinews, so
it’s a good idea to familiarize ourselves to try to see the connection between East
and West. These images are taken from YiTian Ni’s book,
“Navigating the Channel of Traditional Chinese Medicine,” and I’ve only cropped out the
lower extremity portion of these meridians. Starting on the left side, you can see the
Foot TaiYin or Spleen Sinew, and it starts at the big toe, as you would expect the primary
Channel to follow. The Foot ShaoYin, which is the Kidney Channel
Sinew, goes to the baby toe. That’s an important distinction to understand. Whichever muscles belong to the spleen should
control the big toe, whereas whichever muscles that belong to the kidney should be able to
control, at the very least, the small toe. And then for the Liver, Foot JueYin Sinew,
it is also supposed have some kind of effect on the big toe. Poney Chiang: What you’re looking at here
is a dissection done by Thomas Myers. He is the author of “Anatomy Trains.” In Myers’ work, he gives names to various
neuromuscular fascial kinetic chains, and one of these chains is called the Deep Front
Line, as you can see on the top right. And in this Deep Front Line, very interestingly
you see the “Tom, Dick, and Harry” muscles that I was talking about earlier. We have over here, even conveniently labeled,
Deep Posterior Compartment, which is comprised of three muscles: Flexor Digitorum Longus,
Tibialis Posterior, and Flexor Hallucis Longus. They’re all indicated by the red lines. What these muscles have in common is that
they normally are all part of the posterior compartment and connect with each other, they
are myofascially continuous with the Popliteus muscle, which is continuous with the knee
capsule, which then is continuous with the adductor groups, and from there, it goes to
[inaudible 00:08:24] torso. Poney Chiang: So, when I was trying to decode
the Channel Sinew classics and juxtaposing it with the work of Myers and, later on, my
own subsequent dissections that I’m looking forward to showing to you, it became clear
to me that these three muscles, the Posterior Compartment, must have something to do with
the Three Sisters or have to do with the three muscles of the Posterior Compartment because,
as you clearly can see, there is a crossing, there is a junction of these three muscles
going on. And in being flexors and deep inside the calf,
that is consistent with the idea of flexors being Yin and extensors being Yang, which
is a relatively common type of association that we have in Chinese medicine orthopedics. Poney Chiang: So these are the dissectional
images that my group have carried out, and once again we have the Popliteus muscle that
is shared by all of these three Spleen, Liver, and Kidney Sinews. Here you just see for the Spleen Sinew Channel,
because the Spleen Channel 3 says that it has to control the big toe, then logically
the muscle that’s assigned to that would have to be Flexor Hallucis Longus. Interestingly, some of the other big toe movers,
the intrinsic muscles, the foot, the abductor, and the Flexor Hallucis Brevis muscle … as
you surround the tendon of the Flexor Hallucis Longus muscle, so we were able to remove that
together as one long, beautiful, continuous chain. Poney Chiang: Over here on the Liver side,
we have Tibialis Posterior. The Tibialis Posterior tendon actually inserts
under the bottom of the foot, and unfortunately, I lack the imagination of figuring out what
myofascial continuity would allow that line to continue all the way to the big toe as
the Classics seem to be suggesting. However, two out of three ain’t bad. Poney Chiang: Over here on the Kidney side
of the picture, you’re looking at the muscle Flexor Digitorum Longus. The Flexor Digitorum Longus controls the second
through fifth toe, so if it controls the fifth toe, that would be consistent with the Kidney
Channel’s theory of where the Kidney meridians was controlled through the baby toe. Similar to the idea that the tendon of Flexor
Hallucis Longus is surrounded by some intrinsic big toe muscles. The tendons of the Flexor Digitorum Longus
is also surrounded by some intrinsic foot and toe muscles, so they are listed here for
your reference. Poney Chiang: So just a quick little summary
for what I’ve been describing thus far. The Deep Posterior Compartment, if you think
in terms of a Channel Sinew perspective, would include Spleen, Liver, and Kidney Sinew. And in terms of the work done by Thomas Myers,
the Deep Posterior Compartment obviously falls into what he calls the Deep Front Line, and
thus far we have some interesting food for thought, but perhaps the Deep Front Line is
the embodiment of the Three Yin Crossings, at least for the lower part of the leg. So what I would like to show you now, is some
series of videos to help validate and confirm this notion that Flexor Digitorum muscle would
fall under the Spleen Channel, Tibialis Posterior would fall under the Liver Sinew Channel,
and the Flexor Hallucis Longus would fall under the Kidney Channel Sinew. However, I put Foot ShaoYin, or “Kidney Channel
Sinew” in quotations, and I will explain why in a moment. It’s a very interesting deviation in the channel
theory for the Channel Sinews when it comes to Kidney Sinew that actually talks about
how the Kidney Channel Sinew partly takes a detour to become Bladder or Foot TaiYun
Channel Sinew. This is the justification that I will describe
a little bit further later as to why a point on the Bladder meridian, Bladder-59, is actually
part of the Kidney Sinew. Poney Chiang: We’ll start by looking at the
video for Spleen-6. Just standard insertion location of Spleen-6. If you apply a current to that, you’ll see
a very clean inflection of the second to fifth toe. If the big toe looks a little bit like flexing
to you, it’s because the fascia is very continuous so the big toe is coming in for a little ride,
but it’s not truly flexing. That’s the video one more time just to show
you Spleen-6 stimulating Flexor Digitorum Longus, which some authors [phonetic 00:13:32]
Warfo, have demonstrated it’s actually one of the motor points for this muscle. Poney Chiang: Now let’s take a look at Liver-6. I’m able to demonstrate on Liver-6, when needled
posteriorly behind the tibia, it’s able to re-accrue the tibia’s posterior muscle, whose
function is to invert the ankle. So here you see Liver-6 or Tibialis Posterior
being stimulated, and there’s a very clean inversion of the ankle. Poney Chiang: Now before I show you the Flexor
Hallucis Longus, let’s take a look at Ling Shu Chapter 13. This is actually the only chapter in the [Chinese
00:14:16] that talks about the past race of the Channel Sinew. All our knowledge about the Channel Sinew
comes from this one singular chapter, so here it is in part. Poney Chiang: Foot ShaoYin Sinew starts below
the small toe, so no surprise the Kidney starts in the small toe, and merge with the Foot
TaiYin Sinew, very curiously that the Kidney chapter paragraph would talk about merging
with Foot TaiYin. If you’ll entertain my idea that the Foot
TaiYin, or the Spleen, is part of the Flexor Digitorum, and so the Flexor Digitorum muscle
becomes the fifth toe, so you’d hear tell you about the Kidney channel actually merged
with the Spleen channel. So one could say that here’s the Kidney Channel
merging with what would become the Spleen Channel. It diagonally travels below the inner ankle
malleolus, so you can see that this was satisfied diagonally, “traveling under”, that’s the
intermediate malleolus, knotting at the heel … there’s a lot of interesting things happening
in over here in this heel region; these intersections can be interpreted as knotting. And finally you unite with the TaiYang and
the Bladder Sinew Channel. Poney Chiang: Earlier I mentioned that I was
going to show you video that shows you stimulating the bladder meridian, which is actually going
to stimulate his Flexor Hallucis Longus muscle. So, this appears that the Foot ShaoYin does
a little bit of a dance, and borrows the Spleen, borrows the Bladder, prior to continuing on
to the thigh. Poney Chiang: Let’s take a look at a stimulation
of Bladder-59, which is satisfied the TaiYin from the Kidney Channel Sinew description. And then, when you apply a current to Bladder-59,
you get a very nice, clean flexion of the big toe. Once again, the surrounding toes, adjacent
toes, are simply coming for a ride because the close fascial connections. If you were to actually apply resistance against
those toes, they wouldn’t really be pushing up. Poney Chiang: Now let’s take a look at some
of the pathologies associated with these muscles. These images are taken from Travell and Simons. And I’d like to start on the right image over
here. You’ll see the trigger point over here, for
Flexor Hallucis Longus. Looks a lot like Bladder-59. So if you have a trigger point in that region,
you can actually feel pain in the big toe, no surprises, because that’s the function
of Flexor Hallucis Longus. But it’s interesting to notice, when you have
trigger points, or [phonetic 00:17:13] Asher points, when, in Flexor Digitorum Longus and
Tibialis Posterior, as these two images over here shows, you can actually have pain in
the Plantar Aspect. So this is the important differential diagnosis
to keep in mind when somebody presents with possible [phonetic 00:17:31] di-fasciitis
type of distribution of pain. Poney Chiang: Now I’m going to talk a little
bit about the angulation of the needling. If you focus your attention on the video on
the left, you’re seeing just stimulation of Spleen-6, which gives you re-accruement of
the Flexor Digitorum Longus which flexes the second to fifth toe. And this is achieved through very shallow
needling. Look at the length of the needle that’s exposed
here. Poney Chiang: Now if you were to plunge the
needle in deeper, to achieve deeper needling, what you’d get is what I call a “two for the
price of one”. You not only get flexion of the second to
fifth toe, you get flexion of the big toe through stimulation of Flexor Hallucis Longus. Why? Because the origin of Flexor Hallucis Longus
is actually on the fibula. So as you needle deeper, more laterally, you
approach the fibula, you can stimulate those muscles with one needle. Poney Chiang: Now what happens if you were
to angle Spleen-6 anteriorly? Towards the Posterior Aspect of a tibia bone. Then that puts you in the neighborhood of
Tibialis Posterior. Then you would expect a very clean inversion
of the ankle. Poney Chiang: Now the very following video
I’d like to show you on the right is simply putting everything we’ve seen together. If you needle deep and anteriorly, what would
you expect? Well, you would expect all three of the Sisters,
or all three of the Tom-Dick-Harry, to be recruited. And so you will see, flexion of the toes followed
by inversion. Flexion of one to fifth toe, followed by inversion. That’s the inversion of the ankle. Flexion finishing up with the inversion. Poney Chiang: So this slide here summarizeS
the angulation and the target that is being stimulated when we needle Stomach-36. The only thing that I have yet to describe
is what happens if you were to needle the … angle the needle posteriorly towards the
Achilles tendon. If you were to do that, you end up stimulating
the tibial nerve. And this is actually a technique that is used
in a type of neural rehab, particularly a style created by Dr. Shi Xue Ming XingNaoKaiQiao,
a work in the brain opening orifice. Some of you might have seen the movie 9000
Needles, where they went to Tianjin for hospital, for neural rehab, that’s the style of acupuncture
that was done in that hospital. So it would be trying to stimulate the tibial
nerve and get a firing sensation, an electrical burning sensation in the Plantar Aspect of
the foot. Poney Chiang: SP-6 is not … is very, very
complex, depending on what is it do you need clinically. You need to think about the depth and incubation
of this point. Poney Chiang: I’d like to finish up by just
talking a little bit about the function of Spleen-6. Spleen-6, did you know, actually has an optional
name called Xia San Li. And this is a mirroring of Zu San Li, which
is Stomach-36, which I talked about in my previous Facebook show. In TCM, Stomach-36 and Spleen-6 are often
used as a pair, especially for [phonetic 00:21:18] tonifying blood. So it’s interesting to know that perhaps that
combination is informed by the idea that Stomach-36 is called Zu San Li, “Like Three Miles”, while
Spleen-6 has an option to be called “Xia San Li”, “Lower Three Miles”, so that they share
the three miles in common. But also, is it possible, that when you talk
about the “Three Miles”, you’re not just talking about three miles? Because “miles”, in Chinese, also means “inside”;
there’s three things inside. Perhaps they’re talking about the Three Sisters. Perhaps that’s the indication that it’s a
alternate way of looking at Three Yin intersection. Poney Chiang: Now this point is famous for
the ability to treat menstrual, reproductive, and urinary problems, and the actions indications
which has been passed on to us, which I won’t belabor, I’ve listed here for your reference,
also suggests that it has some sort of intestinal function as well. So how can we make sense of this, based on
some of the new anatomy that I’ve been talking about so far? Poney Chiang: To understand this, we need
to review the innervation of the organs through the autonomic nervous system. On the left, we have the Sympathetic, which
is primarily thoracolumbar. On the right, you have this Parasympathetic
Nervous System, which is primarily cranial ad sacral.and if you were to focus on the
sacral component, S2,3,4, you’ll see that, starting for S2, it innervates the large intestine,
particularly the descending colon, it innervates the rectum, it innervates the bladder, it
innervates the genitalia as well. Poney Chiang: So, as it turns out, it should
be of no surprise, that Flexor Digitorum Longus muscle receives innervation from the tibial
nerve via L5-S2. So what that means is that when you needle
Stomach … Sorry, Spleen-6, you are indirectly stimulating the S2 segment, which can provide
a parasympathetic innervation to the pelvic organs that I would describe in a previous
slide. And therefore, when you stimulate Stomach-36,
you are creating a autonomic modulating effect on all the organs that are innervated by the
S2 segment and also below those segments. Poney Chiang: So, with that, I hope that gives
you a little bit of interesting food for thought. Hopefully you will never look at Spleen-6
the same way again. I thank you much for your attention and please
don’t forget to join us next week. Our next co-host is Virginia Doran. If you like this video, please don’t forget
to like it, to share it, and to post any comments. I’ll be happy to answer any questions that
you may have. Thank you very much.

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