The Gluteal Muscles

The gluteal region is important for treating pain in the back, hip, and lower limb. Although there are only two HAs—H14 superior cluneal and H16 inferior gluteal—in this region, additional SAs will appear around these two HAs. Practitioners should be very familiar with the bony landmarks and surface markings of this region.

The iliac crest extends from the anterior superior iliac spine to the posterior superior iliac spine. Between the left and right posterior iliac spines is the posterior aspect of the sacrum. The spinous process of L4 vertebra is at the level of the summit of the posterior iliac crest. The spinous process of S2 is just between the left and right posterior superior iliac spine.

The gluteal muscles include (1) the three large glutei (gluteus maximus, medius, and minimus) and (2) four deeper small muscles (piriformis, obturator internus, gemelli, and quadratus femoris) (Figure 11-5). The three large glutei are extensors and abductors of the thigh at the hip joint and they also stabilize the pelvis. The small muscles are lateral rotators of the thigh at the hip joint and stabilize the femoral head in the acetabulum. Table 11-1 shows a summary of the muscles of the gluteal region.

Figure 11-5 The gluteal muscles.

(From Jenkins D: Hollinshead’s functional anatomy of the limbs and back, ed 8, Philadelphia, 2002, WB Saunders, p 316.)

The Thigh Muscles

The large, powerful thigh muscles are organized into three groups: anterior, medial, and posterior. The three groups are separated by fascial intermuscular septa.

The Anterior Thigh Muscles (Flexor Group)

The major muscles of the anterior group are iliopsoas, tensor fasciae latae, sartorius, and quadriceps femoris (Figure 11-6). They are accessible to acupuncture needling. Their anatomic function is summarized in Table 11-2.

Figure 11-6 Anterior thigh muscles (flexors).

(From Jenkins D: Hollinshead’s functional anatomy of the limbs and back, ed 8, Philadelphia, 2002, WB Saunders, p 317.)

The Medial Thigh Muscles (Adductor Group)

The medial thigh muscles (the pectineus, adductor longus, adductor brevis, adductor magnus, gracilis, and obturator externus) are adductors of the thigh (Figure 11-7). All of these muscles are supplied by the obturator nerve (L2, L3, and L4) except pectineus, which is supplied by the femoral nerve (L2 and L3). The “hamstring” part of the adductor magnus is supplied by the sciatic nerve (L4).

Figure 11-7 The adductor muscles of the thigh.

(From Jenkins D: Hollinshead’s functional anatomy of the limbs and back, ed 8, Philadelphia, 2002, WB Saunders, p 318.)

The Posterior Thigh Muscles (The Hamstrings)

Three large muscles (semitendinosus, semimembranosus, and biceps femoris) of the posterior aspect are collectively known as the hamstring muscles (Figure 11-8). These muscles have the same origin on the ischial tuberosity, but the short head of the biceps femoris has an additional origin on the shaft of the femur. These long muscles extend from the hip joint and across the knee joint so they are all extensors of the thigh and flexors of the leg. In addition, they are all supplied by the same sciatic nerve.

Figure 11-8 The hamstrings: the flexors of the leg.

(From Jenkins D: Hollinshead’s functional anatomy of the limbs and back, ed 8, Philadelphia, 2002, WB Saunders, p 320.)

Tight hamstring muscles can cause gluteal and back problems because the hamstrings restrict spinal flexion.

The topography of the three groups of thigh muscles is shown in Figure 11-9.

Figure 11-9 Transverse section through the thigh to show the topography of the three groups of thigh muscles.

(From Gosling J, Harris P, Whitmore I, Willan P: Human anatomy: color atlas and text, ed 4, Edinburgh, 2002, Mosby, p 233.)

Adductor Muscle Strain

Adductor muscle strain is a common muscle problem that is often overlooked by both healthcare practitioners and patients. Ninety percent of patients with lower back or thigh pain have strained adductor muscles.

When treating patients with lower back disorder or pain of the lower limb, adductor muscles should be palpated and their tender acupoints should be needled.

The Leg Muscles

Anatomically and functionally the leg muscles are divided into three compartments by (1) the tibia, the fibula, and the interosseous membrane between them and (2) the anterior and posterior crural intermuscular septa (Figure 11-10): the anterior, lateral, and posterior. The muscles in the same compartment perform similar functions and share the same nerve and blood supply.

Figure 11-10 Transverse section of the leg to show the three compartments of the leg muscles. Please note that the “small” lateral compartment is surrounded by the fibula and two intermuscular septa.

(From Gosling J, Harris P, Whitmore I, Willan P: Human anatomy: color atlas and text, ed 4, Edinburgh, 2002, Mosby, p 247.)

The anterior compartment is between the tibia and the anterior crural septum. The muscles of this compartment function as extensors of the toes and effect dorsiflexion of the ankle joint (Figure 11-11).

Figure 11-11 The anterior muscles of the leg.

(From Jenkins D: Hollinshead’s functional anatomy of the limbs and back, ed 8, Philadelphia, 2002, WB Saunders, p 339.)

The lateral compartment is surrounded by the lateral aspect of the fibula and anterior and posterior crural intermuscular septa. The two muscles in this compartment are responsible for plantar flexion and eversion of the foot (Figure 11-12).

Figure 11-12 The lateral muscles of the leg.

(From Jenkins D: Hollinshead’s functional anatomy of the limbs and back, ed 8, Philadelphia, 2002, WB Saunders, p 338.)

The posterior compartment contains both superficial and deep muscles (Figure 11-13). The three powerful superficial calf muscles affect plantar flexion of the foot. These large muscles support and move the weight of the body. Four smaller deep muscles of the posterior compartment act on the knee joint (popliteus) and ankle and foot joints. These four smaller muscles are not important in acupuncture therapy and therefore are not listed in Table 11-3.

Figure 11-13 The posterior muscles of the leg.

(From Jenkins D: Hollinshead’s functional anatomy of the limbs and back, ed 8, Philadelphia, 2002, WB Saunders, p 333.)

The Superior Cluneal Nerves

The superior cluneal nerves are branches of the dorsal rami of L1, L2, and L3. They emerge from the deep fascia just superior to the iliac crest and innervate the skin on the superior two thirds of the gluteal region (buttocks). An important homeostatic acupoint, H14 superior cluneal, is formed at the location where the nerves penetrate the deep fascia. Most patients feel tenderness or even pain upon palpation at H14. In patients with chronic lower back or leg pain, the pain may spread over the entire skin area that is supplied by the superior cluneal nerves. In such cases, H14 and adjacent areas should be needled together.

The Sciatic Nerve and Its Terminal Branches: the Tibial, Common Fibular (Peroneal), and Sural Nerves

We have discussed this nerve in Chapter 5 and here we emphasize its relation to HAs and pain in the lower limb. The sciatic nerve is the largest nerve in the body. The ventral rami of L4, L5, S1, S2, and S3 converge at the inferior border of the piriformis muscle to form the sciatic nerve (Figure 11-14). Structurally the sciatic nerve consists of two nerves: the tibial and the common fibular (peroneal) nerve. The sciatic nerve leaves the pelvis through the greater sciatic foramen of the hip bone and enters the gluteal region inferior to the piriformis muscle (Figure 11-15). It runs deep below the gluteus maximus muscle, and does not supply any structure there. The sciatic nerve continues down the thigh covered by the hamstring muscles and ends in the lower third of the thigh, at which point the tibial and the common fibular (peroneal) nerves separate from each other.

Figure 11-14 Sciatic nerve and the piriformis muscle.

(From Jenkins D: Hollinshead’s functional anatomy of the limbs and back, ed 8, Philadelphia, 2002, WB Saunders, p 300.)

Figure 11-15 The distribution of the sciatic nerve.

(From Jenkins D: Hollinshead’s functional anatomy of the limbs and back, ed 8, Philadelphia, 2002, WB Saunders, p 259.)

The tibial nerve, the larger medial branch, descends through the center of the popliteal fossa and sends three articular branches to the knee joint. In the popliteal fossa, acupoint H11 lateral/medial popliteal is palpable. Tender acupoint H11 appears either laterally or medially in different patients. The relationship between H11 and the tibial or fibular nerves is not clear yet.

In the leg region, the tibial nerve supplies the gastrocnemius, plantaris, popliteus, and soleus muscles. In the lower medial aspect of the tibia, the tibial nerve runs very close to the skin, and about 5 to 8 cm above the medial malleolus it forms an important HA, H6 tibial. From this HA, the tibial nerve continues to descend to the plantar aspect of the foot and divides into two branches, the medial and lateral plantar nerve.

The common fibular (peroneal) nerve arises from the sciatic nerve just above the popliteal fossa as a lateral branch. It descends to the lateral aspect of the leg and winds around the lateral surface of the head of the fibula where acupoint H24 common fibular (peroneal) is formed. The common fibular (peroneal) nerve enters the lateral compartment of the leg and divides into two cutaneous branches: the superficial and the deep fibular (peroneal) nerves. The superficial fibular (peroneal) nerve innervates the anterior aspect of the skin in the lower leg and ankle area. The deep fibular (peroneal) nerve descends down to the foot and becomes the cutaneous nerve at a point approximately 2 cm proximal to the web between the great and second toes. Here acupoint H5 deep fibular (peroneal) is formed.

In the upper region of the leg, both the tibial and the common peroneal nerve send branches to unite and form the sural nerve, which runs down to the lateral side of the leg through the lateral Achilles tendon all the way to the little toe. Acupoint H10 sural is formed between the two bellies of the gastrocnemius muscle.

Femoral and Saphenous Nerve

The femoral nerve is the largest nerve formed in the abdomen by the branches of the lumbar plexus (L2, L3, and L4) (Figure 11-16). In the thigh area, the femoral nerve gives off muscular branches to supply the anterior thigh muscles. When affected by injury or overuse, these muscles become tender or painful and form SAs.

Figure 11-16 The femoral and saphenous nerves of the right thigh.

(From Jenkins D: Hollinshead’s functional anatomy of the limbs and back, ed 8, Philadelphia, 2002, WB Saunders, p 289.)

The cutaneous branch of the femoral nerve, called the saphenous nerve, runs down to the medial aspect of the knee. It passes anteroinferiorly to supply the skin of the anterior and medial aspect of the knee, leg, and foot. As the saphenous nerve pierces the deep fascia on the medial side of the knee just below the medial condyle of the tibia, an important HA, H4 saphenous, is formed. You may remember that H4 saphenous and H1 deep radial are used as diagnostic acupoints for quantitative evaluation of acupuncture patients.

Obturator Nerve

The obturator nerve is derived from the same spinal segments as the femoral nerve (L2, L3, and L4). The obturator nerve leaves the pelvis through the obturator foramen and enters the thigh to supply the adductor muscles (Figure 11-17).

Figure 11-17 The obturator nerve.

(From Jenkins D: Hollinshead’s functional anatomy of the limbs and back, ed 8, Philadelphia, 2002, WB Saunders, p 292.)

The adductor muscles are involved in many painful conditions of the thigh, especially in athletic persons, but are often ignored by healthcare professionals. Whenever treating patients with leg pain, particularly pain in the hamstring muscles, the adductor muscles should be carefully palpated and the tender points in the adductor muscles should be needled.

The Hip Joint

The human hip joint is a well-constructed multiaxial joint that has the function of bearing weight, maintaining posture, and facilitating walking. The hip joint is a closely fitting ball-and-socket synovial joint in which the globular head of the femur articulates with the cup-like acetabulum of the hip bone (see Figure 11-1). However, the movement of the femur is limited by the close articular surfaces and strong ligaments of the hip joint. In the case of the shoulder, dislocation of the joints will occur if they are not stabilized by the surrounding muscles. In contrast, the hip joint is able to support the body weight on the head of the femur with little or no muscular energy.

The head of the femur is completely covered by articular cartilage except its small central recess (called fovea). In the acetabulum, only the weight-bearing part of the surface of the ilium, the lunate articular surface, is covered by cartilage.

The joints are enclosed and strengthened by a thick fibrous capsule and ligaments that come from different directions. The ligaments are named according to their anatomic origin: iliofemoral, pubofemoral, and ischiofemoral.

The hip joint permits flexion-extension, abduction-adduction, lateral and medial rotation, and circumduction. Functionally the flexor group and abductor group are the most important muscles in our daily activities. When we walk, for example, the left flexors of the hip raise the thigh as it is swung forward during the gait cycle, while the right abductors stabilize the pelvis during the time that the body is supported only on the right leg.

Understanding the nerve supply to the hip joint helps us to treat the nerve(s) associated with hip pain (Table 11-4). The articular branches of the femoral nerve supply the anterior part of the joint capsule and the iliofemoral ligament. The obturator nerve sends branches to the anteroinferior part of the joint and the medial portion of the capsule. The superolateral aspect of the capsule is innervated by the superior gluteal nerve. The sciatic nerve is believed to supply the posterior portion of the capsule.

General Considerations of Hip Pain Pathology

Hip pain and limping are the chief complaints presented by patients in an acupuncture clinic.

Hip joints sustain enormous stress in daily activities such as walking. For example, during walking, when the left limb is lifted, the right hip joint is subjected to compression forces several times greater than the body weight (Figure 11-18). A person does not feel this huge force of compression because there are no nerves in the articular cartilage. When the cartilage is eroded by degenerative disease or aging, the bony head of the femur, which is richly supplied by sensory nerves, produces pain during every step because of this compression force. As a person ages, the articular cartilage becomes thinner and hip pain may gradually develop.

Figure 11-18 The mechanics of the hip abductors. During walking when one leg is lefted, the hip abductors need to exert force at least 3 times more than the body weight to maintain body balance.

(Redrawn after Cornelius Rosse: Hollinshead’s textbook of anatomy, Philadelphia, 1997, Lippincott-Raven.)

Inflammation of the capsule and/or the ligaments is the major source of hip pain. Soft tissue inflammation of the hip joint is caused by the following conditions:

Usually hip pain is felt in the groin region, or the pain may be referred to the medial side of the thigh supplied by the obturator nerve. Some hip problems are only felt as knee pain.

If afferent nerves of other organs also originate from lumbar segments of the spinal cord, these organs, if diseased, can refer pain to the hip joint. Such referred pain usually appears in the gluteal region and radiates down the back of the thigh.

Blockage of the internal iliac artery in the pelvis results in ischemia of the gluteal muscles and may cause pain in the buttocks during walking or running (intermittent claudication).

A limp without pain is usually caused by mechanical abnormalities such as a shortened leg, muscle contracture, or muscle paralysis. Careful palpation of the hip, thigh, and leg of the affected limb will reveal that the muscles harbor some tender points. Needling of these tender points relaxes the shortened muscles and helps improve the discrepancy between the two legs.

Trochanteric Bursitis (Iliotibial Band Syndrome)

The iliotibial band (IT band) is a sheet of specialized fascia extending from the iliac crest to the lateral plateau of the tibia. In the region just over the greater trochanter the IT band is separated from the bone by a bursa. The hip abductor (tensor fascia lata) and the extensor (gluteus maximus) insert into the fascia. During the gait cycle, both muscles exert a great tensile force on the IT band and the bone below. This tension can cause inflammation of the bursa (bursitis) between the IT band and the greater trochanter.

In some cases, trochanteric bursitis is caused by an imbalance of the muscles. For example, tight abductor muscles of the right thigh may cause the pelvis to tilt to the right and cause the left iliac crest to be higher than normal. This results in a tightened fascia lata stretching over the left greater trochanter and leads to bursitis.

The pain pattern may vary from patient to patient. The common feature is the tenderness over the bursa. A patient may have such severe pain that he or she is not able to lie on the affected side or sit comfortably. Usually the patient feels pain during activity. The pain can be local, right over the greater trochanter, in the iliac crest, or in the knee region.

Some trochanteric bursitis can be treated very effectively by acupuncture because needling relaxes muscles, activates local antiinflammatory reaction, and encourages tissue regeneration. The muscles and IT bands on both sides of the body should be carefully palpated and the tender points should be needled. In addition, the lower back muscles should be examined and needled to ensure the balanced alignment of the pelvis.

Meralgia Paresthetica (Neuralgia of the Lateral Femoral Cutaneous Nerve)

The lateral femoral cutaneous nerve supplies the skin of the lateral thigh. Injury to this nerve causes numbness, hyperesthesia (increased sensitivity to stimuli), and hypoesthesia (decreased sensitivity to stimuli, particularly to touch).

In general, symptoms of numbness are more resistant to acupuncture therapy than symptoms of pain. However, acupuncture helps patients with meralgia paresthetica. We believe that acupuncture needling improves nutrition and oxygen supply to the skin and this may slow down the process of tissue degeneration.

Piriformis Syndrome

The symptoms of piriformis syndrome include sciatica and deep pain in the buttocks, especially pain elicited by flexion, adduction, and internal rotation of the thigh.

The exact cause underlying the piriformis syndrome is unknown, but many healthcare professionals believe that the piriformis muscle compresses the sciatic nerve where the nerve passes under or through the belly of the piriformis muscle.¹

We have successfully treated patients who were diagnosed with piriformis syndrome by medical doctors. The most important acupoint is H16 inferior gluteal because it is just on top of the piriformis muscle. A long needle is needed to reach all the way down to the hip bone. This needling relaxes the piriformis muscle, improves blood supply to the muscle, and reduces inflammation (see Chapter 3).

Degenerative Arthritis

Degenerative arthritis is the most common painful and disabling condition of the hip joint. It is generally believed that the pain is caused by (1) degenerative changes in the hip cartilage, causing the bone tissue to directly sustain the huge force of compression and (2) abnormal articular orientation between the head of the femur and the surface of the acetabulum. As noted in the above discussion of hip pathology, the acetabulum is only incompletely covered by cartilage, so the cartilaged surface of the head of the femur must articulate with the cartilaged surface of the acetabulum of the hip bone. During walking, if a person’s knees come too close together or too far apart, the orientation of the head of the femur in the joints will change, resulting in hip pain because the heads of the femurs will articulate with the noncartilaged surface of the acetabulum.

Mechanical stress from excessive jogging or running, or repetitive impulsive compression, is believed to be a possible cause of later degenerative changes.

Needling can directly relax the muscles and other soft tissues such as fascia, capsule, or ligaments by breaking the contracture of the muscle fibers and the connective tissues. Thus, acupuncture helps to relax and desensitize the muscles and can reduce pain sensations and thus facilitate posture correction. Since needling is able to improve blood circulation and correct hypoxia, acupuncture also will slow down the degenerative process. However, if the hip pain is caused by damaged cartilage surfaces of the femur and/or acetabulum, acupuncture needling is not effective in relieving the pain, but is still helpful in slowing down degeneration of the soft tissues such as muscles.

Stress Fracture

Strictly speaking, a stress fracture is beyond the field of acupuncture therapy. However, patients with stress fracture, especially athletes, do come to acupuncture clinics for treatment and practitioners should understand the nature of this condition and be able to handle these patients correctly.

A stress fracture is an acute repetitive injury without dramatic trauma history. It is caused by fatigue of the bone during a repetitive activity such as running, or by osteoporosis in elderly patients. A stress fracture may occur in amenorrheic female athletes because of their diminished bone density. Stress fractures may occur in different portions of the lower limb, but the most common site for stress fracture in the hip area is the femoral neck. Stress fractures may be classified as incomplete or complete. Incomplete fractures may not be visible on radiographs and a bone scan or magnetic resonance imaging (MRI) is needed to confirm or rule out the condition.

The possibility of a stress fracture should always be considered if an athlete develops an acute hip problem such as a limp, stiffness in the hip or leg, or pain during weight-bearing or vigorous physical activities.

In cases of stress fracture, acupuncture can be used as a supplementary therapy to reduce muscle and periosteum pain and to promote bone healing.

The Knee Joint

Everyday activities such as walking, climbing stairs, or rising from a chair, as well as athletic exercises such as jumping and running, depend on the functional integrity of the muscles of the thigh, as well as on soft tissues such as the capsules, ligaments, menisci, and articular cartilage of the knee.

Any diseases or trauma to the bone or soft tissues can significantly impair the knee’s ability to perform basic motions.

Knee pain is usually caused by:

The Two Joints and Three Articulation Compartments of the Knee

The knee is the largest joint in the body and consists of three bones: the femur, tibia, and patella. The knee joint proper is formed by two joints: the femorotibial and the patellofemoral within the common cavity (Figure 11-19). The joint complex consists of three articulation compartments:

Figure 11-19 The principal structure of the interior of the knee joint. From front (A) and from above (B) with the femur removed. Menisci are shown in dark. A transverse ligament (marked with*) may be present, attaching to both the medial and lateral menisci.

(From Jenkins D: Hollinshead’s functional anatomy of the limbs and back, ed 8, Philadelphia, 2002, WB Saunders, p 277.)

The articular surfaces are covered by cartilage. The medial and lateral compartments are interposed by fibrocartilaginous menisci between the articular surfaces. Disease processes or injury to any of the three compartments will cause pain and deficiency of function in the knee.

The patella is located within the quadriceps tendon and enhances the extension force of the quadriceps muscle. The patella and its surrounding soft tissues, such as the patellar ligament and bursae, are often a source of knee pain. The quadriceps muscle that is inserted in the patella has five bellies (Table 11-5). Any injury to one of the five bellies will misalign the five extension forces exerted on the patellar ligament and will cause knee pain.

All of the structures of the knee, including skin, capsule, ligaments, muscles, and bursae, are innervated by the femoral and obturator nerves with a contribution from the sciatic nerve.

The stability of the knee is maintained by ligaments, muscles, tendons, menisci, and the joint capsule. The bony architecture of the knee depends on the soft tissues for its stability, making the knee the most vulnerable structure in the body to soft tissue injury, and the resulting pain and functional impairment.

From the perspective of acupuncture therapy, this chapter focuses on knee pain caused by or related to soft tissues such as muscles, ligaments, the capsule, and bursae.

Muscles Responsible for Knee Movement

The muscles and their functions are summarized in Table 11-5. The extensor quadriceps femoris is composed of four heads. The rectus femoris originates from the anterior iliac spine, and the other three heads come from the shaft of the femur. All of the muscles share the same tendon that attaches to the tibial tubercle.

The flexors of the knee originate from the ischial tuberosity and are all posterior thigh muscles. The semitendinosus muscle descends medially and joins the sartorius and gracilis muscles to form a common tendon, which is joined by the semimembranosus. This common tendon, the pes anserinus, moves the medial meniscus.

When treating knee pain, these muscles together with the thigh abductor and adductor muscles should be carefully palpated to find the SAs.

The muscles are the most dynamic elements among the possible causes of knee pain. They are the movers of the knee joint and are indispensable components of the knee, and thus they are liable to injuries from repetitive motion or stress due to overuse. Our experience in treating knee pain shows that most of the pain that is related to soft tissue injuries derives from disorders of the muscle, unless the pain is caused directly by physical trauma to the knee joint. If the muscles are tired or injured, they become tight and resistant to further motion. If they are forced to move under such conditions, it causes overstretching of other soft tissues of the knee such as the ligaments, capsule, bursae, and meniscus, which results in soft tissue inflammation.

If knee problems such as arthritis, infection, or physical trauma are the primary causes of knee pain, they will cause muscle pain because (1) chemical stimuli originate from the diseases and (2) diseased joints and inflamed soft tissues prevent or inhibit the normal coordination of the movement of the muscles, which soon causes fatigue in the muscles.

In acupuncture practice, careful palpation of the muscles and proper needling will help to locate and dissolve muscle tender points by relaxing the muscles, removing the mechanical and chemical stress from the knee structures, and providing a physiologic healing environment with the increased nutrition and supply of oxygen that comes from improved circulation. Acupuncture treatments will help heal some knee disorders regardless of whether the pain is caused by injury to the knee or by a muscular disorder.

Four ligaments play essential roles in stabilizing the knee joint. The inner layer of the medial collateral ligament (MCL) connects with the medial meniscus and the capsule. The MCL prevents valgus rotation (bending or twisting medially at the joint). The lateral collateral ligament (LCL) passes the lateral epicondyle of the femur to the fibular head. The LCL has no connection with the lateral meniscus but receives fibers from other adjacent ligaments to strengthen the knee laterally.

The two cruciate ligaments are named according to their attachment to the tibia. The anterior cruciate ligament (ACL) originates from the anterior tibial plateau and runs upward and backward to attach to the medial aspect of the lateral femoral condyle. The ACL prevents anterior translation (shear) motion of the tibia on the femur. The stronger posterior cruciate ligament (PCL) runs behind the ACL from the posterior tibial plateau to the anterior part of the lateral surface of the medial condyle of the femur. The PCL restrains posterior translation (shear) motion of the tibia on the femur. The two cruciate ligaments together restrict excessive rotation of the leg.

Of the four ligaments, the MCL is the one most often injured during sports-related activities. The medial meniscus is also vulnerable to mechanical injury as it attaches to the MCL. In the early phases of this type of injury, a patient may feel knee weakness rather than pain. Tender areas can be palpated in the MCL area. Needling this ligament and the painful muscles associated with the injury improves blood circulation and reduces inflammation, thus relieving tenderness and pain, but recovery of function may take longer because the healing of ligament tissue is much slower than that of muscles. The LCL, ACL, PCL, joint cartilage, and joint capsule may also be damaged. Injuries to the LCL are less common but more threatening because they may cause damage to the fibular (peroneal) nerve.

Patients should be referred to specialists for further medical evaluation if severe tearing of the ligaments or meniscus is suspected.

Bursae of the Knee

The knee joint has several bursae to minimize the friction that occurs wherever skin, muscle, or tendon rub against the bone. Inflamed or swollen bursae are frequently the source of knee pain, and acupuncture practitioners should be sure to know the locations of the most important bursae for this reason.

There are four bursae anterior to the knee:

There are five bursae on the medial aspect between the tendons and the muscles. Four bursae are located on the lateral aspect between the tendons and the muscles. Two posterior bursae are associated with the tendons of the posterior muscles of the posterior knee. All of these bursae may contribute to knee pain if irritated or inflamed.

Acupuncture needling into the bursae relaxes the muscles that sandwich the bursa and improves blood circulation to the muscles and bursa, which helps to reduce inflammation, swelling, and pain. If the patient is suffering from an infectious disease, needling the joint should be avoided to prevent spreading the infection. In such a case, needling the thigh and leg muscles and HAs in other parts of the body should be done to control the immune system and bring the local infection under control.

Anterior Knee Pain

Anterior knee pain, or the pain in the patellofemoral articulation, is one of the most prevalent types of knee pain. Usually it is caused by degeneration of the cartilage of the patella, but it also happens that disorders of the quadriceps muscle can break the coordination among its five bellies during extension and cause misalignment of the patella, producing pain.

Patellar tendinitis is a common symptom of anterior knee pain. It is usually an overuse injury caused by repetitive motions such as running, jumping, and climbing in sports such as basketball, tennis, soccer, and weightlifting.

Acupuncture needling relaxes the muscles, increases blood circulation, and reduces the inflammation and swelling of the muscles, ligament, capsule, and bursae, which help to restore the normal function of patellofemoral articulation. After the stresses of swelling and inflammation are removed, the degeneration process will slow down and partial or even complete recovery of function can be expected, depending on the extent to which the causes of the pain are inherently healable.

The Ankle Joint (Talocrural Joint)

The ankle joint articulates the leg with the foot. The ankle comprises three bones and two articulations. The distal ends of the tibia and fibula form the tibiofibular joint. The inferior ends of the tibia and fibula articulate with the superior part of the talus and form the ankle or talocrural joint (Figure 11-20). The foot itself consists of numerous joints of different types among its 26 bones, the description of which is beyond the scope of this book.

Figure 11-20 Frontal section through the ankle and subtalar joints. Ligaments and interosseous membrane are illustrated.

(From Jenkins D: Hollinshead’s functional anatomy of the limbs and back, ed 8, Philadelphia, 2002, WB Saunders, p 357.)

From the perspective of acupuncture therapy, this chapter focuses on pain associated with soft tissues such as collateral ligaments, the calcaneous tendon, and plantar fascia.

The ankle joint is supported by the strong medial and weak lateral collateral ligaments. The MCL is known as the deltoid ligament. Superiorly the ligament attaches to the margin and tip of the medial malleolus. It fans out downward in a delta shape and its broad base attaches from the navicular bone anteriorly to the talus and calcaneus posteriorly. The lateral collateral ligaments consist of three discrete bands that attach the lateral malleolus to the talus and calcaneus: the anterior and posterior talofibular ligaments, and between these two short ligaments—a long, cordlike calcaneofibular ligament (Figure 11-21).

Figure 11-21 Diagram of the ligaments of the ankle and subtalar joints in medial and lateral views.

(From Jenkins D: Hollinshead’s functional anatomy of the limbs and back, ed 8, Philadelphia, 2002, WB Saunders, p 358.)

Of the three lateral collateral ligaments, the anterior talofibular ligament is the weakest ligament, and the most commonly injured. Ligament injuries are discussed later in this chapter.

Ankle Strains

Ankle strains are among the most common injuries to the ankle joint, both from daily activities and from sports like basketball and volleyball. Most ankle strains are caused by excessive inversion and the injury varies from a simple ligament strain (mere elongation of the ligaments with microtrauma) to a major injury with a severe or even complete tear of the ligamentous fibers.

The tibia and fibula are closely joined together by the tibiofibular ligament. The trochlea of the talus is tightly fitted into the space (called the mortise) between the medial malleolus of the tibia and the lateral malleolus of the fibula. During an accident, the excessive force of the inversion created by the tilted talus will strain or break the tibiofibular ligament and lateral collateral ligaments, especially the anterior talofibular ligament, which is the weakest of the three lateral collateral ligaments. Medially the tilted talus may violently impact the medial malleolus and cause a malleolar fracture.

When an ankle strain occurs, a person feels a sudden sharp pain. This initial pain may soon subside, so that the person may not seek immediate treatment, but if it is possible to apply acupuncture treatment immediately after the injury, the inflammation reaction can be effectively controlled and the healing process is greatly quickened. In the first 6 to 12 hours after injury the ankle gradually becomes swollen and tender points or areas appear on both lateral and medial aspects. Bruising (ecchymosis) also develops in the foot and the lower leg. The patient is then no longer able to perform activities such as running or to bear normal weight on the injured ankle.

When treating ankle sprain, a practitioner should carefully palpate the ankle area, especially the surfaces above the medial and lateral collateral ligaments. Then the practitioner should palpate the entire foot and leg to find the locations of the injured soft tissues. The ankle is a weight-bearing structure, so if the soft tissues of the ankle, such as ligaments or the interosseous membrane, are injured, pain will radiate to the leg muscles and sometimes to the thigh muscles. The swelling and inflammation will spread from the injured ankle to the distal part of the foot and the muscles of the leg.

To reduce pain and heal the injured tissues, the swelling and inflammation should be controlled first. For this purpose, all the injured and affected regions where tender areas are palpable should be needled simultaneously: ankle, foot, leg, and thigh. Usually swelling and inflammation can be brought under control within hours or 1 to 2 days in acute cases.

If severe tears are suspected, a patient should be referred immediately to specialists for further medical examination.

Rupture of the Calcaneal Tendon (Achilles Tendinitis)

Rupture of the calcaneal tendon is often caused by excessive stress on the calf muscles. After overuse caused by repetitive activities such as running or jumping, the calf muscles become fatigued and weak, and tender points develop around acupoint H10 sural. Physiologically the calf muscles start to resist any contraction or relaxation. If the person continues to use the calf muscles, stress is transferred to the calcaneal tendon, finally resulting in tendon rupture.

A patient with a ruptured calcaneal tendon can still walk, but only with a limp. The ruptured site on the calcaneal tendon is usually 4 cm above the point where the tendon is connected, and there will be thickening from edema and effusion of blood. The thickened portion of the tendon is painful or tender upon palpation.

Acupuncture is effective in treating Achilles tendinitis, especially the acute injury. Direct needling into the swollen, painful tendon introduces an antiinflammatory reaction that helps to relieve pain, and the needle-induced lesions activate the process of tissue regeneration. Like an ankle injury, calcaneal tendon injury will radiate pain to the calf muscles. In fact, tight calf muscles are often the cause of calcaneal tendon injury because the tightened muscles subject the tendon to excessive force.

The practitioner should carefully palpate the calcaneal tendon, the whole calf muscle, and both sides of the leg to find the tender points. At the rupture site, a few needles should be inserted deep into the ruptured tissue (Figure 11-22). The tender points on the calf muscles should also be needled. The procedure should be repeated every 3 or 4 days for the first 2 weeks. Pain relief can be achieved almost immediately in acute and fresh cases but recovery of function takes longer. In chronic cases, both pain relief and recovery of function will take longer. During the period of treatment, the patient should use a heel insert to elevate the heel about 2 cm, which will reduce the stretch of the Achilles tendon and the gastrosoleus muscles and thereby facilitate healing.

Figure 11-22 Needling method for Achilles tendinitis and plantar fasciitis.

Plantar Fasciitis

Patients with plantar fasciitis feel moderate to severe pain under the heel, often radiating into the sole of the foot. The pain is worse during the first few steps after getting up in the morning. Weight-bearing activities including normal walking, climbing stairs, or standing on tiptoe increase the pain. Some patients feel more severe pain in the evening, after the day’s work. The pain subsides after rest or if the foot resumes stretching exercises. If trauma is not involved, the onset is insidious in most patients.

Plantar fasciitis may occur in one or both feet. Activities such as carrying excessive weight, standing for long periods of time, walking, running, or wearing ill-fitting shoes will increase the risk of plantar fasciitis. We have seen one patient who developed plantar fasciitis after ankle surgery.

Palpation of the foot reveals a deep tender area beneath the anterior portion of the heel, especially at the anteromedial area of the calcaneus, the attachment point of the plantar fascia (see Figure 11-22). In some patients with acute or chronic heel pain, calcium can be deposited at this attachment site to form bone spurs, although most bone spurs will not result in pain. Other conditions causing a similar pain pattern include bursitis under the fascial attachment, atraumatic periostitis, and entrapment of the calcaneal branch of the tibial nerve.

In our clinic we have successfully treated both acute and chronic plantar fasciitis. The practitioner should perform a systemic examination of HAs, especially in the lower back area, posterior thigh, and calf muscles. It is necessary to carefully palpate the sole of the foot and the whole foot, paying attention to the heel bone (calcaneus), to find the most sensitive area. Two or three needles of 4 cm in length should be used to needle this tender area, as well as other tender points on the sole. In addition, it is advisable to needle HAs on the leg, thigh, buttock, and lower back. After treatments, a patient should resume mild lower limb activities and wear an orthopedic shoe or insert to support the foot arch and to avoid stretching the plantar fascia during walking.

Further medical evaluation is needed in patients with severe foot pain to confirm or rule out a possible stress fracture.

Hip Pain

Palpate the gluteal area around H18, the area around the greater trochanter, the hamstring muscles and the iliotibial band on the thigh.

Thigh Pain

Carefully palpate the hamstring, the iliotibial band, and the quadriceps and adductor muscles including their attachments to the hip bone and the knee. Figure 11-23 shows the treatment of adductor muscle strains.

Figure 11-23 Needling method for adductor muscle strains.

Knee Pain

Knee pain is always related to the muscles attached to the knee. First examine the knee area to understand the location of the pain and the possible tendons, ligaments, and bursae involved in this condition. Then carefully examine the muscles. For example, if pain is felt at the area of the MCL and the attachment of semitendinosis, the adductor muscles and semitendinosis should be palpated. The tender and painful points in the knee area and related muscles should be needled (Figure 11-24).

Figure 11-24 Needling method for knee pain. SAs in the thigh should always be needled.

Leg Pain

Examine the leg muscles, thigh muscles, ankle, and foot. The entire lower limb should be treated as one entity. In cases of severe pain where the patient does not experience relief after two to four treatments, the patient should be referred for further medical evaluation to confirm or rule out other causes of underlying pain such as a stress fracture.

Ankle and Foot Pain

Examine the ankle, foot, and leg. The three parts should always be treated together.