Patient A (with elbow pain)		Patient B (with knee pain)
HAs	Primary HAs	Primary HAs (same as patient A)
SAs	Locate SAs in elbow and arm	Locate SAs in the knee, thigh, and leg
PAs	Use PAs along C4-T1	Use PAs along L2-5

THE RANDOM AND PREDICTABLE PATTERNS OF TENDER ACUPOINT FORMATION

All acupoints consist of peripheral nerve fibers, including the sensory and postganglionic nerve fibers and other soft tissues (see Chapter 1). Acupoints become tender in two distinguishing patterns: the random pattern of SAs and the predictable pattern of HAs.

As previously explained, when homeostasis declines, homeostatic acupoints are gradually transformed from a latent phase (nonsensitive) to passive or active phases. In general, HAs appear symmetrically in predictable locations and predictable sequential order in the human body, and this is referred to as the predictable pattern of tender HA formation. There can be more than 100 HAs in some patients; the first 24 HAs are shown in Figure 5-1. All other HAs appear around these 24 primary HAs, as discussed previously.

Acute injury or acute disease always sensitizes some localized sensory nerves (tender acupoints). These tender acupoints can appear anywhere in the area affected by the injury or disease. This is the random pattern of SA formation.

The SA random pattern and HA predictable pattern of tender acupoint formation often coexist. For instance, primary acupoint H1 (deep radial; see later discussion) is tender in all healthy and unhealthy people alike. Patients with neck, shoulder, elbow, wrist, and hand pain have a common tender primary acupoint H1 deep radial as well as different, random additional tender acupoints around the H1 deep radial.

The three pathophysiologic phases of acupoints reveal the quantitative and qualitative dynamics of an acupoint: when pathologic factors persist, the number, size, and sensitivity of tender HAs and SAs increase. With proper treatment, the number of tender acupoints decreases and the sensitivity of each acupoint subsides (see Chapters 2 and 3). In the absence of proper treatment or when the self-healing potential is impaired, the size of an acupoint will increase and it will finally become a permanent pathologic structure such as a palpable nodule in the muscle.

There are no “sham” acupoints (see Chapter 4). Stimulated by acupuncture needling, any sensory nerve fiber, sensitized or not sensitized, will produce and send electrical signals to the spinal cord and the brain. Important acupoints, such as the 24 primary acupoints, provide stronger signals, and “sham” acupoints provide weaker signals.

Electrophysiologic experiments show that certain nerve fibers, when sensitized, will generate stronger signals by normal mechanical or thermal stimulation (unpublished data, Dr. Yun-tao Ma). Clinically important acupoints often produce more needle sensation (de qi), such as aching, soreness, numbness, heaviness, pressure, or electric shock. Therapeutically these acupoints produce strong signals and are more effective than acupoints with weaker signals.

All three types of acupoints must be combined to achieve the best therapeutic results when treating any symptom. The following is one example of how to combine three types of acupoints to treat a patient with knee pain. First, have the patient assume a supine position and palpate the area around the knee to find and then needle these local SAs. Then palpate and needle the HAs accessible in the supine position. Finally, turn the patient over to a prone position and needle tender points in a popliteal area and the PAs around L2-S2, plus HAs accessible to this position in the shoulder and neck areas. This combination, including both local (SAs) and distal points (HAs), provides the best efficacy. The number of acupoints needled for each treatment depends on the severity of the injury, the homeostatic status of the patient, and his or her needling tolerance. We discuss this in greater detail in later chapters.

NEUROANATOMY OF 24 PRIMARY HOMEOSTATIC ACUPOINTS

For 30 years Dr. H.C. Dung studied the pathophysiology of HAs in both clinical practice and laboratory research. He found that as many as 110 HAs may develop when homeostasis declines. Of these, 24 acupoints are the most important, as discussed previously.¹

This discovery of HAs and their quantitative relation to homeostasis makes it possible to evaluate the pathophysiological condition (the self-healing potential) of a patient and predict the duration and prognosis of the acupuncture treatment (Chapter 6).

The 24 primary acupoints are named with their homeostatic sequence number, followed by the name of the related peripheral nerves or anatomic landmarks (see Figure 5-1). Consider, for example, the H1 deep radial acupoint. H1 means that this acupoint is the first of all the HAs to become tender on the body, and deep radial indicates that this acupoint is located on the deep radial nerve. Acupoint H19 infraorbital is located on the infraorbital foramen where the infraorbital nerve emerges and usually becomes tender after the H18 iliotibial point.

Needling safety and efficacy should be the primary concern of a practitioner. For example, when working in the region of the upper and lower extremities, the risk of an accident is low. In other body regions, a practitioner should be careful to avoid causing injury to the vital organs, such as the lung or the heart. With experience each practitioner can create his or her own needling method in treating each patient, keeping in mind that no two patients are identical.

All the acupuncture needling methods described in the following section apply to prone or supine positions. The actual location of an acupoint varies in different patients. To achieve the best results, a practitioner should always palpate the body to locate the actual acupoints before needling them. The 24 primary homeostatic acupoints (see Figure 5-1) are described below according to body region.

Homeostatic Acupoints on the Head and Neck

The five primary homeostatic acupoints are two on the face; two on the neck; and the fifth acupoint, H3 spinal accessory, on the shoulder bridge region. The H3 spinal accessory acupoint is included in this section because it is innervated by the spinal accessory nerve, which contains both cranial and cervical nerve roots.

H19 Infraorbital

This acupoint is located exactly on the infraorbital foramen (Figure 5-2). The infraorbital nerve, a cutaneous nerve from the maxillary branch (V2) of the trigeminal nerve, passes the foramen and innervates the facial skin. To avoid hematoma use 38- or 36-gauge needles (diameter, 0.18 or 0.20 mm, respectively). The depth for needling ranges from 2 to 5 mm.

Figure 5-2 Locations of acupoints H23 supraorbital and H19 infraorbital.

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

Clinical Notes

The H19 infraorbital is always the first tender acupoint on the face because the infraorbital nerve is the largest cutaneous nerve in this area. In addition to homeostatic decline, all symptoms related to the face and the head may further sensitize this acupoint and increase its size. Thus the sensitivity and size of the point provide useful information about the severity or chronicity of the symptom. The common symptoms that may aggravate this acupoint are cranial neuralgias; all kinds of headache; facial, myofascial, and temporomandibular disorders; pain of dental and intraoral origins; ocular and periocular pain; pain in the ear; sinusitis; cold; allergy; and facial paralysis. The H19 infraorbital acupoint should be used for all these symptoms. It should be noted that pain caused by cancer of the head and neck also sensitizes this acupoint.

H23 Supraorbital

This acupoint is formed right on the supraorbital notch, which is the passage for the supraorbital nerve (see Figure 5-2). This cutaneous nerve from the ophthalmic branch (V1) of the trigeminal nerve extends to the top of the head. The method of needling this point is similar to the H19 infraorbital.

Clinical Notes

Because the supraorbital nerve is smaller than the infraorbital nerve, the H23 supraorbital becomes tender after the H19 infraorbital does (see Chapter 1). For example, the H19 infraorbital is always tender in a patient with a slight headache. If the headache lingers for some time, the H23 supraorbital becomes tender, too. If the headache continues to deteriorate, other points in the face, such as the mental nerve (V3), the zygomaticofacial nerve (V2), and the zygomaticotemporal nerve, also appear tender. More tender points indicate that the symptom is more chronic and more severe and requires more treatments.

When treating patients with facial problems such as temporomandibular pain, chronic sinus pain, or facial paralysis, other points innervated by the facial nerve (VII) (Figure 5-3) should be carefully palpated and selectively needled according to the individual symptom.

Figure 5-3 Acupoint H2, greater auricular, and diagram of the facial nerve (VII) and two less important acupoints: the lesser occipital nerve and the transverse cervical nerve.

(Modified from FitzGerald M, Folan-Curran J: Clinical neuroanatomy and related neuroscience, ed 4, Edinburgh, 2002, WB Saunders.)

H2 Greater Auricular

This acupoint is located just behind the earlobe and on the anterior border of the sternocleidomastoid muscle (see Figure 5-3). The greater auricular nerve is one of the four branches from the cervical nerve plexus (CNP, C2-4). The anterior rami of C2 to C4 interconnect to form the cervical nerve plexus. The CNP lies deep below the internal jugular vein and the sternocleidomastoid muscle. Four cutaneous branches from the CNP emerge around the middle of the posterior border of the sternocleidomastoid muscle.

The greater auricular nerve curves over and ascends obliquely toward the earlobe and the angle of the mandible. This nerve bundle surfaces through the investing fascia just below the earlobe and divides into branches to supply the skin on the inferior part of the ear and the area extending from the mandible to the mastoid process. The three acupoints formed by the CNP are shown in Figure 5-3.

Clinical Notes

The H2 greater auricular is tender in almost every patient. Needling this point, however, often causes bleeding because the external jugular vein descends just beside the greater auricular nerve. If the external jugular vein is observed to be prominent throughout its course, this is a sign of raised venous pressure resulting from heart problems, and this point should not be needled to avoid an accident such as a venous air embolism. A fine 36- or 38-gauge needle (diameter, 0.20 or 0.18 mm) may be used to needle this point. The needling depth is about 5 to 8 mm.

Several acupoints on the neck are formed by three other nerves derived from the CNP. These nerves are the (1) lesser occipital nerve, which forms an acupoint located on the insertions between the sternocleidomastoid and the trapezius muscles on the occipital bone; (2) the transverse cervical nerve, which curves around the middle of the posterior border of the sternocleidomastoid and then passes transversely to the anterior border of the same muscle (several acupoints are formed over the anterior triangle of the neck); and (3) the supraclavicular nerve, which divides into medial, intermedial, and lateral branches. These nerves send small branches to the skin of the neck and then emerge from deep fascia just superior to the clavicle to supply the skin over the anterior aspect of the chest and shoulder. When needling tender acupoints in this area, a practitioner always should pay attention to the direction and depth of the needling so as not to puncture the lung. A safe needling method is suggested later in this chapter.

H7 Greater Occipital

This acupoint is located at the base of the occipital region, 2 or 3 cm from the midline (see Figure 5-1). This acupoint can be palpated easily because it is tender in more than 95% of patients. The dorsal rami of the C2 spinal nerve form the greater occipital nerve. This nerve emerges between the posterior arch of the atlas (C1) and the lamina of the axis (C2), below the small muscle obliquus capitis inferior. It then surfaces to supply the skin of the occipital region.

Clinical Notes

The H7 great occipital is frequently used because many symptoms can be traced to the problems of the neck. Neck-related problems are discussed in detail in Chapter 9. For effective treatment, we usually use needles of gauge 34 (diameter: 0.22 mm). The depth varies from 2 to 4 cm, depending on the thickness of the patient’s neck tissues.

H3 Spinal Accessory

The spinal accessory nerve (XI) originates from both cranial roots (nucleus ambiguus in medulla) and spinal roots (C1 to C6), and it contains both afferent (sensory) and efferent (motor) fibers. The branch of the spinal accessory nerve enters the trapezius muscle at the point over the shoulder bridge in the middle of the front edge of the upper trapezius muscle (see Figure 5-1). This acupoint is a neuromuscular attachment point.

Clinical Notes

The H3 spinal accessory appears tender in more than 98% of the population. We use a needle no more than 2.5 cm long and insert the needle perpendicularly to the skin. Practitioners should be extremely careful when needling this point because the apex of the lung is just below this point. We suggest four needling methods in Chapter 9. A practitioner can choose the method he or she is most comfortable with or explore other safe methods. Another branch of the spinal accessory nerve also innervates the sternocleidomastoid muscle, but the acupoints formed in that muscle are less important.

Other Facial Acupoints

Two cranial nerves, the trigeminal nerve (V) and the facial nerve (VII; see Figure 5-3), are involved in the formation of facial acupoints. The trigeminal nerve contains both sensory (afferent) and motor (efferent) nerves and is responsible for general sensations in the skin of the face and front of the head as well as controlling the chewing muscles. The two types of facial muscles are the muscles of mastication (chewing) and the muscles of facial expression. Two important muscles of mastication, the temporalis and masseter muscles, are innervated by the motor nerves of the trigeminal nerve. The acupoints formed in those two muscles are essential in treating some headaches and facial symptoms such as temporomandibular joint syndrome (TMJ) and facial paralysis.

The five branches of the complicated facial nerve innervate 20 known muscles of facial expression and other structures, including the tongue. Injury to the facial nerve or some of its branches leads to paresis (weakness) or paralysis (loss of voluntary movement) of all or some of the facial muscles on the affected side. The injuries may be caused by chilling the face, inflammation, middle ear infection, fractures, tumor, and other disorders. Proper needling of the affected muscles helps to reduce inflammation and accelerates healing in many facial symptoms, including Bell’s palsy.

Homeostatic Acupoints on the Upper Extremity

The upper extremity is the organ of manual activity. It consists of two parts: the shoulder (junction of the arm and the trunk) and the free arm. The free arm includes four parts: the arm (brachium, between the shoulder and the elbow), the forearm (antebrachium, between the elbow and the wrist), the wrist (carpus), and the hand.

The bones of the upper extremities comprise the clavicle (collar bone) and the scapula (shoulder blade) in the shoulder, the humerus in the arm, the radius and ulna in the forearm, the eight carpal bones in the wrist, the five metacarpal bones in the hand, and 14 phalanges in the digits (fingers). More than 50 large and small muscles are attached to the bones of the upper extremities.

The large nerve network of the brachial plexus supplies the upper extremities. The brachial plexus is formed by the union of the ventral rami of nerves C5 to C8 and most of the ventral ramus of T1 (Figure 5-4). To supply the upper extremities, these five rami interconnect to form three nerve trunks: upper (C5-6), middle (C7), and lower (C8 and T1). Each trunk splits into anterior and posterior divisions. All the posterior divisions unite to become the posterior cord, which has two major nerves, the axillary and radial nerves. The anterior divisions form the lateral cord and the medial cord. The lateral cord becomes the musculocutaneous nerve, and the medial cord the ulnar nerve. The union of fibers from both the lateral and the medial cords forms the median nerve. The small branches from the upper trunk and the three cords supply the shoulder (back and front); the five major terminal nerves are made up of the three cords innervating the free arm. Six primary homeostatic acupoints are located in the upper extremities: one on the chest, two on the shoulder, two on the forearm, and one on the hand. Here we discuss only the major nerves that give rise to the primary homeostatic acupoints.