Exercise Prescription for the Acupuncturist — Elevated Ilium and Medial Knee Pain: A Channel Sinew Perspective
Rehabilitative exercise is a comprehensive science based on a thorough knowledge of anatomy, physiology, biomechanics and tissue healing. Exercise prescription, like Chinese herbal medicine, can be seen as an important skill for the sports acupuncturist to learn and prescribe to their patients. In addition to benefiting the musculoskeletal injury and helping to correct the postural imbalances that have contributed to the injury, rehabilitative exercises further empower the patient to take an active role and responsibility in healing their injury.
Prescribing particular movement patterns to patients is not a new concept as TCM practitioners for thousands of years have been educating their patients with martial art, tai chi and qi gong exercises as part of their treatment. Movement therapy is a strong part of the TCM healing paradigm. The ability of the practitioner to effectively prescribe even basic exercises will markedly improve their clinical results, although care must be taken when prescribing physical exercise. As in acupuncture practice, there are numerous methods and schools of thought within the field of rehabilitative exercise.
Elevated Ilium and Medial Knee Pain: A Channel Sinew Perspective
Combining ideas behind exercise prescription with a thorough TCM assessment provides the practitioner with unique insight when developing an exercise program. In this blog, we are taking a common postural disparity “Knee Moves In” that is discussed in the Postural Assessment and Corrective Exercise III (PACE III) class and its association with an elevated ilium (Fig. 1) and medial knee pain. An elevated ilium will often result in the same-sided (ipsilateral) knee to move inward (knee valgus) while the patient performs an overhead squat (Fig. 2). The practitioner will often find patients with medial knee pain will demonstrate this dysfunctional motion and have an imbalance between the Liver and Gallbladder channel sinews (jingjin)
The practitioner will often find on the ipsilateral side of an elevated ilium:
- Inhibited and lengthened gluteus medius/minimus fibers (deficiency xu) are not holding proper tension and allowing the knee to move inward. These tissuesare associated with the Gallbladder sinew channel.
- Facilitated and shortened adductors (in particular adductor longus and adductor brevis) fibers (excess shi)pulling the knee inward. These tissues are associated with the Liver sinew channel.
- Facilitated and shortened quadratus lumborum elevating the ilium. This tissue is associated with the Liver sinew channel.
The motion of the knee moving in during an overhead squat informs the practitioner that excessive tension is placed on the tissues of the medial knee (primarily Liver jingjin) during the patients’ activities of daily living. For example, standing from a seated position or walking upstairs, the knee will have a tendency to move inward and from overuse, pain and injury will eventually be the result. Medial knee pain injuries associated with this pattern are MCL sprain, medial meniscus injury, pes anserine tendinopathy and soft tissue insertional strain.
The goal for the practitioner is to level the pelvis and stabilize the tension in the myofascial sinew channels associated with the Liver and Gallbladder. There are many ways to treat this condition with acupuncture and TCM modalities. However, for this article, we will discuss one of the most important exercises to prescribe in cases of an elevated ilium contributing to medial knee pain. The Figure 4 exercise (a practitioner and patient favorite) helps to reinforce the acupuncture treatment by engaging the weakened and inhibited gallbladder channel of the hip (gluteus medius/minimus) and to reduce the facilitated liver channel (adductor longus/brevis). Having the patient perform this exercise (and other exercises that fit the pattern) post-acupuncture treatment will help to reinforce the acupuncturist plan to reduce tension in the Liver channel and reinforce tension in the Liver jingjin.
The Figure 4 exercise (a practitioner and patient favorite) helps to reinforce the acupuncture treatment by engaging the weakened and inhibited gallbladder channel of the hip (gluteus medius/minimus) and to reduce the facilitated liver channel (adductors). Having the patient perform this exercise (and other exercises that fit the pattern) post-acupuncture treatment will help to reinforce the treatment plan.
Figure 4 Spinal Rotation
This exercise is very effective for lowering an elevated ilium post-acupuncture treatment. This exercise is contraindicated in cases of radicular pain.
- While lying on the floor in a supine position, the patient flexes both knees to 90˚ with the feet placed on the floor in a neutral position in alignment with the hip joints.
- The leg on the same-side of the elevated ilium is placed into a Figure 4 position so that the lateral malleolus is placed onto the distal thigh of the opposite leg near the extra point heding. The shoulders are abducted to 90˚ with the palms down (Fig. 3A).
- While maintaining the Figure 4 position, the patient rotates the lumbar spine so that the foot of the Figure 4 leg reaches the floor. The bottom of the foot needs to be placed so that the K 1 (yongquan) region and heel are on the floor. The lateral aspect of the opposite thigh and leg should be resting on the floor.
- If it is comfortable for the patient’s neck, they can turn their head to the side opposite of the lumbar spine rotation.
- The patient is instructed to use their hip muscles to push the knee of the Figure 4 leg outward. The lateral malleolus of the Figure 4 leg must not move away from its placement on the distal femur. The patient is actively using the gluteus medius/minimus to externally rotate and abduct the hip joint, thereby passively stretching the soft tissue attachments on the greater trochanter (Fig. 3B). The action of this exercise activates the GB sinew channel (gluteus medius/minimus) with a strengthening contraction and inhibits the LIV channel (adductor longus/brevis).
- Repeat on the opposite side.
- Repeat one more time on initial side to help reinforce the pulling of the elevated ilium downward.
The following recommendation for the number of sets and repetitions is a general guideline and should be modified for each patient depending on their stage of rehabilitation, strength and level of ability.
Sets: 1. Begin on elevated ilium side, repeat to opposite side, finish the third repetition on the initial side.
Repetitions: Hold for 30 – 60 seconds per side.
Breathing: Slow deep breaths. Instruct the patient to breathe diaphragmatically into the dan tian.
If the patient is having difficulty performing an exercise due to proprioceptive deficiency from the injury or if the exercise creates mild discomfort, the practitioner can decrease the discomfort by applying acupuncture during the exercise. Refer to either the blog or the page in the SMA textbook.
Postural Assessment & Corrective Exercise Course
There is no substitute for hands-on experience when it comes to prescribing exercises. The Postural Assessment and Corrective Exercise classes taught in the SMAC program by Ian Armstrong with Matt Callison and Brian Lau consists of incredible and highly effective postural exercises that will not only help align the musculoskeletal system, but are also very effective for upper, middle and/or lower jiao organ disharmonies.
Leave A Comment