San Jiao 5 (Waiguan): Anatomy and Locations

The intent of this article is to discuss the anatomy, locations and some clinical uses of San Jiao 5 (waiguan). The san jiao channel is also known as triple burner or triple energizer.

The anatomy of the SJ 5 point is dependent on the location, for which there are a few different loci descriptions in today’s literature. The following locations have been gathered from common acupuncture textbooks and online resources.

Different Location Descriptions for SJ 5

1. On the dorsal aspect of the forearm, on the line connecting SJ 4 (yangchi) and the tip of the elbow, 2 cun above the transverse crease of the wrist between the ulna and radius.
2. 2 cun proximal to the dorsal crease of the wrist, on the line connecting SJ 4 and the tip of olecranon, halfway between the radius and ulna.
3. 2 cun above SJ 4 halfway between the radius and the ulna on the SJ 4 – SJ 10 line.
4. 2 cun proximal to SJ 4 in the depression between the radius and the ulna, on the radial side of extensor digitorum communis tendons. Note: The point is located between the radius and the extensor digitorum communis tendons, close to the border of the radius.

From the author’s experience in teaching acupuncturists from around the globe for over 27 years, the common way of finding this point (location descriptions #1-3 are currently taught in many of today’s acupuncture schools) is to divide the outer borders of the radius and ulna in half at a point located 2 cun proximal to SJ 4. This location puts SJ 5 in the middle of the extensor digitorum communis (EDC) tendon, and when needled, will commonly create a sharp pain as the needle penetrates the nociceptively rich nerve endings of the tendon’s synovial lining. A sharp pain at this point is, in the author’s experience, not the appropriate qi sensation for waiguan and is missing the incredible effect that this very important acupuncture point has to offer. The 4^th location description puts this point on the radial side of the EDC tendon, which anatomically belongs more to the Large Intestine topography and the territory of the superficial radial nerve.

Before discussing the author’s location of SJ 5, a brief description of the SJ 5 traditional functions and modern-day applications is as follows.

TCM Actions

• Expels wind and releases the exterior
• Clears heat
• Benefits the head and ears
• Signals the yang qiao and dai mai vessels, activates the san jiao primary (jingluo) channel and relaxes the myofascial san jiao channel sinew (jingjin).

Clinical Uses of SJ 5 (Waiguan)

The following are a few clinical cases for using this point:

• Commonly used for shao yang type of headaches, especially when contracted from external wind.
• It is a common point used in pediatrics for heat type of ear infections.
• It is a confluent point for the yang qiao channel and when combined with GB 41 (zulinqi), and has a consistent effect on not only internal zang fu pathologies such as regulating the menses and decreasing lower jiao discomfort from painful periods, but also has an incredible effect on any type of musculoskeletal pain involving rotation. The author has shown for decades this point combination’s remarkable effect in changing the pelvic bone movement pattern when assessing Gillet’s test before and after needling.
• 

  Figure 1: The san jiao jingjin

  It is the connecting-luo point of the san jiao channel and also in the same area as a “binding region” of the san jiao channel sinew (jingjin) (Fig. 1). The connecting-luo points are known to “clear obstructions from the channel,” and therefore SJ 5 is an excellent point to help release the binding regions of its sinew channel and also its obstructions in the primary channel (jingluo). This would include musculoskeletal injuries involving the dorsal wrist, elbow, lateral ribcage, shoulder and neck. This point will often increase limited range of motion, especially involving shoulder adduction and horizontal adduction. Because it is a luo point, and in cases where there are excess and deficiency discrepancies between these two channels, SJ 5 can be combined in treatment with its paired internal/external related (biao li) channel, the Pericardium channel at P7 (daling), the source-yuan SJ 5 is sometimes needled with a through and through (tou ci) technique toward P6 (neiguan), the Pericardium channel’s connecting-luo point. This advanced technique is for chronic types of pain and stiffness conditions, especially when involving tissue dysfunction affecting these two channels (difficulty with shoulder abduction/adduction and/or forearm and wrist pronation/supination). It can be effective with carpal tunnel syndrome when limited range of motion of the distal radius and ulna affect the shape and integrity of the carpal tunnel itself. The author finds this technique easiest when inserting the needle in order to penetrate the interosseous space between the radius and ulna.

• Various types of needle stimulation to SJ 5 have been researched to activate different brain areas in ischemic stroke patients (Chen, 2014), improve brain glucose metabolism for ischemic stroke patients (Liu, 2013), and also affect the sensorimotor networks and synchronization between the cerebellum and cerebrum (Wang, 2014).

Callison, M. Sports Medicine Acupuncture textbook 2019
Figure 2: The radial nerve and its bifurcation into collateral branches.

Sports Medicine Acupuncture (SMA) Location for SJ 5

As discussed earlier, the location of SJ 5 has been shown to vary amongst practitioners but with clinical results seemingly still effective. However, the author invites the reader to try a modified location (discussed below) due to its ability to propagate a qi sensation up and/or down the san jiao channel with needle stimulation. This effect is most likely due to the direct stimulation of the deep radial nerve (posterior interosseous nerve) that traverses the san jiao channel in the forearm and wrist. When needling SJ 5 at the other point locations discussed in this article, the needle sensation is often sharp or does not have a traveling sensation that follows the san jiao channel. The posterior interosseous nerve is one of two collateral branches that bifurcates near the LI 10 (shousanli) region. This nerve is a deep radial branch that traverses the san jiao channel innervating much of the tissue found along it. The other bifurcating branch of the radial nerve, the superficial radial nerve, traverses along the large intestine channel of the forearm and wrist (Fig. 2).

The standard method to locate SJ 5 is to divide in half the “outer borders” of the radius and ulna at a point located 2 cun proximal from SJ 4. As discussed previously, this will put SJ 5 in the middle of the EDC tendon. The following modification to this common location is to place SJ 5 halfway between the “inner borders” of the radius and ulna approximately 3-4 mm to the ulnar side of the standard SJ 5 point. This location will be between the EDC tendon and the extensor digiti minimi tendon. While palpating this point, when the patient extends their little finger, there is a small gap between the EDC and EDM tendons. The needle should be inserted between these two tendons to a depth of 0.5-1 cun. There is an indentation on the ulnar side of the EDM tendon, this is not the intended point. Be sure to be between the EDM and EDCC tendons. The author has found that this particular point has a greater effect when compared to other locations when relaxing the san jiao myofascial jingjin and its ability to change range of motion. Note: if needle stimulation propagates a sensation along the san jiao channel at approximately 0.25 in depth, the posterior cutaneous nerve may have been affected. If the practitioner wishes to affect the primary or sinew channels, a deeper insertion, as previously recommended, is necessary.

Refer to the following video for more information on these tendons and the anatomical location of San Jiao 5 on a cadaver specimen:

Because needle stimulation to this point consistently propagates a qi sensation along the san jiao channel, perhaps this modified location is the traditional location of waiguan, and possibly, the other locations were a result of missed translation over the centuries. It is difficult to say for sure, but the author hopes the reader will try this point location for themselves and compare the results of treatment success using this SMA location of SJ 5.

References:

• Chen J, Huang Y, et al. Acupuncture at Waiguan (SJ5) and sham points influences activation of functional brain areas of ischemic stroke patients: a functional magnetic resonance imaging study. Neural Regen Res. 2014;9(3):293‐ doi:10.4103/1673-5374.128227) ,
• Liu, E. T., Wang, S. X., Huang, Y., Lai, X. S., Tang, C. Z., & Cui, S. Y. (2013). Effect of needling at waiguan (SJ5) on brain glucose metabolism in patients with cerebral infarction. Zhongguo Zhong xi yi jie he za zhi Zhongguo Zhongxiyi jiehe zazhi= Chinese journal of integrated traditional and Western medicine, 33(10), 1345-1351.
• Wang J, Huang Y, Lai X, Tang C, Yang J, et al. (2014) Modulatory Effect of Acupuncture at Waiguan (TE5) on the Functional Connectivity of the Central Nervous System of Patients with Ischemic Stroke in the Left Basal Ganglia. PLoS ONE 9(6): e96777. https://doi.org/10.1371/journal.pone.0096777)

Resources:

• de Morant, G. S. (1994). Chinese acupuncture. Paradigm Publications
• Deadman, P., Al-Khafaji, M., & Baker, K. (1998). A manual of acupuncture. East Sussex, UK: Journal of Chinese Medicine Publications
• Ross, J. (1995). Acupuncture point combinations: The key to clinical success. Edinburgh: Churchill Livingstone
• O’Connor, J., & Bensky, D. (Eds.). (1981). Acupuncture: a comprehensive text. Editora Roca
• Xinnong, C. (1987). Chinese acupuncture and moxibustion. Beijing: Foreign Languages Press
• sinewchannels.com
• Buy Sports Medicine Acupuncture Textbook at smatextbook.com
• Learn more about AcuSport Education’s Sports Medicine Acupuncture Certification Program