The Huang di Nei Jing Su Wen and Acupuncture Sports Medicine

The treatment of pain and injury is among the most common reasons the patient seeks medical care. It could well be the single most important reason the individual is getting acupuncture treatment specifically. Most practitioners use some sort of eclectic treatment protocol, choosing points based upon multiple assessments and systems of diagnosis. For instance, the patient maybe treated with points on the affected meridian, points at the site of the injury, empirical points that are not located on the injured tissues or the affected meridian, and so forth.

But what do the classic Chinese texts have to say about the treatment of pain? Let’s use The Huangdi Nei Jing Su Wen, as translated by Maoshing Ni (Shamblala Publications 2011) as our foundation. It is an easy text to follow, and in the early pages of this classic, the Yellow Emperor asks the physician, Qi Po, “I would like to understand the pain and its causes”

The response: “When the qi and blood flowing continuously through the body within the channels are attacked by a cold pathogen, they stagnate. If the cold pathogen attacks outside the channels in the periphery, it will simply decrease the blood flow. When it attacks within the channels, it actually blocks the qi flow and creates pain.” Commentary in this passage continues, stating that it is not just cold, but wind, heat, and damp that are responsible for these painful conditions in the patient.

Interestingly, several comments must be considered. First, the attribution of cold pathogen as the cause of pain. I think this is one legitimate cause of pain, but we must remember that due to environmental differences over two thousand years ago, especially in terms of the lack of adequate heating and cooling of homes and works spaces, cold may not be as significant a cause of disease in our present lifestyle. But what is important to note in these statements are that some pathogen attacks the channels, and they “stagnate”. Which bring us to this second important point. That if the qi flow is blocked, it creates pain. We all know this clearly from the dictates of our medicine, and qi stagnation is a fundamental diagnosis in our clinics for the patient experiencing pain.

Qi Po continues with commentary on anatomical tissue, rather than channels and vessels. For instance, when needling to the bone level “take care not to injure the tendon level. When needling the tendon level, do not injure the muscles. When needling the muscles, do not injure the channels and vessels. When needling the channels, do not injure the skin. When needling the skin, do not injure the flesh and the muscles. When needling the muscles, do not injure the tendons. When needling the tendons, do not injure the bones.”

I must admit that I do not understand this statement. However, the commentary suggests that the precision in treatment of the local and adjacent tissues is warranted, and it is described in anatomical terms. This maybe more important than many in the profession have understood. Thus, typical needle techniques like “pecking and rotating” may not be the most suitable manipulation method, based upon the commentary above. But, let us continue.

The Emperor asks: “What is meant by acupuncturing the bone level but not injuring the tendons ?” The response continues with precise instructions: “When needling deeply, do not stop at the level of the tendons before reaching the bone level. Goal l the way in one breath, or in a series of breaths, depending on your technique. But reach that depth without removing the needle. When needling to the depth of the tendons, one can avoid injuring the muscles by inserting past them. This logic follows with each specific level.”

Again, these instructions are somewhat difficult for me to grasp. Yet what follows in the Neijing is a critically important response, as it speaks to the precision of what we must accomplish as an acupuncturist: “The needle must go to the proper depth; any depth other than the correct one will cause undesireable effects”. Let me repeat that response. We must needle to the proper depth.

The commentary continues: “When the condition is in the tendon level, causing spasm or contracture of the four extremities, pain in the joints, and limited mobility, we call it jinbi, bi syndrome of the tendons. Begin by needling at the painful location on the tendon itself. Because the tendon connects the muscle to bone, be careful not to injure the bones. When the tendon begins to feel warm, this indicates that the condition is improving. When the disease is completely cured, stop acupuncturing.”

So here we have the description of “jin bi” , bi syndrome of the tendons. While many acupuncturists in this era continue to define their treatments of pain and injury in terms of the affected meridian or meridians, with the use of the logically indicated points there of, we have this continued commentary on an atomically significant tissues, such as muscle, tendons, and bone. These tissues, it would appear, all lie deeper to the more superficial channel and collateral system. But they must be considered in treatment, it appears, as a specific concern that is not explained in terms of zang fu or jingluo.

Another point to acknowledge is the feeling of “warmth” in the tendon, which as stated is an indication that the condition is improving. With the needle that must be inserted to the proper depth, does the increased profusion of blood to the tissues “warm” up the tendon and the tendons heath as part of the actual healing process ?There is much discussion about micro-circulation. created by the inserted needle, which would cause as light regional inflammatory response. Could this be part of the mechanism of action for acupuncture?

The argument for other anatomically significant tissues continues in another passage: “Acupuncture deeply, but do not injure the vessels and flesh. In the passage to the bone level, one must select carefully between the large and the small muscle groups. Elicit heat sensations radiating from the bones to speed recovery. Stop treating when the patient is well.”

Again, there is insistence upon precision of needling. Remember the earlier line, “we need to needle to the correct depth”. But also reiterated is the selection to needle between the large and small muscle groups. This is very important in my practice. It end to consider that the large muscles, like the upper trapezius, the deltoid, and the gluteus maximus, as not as clinically significant as the smaller muscles that lie beneath them, such as the levator scapula (under the upper trapezius), the supraspinatous tendon (under the deltoid), and the rhomboid minor (under the trapezius).

After considerable discussion of points election and technique, Qi Po continues: “Xi and gu areas, or small and large clefts, are where the bundles of muscles meet; at this meeting place there is a depression or indentation.” This seems vitally important for us to understand, as it is now the depressions and indentations found in the muscles and other tissues via palpation that are used in the treatment of pain. Understanding the anatomical significance of these small and large clefts would be important determinate of clinical success, based upon these teachings. This is very simple yet profound sampling of the Neijing, and is remarkable to me the clear concise anatomical language used for the treatment of pain. And the unmistakable statement that needle depth is essential to good clinical outcomes always gets my attention. I think it supports all of us in the larger community of sports medicine, orthopedics, and anatomically-based acupuncture. As we continue to develop a modern profession based upon traditional Chinese medicine, our efforts can be viewed as inclusive to the classic writings and principles, rather than operating outside the confines of TCM.