LIV-5 (ligou)
is the luo-connecting point
of the Liver channel. It is 5 cun above
the prominence of the medial malleolus and lies between the tibia and
the triceps surae
(gastrocnemius and
soleus
muscles).
I would like to discuss some of the specific anatomy of this point, which will help both with point location (where exactly is this point
and what is the target tissue you are aiming for) and with
understanding some of its indications,
specifically back and groin
pain. This will help
determine when
you would use this point for
greatest effectiveness for these indications.
A
couple of the many indications of this point include groin (and genital)
pain and low back pain. For low back pain, Deadman, author of A
Manual of Acupuncture, lists
“inflexibility of the back with inability to turn.” Wang Ju Yi, author of Applied Channel Theory,
discusses this point and further states: "because of the commonly seen relationship of the musculature of the groin to the low back, this point can be helpful in treating lumbar pain, especially when there is also tenderness at the point."
Why
would both groin pain and low back pain be treated by this point? Moreover, for patients who present with low back pain, when is LIV-5 indicated? And why might there be a relationship to both back and groin pain in
these cases?
First
off, let's explore the anatomy and target tissue of LIV
5 and
a related acupuncture point,
SP 6 sanyinjiao. The
anatomy involves the interaction of two muscles which are directly posterior to the tibia for most of their length: the tibialis posterior
and the flexor digitorum longus (FDL).
These muscles are each part
of a separate jingjin
or sinew channel. The tibialis posterior is a muscle of the Spleen
jingjin, while the
flexor digitorum longus is on the Liver jingjin.
Finally, the soleus, part
of the Kidney jingjin,
will play a part in understanding SP 6 sanyinjiao, a
point where we can see in the
anatomy a place where the three yin channels cross.
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| Fig. 1: Posterior compartment with tib. posterior (highlighted) and FDL. Gastrocnemius and soleus removed. Image modified from Gray's Anatomy |
Deadman places LIV
5 and
SP 6 at interesting
anatomical locations.
The
tibialis posterior muscle travels lateral to the FDL for most of its length. But, at the distal tibia, it crosses anterior to the FDL to become the most medial muscle (Fig. 1). It then
becomes the most anterior muscle to pass behind the medial
malleolus. Some might recall the mnemonic 'Tom, Dick, And Very
Nervous Harry' which alludes to Tibialis
posterior, flexor Digitorum
longus, posterior tibial Artery and Vein, tibial Nerve,
and flexor Hallucis
longus; this is the order in which these structures pass behind the medial malleolus.
The
tibialis posterior muscle (SP
jingjin) crosses the
FDL (LIV jingjin) approximately
3 cun above
the medial malleolus. Proximal
to this, the soleus (KID jingjin)
is thicker and covers the medial
leg, but starts to taper and become thinner, more tendinous and more
posterior as it approaches
the Achilles tendon. So,
this location at SP-6 sanyinjiao is
a place where the three yin channels, or at least their associated
channel sinews, can be seen to literally cross. This crossing leaves
an indentation, and needling SP 6 would advance the needle towards the
tibialis posterior muscle and
its associated fascia (Fig. 2).
Because
of the
crossing of the tibialis posterior muscle at SP 6, the flexor
digitorum longus (LIV jingjin)
is pushed slightly posterior, which alters its position and creates
another
indentation approximately 5 cun proximal
to the medial malleolus at the location of LIV 5 (Fig. 2). Advancing the
needle at LIV 5 penetrates this muscle and/or its associated fascia.
The most predictable results, especially if you are trying to sedate,
are accomplished with an
oblique needle
angle pointing
distally and against the
channel. The needle would be directed towards the posterior surface
of the tibia; a sensation usually travels down the channel, with
an occasional fasciculation observed
in the FDL muscle, and a slight
observable toe flexion occurring as the muscle is stimulated.
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| Fig. 2: Cadaver image of medial leg, gastrocnemius removed. Image shows tibialis posterior traveling anterior to FDL and emerging at SP 6. LIV 5 is also illustrated. |
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| Fig. 3: Liver jingjin from adductors through the iliacus and quadratus lumborum to the posterior diaphragm. |
Following
the Liver sinew channel along its course helps connect some of the
actions of this point. The Liver sinew channel includes many of the
adductor muscle group (adductor longus, brevis, gracilis, and
pectineus); the iliopsoas; and, in my opinion, the quadratus
lumborum, which is on the same fascial plane as the
adductors and the iliacus muscle (Fig. 3). Although
the QL is palpated at the low back (Fig. 4), it is a deep muscle which has
connections to the iliacus below and the diaphragm above. It is really a
yin muscle in terms of depth, and it is on a direct line from the adductors through the iliacus to the posterior attachments of the diaphragm.
Pain
at the quadratus lumborum, especially its iliac attachment which is
at the extra point yaoyan,
can cause moderate to severe
back pain which is often worse with turning. The pain can
radiate to the groin. Shortening
and contraction of the QL can elevate the ilium at that side. With
an elevated ilium, both the quadratus lumborum and the adductors are
in a shortened position, and may both present with pain.
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| Fig. 4: Palpation of yaoyan. Top image shows palpation of the superficial vector, which is at the iliocostalis muscle. Bottom image shows palpation of the deep vector, which is at the quadratus lumborum deep to the iliocostalis. Image courtesy Matt Callison / Sports Medicine Acupuncture |
When
there is palpable pain at the QL attachment at yaoyan,
LIV 5 becomes hypersensitive. Due to the tension in the sinew channel, LIV 5 is often much easier to find, as it has a
more defined and palpable indentation.
Proper needling of LIV 5 when there is pain at the QL attachment at
yaoyan will reduce
this pain by fifty percent. Try this: if you have successfully diagnosed that
there is pain at yaoyan*,
palpate yaoyan and ask
for a pain level from the patient on a scale of 1-10 (Fig. 4, bottom image - deep vector). Then needle
LIV 5, obtain qi,
and return to yaoyan for
palpation. Again, ask the patient to quantify the pain level. I find
that it frequently reduces by about fifty percent. However, I do not find that
this pain reduction will hold once the needle is removed unless you
successfully needle the quadratus lumborum at yaoyan
to further reduce
contraction into this muscle.
Needling of reactive motor points
in related muscles such as the gluteus medius and minimus greatly
increases therapeutic outcome. These
muscles are part of the Gallbladder jingjin, and are usually inhibited and locked-long as part of dysfunction with the
quadratus lumborum (which is
often overactive and
locked-short). Local, adjacent, and distal needling is a very
effective strategy when pain is diagnosed at yaoyan.
Points to consider are:
This produces a balanced TCM treatment with sustained results.
Points to consider are:
- yaoyan (deep vector)*
- gluteus medius and minimus motor points
- a host-guest point combination (source-luo) which includes LIV 5 (luo-connecting point of the Liver channel) and GB 40 (yuan-source point of Gallbladder channel)
- Dijia, usually on the contralateral side. This extra point is the motor point of the levator scapula, a muscle on the Small Intestine sinew channel. It frequently becomes dysfunctional along with QL. When the QL shortens and elevates the ilium, usually the levator scapula shortens and elevates the scapula on the contralateral side. This is a midday-midnight channel relationship involving LIV and SI
- other points for any internal disharmony (back-shu points, other channel points).
This produces a balanced TCM treatment with sustained results.
*Yaoyan is located approximately 3.5 cun lateral to the lower border of L4. It is at the iliac crest of one of two muscles: the iliocostalis lumborum, which is superficial, and the quadratus lumborum, which is deep. For the above discussion, LIV 5 reduces pain when there is pain at the deep vector which is at the iliac crest attachment of the quadratus lumborum.
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