Acupuncture is now widely used outside China by over 1,000,000 practitioners. In
fact, in a German pain clinic 90% of the Medics used acupuncture. Acupuncture
was first brought to Europe in the 17th Century but because of conflicts between
Eastern and Western therapies it was not widely used. The Traditional Chinese
Medicine (TCM) approach is based on holistic patterns and no linear logic, where
in contrast the Western approach is based on linear causal scientific theories.
Historical Development of Acupuncture in China
3000 –476 BC Earliest records
475 BC –24AD Theory of Meridians
24 –265 Systemised Acupoints (349 points)
265 – 581 Consolidation of knowledge
581 – 907 Meridians Mapped Out
907 – 1368 Acupoints
1368 1644 Revision of previous work
1644 – 1840 Decline of Acupuncture
1841 – 1945 Pro-Western Medicine (365 points)
1950 – now Systemised the basic theory. Clinical trials. Acupuncture
Analgesia. Developing ear, foot and hand points. (1000+ points)
Over the last 20 years, controlled clinical trials on chronic pain have
demonstrated acupuncture helps 55 to 85% of patients 1 and has lead to causal
mechanisms for the effects to be identified. One of the major steps forward was
the finding that Acupuncture Analgesia was inhibited by Naloxone (Mayer et al,
1977 & Pomeranz, 1976) indicating a link to opiate like systems. Further work
was undertaken and found that neurotransmitters (monoamines) were involved in
the process of acupuncture analgesia.
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Traditional Chinese Medicine focuses upon the effects on the vital energy / life
force (Qi). Apart from the polar system of yin and yang, there is a system of five
phases involving the elements of fire, wood, water, metal and earth all inter-
related and dependent upon each other. They are also related to body organs,
senses and emotions, as well as, external factors such as colour, weather,
seasons, direction and development.
Chinese syndromes are developed from assessment of key diagnostic criteria of
the interior / exterior, deficiency / excess, cold / heat and yin and yang.
Comparison of Traditional Chinese Medicine Approach
and Western Approach to Acupuncture
Traditional Chinese Medicine (TCM) Western Acupuncture
Formally an important part of the Incorporating Acupuncture into
"Holistic Medicine". Now Western and Western Medicine.
TCM are both offered in the medical 1. Does it rally relieve pain?
system in China. 2. How does it work?
3. Do meridians really exist?
Traditional Applications Applications
Dry Needling, Dry Needling,
Acupressure. Trigger Points,
Additional Applications Laser
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2. The Neurophysiology of Acupuncture
However the medical opinion at the time was that since there were no proven
physiological effects all of the treatment outcomes were due to other causes i.e.
hypnosis, placebo etc
2.1 The physiological mechanism of acupuncture
Of all the benefits of acupuncture (brochodilation in asthma, effects on gastric
motility, mood, addictive behaviour etc.), the analgesic effect of acupuncture has
received the most attention. The key research mechanisms of acupuncture
analgesia were the discovery of endogenous opioids and the neurochemical
process of pain.
The discovery of Acupuncture Analgesia and its inhibition by Naloxone
Acupuncture research made a substantial leap forward when two groups,
working independently, discovered that the opiate antagonist Naloxone blocked
acupuncture analgesia (Mayer et al, 1977; Pomeranz et al, 1976). These
substances are present in a multitude of centres in the central nervous system
and are also present in the nerve terminal of C-fibres in the periphery. They have
a range of effects on mood, control of breathing, coughing, possibly inflammation
and, of course analgesia. The function of these substances is directly related to
the specific receptors to which they bind (µ, , , ).
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2.2 Sequence of Events
Over the last 20 years, controlled clinical trials on chronic pain have
demonstrated acupuncture helps 55 to 85% of patients (Lewith et al, 1983) and
has lead to causal mechanisms for the effects to be identified. One of the major
steps forward was the finding that Acupuncture Analgesia was inhibited by
Naloxone indicating a link to opiate like systems. Further work was undertaken
and found that neurotransmitters (monoamines) were involved in the process of
The western theorisation of the acupuncture analgesia process relates the effects
of acupuncture to physiology. The simple insertion of a needle into the skin and
deeper tissues will result in an increase in endogenous opioids. The sensations
of tingling (A beta fibres), deep aching (A delta, C fibres) and distension or hot
sensations (A gamma fibres) are all frequently recognised and described by
patients. The sensations described are explained in Traditional Chinese Medicine
Following stimulation of the nerve fibres, the spinal cord receives impulses at the
dorsal horn at various levels (Laminae II – A delta & C, Laminae V – A beta). The
gate theory gives an explanation for the reason why the painful stimuli are not
transmitted to the higher centres of the brain and the blocking of pain stimuli.
Further complex neurophysiological processes resulting in transmission of the
stimuli to the brain stem and cerebral cortex also occur and result in both
ascending and descending inhibitory systems being activated. The main
structures stimulated are periaquaductal grey, substansia nigra, nucleus raphe
magnus, reticular formation, limbic system, thalamus and cerebral cortex. The
overall chemical effects are given in table 2.
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Table 2 Chemical Effects of Acupuncture
Area Chemical Effect
Local Histamine Healing Process
Spinal Cord Serotonin Regulate Analgesia
Central Endorphin Analgesia
2.3 The Pain Pathway (See Diagram 1)
Nerve Type Structure Function
A beta Large diameter myelinated touch, vibration, deep
A delta Small diameter myelinated Pain – sharp & localised
A gamma Muscle fibres
C Fibres Small diameter unmyelinated Pain – diffuse, dull (chronic
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A simple overview of the transmission of a painful stimulus would commence with
activation of A delta and C fibres. These fibres (1) carry the signal to the spinal
cord where the fibres synapse with cord cells (2&4) that carry the signal to the
cortex (5) via the thalamus (3) and limbic system (4).
2.4 Segmental Analgesia & Gate Control
Insertion of a needle into tissue and muscle will stimulate A delta & gamma fibres
(6) and transmit a signal to the spinal cord to the Anterior lateral Tract (ALT) (7).
This process also stimulates the "gate control" cell (8) which prevents
transmission of the original pain signal up the spinal cord. It is believed that this
process may occur via enkephalins and dynorphins (monoamine system).
This same gate control cell can also be activated via a second mechanism down
from the mid-brain (Dorsal lateral tract) (12). The ALT carries the signal to the
periaquaductal grey matter (9&10) from which it travels to the medulla oblongata
(11) and mid-brain (DLT) (12).
2.5 Systemic Mechanism
The signal from the ALT also travels to the pituitary & hypothalamus (13,14&15)
where it results in the release of b-endorphin, ACTH (cortisone = anti-
inflammatory) and enkephalins.
The emotional components of pain (depression, anxiety and attitudes) are
developed through the limbic system.
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Acupuncture Needle Painful Stimulus
Muscle 1 C & A Delta
Type II 6
7 2 4
11 3 System
Pituitary Hypothalamus Complex
Circulation Diagram 1.
Adrenal Cortex The Pain Pathway &
+ B Endorphins Effects of Acupuncture
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Direction of impulse Nerve cell
Excitatory Synapse Inhibitory Synapse
DLT Dorsolateral Tract ALT Anterolateral Tract
STT Spinothalamic Tract M Monoamines
2.6 Local / Distant needling
Local needling produces a fast intense analgesia which is short acting. Distant
needling produces a slower longer-term analgesia via the pituitary & thalamus
2.7 Electrical Effects
Low frequency (2-4Hz) high intensity stimulation produces an effect of the opoid
system (pituitary & Thalamus). Slow onset but long lasting analgesia, cumulative.
High frequency (50-200 Hz) low intensity stimulation produces an effect on the
gate control cell (dynorphin & enkephalin) fast onset but short-term analgesia, not
2.8 Manual Effects
Appears to act in a similar manor to low frequency stimulation.
Therefore, the best mechanism would be stimulate local and distant points over a
regular given period of time to develop the cumulative effect.
Note that some patients have limited endorphin receptors and therefore the
results of acupuncture are poor.
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Needles – mostly stainless steel solid needles, which are flexible and
unbreakable. The diameter varies from 0.2 to 0.5mm (gauge 26-32). Remember
the smaller the gauge the thicker the needle!
Commonly 30 gauge (0.3mm) are used of various lengths from 1 to 10cm. They
consist of tip, body and a handle. It is recommended that sheathed needles be
used until experience is gained in needling.
Use only sterile needles and never reuse.
4. Safety and Contraindications
The following advice is provided to enable you to treat patients safely and should
therefore be thoroughly understood. The patient should be warned of fatigue
post treatment and the treatment protocol should be explained prior to
commencement of needling.
4.1 Contraindication to needling
1. Avoid treating disturbed patients. For safety the patient must be able to
cooperate with the therapist.
2. Avoid treating fatigues patients. Acupuncture can exacerbate existing
fatigue. It can be treated, but this is not covered on this course.
3. Avoid treating hungry patients and unstable diabetics, as low blood sugar
levels could cause fainting.
4. Do not treat patients with acute cardiac arrhytmias and heart failure.
Needling can affect blood pressure and interfere with medication.
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5. Avoid lumps and bumps. They might be malignant or a mass of unknown
6. Do not treat pregnant women. We advise not to treat pregnant patients
with acupuncture, as any problem during pregnancy could be attributed to
it. Acupuncturists do treat pregnant women but this is beyond the scope
of this course.
7. Children. Although acupuncture is routinely used on children we do not
recommend its use by students as they can react strongly.
8. Avoid the traditional Forbidden Points of Traditional Chinese Medicine
a) Ren 8 – over the umbilicus. This point only treated with moxibustion
and never needled.
b) Stomach 17 – Over the nipples. This point is used as a landmark for
locating other acupuncture points.
c) Heart 1 – In the axilla, due to it's proximity to delicate structures.
9. Varicose veins, inflammation or unhealthy skin
Caution is required when needling the following:-
1. Patients on anticoagulants as bleeding can be expected.
2. Patients on steroids. These patients respond less well to acupuncture and
it is advisable to leave 3 months once steroids are stopped before using
acupuncture, as the presence of steroids in the blood can reduce its
3. Patients with impaired sensation. Extra care during treatment is required.
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Be Careful when needling the following points.
1. Stomach 30 – near to femoral artery.
2. Bladder 1 and Stomach 1 – near the eye.
3. Stomach 21 – on the right side, it overlies the gall bladder.
4. Neck region – Ren 22, Colon 18, Stomach 17, Du 15 and Du 16. Due to
their proximity to dangerous structures.
5. Points over the chest
- Lung 1 and Gall bladder 21. Due to the danger of pneumothorax.
- Bladder 11 to 23. Posterior to the trunk/chest.
6. Liver 3 – This point can be sensitive on some people.
7. Lung 9 – Radial artery.
4.2 Possible complications
Methods of dealing with these complications will be dealt with during the course.
1. Stuck needle
2. Bent needle
3. Broken needle
4. Fainting and nauseating
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7. Delayed complication – hepatitis
8. Allergy from swab
9. Infection especially near the ear
10. Delayed bleeding (patient on anticoagulant)
11. Allergy to stainless steel
5. Methods of Locating Acupuncture Points
5.1 Anatomical Landmarks
Prominent anatomical markings on the body surface can be used to locate
acupuncture points i.e. joint creases, the eyebrows, hairline the nipple etc.
Example: Yintang (Ext1) midpoint between the eyebrows
Weizhong (B40) in the middle of the posterior crease of the knee joint
5.2 Finger Measurements
The Chinese 'body inch' or cun is the standard measurement.
The breath of the distal phalanx of the thumb equals I cun.
The distance between the interphalangeal creases of the middle phalanx of
the middle finger equals 1 cun.
The combined breath of the four fingers at the level of the proximal
interphalangeal joint of the little finger equals 3 cun.
(See Diagram 2)
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5.3 Using a cunometer
A special designed pair of calipers which measure the patient's cun allows
more accurate measurement especially if the patient's body differs widely for
Location by reference to another point
Eg. Fenglong (St40) located 1 finger breath lateral to Tiaokou (St38).
5.4 Proportional Measurements
In an average person the points of the body are in proportional to each other.
Eg. Between the two nipples = 8 cuns.
Inferior margin of sternum to umbilicus = 8 cuns.
(See diagram 2b)
5.5 Using an Acupunctoscope
The skin over an acupuncture point has a higher electrical conductivity due to
lower electrical resistance. Therefore an electronic point detector which
flashes or sounds an alarm when it detects this can be used for locating
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6. Deqi Techniques
Deqi is the sensation experienced by patients receiving acupuncture when
the needle reaches the correct depth. It is a mixed level of the sensations
of fullness, heaviness, tingling or warmth.
1. Thrust and withdraw rapidly
2. Small rotations
3. Flicking needle handle
4. Scraping needle handle
7. Tender Points (Ahshi points)
Certain points on the body which may or may not coincide with acupuncture
points become tender in certain conditions. There points can be needled to
help relieve pain.
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8. Specific Acupuncture Points Table 3
Effect Point Location
Analgesic LI 4 Highest point m. adductor pollicis with the thumb
and index finger adducted.
St 44 0.5cun prox to margin of web between 2/3 mets.
St 43 Depression distal to junction of 2/3 mets.
Tonifying Ren 6 Midline 1.5cun below umbilicus
Ren 8 Umbilicus
St 36 Finger's width lateral to lower border of tibial
tuberosity, 3cun below knee joint.
Sp 6 3cun above medial malleolus, dorsal to posterior
border of tibia.
Sedative Du 20 Line connecting lowest & highest points of ear,
on median line of the head. 7cun above
posterior & 5 cun behind anterior hair line.
Ex 6 (head) 4 points, 1 cun anterior, posterior, lateral (2) to
He 7 Transverse crease of wrist, radial, to tendon of
m. flexor carpi ulnaris.
UB 62 0.5cun below lateral malleolus.
Homeostatic LI 11 At end of lateral transverse elbow crease, when
forearm is flexed at 90 deg.
Sp 6 As above.
St 36 As above.
Immune Enhancing LI 11 As above.
Du 14 Below spinous process of C7
Du13 Below spinous process of T1
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9. The Extra-ordinary Points
After the acupuncture points had been numbered in ancient times and placed
in their appropriate channels, many new points were discovered during the
course of the succeeding centuries. These new points are termed 'Extra-
ordinary points'. While the majority fall outside the fourteen regular meridians,
some are located on the course of a meridian, and a few even coincide with
regular points of the meridians.
Some of the commonly used Extra-ordinary points are:-
1. Yintang 0.5 Cun Horizontally downwards.
Location: On the ridge of the nose, midway between the medial ends
of the two eyebrows
Indications: headache and rhinitis.
2. Taiyang 0.5 Cun Perpendicularly.
Location: On the temple, in the depression 1 Cun directly posterior to
the midpoint of a line connection the outer end of the
eyebrow with the outer canthus of the eye.
Indications: headache, migraine, trigeminal neuralgia, toothache and
3. Yuyao 0.5 Cun Horizontally along the skin.
Location: At the midpoint of the eyebrow, vertically above the midpoint
of the pupil.
Indications: Frontal sinusitis and facial paralysis.
4. Heding 0.5 Cun Perpendicularly.
Location: On the midpoint of the upper border of the patella.
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Indications: Disorder of the knee joint.
5. Xiyan 0.5 Cun Perpendicularly or Obliquely towards lateral-Xiyan.
Location: In the depression of the medial side of the ligamentum
Indications: Disorders of the knee joint.
6. Baxie 1 Cun obliquely and Proximally.
Location: On the dorsum of the hand, on the webs between the 5
fingers; 4 points in each hand, totaling 8 points. These
points are best located having the patient form a fist.
Indications: Disorder of the fingers, rheumatoid arthritis, numbness of the
7. Bafeng 0.5 Cun Obliquely and Proximally.
Location: On the dorsum of the foot, 0.5 Cun proximal to the borders of
the webs between the 5 toes; 4 points on each foot, totaling
Indications: Arthritis of the toes, numbness of the foot and the toes,
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10. Myofascial Trigger Points
One of the characteristics of this type of pain is its tendency to become
chronic if not treated appropriately and to be associated with trigger or tender
points. These are exquisitely tender to mechanical stimulation points in the
muscle proper, i.e. not at the musculotendinous junction and usually situated
amidst an area of the muscle which feels like a taut band upon palpation.
Palpation of a trigger point will elicit the pain which the patient is originally
complaining. According to Baldry (1993) trigger points are sites of
hypersensitivity in muscles, tendons, ligaments and joint capsules. They can
either be latent or active. If latent they are painful only when palpated, if
active they are able to produce pain spontaneously.
The formation and biology of the trigger point has been the point of
controversy amongst scientists and clinicians alike. The current consensus is
that these points are formed within the muscle fibres due to a local
disturbance of the contractile apparatus of the muscle (i.e. the actin-myosin
complex) which is caused either by local ischemia or disruption of the
cascade of events governing muscle contraction (Mense 1997). Travell
(1952) postulated that when muscle sarcomeres, the muscle unit containing
the contractile elements of actin an myosin, are damaged the calcium usually
stored in the surrounding sarcoplastic reticulum pours out onto the actin and
myosin filaments causing them to contract. When this occurs in a number of
units the section of muscle tightens without stimulation by a nerve impulse.
The tightness or spasm does not appear to fade as the calcium is gradually
lost from the actin-myosin unit, as one would expect.
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The issue of the pattern of referral of the pain due to a trigger point has been
extensively studied and it has been found that it is due to the complex
neurophysiological connections of the afferents innervating the muscle. In
short, each nociceptive afferent (i.e. a nerve fibre that transmits stimuli which
are translated into pain in the brain) located in the muscle has a connection in
the spinal cord and/or in the periphery with a nociceptive afferent which is
responsible for an area on the skin, distal to that of the ailing muscle. For a
very detailed description of these patterns of referral see Travell and Simons
(1983) and Baldry (1993).
Once trigger points are activated, tension will be produced in surrounding
tissues. This could cause the development of further trigger points or
activation or pre-existing trigger points. Trigger points in muscles could
therefore stress other, non muscular soft tissue structures and produce trigger
points. Like acupuncture points, there is consistency in the site of trigger
points from person to person. The common clinical diagnostic criteria of a
trigger point are summarised below:
Table 4: Clinical characteristics of myofascial trigger points.
1. Localized tenderness in a taut band of muscle
2. Local twitch response to the contracted, taut band upon palpation
3. Referred pain felt in a distant region
4. Restricted movement
6. Autonomic dysfunction (e.g. pilomotor effects, increased temperature etc.)
(After Gerwin, 1994)
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Muscles with activated trigger points frequently have palpable taut bands
which can be found as tight rope-like structures. Needling these taut bands
can release the spasm almost immediately. If no taut bands can be found,
trigger points can quickly be desensitized by needling. It may be necessary to
needle repeatedly in the same muscle to desensitize each activated trigger
point. The needles are left in place a matter of 30 seconds to a minute and
then withdrawn. Traditional acupuncture points are not used unless they
correspond with trigger points although it has to be stressed that Fax,
Melzack and Stillwell found a correlation of 91% between trigger points and
acupuncture points. Baldry uses a shallow needling technique rarely using a
needle longer than one inch in length. He believes it is not necessary to
insert the needle deeply into muscle to release the trigger point. Gunn,
however uses a much deeper needling technique believing the needle should
be inserted to the centre of the site in spasm.
10.1 Myofascial Pain Syndrome & Fibromyalgia
Occasionally in our clinics we come across patients who defeat our best
efforts at diagnosis. Their history is non-specific and their pain pattern does
not fit with any previously encountered conditions. They are sometimes
referred to as 'pain everywhere' patients. At the end of the assessment the
therapist is often non-the-wiser as to the diagnosis.
The typical presentation of multiple areas of pain, without a clear history can
be very confusing. Tow syndromes have been described.
What are now known as two conditions, myofascial pain syndrome and
fibrositis have undergone several name changes and been the focus of
considerable argument as to whether or not they are two extremes of one
condition or two entirely separate conditions. For example summary of the
history and development of this subject see PE Baldrys' Acupuncture, Trigger
Points and Musculoskeletal pain (1993) Second Edition.
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Although both have symptoms of muscle pain in common, myofascial pain
syndrome pain is characteristically localized to one area of the body, although
at times several sites maybe affected simultaneously. Fibromyalgia pain
symptoms are far more widespread. Myofascial pain syndrome effects men
and women equally whereas fibromyalgia affects approximately 90% women.
Myofascial pan syndrome often has an identifiable trauma as its origin, unlike
fibromyalgia. The American College of Rheumatology's Multi-centre
Fibromyalgia Criteria Committee (Wolfe et al 1989) have found that the best
criteria for diagnosis was widespread pain and the finding of 11 or more
tender points on digital palpation at 18 possible sites.
According to Baldry (1993) Myofascial pain syndrome can be effectively
treated if the myofascial trigger points are desensitized by needling.
Fibromyalgia however is more difficult to treat. Symptoms may be eased
temporarily by needling but they generally return. The trigger points are
hypersensitised, possibly by an unrecognized noxious substance in the
circulation, therefor efforts to desensitize these by needling tend to have only
short term results. Diagnosis is not easy and what one may initially believe is
fibromyalgia may turn out to be myofascial pain syndrome and respond well to
acupuncture. An open minded approach is recommended but with the
realization fibromyalgia patients can become dependent upon the short term
relief acupuncture can give.
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11. Common Podiatric Conditions of the Lower Limb
and Associated Acupuncture Points
1. Locomotor Disorders
The principles of treatment are
i) to locate and needle the Ah Shi points
ii) Treat the pain located to the channel both locally and distally
iii) Select the corresponding axis
iv) If muscle or tendon - GB34 indicated
If bone, joint or cartilage - UB11 indicated
Analgesic points - Co 4 & ST44 indicated
2. Peripheral Blood Flow
TCM approach is that of stagnation of the Qi and blood with vigorous stimulation
Homeostatic points are Co11 and ST36 plus Blood vessels Lu9 & EX28, 36.
Other points include: UB15 Co4 GB34 Ren17 He3 Liv3
3. Leg Ulcers & Wound Healing
Points should be proximal and distal to the ulcer site plus points located on ulcer
site or channel of opposite limb.
General points include: Lu7 & 9 Liv11 Sp6 Du14
TCM approach is a deficiency of Yin in the lung. Points are located through Lung
and Liver. Also requires a change in nutrition.
Points include: regional points + Du14 Liv 4 &11 He7 Sp6 &10 St36
Long term treatment of 2 to 4 cycles with 10 –12 sessions in each.
Points in affected area (surround the dragon) + Du20 Liv11 Lu5 & 7 Sp6, 10 & 36
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6. Lateral Ankle Pain (Peronneal)
B11 & 62 GB40,42,34 ST44
7. Medial Ankle Pain (Posterior Tibialis and Tarsal Tunnel Syndrome)
Focus points on Kidney, Spleen and Liver channels
SP5 & 6 Liv 3 & 4 Ki 3,4 or 5 B11
8. Dorsal / Anterior Ankle Pain (Extensors)
Focus on Stomach and Liver.
Liv 3 & 4 GB34 St41 & 42 B11
9. Posterior Ankle Pain (Gastrocnemius Group / Tendon)
Focus on Kidney and Bladder.
Ki3 & 7 GB34 B11 &60 + B55 through to 67
10. Mid tarsal Joint Pain
Points at location of pain + B11, 62 & 63 GB40 &41 Ki2 Liv3 St42,43 &44
Points at location of pain +
B62 & 63 GB42 & 43 Liv 1,2 & 3 Sp2 & 4 St43 & 44
12. Medial Arch Pain
St44 Sp3 & 4 Liv 2 & 3
13. Heel Pain Syndrome (inc Plantar Faciitis etc)
Points at trigger points of pain + ki1 Co4 St44
Periosteal pecking may be useful.
Sp 2 & 3 St44 B11 Liv1
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15. Post Operative Pain
Dependent upon cause, area and meridian involved + C04 and St44
16. Reflex Sympathetic Dystrophy
“Surround the dragon” + Co4 St44
Du14 for anti inflammatory & immune effect
Sp6 for influential point for skin
17. Rheumatoid Arthritis
Known as Bi in TCM and is the result of a disturbance of Qi and Blood from wind,
cold, damp and loss of protective Wei Qi.
There are a number of syndromes with varying points. However, acutely inflamed
joints can be treated by local and distal meridian techniques.
Other conditions that could be considered
OA joints Neuroma of intermetatarsal spaces
Knee pains + other joints as part of secondary therapy to orthosis.
Next follows Meridian points and a list of diagrams. Have not included due to size
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