If you’re a Chinese medicine student or new practitioner, getting confident with herbal formulas can feel overwhelming—especially for common patterns like Liver Qi Stagnation. Where do you start? Which herbs actually matter? And how do experienced clinicians think about formulas and modifications?
This guide is designed to help you build a solid foundation. You’ll get a clear overview of the key single herbs, classical formulas (with a special focus on what’s most useful in practice), and the clinical thinking behind them.
Think of this as an idea-starter—not a prescription manual. The nuances of dosage, modifications, and real-world application must always be guided by your supervisor, your textbooks, and your ongoing experience. If you’re looking for basic pattern definitions or symptoms, see What is Liver Qi Stagnation? for a full, plain-language breakdown.
Ready to move beyond rote memorization? Let’s dig into the core herbs and formulas that every TCM student should know for managing Liver Qi Stagnation.
🟩 Regulating Qi—Not Tonifying
The classical treatment principle for Liver Qi Stagnation is to regulate (sometimes called “rectify”) the Qi—restoring its smooth flow throughout the body. In practical terms, this means focusing on herbs and formulas that move or spread Qi, not those that tonify or supplement.
Why is this so important?
Many students confuse symptoms of Liver Qi Stagnation—like fatigue, cold hands and feet, or digestive changes—with deficiency patterns. In reality, these symptoms are usually a result of Qi not moving as it should, not because there isn’t enough Qi. Adding tonics can actually make the stagnation—and the symptoms—worse.
Key clinical points:
Avoid tonics in pure stagnation: Tonifying or cloying herbs (especially sweet herbs like Dang Gui or Di Huang) can further aggravate digestive symptoms related to blocked Qi.
Recognize the real cause of fatigue or appetite issues: In Liver Qi Stagnation, energy and appetite often fluctuate with stress or emotional states. If the patient’s symptoms wax and wane, especially getting worse under pressure and better with movement or relaxation, think stagnation—not deficiency.
Loose bowels and cold extremities?
These are common in Liver Qi Stagnation due to disrupted Qi movement—not true Yang or Qi deficiency. Stress-related diarrhea and variable digestion are classic.
Bottom line for students:
When in doubt, look for patterns of fluctuation (better or worse with stress, mood, movement) and signs psychological distress (sighing, holding emotions in, mood disorders). Save tonics for clear deficiency patterns confirmed through careful differentiation.
🟩 Key Single Herb is Chai Hu: The Centerpiece for Regulating Liver Qi
Chai Hu (Bupleurum) is the foundational herb for treating Liver Qi Stagnation in both classical and modern practice. It’s central to nearly every important formula for this pattern and is unmatched for its ability to restore the smooth, natural flow of Qi—especially in those who are constitutionally prone to constraint.
Much of the understanding around Chai Hu, constitutional types, and classic formulas presented here is drawn from the work of Professor Huang Huang (Nanjing University of Traditional Chinese Medicine), especially his books Ten Key Formula Families in Chinese Medicine and A Manual of Classic Formulas for Primary Care. These resources are highly recommended for students seeking a deeper clinical perspective.
What Chai Hu Treats—Beyond Just Patterns
Chai Hu doesn’t treat abstract patterns. It targets specific symptoms and presentations—most often related to pain, fever, and fluctuation.
Key presentations include:
Chest and hypochondriac fullness or discomfort:
Feeling of pressure, tightness, or fullness in the chest or rib-sides.Alternating or episodic symptoms:
Classic example: alternating chills and fever, like during influenza. But can also relate to symptoms that come and go, or cycle with stress, emotions, the seasons, or menstruation.Symptoms along the Shao Yang channels:
Discomfort, strange sensations, or lumps appearing anywhere along the lateral line of the body: chest, flanks, shoulders, neck, forehead, lower abdomen, hips, and groin—especially the sides. This is a classic Chai Hu territory.
🟩 Chai Hu Constitution—Who Is Most Prone?
Anyone can develop Liver Qi Stagnation, but certain constitutions are more likely to both show these symptoms and respond to Chai Hu-based formulas.
Hallmarks of the Chai Hu constitution:
Build: Skinny to medium, often with a darker, less lustrous complexion. Muscles may be firm, especially in the hypochondrial area (below the ribs).
Tongue and pulse: Firm, dark tongue, sometimes dry; pulse tends to be sunken, thin, and forceful, occasionally wiry, but not weak.
Subjective, shifting symptoms:
Feeling hot or cold, mood swings, appetite that changes with emotions. Nausea, stuffy or tight sensations in the neck, diaphragm, or abdomen. Along with dizziness, anxiety, or depression. These symptoms are often more subjective than objective—patients feel worse than they look, and medical tests are often unremarkable.Cyclical, stress-aggravated complaints:
Symptoms fluctuate with weather, temperature, stress, or sleep. Discomfort worsens under pressure, but improves with exercise or positive social experiences.Women:
Irregular periods, PMS, and symptoms worsened by stress or overwork are very common.Predisposition to chronic, even autoimmune disease:
Although Chai Hu constitutions often “look healthy,” they can be prone to more serious disorders over time.
Clinical Indications—What to Look For
Emotional symptoms: frustration, irritability, anxiety, low mood
Stress-related digestive issues: nausea, fluctuating appetite, abdominal distension, stress diarrhea
Rib-side, abdominal, chest, or neck and shoulder discomfort.
Cyclical or alternating symptoms (hot/cold, well/sick, up/down with changes in environment, stress, and sleep)
PMS, menstrual irregularity, especially stress-aggravated
Cautions for Students
Not a tonic: Chai Hu is about regulation, not supplementation. Patients appear well nourished and have a variety of subjective complaints.
Blood stagnation overlap: Chai Hu treats Qi constraint, but if blood stagnation dominates, Chai Hu formulas are still utilised with modifications.
Not for every patient: If symptoms are related to long-term illness, malnutrition, fatigue worse on exertion, weight loss, this may be deficiency, and you should re-evaluate the pattern.
Clinical Tip
Chai Hu shines in cases where the main story is “fluctuation.” If your patient’s symptoms are mostly subjective, stress-reactive, and if the lateral aspects of the body or mood are involved, think Chai Hu first. Always individualize your formula, and remember: you are treating the person, not just the label.
🟩 The Core Formula is Si Ni San: Ancient Roots, Modern Application
Si Ni San (Frigid Extremities Powder) originates from the Shang Han Lun (Discussion of Cold Damage), one of Chinese medicine’s most foundational texts. Section 318 famously states:
“Shaoyin disease, if there is counterflow cold of the limbs, cough, palpitations, difficult urination, abdominal pain, or diarrhea with rectal heaviness, Si Ni San governs.”
Although this formula appears in the “Shaoyin” section (often associated with Yang deficiency), modern commentators agree: Si Ni San treats Liver Qi Stagnation, not Yang deficiency.
What does this mean for students?
Si Ni San is not a warming formula for deficiency; it’s a powerful Qi regulator for constraint caused by psychological or emotional distress.
The inclusion of cold extremities is critical, but the underlying problem is blocked or depressed Qi—not a lack of Yang.
A Formula for Physical Symptoms of Psychological Distress
Si Ni San’s true genius is its broad application: it treats the many physical symptoms that can arise from stress, emotional strain, and internalized tension. It is as relevant today as it was centuries ago.
Symptoms Si Ni San Treats:
Chai Hu presentation or constitution:
Skinny-to-medium build, dark complexion, dry skin, and a tendency to subjective, fluctuating symptoms.Pain as a chief complaint:
Jaw pain, headaches, neck and shoulder pain, chest pain, premenstrual breast distension, abdominal pain, or even spasmodic complaints like leg cramps, hiccups, bruxism. These pains are usually aggravated by emotions, stress, or poor sleep. Patients are often very sensitive to pain.Abdominal distension and organ discomfort:
It is important to find tightness, especially beneath the ribs (palpation reveals a hard, sometimes painful area). Subjectively the patient feels discomfort and stuffiness in this area. On occasion, Si Ni San can also be used for actual organ disease like gastric ulcers, gallbladder disease, gastritis, and kidney stones. Symptoms are likely to be colicky and intermittent.Cold extremities—especially at the fingertips and toes:
The cold is most severe at the tips and can fluctuate with stress or emotion (e.g., becoming clammy or cold when nervous). Skin colour remains normal, despite the sensation.Tongue and pulse:
Dark and firm tongue; pulse is sunken, thin, but with strength—sometimes wiry.
Clinical Insights & Application
Wider scope than many realize:
The original Shang Han Lun description points to Si Ni San’s utility across respiratory, digestive, urinary, circulatory, and even reproductive complaints—whenever symptoms stem from Qi constraint and emotional/psychological triggers. For instance, chest pain and cough with little to no phlegm, worse when the temperature changes, worse when thinking about it, and no signs of lung disease.For “constraint, not deficiency”:
If the main issue is stagnation—especially with clear emotional or stress links—Si Ni San is often the right starting point, even if symptoms look complex.Classic modifications:
Adjust with added herbs for heat, blood stasis, digestive symptoms, or other symptoms. Example, plus Gui Zhi for palpitations, or plus Chuan Xiong for headache, or plus Dang Gui for painful periods.
Student Takeaway
Si Ni San is the blueprint for treating physical symptoms that arise from emotional struggle and internal constraint. Mastering its indications—and learning to palpate for that characteristic hypochondriac tension—will serve you across countless clinical scenarios.
🟩 Common Modifications and Other Formula
Why Modify?—while Si Ni San is a foundational formula for Liver Qi Stagnation, real patients rarely fit a textbook case. Modifying the formula—by adding or swapping herbs, or by blending formulas—lets you tailor the approach for each person’s symptom cluster, especially in functional disorders.
Chai Hu Shu Gan San
A classic example of Si Ni San’s adaptability.
Commonly prescribed for rib-side discomfort, alternating chills and fever, gastric symptoms, and a poor appetite.
Built from Si Ni San and enhanced by adding herbs like Chen Pi, Chuan Xiong, and Xiang Fu.
Especially useful when Qi stagnation coexists with pronounced upper digestive symptoms.
Si Ni San + Ban Xia Hou Po Tang
Excellent for sensations like a lump in the throat (“plum pit Qi”), neurogenic nausea/vomiting, frequent urination, or stress-affected bowel symptoms.
Often combined with Si Ni San for complex functional disorders—especially IBS, stress diarrhea, or other psychoemotional presentations.
Xue Fu Zhu Yu Tang
Used when stubborn pain, insomnia with restlessness, or irritability seem linked to blood stasis.
Modification involves adding herbs like Dang Gui, Chuan Xiong, Tao Ren, and Hong Hua to move blood and address pain. Herbs like Di Huang, Jie Geng, and Niu Xi are also standard in this formula, but some feel they are unnecessary.
Particularly effective for chronic upper body pain, spasmodic pain, or sleep issues in emotionally distressed patients.
How to Approach Modifications as a Student
Start with the parent formula: Understand Si Ni San—what it does and who it helps.
Adjust for prominent symptoms: Add or modify ingredients to suit digestive, gynaecological, pain, or emotional features as needed.
Study other formula families: Many successful prescriptions are built on adapting and combining core formulas like Si Ni San + Ban Xia Hou Po Tang. Other examples not mentioned above include Si Ni San + Zhu Ling Tang, Si Ni San + Si Wu Tang + Gui Zhi Fu Ling Wan.
Always cross-check: Discuss modifications with a supervisor or refer to authoritative texts before prescribing—modification is where most clinical nuance lives.
🟩 Dietary and Lifestyle Adjuncts for Smoothing Liver Qi
While herbal formulas can be at the heart of managing Liver Qi Stagnation, practical dietary and lifestyle choices can play a meaningful supporting role.
Dietary Tips
Reduce greasy, rich, and spicy foods:
These can worsen stagnation, especially if symptoms include digestive sluggishness or bloating.Limit alcohol and caffeine:
Both are considered aggravating to the Liver, while some find them temporarily relieving, they may make emotional and digestive symptoms more volatile.
Lifestyle Tips
Exercise regularly:
Physical activity is vital—many symptoms of Liver Qi Stagnation improve after exercise, whether it’s brisk walking, swimming, cycling, or your preferred form of movement.Express emotions and connect with others:
Socialising with trusted friends or family, honest conversations, journaling, or creative hobbies can all help release held-in frustration, anger, or sadness. In Chinese medicine, holding in emotion—especially anger—is seen as a key driver of Liver Qi Stagnation.Prioritise sleep and relaxation:
Overwork and lack of good sleep can aggravate stagnation. Aim for a regular sleep routine, create a restful environment, and consider activities like listening to calming music to support relaxation and mood.
Clinical tip:
These simple adjustments support herbal treatment, but do not replace the need for professional assessment or ongoing supervision, especially for persistent or severe symptoms.
🟩 Safety, Scope, and Professional Practice—A Note for Students
Herbal medicine can be powerful, but it’s never “one size fits all.” Even classical formulas like Si Ni San require careful assessment, individualisation, and ongoing supervision.
Always consult your teachers, clinic supervisors, and trusted textbooks for issues around patient safety, interactions, suitability of treatment, and correct dosing.
Never prescribe or modify formulas on your own—especially for complex, chronic, or unfamiliar presentations.
Use this resource as a guide for foundational ideas and clinical reasoning, not as a substitute for hands-on teaching or authoritative references.
Your growth as a practitioner comes from asking questions, seeking guidance, and learning from every case. Start here, but always check with an experienced supervisor before bringing any herbal principle into practice.
🟩 Final Thoughts—Building Your Clinical Confidence
Liver Qi Stagnation is one of the most common and complex patterns you’ll encounter as a Chinese medicine student or new practitioner. Understanding the role of herbs like Chai Hu and foundational formulas such as Si Ni San is a valuable starting point—but it’s only the beginning.
Remember, your real skill will come from:
Listening to your patient’s story and symptoms, not just matching patterns.
Asking thoughtful questions, seeking mentorship, and cross-referencing your choices with classical texts and clinical guidance.
Respecting the nuance and individuality of every case—herbal medicine is never “one size fits all.”
Let this guide inspire your learning, deepen your clinical reasoning, and encourage you to keep refining your approach. Most of all, remember: effective practice is a lifelong journey, and every patient is your next teacher.
🟩 Author
Adam Hjort is a Registered Acupuncturist and member of Australian Acupuncture & Chinese Medicine Association (AACMA). He has been practicing since 2010 and maintains a clinic dedicated to the treatment of pain, inflammation, stress, and other health conditions, located in Ashmore, Gold Coast.
