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Starter Content >> Body Regions >> Upper Extremity

UPPER EXTREMITY: 

Nerve Entrapments

Nerve Entrapments

Nerve Entrapments

This section shows you MAR® and IAR® for the most common upper extremity nerve entrapments. These are involved in at least 50% of cases in this region and are among the most underdiagnosed and under treated conditions in the human body. 

 

Upper extremity nerve entrapment locations:

  1. Nerve Roots with Scalenes
  2. Neurovascular Bundle with Subscapularis
  3. Median Nerve
    • with Pronator Teres
    • with Flexor Digitorum Superficialis
    • with Carpal Ligament
  4. Ulnar Nerve
    • with Flexor Carpi Ulnaris
    • with Hypothenar
  5. Radial Nerve with Posterior Forearm

 

Nerve entrapment is suspected when the first order history is consistent with nerve adhesion and confirmed with positive exam findings. Particularly palpation of adhesion with diagnostic passes using the following protocols.

MAR: Nerve Roots at Scalenes

Cervical nerve roots can become adhered to the middle and anterior scalenes. This can contribute to any upper extremity nerve symptom and alter cervical biomechanics and load. 

MAR: Subscapularis with Neurovascular Bundle

The neurovascular bundle can become adhered to the subscapularis. This can contribute to many upper extremity nerve symptoms and alter shoulder biomechanics and load.  

Median Nerve

Median Nerve entrapments can cause symptoms:

  1. Aching and/or burning anywhere along it’s course (including cutaneous nerve branches)
  2. Pain/Tenderness/Hypertonicity to any of the structures it supplies (medial elbow/flexor group)
  3. Numbness/tingling/decreased sensation to the palm of the hand and first 3 1/2 digits.

Starting proximal and working distal the most important median nerve and related entrapments are:

MAR: Median Nerve at Pronator Teres (Model)

MAR: Median Nerve at Pronator Teres

MAR: Median Nerve at Flexor Digitorum Superficials 

IAR: Median Nerve at Transverse Carpal Ligament 

Ulnar Nerve

Ulnar Nerve entrapments can cause symptoms:

  1. Aching and/or burning anywhere along it’s course (including cutaneous nerve branches)
  2. Pain/Tenderness/Hypertonicity to any of the structures it supplies (medial elbow/flexor group)
  3. Numbness/tingling/decreased sensation to the hypothenar palm and medial 1 1/2 digits.

Starting proximal and working distal the most important median nerve and related entrapments are:

IAR: Ulnar Nerve at Flexor Carpi Ulnaris

IAR: Ulnar Nerve at Hypothenar

Radial Nerve

Radial Nerve entrapments can cause symptoms:

  1. Aching and/or burning anywhere along it’s course (including cutaneous nerve branches)
  2. Pain/Tenderness/Hypertonicity to any of the structures it supplies (extensor group)
  3. Numbness/tingling/decreased sensation to the dorsum of the hand and dorsum of the lateral 3 1/2 fingers.

Starting proximal and working distal the most important median nerve and related entrapments are:

IAR: Radial Nerve with Extensors

There you have it. You can effectively treat the 8 most important and common nerve entrapment sights in the upper extremity. 

Check the Hands-on Courses calendar to register for the corresponding seminar.

Forearm

Forearm

Forearm

Elbow and wrist dysfunction most commonly causes lateral and medial elbow symptoms. This section covers assessment and treatment of these regions. 

 

LATERAL ELBOW PAIN

The prevalence of lateral elbow pain in the general population is about 2%. There are several tissues and pathologies commonly responsible for lateral elbow pain:
 
1. Common Extensor Tendinosis
2. Extensor Adhesion
3. Radial Nerve Entrapment

 

Common extensor tendinosis is a degenerative condition secondary to excessive load and decreased blood supply. The tendon becomes tender/painful, the collagen disorganized and strength decreases.  

Lateral Elbow Pain and Tendinosis 

Make sure you learn and use the whiteboard demonstration at 5:04 to explain tendinosis. You need patient understanding and compliance to get results. 

Nirschl Tendinosis Pain Phases:

Phase 1: Mild pain after exercise, resolves within 24 hours
Phase 2: Pain after exercise, exceeds 48 hours, resolves with warm-up
Phase 3: Pain with exercise that does not alter activity
Phase 4: Pain with exercise that does alter activity
Phase 5: Pain caused by heavy activities of daily living
Phase 6: Intermittent pain at rest, does not disturb sleep, and pain with light activities of daily living
Phase 7: Constant rest pain and pain that disturbs sleep.

Treatment for common extensor tendinosis is several fold:

1. Decrease Load: Reduce use/load on the tissues with activity modification. This is your number one option, as it works best. Have the patient switch hands, use a roller bag instead of carrying bags etc. Load must be decreased for treatment to be maximally effective. In instances where load can not be decreased treatment will take a long time and other load management options can be used (use of a compression strap to redistribute load off the tendon).

2. Reduce adhesion from the extensor/elbow tissues. Adhesion causes the tissues to be weaker, less flexible and have a further decreased blood supply. See the extensor adhesion section below.

3. When the tissue is ready for some increased load institute eccentric exercises. This is the best way to reorganize and regrow the tendon substance. The dose of eccentric exercise is base on the tissue tolerance. Work your way up to 2 sets of 15 reps twice per day. 

4. The common extensor tendon can be directly worked with IAR to breakdown some of the tendinotic granulation tissue, stimulate healing and small amounts of inflammation/blood flow. 

With patient compliance and excellent treatment 80-95% of common extensor tendinosis can be successfully treated with conservative measures. If the tendinosis is severe, the patient is non-compliant or there are confounding factors (stress, diet, metabolic issues) surgery is a very successful option. Surgery is only considered after failure of conservative treatment.

From this research article: “Among patients with chronic unilateral lateral epicondylalgia, the use of corticosteroid injection vs placebo injection resulted in worse clinical outcomes after 1 year, and physiotherapy did not result in any significant differences.” This is why your patients need the ID system!

Extensor adhesion develops from overuse related hypoxia. The extensors are used in gripping, carrying, typing- really any use of the hand or the wrist. The extensors primary function is to provide compressive stabilization of the wrist as with carrying luggage, deadlifts, chin-ups etc. With typing and mousing the extensors are nearly always active; the only rest is the fraction of a second when a key or button is pressed.

There is no reliable biomechanical test for length the extensor group. Wrist flexion is limited by the joint shape and would require massive adhesion to be limited by extensor muscles.

When this area is symptomatic use IAR for assessment and treatment.

IAR: Extensors

This protocol includes the following structures:

  1. Brachioradialis
  2. Extensor Carpi Radialis Longus
  3. Extensor Carpi Radialis Brevis
  4. Extensor Digitorum
  5. Extensor Digiti Minimi
  6. Extensor Carpi Ulnaris

IAR: Proximal Extensor Tendon

After the majority of the extensor group has been successfully treated or if there are radial nerve symptoms, palpate and treat the radial nerve entrapment locations. See the upper extremity nerve entrapments page.

Review of flow for lateral elbow symptoms, diagnosis and treatment. 

MEDIAL ELBOW PAIN

Medial elbow pain most often results from an imbalance between load and capacity of the flexor region of the anterior forearm. This region is subject to less load and has a better blood supply than the lateral elbow, therefore medial elbow symptoms are less common than lateral elbow symptoms.

Adhesion in the flexor region can limit wrist extension. Assessment begins with the wrist extension testing.

Wrist Extension

Wrist extension range of motion must be full and pain free to engage in many sports (push-ups, pitching, pressing, front rack position in weight lifting…) and is a reliable window into the strength and function of the flexor muscles (anything involving grip, wrist or finger motion). 

Wrist Extension Anatomy: these structures have to lengthen to achieve wrist extension

  1. Flexor Carpi Radialis
  2. Palmaris Longus
  3. Flexor Carpi Ulnaris
  4. Flexor Digitorum Superficialis
  5. Flexor Digitorum Profundus
  6. Flexor Tendons with Palmar Fascia
  7. Anterior Wrist Ligaments (really only involved post trauma or immobilization)

We will utilize selective tension to narrow down the tissue list.  

Wrist Extension with Fingers in Flexion 

  1. Have the patient place the flexor portion of their forearm against the wall at about shoulder height.
  2. Place the index finger of the opposite hand on the metacarpalphalengeal joints and pull the wrist into extension.
  3. Keep the fingers flexed and relaxed.
  4. Normal range is about 90 degrees.
  5. With healthy soft tissue the carpal joints will reach end range without pain, tightness or stretching.

This test is positive when the range is less than 90 degrees or significant pain or tightness is present. When positive palpate and treat the following structures with Instrument Adhesion Release. These structures cross the wrist but not the fingers and are therefore most likely to limit wrist extension with fingers in flexion: Flexor Carpi Radialis, Palmaris Longus and Flexor Carpi Ulnaris. 

IAR: Superficial Flexors

 

IAR is used instead of MAR because these tissues are superficial rendering IAR superior: less work for the provider AND better results. 

Wrist and Finger Extension 

  1. Have the patient place the flexor portion of their forearm against the wall at about shoulder height.
  2. Place the fingers of the opposite hand across the fingertips of the hand being tested, and pull into full wrist and finger extension.
  3. Keep the fingers and wrist in full extension.
  4. Normal range is about 80 degrees of wrist extension and 65 degrees of finger (MCP) extension.
  5. With healthy soft tissue the joints will reach end range with mild generalized stretching.

The wrist range is 80 degrees instead of 90 because the wrist will tend of back out of full extension as the fingers are pulled (path of least resistance). The test is positive when the range is reduced or significant pain or tightness is present.

 
When this test is positive palpate the flexor digitorum superficialisprofundus and flexor tendons with palmar fascia (they cross the wrist and finger joints).

IAR: Deep Flexors 

IAR: Flexor Tendons with Palmar Fascia

After the bulk of the flexors have been assessed and treated, wrist extension maxed out and symptoms persist the median nerve and ulnar nerve will require assessment and treatment. See the upper extremity nerve entrapments page for evaluation and treatment of these locations.
Shoulder

Shoulder

Integrative Diagnosis shoulder assessment begins with the shoulder abduction test.

SHOULDER

Perform this motion assessment for every patient with shoulder symptoms. Some cervical and thoracic problems will also require shoulder assessment and treatment.  

Shoulder Abduction Test

1. Patient has their shirt off or tank top/gown
2. Demonstrate motion
3. Observe from the posterior for a few reps (to ensure proper technique)
4. Hold top position
5. Observe from the side to check for flexion compensation. Correct if present.
6. Take picture from posterior while patient holds top position
7. Note symptom location, quality and intensity
8. Measure range and grade function

Shoulder Abduction Test: Grading Function

 

There are two ways to measure SA:

  1. Actual Angle Measurement: This method should be used on the initial exam and after significant progress has been made (usually around visits 3-6). Use the picture you took at the top of SA. Import the photo into Keynote. Add a line from the GH joint to the middle of the elbow. Measure this angle. Show and explain this to your patient. Use it  for comparison pre and post treatment. Watch this video:

Measuring Shoulder Abduction: Keynote Software
 

2. Arm to Head Distance: This is the middle column on the above chart. This is best used for immediate feedback pre and post most visits. It’s quick and easy but a little less accurate and A LOT less compelling for the patient. The fastest way to measure this distance is to use your fingers (4 fingers is about 3″, one finger is about 0.75″) This is similar to how we measure Supine Hip Flexion. 

After assessing and recording the range of motion data, move to palpating the five tissues that commonly restrict SA. Palpation allows us to determine the extent and severity of adhesion. Shoulder Abduction worksheet.

When Shoulder Abduction is restricted palpate and treat the following structures in this order:

Manual Adhesion Release: Infraspinatus

 

 

Manual Adhesion Release: Teres Minor

 

 

Manual Adhesion Release: Subscapularis

 

 

Manual Adhesion Release: GH Capsule (Posterior Inferior Fibers)

 

 

 

You must attend the hands-on seminars to even get close to proficient MAR treatment. The online material is only designed to prepare you for the hands-on courses.

Test-Treat-Retest:

After treating one structure retest shoulder abduction test. This will allow you to mentally link what you feel with immediate feedback (improvement or no change). This is a big part of how you improve palpatory skill and ultimately determine if a tissue has adhesion or not. When first learning these techniques it is tempting to base results on motion improvement alone. Please do not do this. It helps to think of palpation as language immersion- you just do it until you start picking up the language. Practice, practice, practice.

SACPULOTHORACIC MOTION

As patients progress through treatment and pass 90%, observation of dysfunction becomes more subtle. It is now important to distinguish between glenohumeral (GH) and scapulothoracic (ST) motion. Excessive ST motion can compensate for restricted GHmotion. 

Excessive ST motion is produced via elevation and rotation of the scapula. There are many difficult ways to determine if ST motion is excessive… don’t bother with those inferior tests. There is one very reliable assessment to determine if ST motion is excessive: look at the space between the neck, upper trap and deltoid at the peak of SA. There should be space here, if not ST is excessive.

When ST motion is excessive you address restriction of the GH range with more treatment of the infraspinatus, teres minor, subscapularis and GH capsule (watch and practice the above MAR procedures again). This will correct the vast majority of cases with excessive ST motion.

HOW WELL DOES ID AND MAR WORK? 

As an intro to the April 2018 hands-on seminar Dr. Brady treated two attendees with limited shoulder abduction. This is the same assessment and treatment outlined above. See for yourself how well these methods work! 

Shoulder Assessment and Treatment: Part 1

Infraspinatus: 5 passes for 63 seconds
Teres Minor: 3 passes for 39 seconds
Subscapularis: 3 passes for 90 seconds
GH Capsule: 3 passes for 45 seconds 

4 structures > 14 total passes > 4 minutes! 

 

 

More videos to be posted as we get them edited!

Scapulothoracic and Glenohumeral Relationship:

SA directly involves the glenohumeral (GH), scapulothoracic (ST), acromioclavicular (AC) and sternoclavicular (SC) joints. Unless otherwise obvious on history (i.e. AC separation) the GH joint is responsible for restricted SA at least 95% of the time.

Excessive scapulothoracic (ST) motion is a functional compensation for restricted GH motion. The idea that excessive scapular motion during SA is the result of inhibited lower traps or weak rhomboids is false. The levator scapula and serratus anterior activate while the mid/lower traps are inhibited. This allows ST motion to increase, as a compensation, so the arm can still contact the head with limited GH function.

Simply put: when GH range is limited ST motion becomes excessive to compensatorily improve gross range.

Knowing this you should not perform scapular stability and/or facilitation exercises, as the scapular motion will normalize without the need for stability or facilitation exercises.

With good Manual Adhesion Release treatment on these structures (infraspinatus, teresminor, subscapularisand GH capsule) the shoulder abduction test and scapulothoracic assessment should become normal. If the patient has plateaued, still has symptoms or requires an even higher level of function proceed to the elevation/depression test.

SCAPULAR ELEVATION/DEPRESSION TEST

After shoulder abduction and scapulothoracic tests are normal scapular elevation/depression can be tested. However, most patients will not need this high level of function. If the patient still has symptoms or requires a very high level of function (overhead athletes, crossfit, gymnast etc.) proceed with this test.

  • Perform shoulder abduction test and ST tests (must pass)
  • In top position have patient place hands palm to palm
  • Have patient lock elbows with biceps still touching the head (If they can’t do this stop here, it’s a positive test)
  • Instruct patient to elevate and depress scapula while maintaining palm contact, locked elbow and biceps touching head

Combined elevation and depression range should be 2-3 inches (measured at the inferior angle of the scapula)- again while maintaining palm to palm contact, locked elbows and sliding biceps along the head. This is a very demanding test! 

Scapular Elevation/Depression Test 

The test is positive if they can’t get into position, range is limited, effort is excessive or significant symptoms are produced.

When the Scapular Elevation/Depression Test is positive palpate and treat the Latissimus Dorsi 

IAR: Lat