Confused about a nerve impingement

[My Question]

I have a regular client, late 60's male, who has been complaining of tingling and numbness in the arms and hands (little finger, ring finger) and sharp pain at and above 90 degree abduction. I have been an MT for almost 10 months and have been dealing sucessfully with nerve impingements of this sort, but this one seems to involve more muscles and I'm a bit confused on the best approach.

So far I have had two sessions focused on this, and went about checking for a response from the common problem sites - scalenes, pec minor, ant. deltoid. They were tight as he has a protracted posture, but didn't elicit the response. When I went to work on his usual complaint site - upper back, his levator scapula, particularly at the origin, set it off. That coincides well with the limited abduction beyond 90degrees.

But, I found during that and our last session that supraspinatus and infraspinatus sets it off as well. He has no history of shoulder injury, but he does have a history of recreational baseball and his chief complaint is that he can't throw a baseball with his grandson.

I also notice that his head is always inclined to flex to his right when he is supine on the table.

I don't see the connection between levator scapula, and the rotator cuff muscles involved. Is it possible for infraspinatus to cause to refer pain down the arm to the hand?

 

[Stephen T]

Confused about a nerve impingement

Well, to build upon this...I found a muscle I don't think about often - Serratus Posterior Superior. It refers pain down the arm into the pinky and ring fingers. And it is deep to the superior angle of the scapula which is why the origin on levator was suspect, as well as supraspinatus at it's origin as well. And it can be felt at teres minor which is close enough to infraspinatus. But that doesn't explain why it is triggered at and above 90 degree abduction

 

[Superdave]

Confused about a nerve impingement

Great detective work!

Maybe I can shed some light on this... (?)

Thought #1 - I'm willing to bet that there's a history of an MVA or a work injury somewhere along the line.
Thought #2 - If this is happening, and especially on both sides, it's most likely a problem with the position of the vertebrae. I say this because of:

• The presentation of the levator scap symptoms, especially at their origin, which is C1-C4
• The presence of not only pain (which would fit well with the trigger point idea) but also neurological symptoms (the numbness and tingling) - this suggests the nerve impingement involved commonly at the nerve roots, and almost always due to vertebral misalignments - the distribution described is roughly C8 - I would then also check for forearm flexor muscle issues and finger muscle extensor and side-to-side movement issues (T1) (basically the neighboring nerve roots to C8).
• The bilateral nature of the symptoms - also suggestive of a more central root cause (i.e. spinal/vertebral) versus a peripheral one

Thought #3 - I also don't rule out brachial plexus, so you're spot-on to check scalenes (the first site of muscular impingement, and check the pec and axillary areas as well as pronator teres. Check for this on both sides. I wouldn't be surprised to find it on both sides, but secondary to something more central, such as vertebrae malposition.

Hope that helps! If you need a good chiro doc referral, lemme know and I'll do my best. I'm both a DC and an LMT so I know some trusted, talented people

 

[Rob S]

Confused about a nerve impingement

Interesting information, jyoti.

I will ask him next time if there is a history of MVA or work injury.

I don't know if you read my post about Serratus Posterior Superior, but this muscle can cause the specific nerve pain referals that my client experiences. It explains also why the pain is felt around the superior angle of the scapula. It doesn't directly explain the pain at and above 90degree abduction, but your information on levator scapula's role makes sense, and it can tie into serratus in that the cervicle vertabrae are an attachment site as well as the ribs.

 

[Rhymhey]

Confused about a nerve impingement

Well, when you find out for sure can you let us know.
I recently had an EMG done because of sharp, constant back pain.
I have my own theories and an orthopedic appointment as well.
I also was very symptomatic of right carpal tunnel which was confirmed
with the EMG. Now, within the past three weeks, my left arm started up.
I had cubital tunnel/ulnar nerve operation and it seems to have come back
like gangbusters. I thought it could be that I was maybe overcompensating
with the left arm because of the right, or possibly some diabetic neuropathy
but well, I'm a newbie returning after years of being out of work due to all my
medical *stuff*. But if you can give this person relief, please let us know.

I've heard of cubital tunnel returning but I do have a stitch in my shoulder ever
since this happened.

 

[Mr Phucking NR]

Confused about a nerve impingement

I've just continued to address Serratus Posterior Superior, levator scapulae, and to a lesser extent rhoms, SITS, scalenes. He seemed to respond strongly to Serratus and lev scap an every two weeks i see him he can raise his arm higher and higher and reviews improvement. no mva or work accidents.

 

[KRISTIE]

Confused about a nerve impingement

Good clinical reasoning so far! It sounds like you are on the right track.

I've just continued to address Serratus Posterior Superior, levator scapulae, and to a lesser extent rhoms, SITS, scalenes. He seemed to respond strongly to Serratus and lev scap an every two weeks i see him he can raise his arm higher and higher and reviews improvement. no mva or work accidents.

Continue to address serratus anterior and pecs as well, particularly pectoralis minor. If you know how, use AIS or PNF stretching, or Muscle Energy Technique (MET) to stretch those anterior muscles, and also to strengthen the posterior shoulder muscles you are working with. If he doesn't gently strengthen those tissues, he will remain at increased risk of reinjury when he returns to throwing baseballs.

I also recommend that you check PASSIVE (client relaxed, not helping nor resisting) internal and/or external rotation. If the client's shoulder presents a "hard" or "bone-on-bone" type end feel, he probably also has some form of capsular adhesion restricting normal function of the glenohumeral joint. If so, you need to address that too, sooner rather than later.

 

[Cov]

Confused about a nerve impingement

Nerve root syndromes are those that produce symptoms of nerve impingement (a nerve is directly irritated), often due to a herniation (or bulging) of the disc between the lower back bones. Sciatica is an example of nerve root impingement. Impingement pain tends to be sharp, affecting a specific area, and associated with numbness in the area of the leg that the affected nerve supplies.

 

[Amar C]

Confused about a nerve impingement

I have a client with a similar issue. I originally thought it was TOS (Thoracic Outlet Syndrome), he has upper-crossed posture, but the tests were negative. I checked the joint play of the Cx and things seemed ok. Eventually I found that a lot of his pain/tingling was caused by Subscap, but not all of it. So we've been working on correcting his posture with corrective exercises, massage, and MET's and he's coming a long well. If you can't figure out the exact cause do some postural observation and correct what is needed. If the Client is balanced out the pain usually goes away... usually.

Also, what someone said above, take him through the passive ROM to rule out jnt involvement.

 

[Yoyo]

Confused about a nerve impingement

Jason, thanks for the tips. You will be interested in the lastest development.

TrP, cool name and your post also comes about at great timing.

This guy is a real onging project because he comes every 2 weeks so he keeps me on my toes. Every visit he can lift it higher, but the cause seems to shift with this new ROM.

It started out as Serr. Post-Sup being the main trigger (believe I didn't learn that one in school!), and then levator, RC lat rots. I WANTED the cause to be pecs and scalenes because they are so unbelievably tight...but they weren't his main complaints, and they didn't elicit a response in the arm and hand. This went on for a few sessions.

One time I see him I was amazed at how "soft" the muscles of his upper back felt, not to mention his middle and low back. I had also worked on (possibly) spinalis and iliocostialis throacis knots that I figured were from a life of desk work. Whether or not that is related - the back seemed softer and the upper back muscles were still eliciting a response, but way less intensely.

Then the weirdest thing happened last week...

He came in and his main complaint with the shoulder wasn't abduction, but rotation - especially when arm is at full extension. Back muscles still felt soft, but lat rotators (teres, infraspinatus) were moderately tender. I decided I could afford to spend more time on the neck and chest and I pounded away at scalenes for a bit and wondered if his neck didn't seem to be as laterally flexed as usual. Then I get to pecs and it's a bit of a new area so I do some pretty general palpation and massage scanning for points and he (a man of little words so i take what i can get) says "Yeah, I think that;s the spot". this after I worked all his usual spots. I asked him whether the sensation was stronger or weaker than the back and he said stronger. I tested lat and med rotation and both were pretty limited.


Anyway, hour was up and he seemed pleased with the immediate results.


I'm wondering what your guys' take is on this. He is my most consistent client and its not of a strong monetary interest that I am posting my treatment - it is wanting to really see what can be accomplished.

TrPAssasin,

I have suspected subscap here and there for some reason, even though I do not work on it often because I am relecutant to dive into my clients' axillae. Any thoughts on the new info I posted in relation to your experience?

Jason and others, any input would be very welcome as well.

Also Jason, I am not familiar with capsular adhesions.

 

[moel]

Confused about a nerve impingement

I think Jason may be on to something, could be Adhesive Capsulitis (Frozen Shoulder) if so, what you are doing is good because no matter what kind of intervention is usually takes around a year to recover from.

Also, how is the quality of movement and is there any pain on active/resisted isometric int/ext rot of the shoulder or any part of ROM? On passive how does the shoulder feel and does the mvt elicit pain? If so then it may be a jnt or jnt capsule/ligament issue.

And thanks about the name

 

[Jack A]

Confused about a nerve impingement

Like I mentioned he experiences pain during isotonic and isometric ext and int rotation of the shoulder.

I haven't assessed the end-feel so much. It is not something I am too familiar with, but I;m sure I can discern a bony end-feel.

I will have to look into this capsule issue.

 

[That guy]

Confused about a nerve impingement

I have been having success with James Waslaski's approach to releasing the shoulder capsule, but I couldn't find a video for you. Here's an alternative method that you might find useful: http://www.youtube.com/watch?v=qf5D7BrXLAY

On that page there is also a link to an Erik Dalton technique somewhat similar to this one. He moves much faster than I would recommend, but the basic idea is similar. Hope that helps!

 

[Christian]

Confused about a nerve impingement

Something I've noticed when working with people with chronic/long term muscle problems is that as you get the initial tight spots and triggers to let go, often the problem spots move somewhere else. When you think about it, it makes sense. The body tries to splint and support painfull areas, and it also tries to balance itself. So, if the front is tight to splint something, the back will grow tight to balance the tension, and vice versa. If the lower body is tight for some reason, the upper body will tighten up to balance. So it is not surprising that when you get good release in one area, you will find that the opposing areas now feel overly tight. And the longer the problem has been in place, the more of the body will be involved. Don't be afraid to assess and treat muscles outside the original problem area, the body has strange and wonderfull ways to cope. You may find that the opposite lumbar or hip is involved, or the other side of the neck, or the other shoulder. Or, you may hit a plateau where nothing you can do further improves things, and the client needs x-rays or an MRI to find underlying causes like spurs or tears. I usually recommend clients see a chiropractor first if massage is not noticeably improving the kind of ROM/tingling problems you describe. From personal experience, I know that subluxations can cause many subtle, hard to describe problems as well as the classic, acute stuff like sciatica. A question: in your state, can you reccommend exercises to your clients? Some homework in the form of ROM and strengthening exercises might just be helpful. :altsmile:

 

[Sheng Thao]

Confused about a nerve impingement

Great detective work!

Maybe I can shed some light on this... (?)

Thought #1 - I'm willing to bet that there's a history of an MVA or a work injury somewhere along the line.
Thought #2 - If this is happening, and especially on both sides, it's most likely a problem with the position of the vertebrae. I say this because of:

• The presentation of the levator scap symptoms, especially at their origin, which is C1-C4
• The presence of not only pain (which would fit well with the trigger point idea) but also neurological symptoms (the numbness and tingling) - this suggests the nerve impingement involved commonly at the nerve roots, and almost always due to vertebral misalignments - the distribution described is roughly C8 - I would then also check for forearm flexor muscle issues and finger muscle extensor and side-to-side movement issues (T1) (basically the neighboring nerve roots to C8).
• The bilateral nature of the symptoms - also suggestive of a more central root cause (i.e. spinal/vertebral) versus a peripheral one

Thought #3 - I also don't rule out brachial plexus, so you're spot-on to check scalenes (the first site of muscular impingement, and check the pec and axillary areas as well as pronator teres. Check for this on both sides. I wouldn't be surprised to find it on both sides, but secondary to something more central, such as vertebrae malposition.

PERFECT! Thank you for clearing up very eloquently, where I would need to work exactly. I was looking for some advice on that same issue. I don't run in to too many clients with impinged nerves through their neck and arm...it is more so with the Sciatic nerve and that's a breeze to correct. This ,on the other hand is doable, but I just needed a little extra advice on where else to massage and if it truly could be a vertebral thing. Thank you once again for your advice
-Malena

 

[Renee P]

Confused about a nerve impingement

Sciatica is a breeze to correct??? Please enlighten me as to how to do that. I've suffered from recurrent sciatica for most of my life, due to an inherent looseness in the apparatus that holds the vertebrae in place, and a bunch of injuries. I've pretty much resigned myself to the fact that one side or the other of my low back, glutes, and legs is going to hurt all the time. I can throw my illiosacral joint out just turning over in bed! Right now the back of my right thigh is burning and tingling so much it is painful to sit. Yesterday, it was the left one, and I went to my chiro to get fixed, and now it is the right side. I'm overweight and getting older, that doesn't help, but this has been a life-long problem. If there is a way to fix, prevent, or even lessen the constant pain, I and my clients would be very gratefull!!

 

[Cheyanne]

Confused about a nerve impingement

At least to find and work on...is what I really meant (about the sciatica). Compared to the nerve impingement around the brachial plexus area, that is.

As far as your injuries go, I do not specialize in medical massage, so I only say that for the clientel that I have recieved and worked on, which vary in size, health,etc..but I am no physical therapist. I am sorry that you are going through so much pain. The only thing that has worked for me and my clients is the more consistent you are about stretching,getting exercise and ,of course, massage, would greatly increase the ability for your muscles to be re-trained into their anatomically correct position. I have had sciatica as well, and it is no fun at all. I have lost about 20 lbs. since then and I don't have it as much or often. I stretch everyday now. I want to be a good example to my clients and not tell them to do things that I don't even practice myself. I take one 10-15 minute hot bath every day to every other day- or I just soak in a hot tub at my gym if I can help it, and that helps substantially with my tight muscles. I only drink water (on occasion a mineral water or soda) and whenever I feel that tingly or strained feeling in my glutes, which is a signal that if I don't take care of that problem, it will turn into sciatica,and I don't want to even go there, so I get my therapist to use his elbow or fist and stretch my glutes out. The tightness is gone, and then I can go about my usual body maintainence routine. I have about a medium muscle tightness...some people have more loose muscles and they have muscles that feel like jello but mine, even if I stretch,etc...still get tight...so you just have to stay on top of it and do what you have to do to prevent any further problems. Every body is different and I just found out what works for me and actually took my own,and other therapists advice. A foam roller is your friend and you should consider purchasing one ( I got mine for $20 at Academy- Sports and Outdoors, and it has been a life saver )A tennis ball or for even more direct pressure,a golf ball would do. The foam roller would be less abrasive but even the tennis ball, if sat on( along the piriformis area) and rolled around, would loosen up your muscles. I have even used a broom stick handle(it was rounded) and just leaned on it and swirled it around...but that is if you don't have anything. There is going to be pain involved when tending to these issues, but you will feel a release when and if properly worked on. I hope this clears things up for you Have a good day.

-Malena