radial nerve case

[Thomas]

Interesting patient case today, perhaps some of you "neuronuts " could
be of assistance :?:

59 y/o female retail worker, onset of pain 3 weeks ago, releates onset
to busy holiday season of repetitive flexion with adduction with internal rotation of the right arm. (reaching and hanging clothes on hangers- she
is about 5'3" and 210# )

CC= pain right pec /chest wall referring pain to right triceps/upper arm with c/o tingling in right hand (fairly constant) . 3 week onset - worsening
course at present. All testing of neck is negative, right shoulder ROM limited in standing , but full passively with patient in supine, and good jt. play of right shoulder.

Pec wall not terribly tender unless right arm in internal rotation, then it
is very tender. CC sx reproduced most strongly with For.Flex/ Adduction
and internal rotation. (Horizontal adduction - no problem) Right arm and
axilla non TTP. Pt has increased "tone" right scapular region and right
shoulder, but this is non TTP. Her arm is held in internal rotation as we
chat with some reluctance to move it. Blah, blah , blah.

Anyway , this sounds to me like a great case for neuromobilization -
haven't gotten the book yet. I would greatly appreciate any wisdom on
how to start these neural glides with her. ( showed her which movements
don't hurt - not holding arm in internal rotation when she left) and started her on movement in pain free range - right hand on medial right thigh with right arm/hand reaching palm up diagonally - ie "asking for change".
(from palm down to palm up )

Any thoughts :?: :idea:

Cheers...........Thomas

[bernard]

Thomas,

Certainly a typical neuronut work to do there!
I'm a breathing/muscular/neuronut and I would try to relax as a beginning the whole body. Some of us will use massage and soft tissue mobilizations, I'm starting almost at every session with an examination of the breathing patterns.

Pain carries often an elevation of muscular tone and a good mean to reduce it is simply restoring a good abdominal/diaphragmatic breathing.

http://www.somasimple.com/forums3/viewtopic.php?t=42

Then I would try to relax shoulders because you found pecs tighten then they are working (certainly with latissimus dorsi...). Internal rotation is a consequence of this constant activation. I'm not sure that the woman is able to move alone these area since they are painful but you have to go in that way with pain free activation.

1/ restore breathing
http://www.somasimple.com/forums3/viewtopic.php?t=438
2/ try a shoulder elevation against resistance
http://www.somasimple.com/forums3/viewtopic.php?t=47

The neuromobilization may be started after these ones
http://www.somasimple.com/forums3/viewtopic.php?t=435

Try this simple one.

[nari]

Thomas

I have reread your post several times and am a bit stuck on the abbreviations -

What is CCsx?

What is TTP?

I would test her median and radial nerve, which requires the opposite direction to the position that possibly invoked pain.

Are you familiar with PNF? If so, that is worth trying. It actually mimics some of the movements that are quite neural in nature, and provides movement for other structures too.

The other interesting manouevre is to have her place her (R) hand on her left shoulder (supine or sitting) and raise her elbow towards her face as far as she can, and repeat the manouevre about 5 times, if it provokes pain on the first movement. It gives the supraclavicular and suprascapular nerve a bit of a gentle rattling.

Bernard's suggestions are also well worth a try!


Nari

[Thomas]

Hello Bernard and Nari,

Cheers Bernard, thank you for the links (once again!) I am familiar
with PNF, and will definitely try the breathing patterns and the links
mentioned when she returns this week .

Sorry about the abbreviations, CC=chief complaint, Hx= history, Sx= symptoms and TTP= tender to palpation. These approaches that you offer are a radical departure from my previous way of treating , and am excited to give it a go. Greatly appreciate all of your help :D

Thomas

[Thomas]

P.S.- This patient was referred for a "Frozen Shoulder" :D :D :roll:

[Diane]

Thomas, looks like you've gotten a lot of good advice already. Still, I'd like to chime in with some ideas, from a soft tissue manual therapy standpoint, if I may.

A couple things struck me about your patient. First, she's short, and second, she was hanging up clothes for an extended period of time before she developed pain, 3-4 weeks ago. (Reaching up under load.). The pain is getting worse as time goes by.
There are these nuances:
1. pain right pec /chest wall
2. pain to right triceps/upper arm
3. tingling in right hand (fairly constant)
4. You've ruled out neck and shouder joint restriction
5. Pec wall is very tender with right arm in internal rotation
6. Pain increases with For.Flex/ Adduction and internal rotation. (Horizontal adduction - no problem)
7. not tender right arm and axilla.
8. increased "tone" right scapular region and right shoulder, not tender.
9. Her arm is held in internal rotation as we chat with some reluctance to move it.

Here's what I think (I see this all the time):
Lats are pulling down on the humerus from below. They aren't a problem except for on most people they are too shortened, bad for people who are already short. When she did her hanging up of clothes for an extended period of time, the lats interfered with her deltoid/pec that were trying to lift the arm up/forward. Not the supraspinatus, or there would be a bigger mess to deal with. The deltoid isn't really off line, because she can abd. her arm OK. So the lats and delts fought and it was a draw. Who got hurt in the process was the axillary nerve, probably, around the top of the shoulder, and is part of the same part of the brachial plexus that becomes the radial nerve.

Her pec might have been involved too, with the struggle to lift the arm. If so, the nerve that pokes up to the surface through pec minor (I can't recall its name just now) about the level of R3 mid clavicular line, may need solace.

I do hands-on, and what I usually do for the axillary nerve is sustained traction of the arm.
1. Patient is lying supine, a towel roll under the top of humerus to support it forward in the socket, arm down along side.
2. I position myself so that one hand can moniter the deltoid (If you check, I bet there is a cranky spot somewhere in it, usually somewhere at the top of middle deltoid, that you might have missed) and the other hand can traction from the patient's hand.
3. I grasp the entire middle finger of the patient's hand (the middle finger is the axis of the whole arm.) I pull lightly and slowly, until the whole deltoid softens and there is no tenderness. I hold it in a 'shutoff' position until the brain has had time to fix the pain problem, about two minutes, maybe a little longer. (The patient will usually go into a quiet relaxed mode.)
4. I let go just as slow as I pulled. We don't want any rebound. We're pulling on elastic structures and want them to stay/want her brain to keep them 'long'. Axillary nerve is usually much happier and less cranky following. I throw Kinesio tape around the deltoid sometimes, if I've had to give up before the nerve is completely better; one strip from posterior to anterior around the top of arm, and another strip up the side from mid humerus up and over the AC joint. Feels good, like a bungee cord holding up the deltoid.


Treating the pec part might no longer be necessary, after you stand the patient back up to check her movement again. But if it is, patient goes back to supine. I lay the arm out a bit from the side, hanging just off the bed, supported on a pillow on my lap. Find the tenderness (usually near the third rib on the front, but there are lots of nerves in the chest wall, and tenderness might be closer to the GH joint). Monitor there, and with the other hand, just lightly glue to the skin on the front of the arm closer to the elbow, and lightly stretch it downwards toward the hand. It's important to just get that skin layer pulled, not a bunch of muscular tissue. Just pull slowly until the cranky spot on the chest wall feels engaged and softens, then hold. All should then be well pec wise on internal rotation of the arm.

Maintenance movement: I ask patient to stand with feet turned in (to pull down and hold the PNS); I ask them to soften the knees and make themselves tall and do abdominal breathing. Once they've got this organized, I ask them to internally rotate their arms ("turn your thumbs in then back as far as you can, tighten your elbows, make your arms long"..) and then extend them at the shoulders ("lift them up behind you as far as you can. Stay tall, keep breathing.") Once up in the air I ask them to rotate their arms at the GH joint a very tiny amount ("size of a quarter") while maintaining the deep slow breathing. I ask them to stay there as long as they can, 30 seconds-a minute, and when tired to s-l-o-wly allow their arms to descend. (Don't want those pecs to snap back to the length they were, or that radial complex to slide right back into trouble territory.)

Good luck with all this,
Diane

[Thomas]

Hello Diane :P

Thank you for your comprehensive soft tissue approach. I have learned a lot from all of these posts and will definitely try these approaches with this lady. She comes back tomorrow , so will let you
know how things go.

Cheers........Thomas

[Thomas]

The radial nerve client returned today feeling better and with improved shoulder flexion after "asking for change" small range PNF type pattern, palm down to palm up. Couldn't get patient to actively touch opposite shoulder (breasts are too big),

Today used the Bernard , Nari, Diane approach.
:arrow: diaphragmatic breathing to start the session
:arrow: traction to right arm via middle finger for 3 minutes
:arrow: small range PNF per above
:arrow: traction to right arm repeated per above
:arrow: Dianes kinesio taping anter to poster and mid arm to A/C jt.

Post Rx: patient unable to find any tenderness in her right pec wall and no longer holding it with shoulder movement. Also, unable to palpate any tenderness after Rx in the shoulder area. Diane, I wasn't sure of the correct position to have the arm in during traction , so I did it via having the arm /hand slightly palm up. Overtreated a bit initially to get some internal rotation of the shoulder, but this was eased with the second traction attempt. Will keep you posted. Perhaps a consulting fee is on the horizon. :D

[Diane]

Hi Thomas,
I wasn't sure of the correct position to have the arm in during traction , so I did it via having the arm /hand slightly palm up. I use a neutral position, (radius up) or arm slightly internally rotated. I'm sure the forearm position isn't so crucial as using the middle finger is. Perhaps a consulting fee is on the horizon. Haha! We're PTs! It's free sharing of info!
Diane

[fapt]

may i ask....why do u know this patient has radial nerve problem?

I don't understand....

[Diane]

Hi Lin,
why do u know this patient has radial nerve problem?

Because of the distribution of the symptoms mostly. Chief complaint: pain right pec /chest wall referring pain to right triceps/upper arm with c/o tingling in right hand (fairly constant)

Cheers,
Diane

[Thomas]

Well.... the radial nerve case client returned today for her fifth appointment and was totally pain free with full and effortless ROM. No fancy shoulder mobs, strengthening memes, stretching etc... . Followed the regimen recommended above with pain free oscillations added to Upper trap with patients right hand near buttock. Wow...maybe these neuromobs really do work :D :D

Thanks to all for their insight and help.


Cheers.....Thomas

[Diane]

Congratulations Thomas! At first it's like swimming, you aren't sure the water can really hold you up. Then you find out it can and does! It's all in the relationship you take with the water and the associated physics.
Diane

[nari]

G'day Thomas

Welcome to the wonderful world of treating a process rather than a segment or a joint or some other item - maybe the other techniques work too, but I find much faster results with neuro stuff and education re the pain experience.

When I first started these techniques I did not know about the number of repetitions or frequency, and nobody else (including the protagonists at NOI) so I decided to play safe and mobilise frequently (every hour or more) for about 20 seconds at a time. Fewer flare-ups, and progress ensued, so, because I am so anti-strengthening repetitions (dozens of reps per day), that is how I have more or less continued, sepending on the judgment of how likely a patient's pain will flare.

keep thinking - brain - process - education...

Nari