In order to give you a better idea about how we work at Art of Physio we are going to write a series of case reports.
This case report is purely for informational purposes.
The report gives a detailed description of an actual case I (Pieter) saw in the clinic recently. It describes what we found and did, sprinkled with some extra information and insight on the subject of nerve entrapments.
Enjoy, and please let us know what you think!

 

Client overview

A woman, 30 years of age came in with severe pain in the right (dominant) hand, wrist and fingers. It started 6 months ago when she started working from  home with her laptop on a raised surface. When she was typing she had her hands at chestlevel. From there the complaints gradually built up over time. Five weeks ago while playing golf, she hit the ground which hurt her hand even more. That aggravated the complaint significantly.

The physical complaints she was describing were:

  • lack of strength in her hand (she couldn’t pump a soap pump),
  • a numbing, sometimes shooting pain in her forearm, wrist, hand and fingers on the pinky side when she was cutting vegetables, flipping a pan or slicing cheese. She had to stop after a minute because it would hurt so much.
  • Also she was unable to work behind her laptop for more than 15 minutes because of the pain. Her wrist was also making all kinds of clicking noises.

Her work was busy, but she liked her job and it was not particularly stressful.

Her pain levels were 8/10 (on a scale from 0-10 ).

She had never experienced these kinds of issues before and was quite worried. She was going into another job which would require some manual lifting etc and she didn’t feel she would be up for the job because of the pain.

In her history there is 1 ski-thumb (’13) on the right side, and she broke her right wrist twice in ’04 and ’06

 

Analyses

When I hear a story like this, I always try to determine the timeline first. Is there a specific thing that happened and caused the issue, or did it build up over time. 

In this case there was a combination, a build up over time because of a different working position that got an extra hit when she hit the ground playing golf. This strained the same tissue that was already sensitive and worsened the issue. 

Another thing I always ask and screen for are previous injuries. This is because we often see a link between the current injury and previous injuries. She has had several other issues (2x a wrist fracture and a skithumb). Even though they happened a long time ago, it doesn’t mean they can’t influence today’s issue. In this case there is not a clear relation between previous injuries and the current, other than that the forearm and wrist mobility might have decreased because of the two fractures.

 

Because of the numbing and shooting pain I was thinking more towards a nerve involvement versus a joint or muscle issue. To be more precise, the brachial plexus and the ulnar nerve.

 

During the physical examination we found:

  • Her neck was limited in side bending towards the left (tightness on R front side of the neck). Other neck movements were ok.
  • Nerveroot provocation test was negative (Spurling test)
  • Limited shoulder movement on the right side towards forward and sideways movements (flexion and abduction). The clavicle bone wasn’t rotating, and there was a lot of tension in the subclavius and pec minor muscle)
  • Her forearm had a limitation in rotation, pronation (rotating the palm down) was more limited than to supination (rotating the palm up)
  • Her wrist movements were also limited. Mainly towards extension.
  • Fingers were ok

 

ulnar nerve

nerves in the arm, wrist and hand

The arm is innervated by the brachial plexus. This is where the spinal nerves get reorganized and redistributed as peripheral nerves.

There are 3 nerves that travel towards the hand and fingers. The medial nerve, the radial nerve and the ulnar nerve (the blue one on the picture). Each has a different area they innervate. Where you feel the symptoms often gives a good indication which nerve (or nerves) is involved. 

Symptoms on the pinky side correlate with ulnar nerve involvement. 

The ulnar nerve travels from the brachial plexus down towards the medial elbow, forearm, wrist and the pinky side of the hand. There are 6 common sites (circles in photo)where the ulnar nerve can become entrapped between tissues.

Upon palpation, we found 2 spots (red circles) that duplicated her symptoms in her hand, wrist and fingers. One at the flexor carpi ulnaris muscle (red circle at elbow) and a bit higher up at the plexus brachialis level. we found that the nerves of the plexus wouldn’t glide relative to the scallene muscles. This can also cause similar symptoms towards the hand. 

A duplication of symptoms is generally a sign you are in the right spot.

Nerve entrapments

Nerves are stringy strings that run through, in between and next to muscles, tendons, ligaments and fascia. Ideally, these nerves slide smoothly relative to these tissues. When there is a tightness, limitation, or adhesions in that surrounding tissue, it can compress or ‘tug’ on the nerve. This creates friction and can cause a compression or irritation of the nerve. 

When there is a mechanical compression of a nerve, it can also compress the internal blood vessels of a nerve. This leads to a decrease of oxygen and nutrients in the distal part of the nerve and you will start to develop symptoms after a while. That is often why these type of issues can start at one spot and then spread out over the entire arm or leg.

A nerve entrapment can cause a variety of symptoms like tingling, numbness, muscle weakness, burning, ache, electric shock pain, hypersensitivity and/or circulatory changes. It is surprising to see how much nerve entrapments are influencing ‘regular’ injuries. Most people know carpal tunnel syndrome, sciatica or hernia’s. However, throughout the body there are over 92 common spots where nerves can get entrapped and cause issues. It is always a good idea to check the nerves too. 

It always surprises me how well you can locate nerves (and entrapments) if you know what to look for. Being able to find, assess and address neural movement is one of the perks of being a Active Release Techniques provider. 

Our treatment

Our first contact was over the phone and I advised her to start doing nerve flossing for the ulnar nerve (see the video). In the 10 days between our first contact and the first session in the clinic, her symptoms already decreased with about 40% because of the nerve flossing.

Our go-to treatment modality for a nerve entrapment like this is Active Release Techniques (ART). With ART it is possible to identify nerve entrapment sites and then improve the relative movement between nerves and the adjacent tissue until the entrapment is resolved.

Combined with the ART treatment we gave her some nerve flossing exercises, and mobility exercises for her elbow, wrist and forearm.

In this case we’ve had 6 sessions spread over 12 weeks. After the 6 sessions less than 5% of the issue remained. She still felt it sometimes, but that went away after a few exercises. Also her clicking wrist disappeared.

Most importantly, she was able to do her job without limitations.  Suffice to say we were both very happy with the results. 

Other considerations with Nerve entrapments

  • Important to remember with nerve issues is that they react different and slower than muscles. When there is a ‘simple’ nerve entrapment, it can often be resolved quite fast. When there is an irritation and inflammation of the nervous tissue, the nerve starts its own healing once the entrapment is resolved, The healing of a nerve takes more time compared to a muscle for example. This has to do with circulation. Muscles have a lot more blood flow compared to nerve tissue. The more blood flow, the more oxygen and nutrients are available for healing and vice versa. That is why (chronic) nerve entrapments can take some time to resolve. 
  • Where you feel the pain is probably not where the actual issue is. The actual cause is often one or two joint above where you feel the nerve symptoms. 
  • Foam rolling is a very common thing people do when they have an injury. Although it might give some relief with ‘regular’ muscle injuries, it can actually aggrevate a nerve entrapment. Foam rolling compresses the tissue even further and that is not something you want to do. 
  • Also stretching should be done carefully. While muscles react well to stretching because of the muscle filaments that are designed to shorten or lengthen, nerves don’t have that. It is okay to elongate a nerve, but you don’t want to forcefully stretch a nerve. It will just cause irritation. That is why flossing is advised in the initial phase. 
  • Use medication wisely. Medication is a great short term solution to help with (severe) pain, but in my opinion it shouldn’t be your long term solution. Besides treatment like Active Release Techniques, improving your lifestyle, fitness, sleep and nutrition often leads to less pain, an increased quality of life and more energy.

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