As doctors specializing in the diagnosis and treatment of musculoskeletal disorders, we at Integrated Health Solutions tend to see a very, very wide variety of conditions and complaints walk through our doors. No two conditions are exactly alike, and the ability to not only differentiate but also determine the best course of treatment for each individual is what sets us apart. For example, recently a patient came in for an initial consultation. They had been dealing with right arm pain for years and had undergone 2 unsuccessful surgical procedures and over 3 months of physical therapy for what she thought and was told was carpal tunnel syndrome. She wasn’t sure what we could do to help her but she was desperate and had been referred to our clinic by a family member.
After performing a thorough history and having the patient perform several functional capacity tests it was determined that she had been misdiagnosed and that what she was dealing with was not true carpal tunnel syndrome but, in fact, pronator syndrome caused by repetitive actions. Pronator syndrome is a neuropathy caused by an entrapment of the median nerve as it passes through the pronator teres muscle in the forearm. This patient had been cut open twice and rehabbed the wrong area!
Peripheral Nerve Entrapment is defined as any number of neuropathies, or injuries to the nerves, that occur anywhere beyond the spinal cord and its spinal roots. A nerve entrapment or “pinched nerve” is whenever a peripheral nerve loses mobility, flexibility, or becomes compressed by surrounding tissues. A nerve entrapment can cause neurogenic pain at the site of the entrapment or further along its dermatomes. A dermatome is an area of the skin that is mainly supplied by one nerve of the spine. These dermatomes can present as referred pain, meaning the pain is not the site of the injury. Peripheral nerve entrapments are relatively common clinical disorders. The peripheral nerve system is a network of 43 pairs of motor and sensory nerves that connect the central nervous system (the brain and spinal cord) to the entire human body.
Symptoms of nerve entrapment can vary. For some, pain is the only symptom that they experience. Other people may be pain-free, but experience any of the common symptoms listed below.
1. Burning Pain or Ache
The most common symptom(s) of a new entrapment, this pain occurs because something near the nerve is inflamed and compressed, or the nerve itself is irritated. This will be a sharp or burning pain that possibly radiates outward to where the nerve ends, as in the foot or hand.
2. Decreased Sensation or Numbness
Numbness or sensation loss is a result of the pressure constricting/restricting the blood flow and depriving the nerve cells of oxygen and other nutrients. With less nutrients, your nerves are unable to function correctly and therefore the signal is recognized as diminished sensation.
3. Foot or Hand “Falling Asleep
We’ve all experienced the sensation of resting your arm or leg a certain way for too long. This is often caused by compressing the nerve ending with surrounding tissues and tendons temporarily. When this symptom occurs in otherwise normal posture, or during movement, it may be a sign of a peripheral nerve entrapment.
4. Pins and Needles
The human body consists of three main types of nerves—sensory nerves, motor nerves, and autonomic nerves. Pins and needles, or paresthesia, occurs when your sensory nerves are being compressed and cannot transmit signals to the rest of your body.
5. Muscle Weakness
Muscle weakness is a symptom that one of your motor nerves, nerves that send messages from your brain to your muscles, is being pinched. Causing muscle fatigue or weakness—this symptom is a sign that the muscle connected to the nerve is not functioning correctly.
There are a variety of causes of nerve entrapment. It can be caused by trauma, such as from sprains or bone fractures, but is often due to repetitive or overuse activities. Requirements of jobs, such as painting, driving or desk work are examples. Other examples include repetitive movements in sports and exercise. Peripheral nerve entrapments around the shoulders are common with overhead athletes like baseball players whereas entrapments around the knees are more common with runners. Even pregnancy that causes swelling of the extremities can result in compressed nerves.
Nerve injury may also mimic other common musculoskeletal disorders. For example, aching lateral elbow pain may be a symptom of lateral epicondylitis or radial tunnel syndrome; patients who have shoulder pain and weakness with overhead elevation may have a rotator cuff tear or a suprascapular nerve injury; and pain in the forearm that worsens with repetitive pronation activities may be from carpal tunnel syndrome or pronator syndrome.
Now back to the case of the woman with the pronator teres syndrome. This case was treated using the integrated approach of medical dry needling along the median nerve pathway, including key structural points, as well as soft tissue techniques Graston technique and Active Release Technique. The entire shoulder and rotator cuff was assessed for synergy by releasing trigger points in the involved tissue, not just the pronator teres. Furthermore, the patient was not only given dynamic rehab exercises that treated her muscular imbalances and weaknesses, but also addressed her posture and her movement. By listening to her story and truly understanding her day-to-day activities, we were able to identify and correct specific faults in the repetitive movements associated with her job as a legal assistant. The way she sat, typed and even how she answered the phone were modified.
One last note on this case and perhaps particularly relevant to you the reader (since you are most likely reading this blog on the computer or laptop) is that we have started noticing a trend with the patient population that we affectionately refer to as the “desk jockeys”. During medical dry needling treatment, we have consistently found certain muscles (rhomboids, infraspinatus) that are involved in deceleration or opposition of shoulder movements related to desk work and typing tend to be the muscles that are most sensitive to palpation and have the most trigger points. Conversely, the overactive muscles causing the dysfunction of the shoulder (pec minor, subscapularis) are not always strong and, although tense, are also sensitive to palpation.
Let’s break that last part down a little bit – the rhomboids are found between the spine and the shoulder blade and help to retract the scapula. The infraspinatus is located on the lower part of the posterior scapula and they are responsible for external rotation of the shoulder. So when we are in a true neutral position or ideal posture, these muscles are not being stressed and therefore are unlikely to become inflamed and cause a pinched nerve. However, like most people sitting at a desk all day, the shoulder blades “resting position”- with the arms reaching forwards towards the keyboard and the elbows completely on top of the desk- causes the scapula to be protracted and the shoulder to be internally rotated. The pec minor and subscapularis are both involved in the forward protection and internal rotation of the shoulder, thus causing the dysfunction. Combine this with forward-head carriage – a position defined by the ear lining up in front of the shoulder – and you have a recipe for pain and dysfunction, something that can lead to peripheral nerve entrapment if it is repetitive and goes untreated.
If you are reading through this and believe that there are aspects of this blog that pertain to your current condition, you owe it to yourself to get it checked out. Want a deeper explanation of what our treatment is like? Why dry needling? Do I really need rehab? What is an adjustment?
- Dry needling affects the tissue by creating a very small insult to the muscle, thus activating the brain to send natural biological healing chemicals that will speed up the healing process. Treatment enhances deep tissue healing, decreases and eliminates spasms and promotes targeted soft-tissue rejuvenation and trigger point release.
- Soft tissue mobilization allows for increased blood flow, muscle elongation and continued desensitization of knots (trigger points) in the tissue that cause dysfunction. When the tissue around a damaged region is more relaxed it allows for increased range of motion with decreased pain response.
- When tissue is more relaxed around a joint it allows for more movement of the surrounding tissue and less compression on the nerves. This gives our doctors the ideal opportunity to perform a chiropractic joint manipulation which is a precise, quick force applied to the region of dysfunction to help re-centrate the region. This often created a near instant relief in pain
- Once the manipulation or “adjustment” is performed, it is then the appropriate time for exercise rehab to strengthen and stabilize the tissue around the now-centered joint. Personalized exercise therapy will not only help the tissue restore strength it once had, but this will also allow for less pain during motion over the time of the treatment plan. The best part about treating the body with exercise is the empowerment it gives people when they are away from the clinic. The freedom to move is liberating and encourages us to test the body even more.
If you are suffering from pain that seems to have no cause, or if you have been unable to find solutions through traditional medical routes, call us today so that our physicians can help you relieve your symptoms and treat the underlying dysfunction. Our integrated approach not only helps lower pain, we also help restore the body to its optimal potential while eliminating aberrant factors that are causing the dysfunction. This lets you perform your daily tasks optimally, allowing you to move well and live pain-free!
Content provided by Dr. Drew Hunt