upper extremity nerve special thanks … extremity nerve entrapment syndromes facilitated by bob...

UpperExtremityNerveEntrapmentSyndromes

FacilitatedByBobMcAtee,LMT,CSCS

Pro-ActiveMassageTherapyColoradoSprings,COwww.stretchman.com

#AMTAconv

SPECIALTHANKS

• Wemoveourprofessionforwardbysharingandbuildingontheworkofothers.Thankstothesecolleagueswhoallowedmetostandontheirshoulderstoday:

• DavidLauterstein andTheDeepMassageBook

• JoeMuscolino D.C.,prolificauthor,forhisbeautifulanatomyexamples.

• GroveHigginsD.C.forconsultingandstrategizingonthecoursecontent.

• WhitneyLoweforpermissiontousehisvideoassessments.

LearningObjectives

• Uponcompletionofthiscourse,participantswillbeableto:

• 1.Discussthecommonmechanismsofnerveinjuries.• 2.Delineatethepathwaysofthemedian,ulnar,andradialnervesthroughthearm.

• 3.Listthemajorentrapmentsitesforthemedian,ulnarandradialnervesoftheupperextremity.

• 4.Demonstratetypicalnerveassessmenttests.• 5.Discusspracticaltreatmentinterventionsformassagetherapists.

NerveInjuryMechanisms

• Stretch• Tear• Entrapment/Compression• CumulativeInjury(repetitivestress)• Crush(Double-Crushphenomena)

NerveEntrapment/Compression• AKA:Nervecompressionsyndrome,compressionneuropathy,orentrapmentneuropathy.

• Usuallydefinedasdirectpressureonasinglenerve.

• Symptomsvarywidelyandmayincludepain,tingling,numbness,andmuscleweakness.

CompressionInjurySchematic

DoubleCrushSyndrome• Aperipheralnervecompressionsyndromeinwhichthereisa'central'compressiononanervebundle(e.g.atthenerverootorthethoracicoutlet)anda2ndmoreperipheralcompression(e.g.atthecarpaltunnel).

UENerveEntrapmentSites• 1. spine• 2. scalenes• 3. 1st rib/clavicle• 4. pec minor• 5.coracobrachialis

NerveDistributionRegions ThoracicOutletSyndrome

• Thoracicoutletsyndrome(TOS)describesagroupofdisordersthatresultfromcompression,injury,orirritationofneurovascularstructuresattherootoftheneck,theupperthoracicregion,orbeneaththepectoralisminormuscle.

TOSLocations• AnteriorScaleneSyndrome:entrapmentbetweenanteriorandmiddlescalenemuscles.

• CostoclavicularSyndrome:impingementbetweenclavicleandfirstrib.

• PectoralisMinorSyndrome:entrapmentbetweenpectoralisminorandunderlyingribs. PhotoCourtesyofJoeMuscolino

Brachialplexus(C5–T1)

• Thelastfourcervicalspinalnerves,C5throughC8,andthefirstthoracicspinalnerve,T1,combinetoformthebrachialplexus

• Atangledarrayofnerves,splitting,combiningandrecombining,toformthenervesthatservetheupperextremityandupperback.

NeuralTOS• NeurogenicTOS=95%ofcases,morecommoninwomen

• Bonyand/orsofttissuesinthelowerneck/upperchestcompressandirritatethenervesofthebrachialplexus.

• Symptoms:• Weaknessornumbnessofthehand(esp.4th-5thfingers).

• Atrophyofhandmusclesontheaffectedside.• Pain,tingling,prickling,numbnessandweaknessintheneck,chest,andarms.

ArterialTOS

• Impingementofthesubclavianarterybybonyorsofttissues.

• Symptoms:• Coldsensitivityinthehandsandfingers• Numbness,painorsoresofthefingers• Poorbloodcirculationtothearms,handsandfingers.

• Skinmaybepale.

VenousTOS• Venous:causedbyimpingementtothesubclavianvein.Thisveindoesnotpassthroughthescalenes,soisnotaffectedbyanteriorscalenesyndrome.

• Theconditiondevelopssuddenly,oftenafterunusualandtiringexerciseofthearms.

• Symptoms:• Swellingofthehands,fingersandarms.• Heavinessandweaknessoftheneckandarms.• Theveinsintheanteriorchestwallmayappearswollen.Skinmaybebluish/purple.

Assessment• AccurateassessmentofTOSsymptomsinourclientsisimportantbecauseTOSrespondswelltomassageandbodyworktreatments.

• Duetotheoverlappingofnatureofsymptoms,it’softendifficulttomakeadefinitiveassessment.It’scommontohaveneuralandvascularentrapmentsimultaneously.

Tests• Thesethreeproceduresstartwithlocatingtheradialpulse.Adiminishedpulseduringthetestindicatesarterialimpingementatthestructurebeingassessed.Neuralsymptomsmayalsoincreaseduringtesting.

• Adson’sTest:AnteriorScaleneSyndrome

• Eden’sTest:CostoclavicularSyndrome

• Wright’sTest:Pec.MinorSyndrome

PalpateRadialPulse• Assessmentofthestrengthoftheclientsradialpulsewhentheclientisrelaxedandinaneutralposition.

• ThisisdoneatthebeginningoftheassessmentforeachofthethreeTOSlocations.

Adson’sTestforAnteriorScaleneSyndrome

• Theclientrotatestheheadtoward(oraway)fromtheaffectedside,thenlaterallyflexesawayfromtheaffectedside,thenextendstheneck,whilethepractitionerpalpatestheradialpulse.

• Accentuatethetestbyhavingtheclienttakeandholdadeepbreath(scalenesarerespiratorymuscles).

• Decreaseinstrengthoftheradialpulseispositiveforanteriorscalenesyndrome.

EdensTestforCostoclavicularSyndrome

• Clientpullstheshouldergirdlebackanddownandpushesthechestforward(militaryposture),whiletheradialpulseispalpated.

• Accentuatethetestbyhavingtheclienttakeandholdadeepbreath(liftsribstighteragainstclavicle).

• Decreaseinstrengthoftheradialpulseispositiveforcostoclavicularsyndrome.

WrightsTestforPec.MinorSyndrome

• Passivelymovetheclient’sarmupandback,whiletheradialpulseispalpated.

• Accentuatethetestbyhavingtheclienttakeandholdadeepbreath(liftsribstighteragainsttautpec.minor).

• Decreaseinstrengthoftheradialpulseispositiveforpectoralisminorsyndrome.

TreatmentGoals

• Short-term:relievetheimpingementsontheaffectedstructurestoallowthemtoheal.

• Long-term:correctupperquadrantposturalasymmetries(slumpedshoulders,forwardheads,hyperkyphosis,etc.)tokeepthethoracicoutletopen.

AddressingScalenes

• Reducinghypertonicityinthescalenes,especiallytheanteriorandmiddlebellieswillhelprelievepressureonthebrachialplexusasitexitsthecervicalspine.

• Caution:deepmassagetothescalenes whenthey’realreadytootightiscounterproductiveandmaycausemoreirritationtothenervoussystem.

• Considerusinglightpressureasthiscanbemoreeffectiveinhelpingrestorepropertone.

ScalenesandElevatedShoulders

• Reducingscalenehypertonicityallowsthewholeribcagetodrop,releasingthechronicallyelevatedshouldergirdleandcreatingspacebetweentheclaviclesandthefirstribs.

ScaleneHypertrophy• FromMikeReinold.com:• Oneofthemajorreasonsthat

thoracicoutletsyndromeoccursinbaseballpitchersisfromhypertrophyofthescalenemuscles(andSCM).Throwingabaseballcausesmanyadaptationstothebody,includingthisincreaseinscalenesize.

• Herearephotosoftheathleteinhalingwithhisheadturnedtoeachside.NoticethesignificantlylargerscaleneandSCMonhisrightside.

TreatmentInterventions:Scalenes

• Scalenes Sweep

• Scalenes FacilitatedStretch

ScaleneSweep• Themostcomfortablewayto

workscalenes,whichalsohelpspulltheforwardheadbackandupontopoftheshoulders,istosweepacrossthemfromtheanteriorneckallthewayaroundtothespinousprocesses,thusassistingtheotherneckmusclestomigrateback.

• Inallcases,erronthesideofconservativenesswithyourpressure.Thepointistodrawthemusclesback,nottopressintotheneck- especiallynotpressinghardintotheanteriorandlateralaspect.

CourtesyofDavidLauterstein’s“TheDeepMassageBook”

ScalenesStretchontheTable

1. Active lateral flexion of the neck to stretch the scalenes.

2. Easy isometric contraction of the stretched scalenes.

3. Active stretch to new range motion Askmetodemonstratetheshrug

stretchoption.

AddressingPectoralis Minor

SincethePectoralis MinorisacommonentrapmentareainThoracicOutletSyndrome,reducingthehypertonicity inthethisareaiscritical.

PalpatingPectoralisMinor

• Withtheclientsupine,layyourthumbalongtheclavicle,thenslideinferiorlyintothesofttissue.

• Slidelaterallyuntilyoucometothefirstbonyprominence(thecoracoid),whichisusuallyquitetender.

• Pecminorattachmentisat7o’clock(leftside).

• Coracobrachialisat6o’clock,• Bicepsbrachiiat5o’clock.

TreatmentInterventions:Pectoralis Minor

• PinandStretch

• FacilitatedStretch

PinandStretchTechniquePectoralisMinor:

•Withclientsupine,usethepadsofyourfingerstopalpatethepectoralisminoratthecoracoidattachment.

•Gentlystretchthemuscleinferiorly,awayfromthecoracoidprocess,whiletheclientpullstheshoulderstowardthetableandbringstheshoulderbladestogetheranddown,asifputtingtheminthebackpockets.

•Thenasktheclienttoexternallyrotatethearmsandslidethemupthetabletowardtheirheadtoincreasethestretchonthepecminor(andthepecmajor).

PecMinorStretch• Thisstretchreduceshypertonicityin

thepecminorandmayreducecompressionontheneurovascularstructures.

• Holdtheclient’shandtokeepthearmfrombouncingaround.

• Clientfirststretchesbypullingtheshouldertowardthetableandslidingthescapuladowntheback.

• Duringtheisometricphase,theclientattemptstopushtheshouldertowardtheceiling.

CommonMedianNerveCompressionSyndromes

• PronatorTeresSyndrome

• CarpalTunnelSyndrome

MedianNervePathway MedianNerveEntrapmentSites

• 1. spine• 2. scalenes• 3. 1st rib/clavicle• 4. pec minor• 5. coracobrachialis• 6. ligament of struthers• 7. pronator teres• 8. flexor digitorum arch• 9.carpaltunnel

IllustrationsofEntrapment1.Entrapmentatthepronatorteres

2.Fibrousarchoftheflexordigitorumsuperficialis.

3.Lacertusfibrosus(bicipitalaponeurosis)

4.supracondylarprocessandligamentofStruthers

AssessingNerveMobility

• GlidersandSliders• Usingassessmentstohelppinpointpossibleentrapments

PronatorTeresSyndrome

• Acompressionneuropathyofthemediannerveatthepronatorteres.

• Oftenaccompaniedbymedialepicondylitis

PronatorTeresSyndrome

• Symptoms:• Paresthesiainthumb,index,middlefingerandradialhalfofringfinger(similartocarpaltunnelsyndrome).

• Paresthesiaoftenmadeworsewithrepetitivepronation-supination.

• Differentiate fromcarpaltunnelsyndrome(CTS):• exacerbatedbyrepetitiveelbowflexion• achingpainoverproximalforearm• lackofnightsymptoms

PronatorTeres Syndrome Assessment• The client stands with the elbow in 90 degrees of flexion.

• Place one hand on the client's elbow for stabilization and hold the client's hand in a handshake position.

• The client holds this position as you attempt to supinate the client's forearm (forcing the client to contract the pronator muscles).

• While holding this isometric effort, straighten the client's elbow (stresses flexor digitorum superficialis).

CarpalTunnelSyndrome(CTS)• Compressionneuropathyofthemediannerveasitpassesundertransversecarpalligament.

• Oftenresultsfromtenosynovitisoftheflexortendonsinthecarpaltunnel.

• Consideredarepetitivestresscondition.

• DoublecrushconditionmakesthenervemoresusceptibletoCTS.

CarpalTunnelAnatomy• The carpal tunnel,

formed by the carpal bones and the flexor retinaculum, contains 9 sheathed tendons:

• 1 flexor pollicislongus

• 4flexordigitorum superficialis• 4flexordigitorum profundus• Andthemediannerve.

CarpalTunnelSyndrome(CTS)• Symptoms:• Paresthesia,numbness,paininthemediannervedistributionofthehandandfingers.Atthewrist,thenerveiscomposedofover90%sensoryfibers.

• “Nightsymptoms”causedbysleepingwiththewristsflexed.

• PrimaryAssessment:• Phalen’s Test

NoteAboutCarpalTunnel• Truecarpaltunnelsyndrome

doesnothavesensorylossoverthethenar eminence.

• Thisisbecausethepalmarcutaneousbranchofthenerve(sensory),whichinnervatesthatarea,branchesoffthemediannerveandpassesoverthecarpaltunnel.

• Thisfeatureofthemediannervecanhelpseparatecarpaltunnelsyndromefromthoracicoutletsyndrome,orpronatorteressyndrome.

CarpalTunnelSyndromePhalen’sTest

• Theclientpressesthebackofthehandstogethertoflexthewriststoapprox.900.

• Ifpain,paresthesiaornumbnessinthemediannervedistributionarereproducedwithinabout60seconds,thetestisconsideredpositive.

CarpalTunnelTetheredMedianNerveTest

• Usefulindetectingchronic,low-grademediannervecompression.

• Producesthegreatestamountofdistalnerveexcursioninthecarpaltunnel.

• Performbyhyperextendingthesupinatedwristandtheindexfingerforoneminute.

CarpalTunnelTinel’s Test

• Lightpercussionoverthemediannerveasitpassesunderthetransversecarpalligament.

• Theleastsensitiveofthemediannervetestsbutisthemostspecifictestformedianneuropathyatthecarpaltunnel.

MedianNerveTreatmentGoals

• Short-term:relievetheimpingementsontheaffectedstructurestoallowthemtoheal.Accomplishthisthroughsoft-tissueworkandstretching.

• Long-term:identifyandcorrectperpetuatingfactors.

EffectiveTreatment Interventions

• PinandStretchTechniques

• TransverseFriction

• FacilitatedStretching

PinandStretch:ForearmFlexors• Clientsupine.• Supinatedforearmfullysupportedonthe

treatmenttable,withthewristfreetoflexandextend.

• Beginningatthefully-flexedwrist,useyourloosefisttoapplyafirmglidingstroketowardtheelbow,alongthelengthoftheforearmwhiletheclientslowlyextendsthewrist&fingers.

• Formorespecificwork,useasmallercontact,suchasaflatthumbpointingalongthelengthoftheforearm.

PinandStretch:PronatorTeres• Clientsupine.Upperarmfullysupported

onthetreatmenttable,withtheelbowbent.

• Withtheforearminneutralorsomewhatpronated,useabroadthumborloosefisttoapplyafirmglidingstrokediagonallyfromtheradialattachmenttothemedialepicondylewhileslowlysupinatingtheforearm.

• OKtokeeptheforearmonthetableandusealoosefistforthestroke.

TransverseFriction:Forearm• Usetransversefrictionworkto

addressadhesionsinmuscles,tendonsandligamentsandtoreleasethemediannerveentrappedinthesetissues.

• Startwithgeneralfrictiontoanentirestructureandthengetmorespecificasnecessary.

• Toperformtransversefrictionwell,palpatethedesiredstructureandthenworkacrossthegrainofthetissue.Applythestrokeusingathumborfinger,asifgluedtotheskin.

TransverseFriction:Wrist• Usefingersorthumbtoapply

transversefrictiontothetendonsandtheretinaculumatthewrist.

• Startwithgeneralfrictionandthengetmorespecificasnecessary.

• Toperformtransversefrictionwell,palpatethedesiredstructureandthenworkacrossthegrainofthetissue.Applythestrokeusingathumborfinger,asifgluedtotheskin.

FacilitatedStretching:WristFlexors• Clientsupine,forearmfullysupported

onthetable,wrist&fingersfullyextended.

• Matchyourfingersandthumbtoclient,useyourotherhandtostabilizetheforearm.

• Directtheclienttoslowlytrytoflexthewristandfingers,whileyoupreventthemovement.Holdthisisometriccontractionfor6seconds.

• Aftertheisometric,theclientactivelystretchesbyextendingthewristandfingerstoanewROM.

FacilitatedStretching:Pronators• Clientsupine,elbowbent,forearmsupinated.• Supporttheforearmwithonehandandplacetheotheracrossthewristandhand.

• Directtheclienttoslowlytrytopronate,whileyoupreventthemovement.Holdthisisometriccontractionfor6seconds.

• Aftertheisometric,theclientactivelystretchesbysupinatingtoanewROM.

CommonUlnarNerveCompressionSyndromes

• CubitalTunnelSyndrome

• Guyon’sCanalSyndrome(cyclistspalsy)

UlnarNervePathway

UlnarNerveEntrapmentSites

• The6sitesofpotentialulnarnerveentrapmentaroundtheelbow:arcadeofStruthers,medialintermuscularseptum,medialepicondyle,cubitaltunnel,deepflexorpronatoraponeurosis(betweentheheadsoftheflexorcarpiulnaris)andGuyon’scanal.

ArcadeofStruthers• Thinaponeurosisextendingfrommedialheadoftricepstothemedialintermuscular septum.

• NottobeconfusedwiththeLigamentofStruthers(whichmaycompressthemediannerve).

• Located8-10cm(3-4in.)proximaltothemedialepicondyle.Notalwayspresent.

CubitalTunnelSyndrome• Ulnarnervecompressionattheelbowisthe2nd mostcommonnerve

entrapmentoftheupperextremity,aftercarpaltunnelsyndrome.• Thecubitaltunnelisformedbythetwoheadsofflexorcarpiulnaris.

Oneheadblendswiththeflexortendonattachmentsatmedialepicondyle(humerus),theotherattachestotheolecranonprocess(ulna).They’reconnectedbyanaponeurosis.

CubitalTunnelSyndrome• Symptoms mayinclude:• pain,paresthesia,burning,andweaknessinthefifthfingerandulnarsideofthefourthfingerandnumbnessinthedorsalulnaraspectofthehandandfingers.

CubitalTunnelSyndromeElbowFlexionTest

• Clientstandswithelbowsflexedandwristsextendedfor30-60seconds.

• Thispositioncompressestheulnarnerveatthecubitaltunnelandaddssomestretchatthelevelofthewrist.

• Symptomsmayappearinlessthan30seconds.

Cyclist’spalsy

• Duetocompressionoftheulnarnerveatthewrist(Guyon’scanal).

• Symptomsincludepinsandneedlesinthelittleandringfinger.

• Mayalsoincludeimpairedmotorfunction.

• Oftenpresentalongwithcubitaltunnelsyndrome(double-crush).

UlnarNerveTreatmentGoals

• Short-term:relievetheimpingementsontheaffectedstructurestoallowthemtoheal.Accomplishthisthroughsoft-tissueworkandstretching.

• Long-term:identifyandcorrectperpetuatingfactors.

EffectiveTreatment Interventions• UlnarNervetreatmentfocusesonthesamemusclegroupsasforMedianNerve,withtheadditionofcoracobrachialis.

• PinandStretchTechniques

• TransverseFriction

• FacilitatedStretching

Coracobrachialis

• Noticethecompactrelationshipbetweenbicepsandcoracobrachialis.

• Palpationandfrictionworkontheinsideofthearmwillhelpidentifynerveentrapmentineitherthemedianortheulnarnerve(ArcadeofStruthers).

CommonRadialNerveCompressionSyndromes

• RadialTunnelSyndrome

• PosteriorInterosseousNerve(PIN)Syndrome

RadialNervePathway RadialNerve&TeresGroup

• Theradialnervedivesposteriorandpassesnexttothelongheadofthetricepsandthroughthespacebetweentheteres minorandtheteresmajor.

RadialNerveEntrapmentSites

• RadialnerveentrapmentistheleastcommonofthethreemainUEnerves.

• Themostfrequentsiteofcompressionisattheradialtunnel(ArcadeofFrohse)attheproximaledgeofthesupinatormuscle.

ArcadeofFrohse• Theedgeofthearcadeisnormallythinandmembranous.

• Athickened,tendinous proximaledgeisdevelopmental,occurringin30–100%ofpeople,likelyduetorepetitivepronation–supination.

RadialTunnelSyndrome• Compressionofthesensoryfibersoftheradialnerve.

• Symptoms: pain,paresthesia,ornumbnessnearthelateralepicondyle.Achingorburningsensationalongthelateralaspectoftheforearm,mimickinglateralepicondylitis.

RadialNerve(PIN):PosteriorInterosseusBranch

• Posteriorinterosseousnervesyndrome(motorfibers):weaknessoftheextensormusclesoftheforearm.

• Alsocalledsupinatorsyndrome.

RadialTunnelSyndromeAssessmentIsometricMuscletests:1.Clientattemptssupination,withelbowextended(tominimizebicepsbrachii recruitment).2.ResistedLongFingerExtension.PositiveTest=increasedpainorweakness.

RadialNerveTreatmentGoals

• Short-term:relievetheimpingementsontheaffectedstructurestoallowthemtoheal.Accomplishthisthroughsoft-tissueworkandstretching.

• Long-term:identifyandcorrectperpetuatingfactors.

EffectiveTreatment Interventions

• PinandStretchTechniques

• TransverseFriction

• FacilitatedStretching

PinandStretch:ForearmExtensors

• Clientsupine.

• Thepronatedforearmisrestingonthetreatmenttable,withthewristfreetoflexandextend.

• Beginningatthefully-extendedwrist,useyourloosefisttoapplyafirmglidingstroketowardtheelbow,alongthelengthoftheforearmwhiletheclientslowlyflexesthewrist&fingers.

• Formorespecificwork,useasmallercontact,suchasaflatthumbpointingalongthelengthoftheforearm.

PinandStretch:ForearmSupinator• Clientsupine.Holdthe

forearminneutral,upperarmrestsonthetreatmenttable.

• Beginningatthedistalendofthesupinator,useyourloosefisttoapplyafirmglidingstroketowardthelateralelbow,whilepassivelypronatingtheclientsforearm.

• Formorespecificwork,useasmallercontact,suchasaflatthumb.

TransverseFriction:Forearm• Usetransversefrictionworktoaddress

adhesionsinmuscles,tendonsandligamentsandtoreleasethemedianentrappedinthesetissues.

• Startwithgeneralfrictiontoanentirestructureandthengetmorespecificasnecessary.

• Toperformtransversefrictionwell,palpatethedesiredstructureandthenworkacrossthegrainofthetissue.Applythestrokeusingathumborfinger,asifgluedtotheskin.

FacilitatedStretching:WristExtensors

• Clientsupine,forearmsupportedonthetable,loosefistwiththumbinside.

• Wrapyourhandoverthefist,useyourotherhandtostabilizetheforearm.

• Directtheclienttoslowlytrytoextend(open)thewristandfingers,whileyoupreventthemovement.Holdthisisometriccontractionfor6seconds.

• Aftertheisometric,theclientactivelystretchesbyflexingthewristandfingerstoanewROM.

FacilitatedStretching:Supinator• Clientsupine,elbowbent,forearmpronated.• Supporttheforearmwithonehandandplacetheotheracrossthe

wristandhand.• Directtheclienttoslowlytrytosupinate,whileyoupreventthe

movement.Holdthisisometriccontractionfor6seconds.• Aftertheisometric,theclientactivelystretchesbypronatingtoanew

ROM.

PalpationPractice

• Locatecoracoidprocess(whatmusclesattachhere?)

• Coracobrachialisinupperarm• Arcadeofstruthers(ulnarnerve)• Ligamentofstruthers(mediannerve)• Pronatorteres(mediannerve)

AssessmentWorkflow• ClientHistoryandSymptomPattern

• WorkingHypothesis:TOSorOther

• AppropriateNeuralTests– TOS:Adson’s,Eden’sWright’s

– AssessforPronatorTeres Syndrome,CarpalTunnel(Phalen’s),CubitalTunnel(ElbowFlexion),RadialTunnelSyndrome.

– NerveGlides

TreatmentStrategies

• Protect(Don’tOver-Treat,WorkinthePain-FreeZone)

• PinandStretch• TransverseFriction• FacilitatedStretching

• Nerveglides

BruggerReliefPosture

• Sitwithyour“sitbones”attheedgeofthebench/chair.

• Lengthenyourbackandneckandtuckyourchin.

• Dropyourshoulders.• Externallyrotateyourarmssothepalmsfacetotheside.Keepyourfingersaswideaspossible.

• Holdthispositionfor10seconds,relax,repeat5-10times.

Self-Care:ResistanceBandPulldowns

• Thisexerciseengagesthescapularretractorsanddepressorsasyoupullthebandslowlyoutwardanddownwardtothebaseoftheskull.

• Tuckyourchintoyourthroatandkeepyourearsoveryourshoulders.Don’tbendtheneckforward.

• Yougetthemostbenefitfromtheeccentricphaseoftheexercise.

Self-Care:ResistanceBandPulldowns

• Exhaleasyoupullthebanddownandout.

• Complete8-10repetitionsperset.

• Performingthisexercisebetweenclientsessionswillretrainyourshoulderandupperbackmuscles.

RecommendedReading• OrthopedicAssessmentinMassageTherapy

• byWhitneyLowe

• FreedomfromThoracicOutletSyndrome

• ByJoeMuscolino,D.C.• AMTAJournal,2006• http://www.amtamassage.org/articles/3/MTJ/detail/1666

References• Miller,T.andReinus,W.NerveEntrapmentSyndromesofthe

Elbow,Forearm,andWrist.AmericanJournalofRoentgenology,2010195:3,585-594,http://www.ajronline.org

• Elhassan,BandSteinmann,S.EntrapmentNeuropathyoftheUlnarNerve.JAmAcad Orthop Surg November200715:1,672-681

• Tubbs,RS,etal.ThearcadeofStruthers:Ananatomicalstudywithpotentialneurosurgicalsignificance.Surg Neurol Int.2011;2:184.

• Graham,B.CarpalTunnelSyndrome.TheWorkplaceSafetyandInsuranceAppealsTribunal,Ontario,Canada.May2001.

• http://www.wsiat.on.ca/english/mlo/carpal.htm

Let’sGetSocial

• E-mail:stretchman@stretchman.com

• Facebook:www.facebook.com/bob.mcatee

• Twitter:@bobmcatee

• Landline:719-475-1172(notexts,VMOK)

• iPhone:719-641-8987(OKtotext)