Massage Therapists’ Association of British Columbia

P: 604.873.4467F: 604.873.6211

research@massagetherapy.bc.camassagetherapy.bc.ca MTABC 2010

Massage Therapists’ Association of British Columbia

Clinical Case Report Competition

West Coast College of Massage Therapy,Victoria

Winter 2010

First Place Winner

Andrea ThorntonDecrease of pain and neurological symptoms

from brachial plexus nerve bundle impingement using massage therapy: A case report

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To the author’s knowledge, no conflict of interest exists Table of contents Abstract Page 3 Introduction Page 3 History Page 4 Assessment Page 4 Methods Page 5-6 Results Page 7 Discussion Page 7-8 Conclusion Page 8 Acknowledgements Page 8 References Page 9 Appendix A Orthopedic tests Page 10-11 Appendix B Treatment subjecting and objective finding Page 12-13 Appendix C Illustrations Page 14-16 Appendix D Case management plan Appendix E Record of treatments and patient consultation forms

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Decrease of pain and neurological symptoms from brachial plexus nerve bundle impingement using massage therapy: A case report.

Abstract

Objective: Can therapeutic massage therapy using myofascial release, joint mobilizations and general swedish massage reduce pain and neurological symptoms and restore of motion to the left upper extremity of a person suffering from a brachial plexus impingement? Methods: Ten 50 minute therapeutic massage treatments were given over a six week time frame. Focus of the treatments was on balancing shoulder movement, decreasing myofascial adhesions through the scapular regions, down into the distal hand of the left upper extremity using the modalities of myofascial release techniques, joint mobilizations and general Swedish massage. A Verbal Analog Scale was utilized pre-and post-treatment to note the progress of pain and stiffness. Ranges of motion of the glenohumeral joint and the cervical spine and a select few orthopedic tests were performed to monitor progress. Subjective findings of how the patient felt after each treatment were also recorded. Results: Patient’s pain and neurological symptoms showed a marked decrease in frequency and intensity, grip strength increased and shoulder mobility increased after ten treatments using therapeutic massage. Conclusion: The use of massage therapy decreased pain and neurological symptoms in a patient’s left upper extremity caused by the compression of the brachial plexus. Keywords: massage therapy, general Swedish, myofascial release, brachial plexus impingement, neurological symptoms in upper extremity, nerve impingement. Introduction: The brachial plexus is a bundle of nerves that supplies the motor and sensory control to the upper extremities. It originates from the spinal cord at the fifth cervical level to the first thoracic level, and is comprised of five nerve roots from C5 to T1. The plexus innervates structures of the chest, shoulder, arm, forearm and hand. This bundle of nerves can be compressed or impinged by multiple structures. This compression can lead to a syndrome called thoracic outlet syndrome or TOS. TOS is a set of symptoms caused by the compression of the brachial plexus and the subclavian vessels in the thoracic outlet region between the neck and the axilla. Abnormalities in the musculoskeletal structures may be responsible for TOS. These include an over-long cervical transverse process, cervical rib, subluxated first rib, clavicle fracture or myofascial adhesions and muscular hypertonicity.

Common locations of muscular hypertonicity causing impingement by compression of the nerve bundle are at the interscalene triangle (which is made up anteriorly by the anterior scalene, posteriorly the middle scalene, and inferiorly the first rib), costoclavicular space (between the clavicle and the first rib) and the coracopectoral space under pectoralis minor where the muscle attaches to the coracoid process of the scapula.1 Refer to Figure 1 in Appendix C.  Once the bundle has passed through the coracopectoral space it separates out into separate branches. Refer to Figure 2 and 3 in Appendix C.1,2

With some of the causes of entrapment being of a muscular nature, massage therapy is a good choice for treatment of TOS symptoms. Massage therapy can be defined as the systematic manipulation of soft tissues of the body for pain reduction or other therapeutic purposes.3 This soft tissue work is administered

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for the purpose of producing effects on the nervous, muscular, fascial, lymphatic and circulatory systems.4 A goal of massage therapy is to restore maximal function of the musculoskeletal system and realign posture and balance.5 This case report demonstrates the value of massage therapy in treating myofascial and muscular imbalances causing compression of the brachial plexus leading to thoracic outlet syndrome symptoms. History: Patient profiled is a 50 year old female, with a history of neurological symptoms of tingling, numbness, heat and pain in her left arm and hand since November 2008. The primary location of symptoms was between her third and fourth metacarpal bones and into the hypothenar eminence of her left hand. She exhibited decreased strength and grip capability in her left hand. The intensity of pain ranged from the worst pain of a six out of ten, to average pain of a four out of ten, prior to treatment. The onset of symptoms may have had to do with poor ergonomics while working at a computer for long periods of time. She did receive physiotherapy and laser therapy treatments on the above area in December 2008, with no improvement. In March 2009 she was treated by a chiropractor with Active Release techniques applied to the left hand intrinsic muscles. Changes did occur in the patient’s hand. The left hand progressed to a “claw hand” appearance with muscle weakness and wasting in her fourth and fifth fingers. The pain was burning hot and tingling. She continued treatment with chiropractor and by October 2009 the nerve pain subsided temporarily, muscle weakness and wasting were gone but still heat was felt in the region. In April 2010 vascular changes were noted as both palms of her hands changed to a bluish tinge intermittently. A lump could be palpated in flexor digiti minimi and some ligament laxity in the fingers and hands were observed on our initial consultation. The patient also had suffered from multiple previous injuries, including multiple whiplash type of injuries, disc prolapse between the fourth and fifth lumbar vertebrae (L4/L5) and possible disc prolapse between the fifth and sixth cervical vertebrae (C5/C6) between the years of 1990 to 1995. A compression fracture of the eleventh thoracic vertebra (T11) in 1992 and her right shoulder suffered soft tissue damage in 1997. All of the fore mentioned were from sporting injuries. Assessment: Treatment with massage started May 10 2010. On initial physical findings a postural scan was completed noting anteriorly rotated shoulders, with the left shoulder displaying more mass posteriorly as the inferior border of the scapula was tipped up. The left forearm hung more pronated compared to the right and a slight head tilt to the left and slight head forward posture was noted. Range of motion of the glenohumeral (GH) joint showed external rotation was limited to 60 degrees and abduction was limited to 160 degrees. In the cervical spine (C/S) side flexion and rotations were the motions most limited. Prior to the first treatment C/S side flexion was limited to 15 degrees to the right and 18 degrees to the left and rotations were limited to 60 degrees bilaterally. See Appendix A for normal range of motion. Some provocation tests were performed bilaterally to determine cause of pain and parasthesia in the left arm and hand. The Adson manoeuvre test produced symptoms of tingling and numbness into the hand, whereas in Wright’s hyper-abduction test no symptoms were reported. Bilaterally the Pectoralis length test showed hypertoned pectoralis musculature as both acromion processes of the scapula hovered three inches above the table while the patient was supine. Upper limb tension tests were performed with the median nerve roots and ulnar nerve roots being affected. For details refer to orthopedic special tests in Appendix A. Throughout the ten treatments multiple tests were repeated to report progress. On the fourth treatment progress and changes were starting to be noticed. At this time two orthopedic tests were selected and used

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each subsequent treatment and reported on. These tests were the Grip strength test and Scapular motion test. The patient’s subjective and objective findings are recorded in chart form in Appendix B. Methods: Patient was treated primarily in side lying and supine positions. I found these positions gave the most ease in working the structures needed. In side lying the shoulder musculature remained more relaxed through treatment compared to working with the patient positioned in prone. Ten 50 minutes treatments were given and reported on. The patient was positioned side lying right side up at commencement of each treatment. Her parascapular region was palpated and restrictions noted. Commonly the upper fibres of trapezius were being pulled anteriorly and laterally. Since patient had slight head forward posture my goal was to realign the muscle fibres more posterior and medial. Spinal erectors also were sitting out laterally from the vertebral column. After finding restrictions I would stabilize the GH joint with one hand and meet tissue resistance at the nape of the neck with other hand/fist. Once tissue was engaged I would wait for release and meld the tissue in an inferior medial direction towards the spinal column. Supraspinatus, levator scapulae superior attachment and trapezius also would be reshaped /melded towards the cervical spine in a superior medial direction towards the attachment point along the C/S transverse processes of levator scapulae and upper trapezius muscles. Changing hand positions I would place my more posterior arm under my patient’s right arm and cradle the head of her humerus in my palm. With this position I found that the patient could completely relax the arm and I could move the scapulothoracic joint around freely. This was also a great position to be able to open up the anterior pectoralis major and minor musculature. While stabilizing the GH in my hand I would draw the shoulder posteriorly. My other hand anchored the medial scapular border against the thorax. I would hold this position until I could feel some fascial releasing, then bring arm back to neutral and work with the pectoralis musculature attachments along the coracoid process with my fingertips Next I would have the patient roll over to her other side and would conduct a repeat of above treatment depending on the restrictions felt the day of treatment. In addition once my arm was cradling the patient’s arm, I would mobilize the scapulothoracic joint and use it as a lever to aid in fascial restriction of the C/S prevertebral fascial layer. The prevertebral layer is a layer of fascia that forms a division around the cervical column and surrounding musculature of scalenes, longus coli, splenii, semispinalis capitis and cervicis, multifidi and nuchal ligmanet. It lies in front of the subclavian artery, and extends laterally as the axillary sheath, which covers the brachial plexus in addition to vessels4,6. Since the brachial plexus is surrounded in this facia layer it is possible that constriction of these vital structures is possible.4 Working mostly with my thumb pad in a superior direction through the lateral, anterior and posterior neck with the facial layers in mind, levator scapulae, longisimus, multifidi, scalenes, sternocleidomastoid, splenius cervicis and capitis, semispinalis cervicis and capitis and the suboccipitals were all addressed by decreasing myofascial adhesions from a side lying position. Before having patient turn to supine position I would flush the previously worked tissue with general Swedish massage techniques to increase the circulation to aid with the removal of stored toxins and metabolites in the previously adhered fascia. Once the patient was positioned in supine I checked the fascia along the anterior chest and into the pectoralis musculature. Since my patient presented with slight head forward posture and anteriorly rotated shoulders, it was not a surprise that the pectoralis muscles were hypertoned. Stabilizing the arm at the elbow with one hand I would find restrictions in pectoralis musculature with the palmar surface of my other hand. I would sink into her tissue to engage it and upon meeting tissue resistance would hold

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pressure until softening of the tissue happened. Primarily all motion was in a superior lateral direction towards the coracoid process and into the bicipital sulcus region. Refer to Figure 4 in Appendix C. Once tissue softened and moved more freely I would ask my patient to actively internally and externally rotate her shoulder joint. This added motion and greater torsion to the stack and load technique. I then followed fascial restrictions out from her thorax and down the arm in an inferior lateral direction following the fascial line into the forearm and hand. Once the pectoralis major muscle hypertonicity was reduced, I would move her arm back into a neutral position and sink into pectoralis minor at the attachment point off of the coracoid process. On the left side pectoralis minor was a culprit in causing entrapment of the brachial plexus causing tingling and heat into my patient’s hand. Deeper muscle stripping along fibres of pectoralis minor recreated many neurological signs and symptoms that my patient was experiencing. Moving into the arm most restrictions were along the anterior deltoid and bicep junction, coracobrachialis and triceps. Spreading techniques were applied to give space to the above structures and to alleviate adhesions from sticking together. The medial superior epicondyle of humerus was another place of entrapment that commonly was tender on palpation. Flexor carpi ulnaris was especially adhered and considerable pain was recorded around the pisiform sesamoid bone. The pisiform bone lies within the flexor carpi ulnaris muscle tendon. Myofascial releasing techniques of picking up and c-bending while stacking and loading the tissue were used through the muscle to encourage space and to break up adhesions.

Moving distally into the wrist and hand, detailed fingertip stack and load technique was used around the pisiform bone and around the carpal hamate. A lot of tingling, pain and heat were recorded in the ulnar nerve distribution region of the hand. Also myofascial spreading, range of motion and muscle stripping were applied into the interossi hand musculature. A pain point for the patient was between the third and fourth metacarpal bones. More time was delegated for that region of the hand. Not every treatment session included hand work. After the myofascial work of the day was completed a treatment of general Swedish massage using petrissage techniques was used to aid in circulation of the tissue. Some treatment sessions included joint mobilizations of the glenohumeral, humeroulnar and carpal bones. These techniques were applied as grade two distractions to aid with decreasing fascial adhesions and increasing range of motion of the joints. On the sixth treatment cervical spine muscle energy techniques were utilized on C3, C4 and C6 vertebral levels with the intent to increase range of motion of side flexion. In conjunction with massage the patient also participated in her treatments at home with a series of exercises and hydrotherapy. Contrast arm soaks were applied to the forearms and hands of three minutes of hot water to one minute of cold water, repeated three times, ending with hot, and were started May 13 2010. The patient was to try to contrast soak her arms every other day. The remedial exercises for her to do at home were a passive pectoralis stretch utilizing a bolster and gravity. Patient was to lie supine with the bolster supporting her neck and spine and to passively open up her arms to stretch the anterior chest open and hold the stretch up to five minuets once a day. Other exercises of shoulder rolls, cervical spine splenius cervicis and capitis stretch, serratus anterior stretch and self massage to the pectoralis musculature were also all recommended.

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Results: Within one treatment the patient noticed changes. Her pain shifted locations and intensity through the six weeks of therapy. By the sixth treatment her grip strength was even. In the seventh treatment her scapulae were tracking in unison and her pulse was strong during the Adson manoeuvre testing for TOS. Neurological symptoms ceased by the eighth treatment and pain had dropped considerably. Internal rotation of the left GH joint had increased five degrees and abduction had increased 15 degrees from initial assessment. The cervical spine range of motion also greatly improved in side flexion, increasing by 25 degrees on the right and 17 degrees on the left, and rotations bilaterally increased by ten degrees. Refer to Appendix B for subjective and objective findings. On postural scan the anteriorly rotated shoulders had decreased and the left posterior mass due to a tilted inferior border of the scapula was no longer present. After ten treatments no colour changes had occurred in the hands. The patient experienced very occasional heat in the hypothenar eminence. Numbness and tingling greatly decreased within a few weeks of the beginning of treatments to the point of no abnormal sensations for days at a time. Discussion: Impingement syndromes are multifactorial conditions. For the body to function optimally there are many length tension relationships between muscle groups which need to be in balance. In the case of a patient with head forward posture and anteriorly rotated shoulders the length tension relationships of the musculature surrounding the GH joint and cervical spine are compromised. Once these are askew the rib cage, spine, head and pelvis are also affected. In considering the shoulder girdle one must also be aware of the muscles that are located on the axial skeleton. Trapezius, latissimus dorsi, pectoralis major and minor, levator scapulae and rhomboid major and minor all are axial muscles that are necessary for shoulder motion and function to stabilize the shoulder. These muscles (except trapezius) are all innervated by small branches from the brachial plexus4, so if the nerve bundle is compressed then the functionality of said muscles can be compromised. Without stabilization of the shoulder, maximum hand mobility would not be plausible. The goal of therapy is to stretch out the shortened tight muscles to enable the return of proper movement. When the axial skeleton muscles responsible for maintaining proper shoulder mechanics are dysfunctional in strength or postural position, the whole shoulder complex will be affected. Typically the GH joint will shift anteriorly leading to a narrowing of the interscalene triangle, coracoclavicular and coracopectoral spaces. With these regions compressed symptoms of TOS arise due to the fact that the brachial plexus passes through these spaces. The kinesiology of my patient’s shoulder girdle mobility and motion definitely had an effect on the neurological function of her hand. Her grip strength was compromised due to the unbalanced musculature of the shoulder girdle. Once balance was regained grip strength returned. Testing the patient’s scapular motion enabled me to monitor the functionality of her upper extremity. During elevation of the humerus, pectoralis minor is lengthened as the scapula rotates upwards, retracts and tips posteriorly.7 Since my patient’s pectoralis musculature was overly hypertoned, this concept was demonstrated during her postural exam with more mass posteriorly on the left scapula, and during scapular motion testing with a delay in upswing. Once the hypertonicity was reduced I was visually able to see changes through each treatment by utilizing a postural scan, the pectoralis length test and scapular motion. Massage therapy including myofascial release techniques can aid in decreasing dysfunction of nerve impingements using a local and systemic approach. Once adhesions are reduced the body can return to a more homeostatic balance. With my findings throughout the ten treatments more work focusing on the

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cervical region and thoracic regions of the spine would have been beneficial. If my treatments had been a bit more aggressive and focused more on pectoralis minor and the cervical spine greater results of a decrease in pain and tingling may have been seen sooner. More accurate postural recording like a plumb line scan would better document the postural changes. Since the interpretation of patient feedback is subjective, using a questionnaire like the Oswestry questionnaire to be used in conjunction with the Verbal Analog Scale to record pain would have been beneficial for a more objective point of view on pain. Conclusion: This case report shows that through the use of therapeutic massage dysfunctional neurological symptoms from a brachial plexus impingement can be greatly reduced. Myofascial release following the path of the brachial plexus reduced pain, increased strength of grip and resolved neurological tingling and heat in the hypothenar and palmar surface of a hand of the patient reported on in this paper. After four treatments of myofascial release and general Swedish massage most neurological symptoms ceased and remained dormant for five days post-treatment. After five treatments grip strength was even. The patient’s complaint of pain dropped from a chronic 6/10 pain at rest to an intermittent 1-2/10 with movement and no pain at rest. Further studies are encouraged to demonstrate the effectiveness of therapeutic massage in treating neurological impingement syndromes. Acknowledgements: I would like to sincerely thank the patient for her time and willingness to receive treatments and her effort to perform the recommended hydrotherapy and remedial exercises. I appreciate her openness and feedback throughout each treatment. Thanks to all the supervisors at WCCMT Victoria who I consulted, for their input and experiences and to Michelle Relf for overseeing this clinical case paper.

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References 1. Netter F. Atlas of Human Anatomy. Fourth Edition. Pennsylvania, USA. Saunders Elsevier 2006. Plate 430 2. Vizniak N. Professional Health Systems. 2009. cited 2010 Aug 8, available from http://prohealthsys.com/anatomy/grays/image_list.php?itn=&sid=90623&eid=90849 3. Ernst E. The safety of massage therapy. Rheumatology 2003 May; cited 2010 Aug 8; 42:1101-1106 available from: http:/rheumatology.oxfordjournals.org/cgi/reprint/42/9/1101. 4. Hertling D, RM Kessler. Management of Common Musculoskeletal Disorders Physical Therapy Principles and Methods. Fourth Edition. Philadelphia, USA. Lippincott Williams & Wilkins 2006. Pages 112, 134-135, 317-318, 357 5. Greenman PE. Principles of Manual Medicine. Third Edition. Philadelphia, USA. Lippincott Williams & Wilkins: 2003. Pages 46, 195 6. Davey E. Myofascial release II lecture notes West Coast College of Massage Therapy. 2010, May Page 16 7. Kisner C, LA Colby. Therapeutic Exercise: Foundations and techniques Fifth Edition. Philadelphia, USA. F.A.Davis Company 2007. Page 486 8. McGee D. Orthopedic Physical Assessment. Fifth Edition. Missouri, USA. Saunders Elsevier 2006. Pages 147, 165, 250, 322.

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Appendix A Orthopedic tests Grip test Patient would squeeze therapist index and middle fingers together bilaterally, left gripping left and right gripping right. Then therapist switched hands so to have patient squeeze therapists fingers on opposite hand. Compare strength bilaterally. Grip Strength Test Date Left hand pre treatment Left hand post treatment May 20 2010 Slightly weaker May 25 2010 Slightly weaker May 31 2010 Even June 3 2010 Even June 10 2010 Even June 16 2010 Slightly weaker Even June 22 2010 Slightly weaker Even Scapular motion test. Therapist stands behind patient. Have hands on patient’s scapulae with web of thumb around inferior border of the scapula. Patient actively abducted shoulders repeatedly for 5 times. Therapist gently follows scapular motion, watching for delay or early engagement of motion. Compare bilaterally. Normal scapular motion starts at 90 degrees of shoulder abduction. Scapular motion Date Motion pre treatment Motion post treatment May 20 2010 Delayed upswing May 25 2010 Early upswing May 31 2010 Delayed upswing & downswing June 3 2010 Delayed downswing Even June 10 2010 Delayed downswing Even June 16 2010 Even Even June 22 2010 Even Even Adson maneuver test 8

Therapist locates the radial pulse. Patient’s head is rotated to face the test shoulder. Patient then extends head while therapist laterally rotates and extends the patient’s shoulder. Patient is instructed to take a deep breath in and hold it. A disappearance of the pulse indicated a positive test.

Adson manoeuvre test Date Pre treatment May 10 2010 Loss of pulse & tingling into

hand June 3 2010 Strong pulse

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Upper Limb Tension Tests 8

Patient supine. Test #1 for median nerve roots: Shoulder is depresses and abducted to 110°. Elbow extended, forearm supinated, wrist extended, fingers extended, cervical spine contra lateral side flexion. Test #4 for ulnar nerve roots: Shoulder depressed and abducted hand to ear. Elbow flexed, forearm supinated, wrist and fingers extended. Shoulder laterally rotated. Cervical spine contra lateral side flexion. Patient gives verbal indication of neurological symptoms. Upper Limb Tension Test - neurological Date Median nerve #1 Ulnar nerve #4 May 10 2010 Symptoms Symptoms May 20 2010 Symptoms Symptoms June 10 2010 Symptoms No symptoms June 16 2010 Symptoms No symptoms June 22 2010 Symptoms No symptoms Pectoralis Length test. Patient supine not pillowed. Therapist measures the distance between the acromion process and the table bilaterally. Pectoralis Length test Date Pre treatment Post treatment May 10 2010 3 inches off table bilateral May 25 2010 2.5 inches off table bilateral May 31 2010 2.5 inches off table bilateral June 3 3010 2.5 inches off table bilateral June 10 2010 2.5 inches off table bilateral Left 2.25 Right 2.5 inches off

table June 22 2010 Left 2.5 Right 2.75 inches off

table Left 2.25 Right 2.5 inches off table

Normal Cervical Spine Range of Motion8 Normal Glenohumeral Range of Motion8

Flexion 80-90° Flexion 180° Extension 70° Extension 60° Side flexion 20-45° Abduction 180° Rotation 70-90° Adduction 130° horizontal Internal rotation 90° External rotation 90° Verbal Analog Scale- Used to record subjective pain “Zero is no pain; ten is the most pain you have ever felt”.

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Appendix B – subjective and objective treatment findings Treatment Date

Subjective findings Objective findings

May 10 2010

Prior to treatment Sore hypothenar eminence No heat in hand today Tingling Post treatment Increase in tingling and numbness in fifth finger and also hot Pain proximal to tunnel of guyon and in medial septum of elbow 4/10 and tender to touch Itch reported in pectorals.

Postural – anteriorly rotated shoulders Left shoulder more mass posteriorly Left forearm more pronated Slight head tilt to left and anterior General muscle test of Left GH joint – pain & weakness with External Rotation Upper limb tension test #1 Median nerve- positive for pain into hand #4 Ulnar nerve – positive for pain into hand Pectoralis Length test – three inches off table – bilaterally even Adson – positive on left – no pulse felt and patient reported tingling sensation into hand

May 13 2010 Prior to treatment Pain 2/10 at elbow 3/10 in hypothenar eminence Post treatment Less pain 1 ½ /10 which has moved over to the medial side of the 4th metacarpal bone. Decreased tenderness with palpation of the elbow.

Elbow range of motion: Limited on left supination and pronation. Both actions have pain associated with them of 1-2/10 located at the fourth metacarpal spot - muscle weakness also for pronation and in flexor carpi ulnaris with pain presenting around pisiform.

May 17 2010 Prior to treatment Pain in hand on off 3/10 With arms in flexion over head notice more stiffness in posterior deltoid Less tingling/ heat in fifth digit since first treatment Decreased pain /tenderness at medial epicondyle with point pressure Post treatment stiffness in posterior deltoid gone Pain dropped to 1/10

Medial epicondyle – tender on palpation

May 20 2010 Prior to treatment Pain in hands between 3 &4 digits localized sharp pain since last treatment. Pain ranging for 4/10 to 1/10 Tingling decreased in hypothenar eminence since last treatment Post treatment No pain in hand

Upper limb tension test #1– pain shooting into hand when put into stretch #4 – pain into 3, 4th digits Grip test – left slightly weaker Scapular motion pre - left delayed upswing with abduction

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Treatment Date

Subjective findings Objective findings

May 25 2010 Prior to treatment Hypothenar eminence cooler to touch Pain between 3 & 4th digits gone Muscle tenderness and fatigue in hypothenar eminence – new symptom

Grip test – left slightly weaker Scapular motion – upswing early Downswing even Pectoralis length test 2 ½ inches off table bilateral

May 31 2010 Prior to treatment More achiness in forearm since last week Noticed increased grip at gym Slight achiness in hand 1/10 Pain between 3&4 metacarpals gone

Grip test- even strength Scapular motion -pre- left delayed up & downswing -post- upswing even downswing delayed Cervical spine quadrant test – positive on left – pain at facets Muscle energy assessment – C6, C4, C3 fixated

June 3 2010 Prior to treatment Left arm and hand felt different ‘ buzzing” sensation Pain around pisiform 2/10 Some hypothenar achiness

Grip test – even strength Scapular motion pre– left delayed downswing post- even motion Adson – negative

June 10 2010 Prior to treatment Pain between 3 & 4 metacarpal 3-4 /10 Dull zingy and heat Post treatment -no symptoms in hand or left arm

Grip test – even srength Scapular motion pre - left downswing delayed post – even bilaterally Upper limb tension test #1 - pain into hand #4 – no symptoms in hand, sensation into mid shaft of humerus

June 16 2010 Prior to treatment Big changes since last treatment Periods of no symptoms at all More sensation back into hand Pain 1-2/10 tight stiff instead of dull or sharp

Grip test – pre-left slight weaker post- even strength Scapular motion – even bilaterally Upper limb tension test #1- pain at mid humerus #4 - no symptoms bilateral

June 22 2010 Prior to treatment Grip at gym great Pain 1.5/10 between 3& 4th metacarpals Soreness around pisiform & medial epicondyle Post treatment -no pain in hand

Grip test – pre left slight weaker Scapular motion – even bilaterally Upper limb tension test #1 pre - slight pain into medial arm post - decreased pull into medial arm #4 – no pain or changed sensation

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Appendix C Pictures

Fig. 1. Anterior neck2 View of anterior neck and the pathway of brachial plexus through interscalene triangle, costoclavicular triangle and coracopectoral space.

Fig. 2. Brachial plexus 1

A composite drawing illustrating the nerve root levels, nerve roots and the intertwining of nerves that form the five main terminal branches of the brachial plexus.

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Fig. 3. Upper Extremity2

Pathway of the brachial plexus main branches as they travel into the arm, forearm and hand.

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Fig. 4. Fascia of the anterior shoulder girdle.4

Illustration of the fascia layers of the anterior shoulder girdle and the structures surrounded.