This Case of the Month is contributed by SOMI’s new national Medical Massage instructor, Dr. Jeff Cullers, DC, CMMP. He is an excellent clinical addition to SOMI, both for his knowledge and for his having had the experience of incorporating Medical Massage into his very successful chiropractic practice in Daytona Beach, Florida. Seeing and appreciating the clinical power of Medical Massage first hand convinced Dr. Cullers of the necessity to spread this knowledge among other therapists.

This clinical case emphasizes the importance of correct step by step examination of the soft tissues as the foundation for future successful treatment. This contribution greatly illustrates how in 15-20 minutes of examination the therapist can gather enough information to make the correct clinical decision. What you will read below is exactly what we teach our students, who eventually become independent thinking CMMPs and who are able to deliver stable clinical results in a relatively short time.

Dr. Ross Turchaninov, Editor in Chief


by Dr. Jeff Cullers, DC, CMMP

Recently a 56 year old female came to my office for chronic neck pain which she had on and off for many years. Upon review of her health history, she stated that she had used chiropractic care and wellness massage in the past for her cervical pain. She had led a very active life, physically working for many hours. Also she had been involved in a car accident many years ago.

At the time of evaluation her main complaints were neck pain and pain and tension in her left wrist all way to the left thumb. She has had wrist symptoms for the past two years. The patient correlated her wrist pain with working many hours on the computer.

I asked her what she used as a treatment. She stated that her neck and back symptoms felt better with chiropractic care and massage but that the symptoms would always return. She had been supplementing her diet with oral glucosamine, white willow bark and MSM and had been drinking organic tart cherry juice every morning.

She noticed that the symptoms in her thumb felt worse when she brought her thumb to her fingers, and when she tried using a wrist/thumb brace at night. In the morning the thumb felt stiff and sore.

She rated her neck pain at a 3-4/10 and her left thumb pain at a 5-6/10 on the Mankoski Scale. She described her neck symptoms as constantly tender, dull and achy and her left thumb symptoms as frequently sharp, shooting, and stinging when she performs wrist flexion as when she holds a jar and tries to open it. She also stated that it hurts when she radially deviates her wrist and that when she does, her symptoms radiate into her thumb.

My initial impression was that she had Styloiditis of the Radius. This is inflammation of the periosteum of the styloid process of the radius just above the thumb.


Here are the results of my examination. I started from the wrist:

Visual Examination

  1. 1. Wrist and Thumb ROM: limited active thumb opposition, limited active radial deviation and limited active wrist flexion all accompanied by pain.
  2. 2. Cervical ROM: bilateral limited cervical lateral flexion. Worse when flexing to the right.

Palpatory Evaluation 

Wrist and thumb

1. Compression Test was positive for the inflammation developed in the tendons of the Adductor Pollicis Longus and Extensor Pollicis Brevis in the area of the radial styloid process.

2. Trigger point in the Opponens Pollicis.

3. Trigger point in the Extensor Digitorum.

4. Sensory Test evaluates the presence of sensory abnormalities. It was positive since the patient felt decrease of sensation on the dorsal surface of the thumb (i.e., condition of hypoaesthesia).

5. Finkelstein’s Test confirmed the presence of chronic inflammation in the periosteum or Styloiditis.


1. Wartenberg’s Test applied above the left clavicle confirmed spasm in lower and middle third of the Anterior Scalene Muscle.

2. Trigger Point Test for the Anterior Scalene Muscle was positive and that confirmed tension in the upper 1/3 of the ASM.

3. Adson’s Test was positive and it confirmed the presence of circulatory abnormalities in the left upper extremity.

4. Vertical Cervical Compression Test was negative and it ruled out acute Cervical Disc Lesion as a possible trigger.

Detailed evaluation of the soft tissues is the foundation for the correct treatment strategy. Let’s put in motion the clinical thinking based on the information we discussed above.

1. Evaluation of the wrist

Finkelstein’s Test and Compression Test confirmed the presence of Radial Styloiditis. However, why would the patient with wrist pain have at the same time sensory deficit and active trigger points, especially in extensor digitorum?

The inflammation of the periosteum of radius or tendinitis of the Adductor Pollicis Longus and Extensor Pollicis Brevis are local pathologies which should not trigger any additional sensory (decrease sensation during Sensory Test) or motor (active trigger point in the extensor digitorum muscle) deficits. The only possible cause of such a combined clinical picture is involvement of the nervous structures which innervate the wrist and thumb.

2. Evaluation of the anterior neck.

The positive Wartenburg’s and Trigger Point Tests are indicators that the entire anterior scalene muscle is under severe tension and it starts to affect the function of the brachial plexus. The fact that Adson’s Test was positive indicated that tension in the anterior scalene muscle started to decrease thoracic outlet space and compress the subclavian artery, which provides the blood supply for the entire upper extremity.

3. Evaluation of the posterior neck

The final piece of the puzzle is the negative Vertical Compression Test which rules out direct compression of the spinal nerves by the invertertebral disks. If the test were positive, the tension in the anterior scalene muscle could be a secondary reaction to the irritation of the spinal nerves on the posterior neck by the bulged or herniated disk.

Considering all of this, the patient had Anterior Scalene Muscle Syndrome (Wartenburg’s and Trigger Point Tests) which moved in the direction of Thoracic Outlet Syndrome (positive Adson’s Test). Since the radial nerve innervates the styloid process of the radius and thumb, the initial clinical symptoms in the wrist were triggered by mild irritation by the tensed anterior scalene muscle to the part of the brachial plexus which gives origin to the radial nerve.


Based on the evaluation of the soft tissues I designed the treatment strategy in two phases:

Phase One: 

MEDICAL MASSAGE PROTOCOL for Anterior Scalene Muscle Syndrome/Thoracic Outlet Syndrome using protocols in Medical Massage Volume I and videos from the Video Library of the SOMI web site. The protocol for Anterior Scalene Muscle Syndrome/Thoracic Outlet Syndrome was performed 30 minutes 3 times per week for one week, including the PIR protocol for the cervical spine to ensure stable clinical results.

Phase Two: 

In two to three sessions I planned to add MEDICAL MASSAGE PROTOCOL for Radial Styloiditis using Medical Massage Volume I and the video protocols from the Video Library on the SOMI web site.


The patient responded well to the designed treatment strategy and stated that the intensity of symptoms in the left wrist/thumb decreased by 50% and the range of motion was less painful.

I then recommended two visits per month while the patient was instructed on how to perform the PIR protocol for Anterior Scalene Muscle Syndrome twice daily. At this point the function is restored and pain eliminated.

In conclusion: This is a textbook case of how Anterior Scalene Muscle Syndrome may present itself as one of its many other secondary pathologies along the affected upper extremity. It also reinforces why the Medical Massage practitioner must thoroughly perform the evaluation steps presented in the Video Library before performing any upper extremity protocols.

The tension in the anterior scalene muscle must be ruled out first before you start any therapy on the upper extremity. Remember that mild to moderate tension in the anterior scalene muscle always presents itself as a local pathology from the shoulder to the pinky and frequently the patient does not complain about pain in the neck. This is why the anterior scalene muscle is nicknamed the “silent killer.”

Dr. Jeff Cullers is a unique practitioner since his deep understanding of somatic rehabilitation is a result of combining experience as a chiropractic physician and massage therapist. Also he is among a minority of educators who preaches to the students what he practices on his patients and he does all of that based on the massage science.

Category: Case Studies