ATTENTION!!! The physician responsible for the patient’s treatment must be informed of the MEDICAL MASSAGE PROTOCOLs that will be used in manual therapy, and the practitioner must obtain the physician’s permission prior to the initiation of such therapy.
This video is a presentation of the MEDICAL MASSAGE PROTOCOL in cases of Radial Nerve Neuralgia. It is based on scientific publications reviewed in Medical Massage, Volume I. Please refer to pp. 304-313 of the Medical Massage, Vol. I textbook to learn more about pathology, clinical symptoms and diagnostic evaluation of tissue in cases of Radial Nerve Neuralgia.
In the videos, we will repeat each technique and approach only two or three times to save time and space. Follow the time guidelines shown at the beginning of each step.
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EVALUATION OF THE PATIENT WITH RADIAL NERVE NEURALGIA (RNN)
While examining the patient with symptoms of RNN the practitioner must rule out the following abnormalities first:
Anterior Scalene Muscle Syndrome/Thoracic Outlet Syndrome
Pectoralis Minor Muscle Syndrome
By clicking on these links, you will be able to access the evaluation of these abnormalities. In these cases, the radial nerve can become mildly irritated and, as a result, the patient will exhibit classical symptoms of RNN.
Only after the practitioner rules out the irritation of the radial nerve on the upper levels he or she can be sure that the symptoms the patient have are the result of the RNN developed on the lower levels (arm and forearm). It does not matter if the patient has already established diagnosis or even results of the nerve-conduction study. The practitioner must inform the physician about somatic abnormality, which irritates the radial nerve on the upper levels (e.g., by anterior scalene muscle) and free the nerve form the irritation there.
RNN below the level of the anterior shoulder can be the result of irritation or trauma of the radial nerve on the lateral surface of the lower third of the arm (as a result of trauma), below the radial head (as a result of trauma) and in the radial tunnel on the dorsal surface of the forearm (as a result of tension in the supinator muscle and/or extensor carpi radialis brevis muscle).
1. Questioning
More likely, the patient with RNN has a job that requires many repetitive movements by the hand (e.g. typing on the computer, or car mechanics). Hours of typing on the computer, without the proper support under the forearms is one of the major contributing factors to the Radial Tunnel Syndrome.
RNN can be the result of traumatic impact on the dorsal surface of the arm and tension in the supinator muscle as it seen in chronic cases of Tennis Elbow (i.e., Lateral Epicondylitis).
Tension in the hand extensors, especially extensor carpi radialis brevis muscle, on the dorsal surface of the forearm may irritate the radial nerve there. In such case the patient will have RNN as a result of Radial Tunnel Syndrome.
Women during and after pregnancies complicated by edema may also have symptoms of the RNN. The women after breast cancer surgery may also exhibit symptoms of RNN because the lymph nodes’ removal frequently triggers local edema on the hand and forearm.
The patient feels tingling, numbness and burning pain on the dorsal surface of the forearm and/or hand along the thumb, the index finger and half of third finger (except the fingertips).
Frequently, pain and other uncomfortable sensations, increases during the night and greatly affects sleep. This factor makes the patients even more desperate.
If the patient feels uncomfortable sensations on the arm, forearm and hand the practitioner can be sure that symptoms of RNN originated in one of these three areas:
1. Posterior neck: tension in the cervical paravertebral muscles (Cervicalgia), intervertebral disk abnormalities
2. Anterior neck: tension in the anterior scalene muscle (Anterior Scalene Muscle Syndrome)
3. Anterior shoulder: tension in the pectoralis minor muscle (Pectoralis Minor Muscle Syndrome)
2. Sensory Test (ST)
Simultaneously stroke the different parts of the hand innervated by each peripheral nerve (radial, median and ulnar) using your fingernails. Be sure that the patient keeps his or her eyes closed and ask him or her to concentrate on the sensation in both hands. In cases of RNN the patient will feel less sensations or very acute electric shock type pain on the dorsal forearm and/or on the dorsal surface of the hand, the thumb, the index and half of the third finger.
If, for example, the patient feels the skin stroking less acute on the area innervated by the radial nerve and also in the area innervated for example by median nerve (e.g., palm), it means that the clinical symptoms of the RNN come from the area where radial and median nerves are still next to each other. This can happen only in three areas: posterior neck (disk pathology or tension in the posterior cervical muscles), anterior neck (anterior scalene muscle) and anterior shoulder (pectoralis minor muscle).
3. Motor Test (MT)
There are two parts of the MT.
1.Examination of the thumb
If the patient has RNN, he or she will exhibit weakness of the thumb extension and abduction. To evaluate MT correctly conduct it on both hands simultaneously. The video shows the examination of the thumb extension.
2. Hand Squeeze Test
Ask the patient if he or she is right or left handed. Stand in front of the patient, cross your forearms and grasp the patients’ right hand with your right hand and his or her left hand with your left hand. Now ask the patient to slowly squeeze your hands with the same force until you tell him or her to stop and maintain the same pressure. The video shows the weaker hand squeeze on the right side.
Concentrate on your sensations. You are examining the general strength of the hand squeeze. Compare the general muscle strength or how the squeeze feels on the unaffected side as compared to the normal side. Remember that the patients’ primary hand is always stronger.
The hand squeeze is generally weaker on the affected side of the patient with RNN because during the squeeze the hand extensors are stretched and it causes uncomfortable sensations on the forearm. To diminish these sensations the patient will use less power during hand squeeze and the practitioner will feel it weaker on the affected side.
4. Compression Test (CT)
CT is very informative because it gives the practitioner information about possible entrapment of the deep branch of radial nerve by the supinator muscle or superficial branch of the radial nerve by the extensor carpi radialis brevis muscle in the so called radial tunnel.
1. CT for the supinator muscle
To execute CT correctly the practitioner should initially form the fold of skin by pushing it laterally. After this, push the extensor digitorum muscle medially (bulk of the tissue above the practitioner’s thumb in the video). Finally apply moderate vertical pressure. The black dot in the video indicates the lateral epicondyle of the humerus. The circle indicates the head of the radius.
The CT is considered positive if during the application of the vertical compression the patient feels pain, numbness or tingling on the distal forearm and hand innervated by the radial nerve.
2. CT for the extensor carpi radialis brevis muscle
CT allows us to examine potential nerve entrapment in the radial tunnel under the extensor carpi radialis brevis muscle.
Place the fingertip of thumb approximately 1-1.5 inch below the radial hand in front of the lateral edge of the extensor digitorum muscle (dashed line) and push this muscle medially first. Now apply moderate vertical pressure and ask the patient to elevate the hand (active wrist extension).
The CT is considered positive it the vertical pressure with the simultaneous active wrist extension by the patient trigger pain, tingling or numbness on the distal forearm and/or hand. The black dot in the video indicates the lateral epicondyle of the humerus; the circle indicates the head of the radius; the dashed line indicates the lateral edge of the extensor digitorum muscle.
MEDICAL MASSAGE PROTOCOL IN CASES OF RADIAL NERVE NEURALGIA
Duration (excluding Steps 1 to 6): 30-45 min
Radial Nerve Neuralgia can be the result of chronic irritation of the brachial plexus by the anterior scalene muscle (see Anterior Scalene Muscle Syndrome) or chronic tension of the pectoralis minor muscle (see Pectoralis Minor Muscle Syndrome). The protocol presented below should be employed only AFTER the brachial plexus is free from such direct irritation.
Step 1 to 6. Similar to those for Anterior Scalene Muscle Syndrome (click here).
Step 7. Work on the forearm
a. Effleurage in the direction of venous and lymphatic drainage
Duration: 2 min
Pressure: below the pain threshold
Start with superficial effleurage and later switch to deep effleurage. While applying deep effleurage, stabilize the patient’s arm with one hand so as to provide counterresistance. Pay attention to the start and to the end of the strokes.
b. Work in the area of sensory deficit
Duration: 2 min
Pressure: at the level of the pain threshold (first sensation of discomfort)
In the area of sensory deficit on the hand (see video), apply a combination of stimulating techniques: circular friction, manual vibration, pinching, superficial friction, etc.
Step 8. Kneading of the affected muscles
a. Kneading of the hand extensor muscles
Duration: 2 min
Pressure: below the pain threshold
Apply kneading of the hand extensors in the inhibitory regime using protocol #1. If the patient exhibits muscle weakness, switch to protocol #2. To review both protocols, click here.
b. Kneading of the elbow extensor muscles
Duration: 2 min
Pressure: below the pain threshold
Apply kneading of the triceps brachii muscle in the inhibitory regime using protocol #1. If the patient exhibits muscle weakness, switch to protocol #2. To review both protocols, click here.
Step 9. Friction along the extensor muscles on the forearm
Duration: 3 min
Pressure: at the level of the pain threshold (first sensation of discomfort)
Work in detail along the extensor muscles especially below the lateral epicondyle of the humerus. Start with the application of intense friction along, and after that across, the fibers. Stabilize the area of the lateral epicondyle with the other thumb. Apply the same combination of friction on the tendinous part of the triceps brachii muscle just above the elbow.
Step 10. Work along the pathway of the radial nerve
a. Friction along the pathway of the radial nerve
Duration: 2 min
Pressure: below the pain threshold
At the beginning, the video shows anatomical pathway of the radial nerve on the arm and on the forearm after it went around the posterior surface of the humerus.
Carefully apply friction along, and later across, the pathway of the radial nerve starting on the anterior surface of the shoulder joint. When applying friction don’t use strong pressure. Compress the tissue to a comfortable level for the patient, and after this apply friction strokes.
b. Mobile vibration along the pathway of the radial nerve
Duration: 1 min
Pressure: below the pain threshold
Apply permanent mobile vibration along the pathway of the radial nerve.
Step 11. Passive stretching
a. Passive stretching along the axis of the upper extremity
Duration: 1 min
Pressure: below the pain threshold
Place the thumb on the occipital ridge and hold the patient’s upper extremity above the wrist joint. During the patient’s prolonged exhalation, pull both hands apart and stretch the upper extremity along its axis.
b. Stretching of the radial nerve
Duration: 1 min
Pressure: below the pain threshold
Keep the thumb on the occipital ridge and grasp the patient’s thumb and the thenar area with the other hand. During the patient’s prolonged exhalation, pull both hands apart and stretch the radial nerve. Note the position of the thumb during the passive stretch.
Cutaneous Reflex Zones
Duration: 3 min
Pressure: at the level of the pain threshold (first sensation of discomfort)
In the area of the cutaneous reflex zones, employ stimulating techniques: skin kneading, skin rolling and superficial friction. Add treatment of the cutaneous reflex zones at the end of the Step 7 of this protocol
Connective Tissue Zones
Duration: 3 min
Pressure: below the pain threshold
Connective Tissue Massage (CTM) is the best way to eliminate connective tissue zones. The video shows the protocol for CTM on the arm and forearm. Add CTM after the treatment of the cutaneous reflex zones (Step 7).
Reflex Zones in the Skeletal Muscles
Add treatment of the reflex zones in the skeletal muscles at the end of the Step 8 of this protocol.
a. Trigger Point Therapy
Duration: 4 min
Pressure: at the level of the pain threshold (first sensation of discomfort)
The video shows the location of trigger points in: the brachioradialis, triceps brachii, extensor carpi ulnaris, extensor carpi radialis, and extensor pollicis longus muscles. There is little likelihood that all of these trigger points will be present in any single patient. However, the practitioner should examine all of them, proceeding to include into the massage protocol those which are active. Apply trigger point therapy only if active trigger points are found. To review the applicable scientifically based trigger point therapy protocol, click here.
b. Postisometric Muscular Relaxation
The decision as to whether PIR protocols should be employed depends on the presence or not of active trigger point in the affected muscles. For example, if the brachioradialis muscle does not exhibit an active trigger point, the PIR protocol of this muscle should not be included in the treatment.
PIR for the brachioradialis muscle
Duration: 4 min
Pressure: below the pain threshold
The patient’s elbow and wrist joints are extended. On the first level of PIR, grasp the patient’s hand and ask him or her to actively rotate the forearm outward (i.e., to supinate it) while you provide resistance. Note the initial position of the wrist joint.
For the second level of PIR, initially rotate the forearm inward (more pronation) and again ask the patient to conduct the active supination against your resistance.
For the third level of PIR, maximally increase the initial pronation and ask the patient to supinate the forearm against your resistance. Note the change of the initial position of the wrist on the second and third levels.
After each level of PIR, conduct 3 to 4 passive stretches of the brachioradialis muscle by flexing the patient’s wrist and fingers at the same time. The white arrows indicate direction of the contraction.
PIR for the extensor pollicis longus muscle
Duration: 4 min
Pressure: below the pain threshold
Place the patient’s hand in the position shown in the video. Firmly grasp the patient’s thumb and ask him or her to elevate it against the resistance.
For the second level of PIR, increase the initial flexion of the thumb and ask the patient to elevate the thumb again.
After each level of PIR, conduct 3 to 4 passive stretches of the extensor pollicis longus by flexing the patient’s thumb and pull the hand in ulnar deviation. The white arrows indicate the direction of the contraction.
PIR for the extensor muscles
Duration: 4 min
Pressure: below the pain threshold
The forearm and hand are flat on the table. The practitioner should resist the patient’s simultaneous extension in the wrist joint and the extension of the fingers.
For the second level, flex the elbow and the wrist joint and ask the patient to extend the wrist and the 2nd to 5th fingers.
Apply three passive stretches after each level of the contraction-against-resistance. The white arrows indicate the direction of the contraction.
PIR for the triceps brachii muscle
Duration: 4 min
Pressure: below the pain threshold
For the triceps brachii muscle, use PIR on three levels. On the first level, flex the elbow to an angle of 100 degrees and ask the patient to extend the forearm against your resistance.
On the second, level place the elbow in 90 degrees flexion and ask the patient to repeat the forearm extension.
Finally, on the third level, flex the elbow completely and have the patient repeat the extension against your resistance one more time.
Apply three passive stretches after each level of the contraction-against-resistance. The white arrows indicate the direction of the contraction.
Periostal Reflex Zones
Duration: 4-5 min
Pressure: exceeds the pain threshold maximally
The video shows the location of periostal trigger points in the acromioclavicular joint, the spine of the scapula, the lateral epicondyle of the humerus, the styloid process of the radius, the head of the first metacarpal bone, the head of the second metacarpal bone, and the head of the third metacarpal bone. There is little likelihood that all of these periostal reflex zones will be present in any single patient. However, the practitioner should examine all of them, proceeding to include into the massage protocol those which are active. Add periostal massage to the very end of the 2nd or 3rd session.
Full Protocol: