Shoulder, Arm and Wrist Pain - Myofascial

Presenting symptoms

An overworked computer data processor presented with left shoulder pain that radiated down her lateral arm and into her wrist. She described a “heaviness and stiffness” with tingling into the first three fingers, especially in the morning. Pain was worse with activities involving sustained forearm flexion: typing, holding a newspaper, cooking, driving and grooming.

Evaluation, clinical reasoning & treatment strategizing

We needed to rule out the soft-tissue entrapment possibilities of four major nerves of the arm: the musculocutaneous nerve as it passes through the coracobrachialis muscle, the ulnar nerve as it passes through flexor carpi ulnaris, the radial nerve as it passes through supinator, and the median nerve as it passes through the two heads of pronator teres. Postural evaluation showed rounded shoulders bilaterally and increased thoracic kyphosis. Her range of motion was limited during shoulder flexion and abduction, and she felt pain lowering her arm. She was unable to externally rotate her arms well and could not supinate her forearms more than 45 degrees.  Exquisite, focal tenderness was palpated in many arm and forearm muscles. There was a positive Tinel’s sign over the median nerve at the elbow.

Treatment

Positive changes were made when freeing up the pathway of the median nerve in its relationship to the two heads of pronator teres where it exits the muscle a third of the way down the forearm. Sustained shearing pressure, lateral rolling, and pin and stretch techniques were followed by gentle rhythmic pronation / supination movements with compression. The ability of the nerve to move freely was reinforced by gentle repeated stretches of pronator teres.

Outcomes and follow-up

Three NMT treatments made significant improvements. Once the forearm muscles became more extensible, tingling symptoms from the soft-tissue entrapment of the median nerve improved. Improvements to her ergonomics and fewer prolonged, fixed postural positioning were emphasized. It was suggested that she break up her workday activities with movements such as the “Wall Angel” sequence for the shoulder.