Shoulder/arm issue... + pec minor stretch issue

[Pompal 09.]

Client originally reviewed:
- pain in forearm, mostly extensors, especially during reaching movements
- numbness in tip of 2nd finger and weakness in 2nd & 3rd fingers
- ache in forearm and shoulder
- this has all been building for the last six months, although he's had various issues for years. Works on a computer all day long.

He says his doctor spent a few minutes with him on it and thinks he has a problem with his cervical vertebrae (C2 & 3 I believe) and recommended physical therapy.

The only ROM restriction I see is minor, mostly involving subscap and pec major. Neither pec minor nor anterior scalene are particularly tender.

We couldn't do a good pec minor stretch because it caused him general pain/discomfort in his posterior shoulder.

Based on something he said during our post-session check in, I did a few minutes of joint capsule work on the shoulder which he reviewed freed it up some; perhaps with this work or more of it, we will be able to do the stretch next time.
But, any other experiences that sound similar, either with the presenting issue or the pec minor stretch problem?

I'll be interested to hear back from him on the effects of today's session... I'm feeling like it might be time to really emphasize seeing a PT or chiropractor if the bodywork isn't helping enough. What do you think?

 

[MikeL]

Seriously, any help on stretching pec minor with clients who experience posterior shoulder pain during the stretch? Two clients so far have this issue, and I won't be surprised if today turns up a third.

 

[Diddy]

My two cents worth

Might I suggest freeing the scapula before you do the pec work?

I experience some similar issues when getting pec minor work. As my arm is brought over my head when I'm supine, my posterior glenohumeral area often barks in pain. I figure it is either subscap adhesions or nerve impingement. Either way, if I first receive some attention to the scapula, making sure that it is moving freely, I rarely hit the brick wall of pain during pec minor work.

That's my two cents for today, keep the change...

 

[czarina]

Mm interesting. I'm willing to try that. It's out of order from the protocol I'm working with, but the protocol obviously isn't working for these clients ;-)

Today's shoulder did fine with the stretches thankfully

 

[Ya-Kno-Im-Riight...]

During my lunch, I thought this through a little bit more.

Here's my rationale... It's critical to warm up muscles before we work deeply. What I've experienced is warming the pecs and anterior glenohumeral area, but no warming on the scapula/posterior glenohumeral tissues.

Hence, if both sides of the body are warmed up; then the action, which clearly involves both the anterior and posterior aspects of the joint, can be performed more effectively.

Let me know if it works! :grin:

 

[The Tank]

I had the same issue myself awhile back and it was my Teres that were the cause.

 

[-hail (:]

If you're talking about Waslaski's 12 step, it's actually not off protocol to work the scap next. If the pec minor stretch is uncomfortable, you may need to go back through the subscap + scapula mobilization, the MFR for delt and infraspinatus, before you can do the pec minor stretch.

Fascial restrictions in the back of the shoulder and the posterior arm can impede the pec minor stretch because the muscles and the scapula do not have an adequate space to move into as the arm comes all the way up into full flexion. Going back to do that bit again is appropriate.

One piece that is not addressed specifically by J.W.'s protocol, (but that Dalton covers,) is releasing lats and serratus to treat shoulder restrictions. If the scap isn't moving out of the way of flexion or abduction, it could be that serratus is the culprit, and doing some mfr in this area could make a difference. As well, lats (and both teres) could be adhered, thus anchoring the scapula.

Last, if the neck is still significantly restricted, flexion/abduction could be impacted. Try it: Stand up, push your head forward as far as you can, then do shoulder flexion and abduction. You will find (unless you are gumby) that your ROM is noticeably reduced. In this case, if you are waiting to complete the shoulder work before you move on to the neck, it might be wise to make a detour, restore some of the neck ROM, and head-forward posture, then go back to your shoulder stretch.

LAST, last thing, occasionally, the problem is actually anticipation of pain, so you might try stopping before the stretch, asking them to move the arm around through full ROM, and just reaching a bit towards the wall above the head of the table and towards the corner of the room (or some other landmark that give you the correct angle.) After they have done all of their own moving first, THEN go back and try the assisted stretch again. It doesn't always work, but it often does.

 

[Reslee]

LAST, last thing, Wink occasionally, the problem is actually anticipation of pain, so you might try stopping before the stretch, asking them to move the arm around through full ROM, and just reaching a bit towards the wall above the head of the table and towards the corner of the room (or some other landmark that give you the correct angle.) After they have done all of their own moving first, THEN go back and try the assisted stretch again. It doesn't always work, but it often does.

OOOOHHHH, I like this idea! Brilliantly addressed the emotional body, while manipulating the physical. Sheer genius!

I've started proping the shoulder up to work on the scapula. Prone position, my knee on table positioned under client's shoulder. Both hands are free to mobilize the scapula from here to Sunday. I've experienced great success from this both as client and practitioner.

Good luck!

 

[Abby A]

i have had some success doing the upper limb tension test to determine where nerve compression/entrampment is taking place and then 'working out the kinks'. It is sort of ocmplicated so I wouldn't know how to explain it.

This nerve mobilization DVD was pretty helpful though:

http://realbodywork.com/nerve/nerve.htm

patrick

 

[mikedemolay]

A client of mine just came to mind, presented very similar pain in the arm... through to fingers, etc. Turns out she had a cardio problem, and ended up with open heart surgery.

Might I suggest keeping really good track of results from work to make sure there is some relief (significant) from the work and possible referrals if needed.

 

[Caiden]

I don't know how your client is progressing, but thought I'd include the followup exercises - which were originally posted by liv-green awhile back. I've found them very helpful when my own problems crop up!

Brachial Plexus Injury (Stinger/Burner) Rehabilitation Exercises:

You can begin these exercises when moving your neck in all directions (up, down, right, left) does not cause numbness or tingling down your arm or into your hand.

Neck Isometric Exercises:

Neck Flexion: Sit tall, eyes straight ahead, and chin level. Place your palm against your forehead and gently push your forehead into your palm. Hold for 5 seconds and release. Do 3 sets of 5.

Neck extension: Clasp your hands together and place them behind your head. Press the back of your head into your palm.
Hold 5 seconds and release. Do 3 sets of 5.

Neck side bend: Place the palm of your hand at the side of your temple and press your temple into the palm of your hand.
Hold 5 seconds and release. Do 3 sets of 5 on each side.


Head lifts

Neck curl: Lie on your back with your knees bent and your feet flat on the floor. Tuck your chin and lift your head toward your chest, keeping your shoulders on the floor.
Hold for 5 seconds. Repeat 10 times.

Neck side bend: Lie on your right side with your right arm laying straight out. Rest your head on your arm, then lift your head slowly toward your left shoulder. Hold for 5 seconds. Repeat 10 times. Switch to your left side and repeat the exercise lifting your head toward your right shoulder.

Hands and knees neck extension: Get on your hands and knees and look down at the floor. Keep your back straight and let your head slowly drop toward your chest. Then tuck your chin and lift your head up until your neck is level with your back.
Hold this position for 5 seconds. Repeat 10 times.

Shoulder shrugs: Stand with your head directly over your shoulders, with your spine straight. Shrug your shoulders up and then relax.
Do 3 sets of 10.

Shoulder abduction and adduction: Stand with your arms at your sides. Bring your arms up, out to the side, and toward the ceiling. Hold for 5 seconds. Return to the starting position. Repeat 10 times.

Tendon Gliding Exercises

Nine tendons pass through the carpal tunnel. Four of the nine tendons bend the tips of the fingers; another four of the nine tendons bend the middle joints of the finger, and the ninth tendon bends the thumb tip. The purpose of these exercises is to glide the tendons gently through the carpal tunnel to minimize microscopic adhesions, reduce congestion, and improve lubrication in the tendons. These are not strength exercises. Perform the exercises gently or they may cause a pain flare-up.

Hook fist - touch your fingers to the top of your palm. The large knuckles should be pulled back as much as possible.

Full fist- touches your fingers to the middle of your palm. All three finger joints should be bent.

Straight fist - touch your fingers to the bottom of your palm. The tips of the fingers should be straight.

Thumb flexion - Start with your thumb pulled back from your palm as if you are hitch-hiking, then move your thumb across your palm and try to touch the tip of the thumb to the bottom of the small finger.


Nerve Gliding Exercises

The three nerves that supply power and sensation to the hand begin at the spinal cord in the neck. They have some elasticity, like a rubber-band, and lengthen and shorten as we move our arms. With repetitive trauma, microscopic adhesions can bind the nerve. Then, when the nerve over-stretches, we experience sensations such as pain, numbness, tingling, or coldness in the fingers.

If you are experiencing nerve symptoms, these exercises to glide (or slide, or pump) the nerves are critical. In fact, in one study, the chances of avoiding surgery improved dramatically when nerve glides were added to the therapy program.

It is very important not to over-stretch the nerve while exercising or you will create symptoms. Perform these exercises at a quiet time when you can pay close attention to the signals from your body. Feeling some tension is good but do not stretch to the point that you feel pain or numbness. You may feel tension anywhere along the nerve pathway, sometimes at quite a distance from the site of pain. I've had clients feel tension in their arms, shoulders, neck, even chest and back!

Gently "pump" the nerve so that it is carefully teased out of adhesions. Some therapists instruct their clients in a sustained hold of 10 seconds. Try it both ways and see which feels better for you.





Median Nerve Glide (the carpal tunnel nerve)

Sweep your arm out to the side until it is slightly behind you, palm facing forward, elbow gently straight .

Pull your wrist back until you feel a gently tension somewhere in the arm

Relax the wrist forward until tension is relieved / Repeat 10 times

Ease the tension on the wrist to about half - Holding this position, gently raise your arm until you feel tension (stay below shoulder height)

Lower the arm until tension is relieved / Repeat 10 times

Ease the tension on the arm to about half
Tilt your head (bring opposite ear towards opposite shoulder) until you feel tension
Straighten the neck until tension is relieved
Repeat 10 times

Ulnar Nerve Glide (the funny bone nerve)

Place your arm out to your side with the wrist pulled back as if you are saying "stop"
Bring your fingers toward your ear as if to cup the ear with the palm, fingers pointing to the shoulder. Stop when you feel a gentle tension.
Bring your hand back out to the side until tension is relieved
Repeat 10 times.

As an alternative:

Hold your arm out to the side, elbow straight, fingers gently curved but not in a fist
Rotate your arm fully until the palm is up.
Gently tilt your head (bring opposite ear towards opposite shoulder) until you feel tension
Straighten the neck until tension is relieved
Repeat 10 times

Radial Nerve Glide (the back of the hand nerve)

Place your hand at your side with the back of the hand facing forward
Push your shoulder down towards the floor (the movement comes from the shoulder, do not lean)
Bend your wrist toward the palm until you are in the "waiter's tip" position (as if you are a waiter unobtrusively taking a tip)
Move your arm back behind you and up at a slight angle to the side until you feel tension
If you feel as if you need more stretch, gently tilt your head (bring opposite ear towards opposite shoulder) until you feel tension. Straighten the head or move the arm back down until tension is relieved . Repeat 10 times

These nerve glides deserve a repeat of the previous cautions. Stretch only until you feel a gentle tension. Avoid pain. Perform in a quiet environment and listen carefully to your body's feedback while performing.

 

[abbylane]

If the 'pec is restricted', them pec minor is prob. also. Also anterior deltoid.
Try my 'sword from the scabbord' stretch:
Laying supine, Imagine yourself drawing a sword from a scabbord and holding it up in the air abaove your head.
This externally rotates the shoulder as it abducts the arm, stretching ant. deltoid, pec major, subscapula, then pec minor (and rhomboid and teres minor) as the elbow raises above shoulder level. the weight of hand and forearm lends a gravity assist if this is done supine over the edge of the table.
Tingling in the hand suggests an impingement at pec minor rather than cervical, because cervical isn't moving...
The pain in the back of shoulder with the usual pec stretch is often caused by overstreched Posterior deltoid which is engaging (more) if the client is standing up and raising the arm. Also, supraspinatus isn't bearing as much load.
As for massasge, fascial restrictions in pec major would be loosened prior to going in and doing the fascia work on pec minor...