Upper Body Pain Topics

Dissection anatomy of the area of the thoracic outlet

Neck Pain| Shoulder and Arm| Overhead Arm Elevation

Friday, March 16, 2007

If any of the shoulder muscles listed below are in pain or discomfort, there will be an impairment of shoulder and arm movements especially with overhead arm elevation.

Overhead arm elevation is a series of movements bringing the shoulder from the side of the body, to 60° away from the body, to 90° and then to a full overhead elevation.These movements have to be smooth and without hesitations showing that movements of the shoulder joint and movements between the shoulder blade and the chest wall is normal.

Normally, for every 2° movement at the shoulder joint , there is 1° of movement the shoulder blade on the chest wall.

Therefore, for overhead elevation of 180°, 120° of movement will occur at the shoulder joint and 60° of the movement is contributed by movements of the shoulder blade on the chest wall. The shoulder blade should not move with shoulder joint movements under 60°.

The arm can be elevated overhead by:

• lifting the arm forward (flexion)
  
• lifting it sideways (abduction).

Muscles that raise the arm overhead through lifting the arm forward (flexion):

pectoralis major supplied by the lateral pectoral nerve from the lateral cord and medial pectoral nerve from the medial cord of the brachial plexus.

infraspinatus and teres minor contract to bring the arm to 90° away from the shoulder and the activity become stronger as the arm is elevated above 90°.

lower four slips of the serratus anterior muscle. The serratus anterior muscle is supplied by the C5, C6 and C7 nerve roots through the long thoracic nerve of Bell. The long thoracic nerve is given off from the C5-C7 nerve roots of before the formation of the brachial plexus. The serratus anterior is also helped by the rhomboid major and minor muscles and the levator scapulae which help to fix the shoulder blade to the chest wall. The serratus anterior helps to pull the shoulder blade out and up. The rhomboid muscles are important in bringing the arm down from the overhead position.

Muscles that raise the arm overhead through lifting the arm away from the side of the body:

• serratus anterior
• trapezius
• infraspinatus and teres minor

To raise the arm overhead, the shoulder must be externally rotated. If the shoulder is in internal rotation, the head of the humerus is caught under the acromion and full overhead arm elevation is not possible.

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If the shoulder is in internal rotation, the head of the humerus (shoulder bone) is caught under the acromion of the shoulder blade and full overhead arm elevation is not possible.

Raising the arm in external rotation can bring about full overhead elevation.

Neck Pain| Elbow Pain| Triceps

January 23, 2007

Neck pain due to C7 nerve root irritation is second only to C6 nerve root irritation. Those with elbow pain commonly have C6 and C7 nerve root irritation.

Triceps is supplied by the C6-C7 nerve roots, especially C7 root carried through the radial nerve. Pain and spasm in the triceps together with pain and spasm in the wad of three supplied by the C5 and C6 nerve roots (brachioradialis, extensor carpi radialis longus and extensor carpi radialis brevis) will give rise to significant elbow pain commonly known as tennis elbow.

Triceps muscle has three heads namely the long head, lateral head and the medial head. The lateral head and the medial head arise from the posterior aspect of the arm bone (humerus).

The long head is the only part of triceps that crosses the shoulder joint since it arises from the tubercle on the shoulder blade bone just below the shoulder joint.

It inserts into an area called the olecranon on the back of the ulnar bone.

It acts to straighten the elbow. The long head however can bring the arm toward the body when it is spread away from the body.

Due to the constant exposure to lengthening contractions, triceps is weak in most people especially in the presence of a C7 nerve root involvement.

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Neck Pain| Wrist Pain| Carpal Tunnel Syndrome| Tingling

Monday, February 12, 2007

Carpal tunnel syndrome can commonly coexist in patients with neck pain or wrist pain conditions. Symptoms of tingling and numbness in the fingers can be a combination of cervical nerve root irritation and the concomitant presence of carpal tunnel syndrome. Symptoms that involve most of the palmar surface of the first three digits but not the back of the hand or the little finger are suggestive of carpal tunnel syndrome.

Such symptoms are more often associated with positive Phalen's sign where tingling and numbness can be brought about by bending the hand down 90° at the wrist. The reverse Phalen's sign where the hand is bent 90° at the wrist with the fingers pointing upward may also be positive (see pictures below for Phalen's and reverse Phalen's maneuvers).

Tinel's tests elicit a tingling sign during nerve (axonal) regeneration by tapping over the nerve with a reflex hammer. A positive test signals the progress of nerve regeneration and is used with the diagnosis of carpal tunnel syndrome and in the evaluation of regenerating peripherally injured nerves.

These positive findings unlike other categories of sensory disturbance, are not related to neck pain or restriction of neck movement in those who have repeated wrist and finger movements at work. There is increasing evidence that occupational factors, including forceful use of the hands, repetitive use of the hands, and hand-arm vibration, are causes for carpal tunnel syndrome.

Those who have underlying conditions such as hormonal imbalance (diabetes, hypothyroid disorders, pregnancy, etc), rheumatologic disorders, autoimmune diseases, and disorders that involve peripheral nerves etc also predisposes the person to carpal tunnel syndrome.

Tingling and numbness are common symptoms and associated condition in patients who have fibromyalgia or chronic myofascial pain. Together with the sensory deficits in the hands, these patients may also have the possibility of carpal tunnel syndrome. They may have tingling and numbness in the hands with weakness and or atrophy of the short muscles that bring about movements of the thumb.

Tingling and numbness are usually due to paroxysmal discharge and extra activity in large myelinated nerve fiber involvement whereas if there is associated pain, this is due to involvement of the small unmyelinated C-fiber nerve axons. Pain and coldness of the upper limb strongly suggest ischemia.

On physical examination, Tinel's and Phalen's signs may be present. If there is suspicion of carpal tunnel syndrome, bilateral electrophysiological tests including the median and ulnar nerves conduction studies and electromyography (EMG) of upper limb and neck muscles supplied by the cervical nerve roots need to be performed. Carpal tunnel syndrome needs to be documented electrophysiologically.

A useful maneuver that eases or abolishes tingling and numbness in carpal tunnel syndrome involves gently squeezing the heads of the knuckles of the affected hand with the palm up. In some instances stretch of the middle and ring fingers is also required. This maneuver may help in the clinical diagnosis of carpal tunnel syndrome, can be useful as a means of relieving symptoms. The authors also suggest basis for the design of an innovative splint. (Manente G. Torrieri F. Pineto F. Uncini A. A relief maneuver in carpal tunnel syndrome. Muscle & Nerve. 22(11):1587-9, 1999).

Alleviating the primary cause of the carpal tunnel syndrome is essential in the treatment of this condition. Pain, tingling and numbness of the hands severe enough to wake the patient up from sleep especially several times at night, dropping objects frequently from the hands is what brings the patient to seek medical help.

Recurrence of symptoms even after surgery is common if the patients also have concomitant proximal muscle tightness, pain and spasm due to multilevel nerve root involvement. Surgery may relieve symptoms significantly better than splinting, however, adequate conservative treatments to alleviate symptoms should be tried before surgery is considered.

Massaging the muscles of the hand especially between the first web space and the thumb muscles as well as the muscles of the back of the forearm, arm, shoulder blades and neck is essential for relieving some of the discomfort symptoms.

In the conservative management for carpal tunnel syndrome, eToims Twitch Relief Method can help in the alleviation of pain symptoms and the healing and stabilization of nerve irritability allowing these patients to have an improvement in quality of life.

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Phalen's maneuver	Reverse Phalen's maneuver

Checking for Tinel's sign by tapping the median nerve at wrist

Neck Pain | Hand Pain| Finger Pain

Friday, November 09, 2007

Patients with neck pain and/or neck stiffness without pain may not associate that their hand and finger pain is related to neck problems. Usually they attribute the hand and finger pain and/or stiffness to arthritis. Initially, self treatments are usually applied to the fingers in terms of using balms, ointments and lotions. Patients may also take analgesic medications and anti-inflammatory medications to help ease the pain. When the pain is severe, they may receive injections into the fingers or wrists and sometimes even surgery to release trapped tendons and nerves in the wrist and hand.

Sometimes patients may exercise the hand against resistance such as squeezing a rubber ball or some gadget hoping to strengthen the hand muscles. If the pain is chronic, these resistive activities will make the pain symptoms worse and can accelerate the progression into bony deformities in the fingers.

One might notice early arthritic deformities such as swelling and formation of soft nodes especially at the tip of the fingers called Heberden's nodes which begin with sub chondral bone formation as a reaction against inflammation. Eventually, these will become more calcified forming bony deformities. A recent survey has shown that one in 12 United States adults have symptomatic hand arthritis and incidence increases with age (Dillon CF. Hirsch R. Rasch EK. Gu Q. Symptomatic hand osteoarthritis in the United States: prevalence and functional impairment estimates from the third U.S. National Health and Nutrition Examination Survey, 1991-1994. [Journal Article] American Journal of Physical Medicine & Rehabilitation. 86(1):12-21, 2007 Jan).

In the early stages before hand deformities occur, pain in the hands can be helped by helping to relax the muscles on the dorsal aspect of the forearm. Neck pain due to spondylotic radiculopathy (arthritis) usually involves the C6 and C7 nerve roots. These roots supply the muscles on the dorsal aspect of the forearm among other large muscles in the shoulder and arm such as the latissimus dorsi and triceps muscles.

When these dorsal forearm muscles which move the wrist and fingers into extension become shortened due to nerve root irritation at C6 and C7 levels, they will pull and tug on the joints of the wrist, knuckles and fingers causing pain in these joints. Additionally, shortening of the dorsal muscles of the forearm places an overwork syndrome to the flexor muscles of the forearm and hand since now the long flexor muscle must work harder to counter-act the resistance provided by the tight and short dorsal forearm muscles that not only cross the wrist but extend to the fingers (extensor digitorum communis, extensor pollicis longus and brevis extensor indicis, extensor digiti minimi and others).

These flexor forearm muscles also eventually become tight and stiff making it difficult for the fingers to bend. Initially, finger bending may be slow due to stiffness but eventually it can progress to the stage of significant pain when there is development of a trigger finger. Triggering of the finger means that there is a tenosynovitis of the flexor tendon (inflammation of the synovial covering of the tendon) such that the tendon becomes thickened. There is a size mismatch between the tendon and the tunnels through which it must pass through at the level of the palmar aspect of the knuckle or the finger joints. A nodule on the flexor tendon may prevent the thickened tendon from passing through the tunnel. The finger may stay locked in flexion at the knuckle joint and there will be significant pain on trying to release it out of its locked position using the other hand. A click may sometimes be heard as the tendon is able to pass through the tunnel.

Significant tightness of the long finger flexors can also lead to tenosynovitis of the long flexors causing compression of the median nerve. This develops into carpal tunnel causing not only pain but tingling and numbness and eventually weakness in the fingers especially in the median nerve distribution (the thumb, index and middle fingers and the thumb ½ of the ring finger) interfering significantly with activities of daily living.

In the early stages, relaxation of the muscles of the forearm especially those on the dorsal aspect can be obtained by constant massaging of these muscles. Relaxation of the muscles can also be helped by using heat over the dorsal aspect of the forearm. Massage should also extend to relax all the muscles of the neck, shoulders and arms. This approach will help to treat the root cause of the finger pain rather than focus the treatments only to the fingers and hand. Activity modification must accompany all treatments in order that progressive healing can take place.

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Neck Pain| Headaches| Jaw Pain

Thursday, February 08, 2007

Various types of work that involves repetitive or prolonged upper extremity work frequently gives rise to neckache and headache.

The headaches are frequently on both sides of the head and originates in the neck. The headaches are also frequently provoked by awkward neck positions.

Sustained extension and rotation of the neck, alone or in combination, increase the neck discomfort.

Patients with neck pain tend to have lower neck muscle strength in all the directions.

Reduced activation and weakness of the muscles of the back of the neck such as the paraspinal muscles and trapezius muscles leads to over activity of the muscles at the front of the neck such as the sternocleidomastoid and scalenes.

Chronic neck pain can lead to poor control of the jaw and head-neck movements during jaw opening-closing tasks, and can compromise natural jaw function leading also to jaw pain commonly known as TMJ (temporomandibular joint) pain.

For normal jaw movements, there must be coordinated activation of muscles that control movements of the jaw, head and neck.

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Tension Headaches

Sunday, December 17, 2006

Tension headaches due to muscle tightness will be the only type of headache that will be in our discussion here. You must consult your physician to find out the cause of headaches before attributing it to just increased muscle tension. Headaches may be a sign of many ominous problems.

Muscle tension headaches can aggravate vascular headaches such as migraines. Relieving the muscle tension type of headache can help to reduce the intensity, duration, interval between the vascular headaches.

There are a lot of muscles which attach to the skull that when shortened and in spasm can put a traction effect on the skull bone giving rise to headaches. Pain in the back of the neck from muscle spasms can go up the back and top of the head as well as the sides of the head. It may be severe enough to cause nausea and vomiting.

The muscles most responsible for tension headaches are the trapezius, levator scapulae, splenius cervices, sternocleidomastoid and the small and short muscles that arise from the neck to attach to the head. These muscles are commonly injured with whiplash, falls or lifting injuries. Usually, the force of the same injury that injures the nerves going to these muscles that initiate or aggravate the headaches will also simultaneously injure other spinal nerve roots in the neck, mid-back and low back. Therefore treating just the neck muscles and other muscles mentioned above will not address the headache problem well.

The trapezius muscles and other muscles mentioned above are not meant for lifting activities. The strong muscles necessary for efficient lifting are the latissimus dorsi, deltoid, triceps, middle back, lower back, pelvic girdle and thigh muscles. If these muscles are weak, tight, or inefficient, you will continue using a shoulder shrug to lift. This will continue to injure all the muscles responsible for tension headaches. Therefore, treatment of tension headaches can never be isolated to treating just the muscles in the local area of the head and neck.

The treatments for muscle tension headaches must address also the muscles along the entire spine and all the large and powerful muscles of the upper and lower limbs.

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Neck pain| Facial Muscles

Saturday, February 03, 2007

Significant neck pain due to pain and spasm in the neck can tug and pull on the facial nerve to irritate it. The facial nerve supplies most of the muscles of the face. The facial nerve comes out from the skull at the stylomastoid foramen to enter the face.

Patients may note facial muscle twitching around the eye, nose and lips in the earliest stages of the facial nerve irritation. Always consult your physician for the cause of the facial twitching.

If the irritation is significant enough, paralysis of the facial muscles can occur. Facial muscle paralysis due to facial nerve irritation from muscle spasms may be of the reversible or permanent type. In fact concurrently, there are nerve fibers which are reversible and there are some nerve fibers which have already progressed to the permanent injury status.

The goal of eToims Twitch Relief Method in facial paralysis is to return as much function as possible by beginning treatments within the first 24 hours.

The twitch movements can stimulate the muscles, frees the entrapped intramuscular nerves and blood vessels and aid in the return of circulation to the areas stimulated.

If the facial nerve injury is primarily that of partial neurapraxia, return of function is facilitated and recovery can be complete.

eToims Twitch Relief Method can be used for support of nerve recovery if the facial nerve injury has already progressed to permanent paralysis.

In addition to stimulating the facial muscles, muscles supplied by the C3 through C8 nerve roots as well as the paraspinal muscles from the skull to the base of the spine have to be included with the eToims Twitch Relief Method.

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