Any pain, numbness, tingling, burning, or stiff ness in the hands and fingers is apt to be blamed on median nerve entrapment in the car-pal tunnel. Myofascial trigger points in the forearm and scalene muscles, however, can create all of these symptoms.1 Some of the patterns of pain referral from forearm and scalene muscles to the radial side of the hand coincide perfectly with the area served by the median nerve. Nerve impingement by certain forearm muscles, and by the scalenes in the thoracic outlet, can cause neurological sensations easily mistaken for the effects of impingement of the median nerve at the wrist. Compression of the subclavian vein and lymph duct by the action of the scalenes may cause enough edema at the wrist to be the ultimate source of genuine carpal tunnel restrictions.
Clinical experience has shown that deep stroking massage is an effective means for deactivating trigger points.1,2
Deep Stroking Massage
Deep stroking massage (DSM) applied directly to the trigger point by a practitioner or by patients themselves is proposed as a safe and efficient method of pain therapy. DSM has a more specific effect on the trigger point than the "spray and stretch" method, as described by Travell and Simons, and carries much less risk to muscle attachments than conventional stretching exercises. Because of its directness, DSM works nearly as well as trigger point injection and is actually superior around blood vessels and nerves where injection can be too dangerous.1 DSM is uniquely adaptable for self-treatment.
DSM appears to work by stimulating local circulation to the sarcomeres and by directly stretching the trigger point's contracted muscle fibers. The focused stretching of the muscle fibers accomplished with this massage stroke should be seen as a microstretch, as opposed to the macrostretch, which is done by stretching the whole muscle.
Previously, trigger point massage was defined as ischemic compression, which requires pressing and holding a trigger point for a specified time.3 Static compression of a trigger point, however, requires the sustained contraction of the practitioner's shoulders, arms, and hands. Instead of static pressure, it's more effective to make a series of strokes across the trigger point nodules. This gets results quicker with less irritation to the trigger point, less pain to the patient, and less risk to the practitioner's hands.
DSM should proceed slowly, at the rate of one stroke every two seconds. The stroke needs to be only an inch or so long-just enough to move from one side of the trigger point to the other. Release at the end of the stroke, then go back to the start point, reset, and repeat. A significant degree of ergonomic efficiency is derived from these repeated strokes because the hands get a brief but vital rest between strokes.
To gain maximum benefits from DSM, exert enough pressure to make it "hurt good" -that is, a pleasant kind of hurting. Aim at a pain level of seven on a scale of one to ten, where "one" is no pain and "ten" is intolerable. Keep the sessions short-no more than 20 to 30 seconds per trigger point. Several brief sessions daily do more good than intensive treatments once or twice a week. Trigger points generally respond very well to massage. Failures are usually the result of treating the wrong spot.1,2
The following discussion deals briefly with some of the muscles most frequently abused by repetitive strain in manual tasks.
Pain is rarely felt in the scalenes themselves, but their trigger points may be the primary source of pain in their referral areas (Fig. 1). Trigger points in the scalenes cause a wide distribution of pain in the chest, upper back, shoulder, and upper arm. Symptoms in the forearms, wrists, hands, fingers, and thumbs can manifest as pain, aching, numbness, tingling, burning, swelling, and hypersensitivity. Scalene-induced weakness in the forearms and hands can cause the patient to unexpectedly drop things.1
Success in dealing with the scalenes depends on an understanding of their relationship to the clavicle and the sternocleidomastoid muscles (Fig. 2). The anterior scalene lies between the sternocleidomastoid and the cervical vertebrae, and is almost completely hidden. The middle scalene is behind the anterior scalene on the side of the neck, with its lower half free of the sternocleidomastoid. The posterior scalene lies behind the middle scalene in the soft triangular depression just above the collarbone at the front edge of the trapezius. When placement of the fingers is correct, scalene massage does not threaten the carotid arteries.
For self-applied massage to an anterior scalene muscle, which is the chief troublemaker, first pull the sternocleidomastoid strongly toward the windpipe with the fingertips of the opposite hand. In this position, you can press the anterior scalene back against the cervical vertebrae with the blunt ends of your fingers (Fig. 3). Execute the massage stroke by pressing with your fingertips as you push them across the muscle toward the side of the neck, moving the skin with the fingers. At the end of the stroke, release the pressure, reset, and repeat. This procedure should be carried out all along behind the sternocleidomastoid, from the corner of the jaw down to the collarbone (Fig. 4). To massage the middle scalene, continue the stroke across the side of the neck just above the clavicle.
To massage the posterior scalene, push your middle finger under the front edge of the trapezius muscle near the point where it attaches to the collarbone (Fig. 5). Press down and drag your finger medially, parallel to the collarbone, moving the skin with it. The posterior scalene can have trigger points when the other scalenes don't. Pressure on any of the scalene trigger points may reproduce or accentuate pain in some part of the pattern area, giving a very convincing demonstration of the reality of referred myofascial pain. Scalene massage can evoke an extremely unpleasant electric kind of pain that feels like you're pressing on a nerve. Pressure on a healthy scalene muscle will not hurt and will not refer pain.
Trigger points in the hand and finger extensors cause pain in the outer elbow and in the back of the forearm, hand, wrist, and fingers. They also cause hand weakness, finger stiffness, knuckle tenderness, numbness, tingling, and loss of coordination.1
Extensor carpi radialis longus trigger points are a common cause of lateral epicondylitis, or tennis elbow (Fig. 6). They also provoke a kind of burning pain in the outer side of the forearm and in the back of the wrist and hand. Trigger points in the extensor carpi radialis brevis cause pain in the back of the wrist and hand and a sense of tightness, burning, or aching in the back of the forearm (Fig. 7). Sometimes, tightness in this short extensor can trap the radial nerve, causing numbness and tingling in the hand. Extensor carpi ulnaris trigger points send pain to the ulnar wrist that feels like a sprain (not shown). These three hand extensors can be overworked to the point of exhaustion at a computer keyboard because of their importance in keeping the hands in position.1
Trigger points in the extensor digitorum are the prime cause of stiff fingers. They also send pain to the outer elbow, the back of the forearm, and the second knuckle of the middle and ring ringers (Fig. 8). Referred pain in the knuckles can be mistaken for arthritis.1
Pain caused by trigger points in the hand and finger flexor muscles is sent to various locations on the inner side of the forearm, wrist, hand, and fingers. Flexor carpi radialis trigger points send pain to the inner wrist near the base of the thumb (Fig. 9). This pain is commonly mistaken for a wrist sprain. Flexor carpi ulnaris trigger points also mimic sprains by sending pain to the ulnar side of the wrist (Fig. 10). When this muscle stays tight, it can compress the ulnar nerve, causing a weakened grip and a sensation of burning or numbness in the fourth and fifth fingers. Trigger points in the flexor digitorum send sharp pain to the palmar side of the fingers (Fig. 11). Pronator teres and palmaris longus trigger points (not shown) also cause forearm and hand symptoms.1
Self-treatment of the forearm muscles is surprisingly easy when done with a tennis ball or similar-sized "high-- bounce" hard rubber ball against a wall (Figs. 12-14). The best tool, however, for maximum penetration and control may be a lacrosse ball. The position shown in Fig. 12 also allows massage of the supinator and brachioradialis, whose trigger points coincide approximately with those of the extensor carpi radialis longus. Strictly speaking, Fig. 13 shows the hand in position for massage to the extensor digitorum. Turn the hand palm up to work the extensor carpi radials brevis. Turn the palm to the floor for massage of the extensor carpi ulnaris. Fig. 14 shows how all the muscles of the inner forearm can be massaged with the arm behind the back.
In all cases, move the arm so that the ball rolls slowly along the muscle toward the elbow. To exert pressure, lean against the arm with the body. The worst trigger points will be found within three inches of the elbow. For ease of understanding of proper positioning, the subject is shown without a shirt. Massage of the forearms should be done through a layer of cloth whenever possible.
Trigger points in the intrinsic muscles of the hand and some of the muscles of the shoulders and upper back also contribute to symptoms that can mistakenly be interpreted as carpal tunnel syndrome.
In the author's experience, myofascial trigger points are the major cause of the pain and other symptoms suffered by patients who subject their hands to repetitive strain. When conventional treatment protocols are less than satisfactory in coping with symptoms in the hands and fingers, it may be due to their not being suited to deactivating myofascial trigger points. Self-applied trigger point massage can be an efficient and cost-effective way to manage the pain and dysfunction so often wrongly categorized as carpal tunnel syndrome.
1. Simons DG, Travell JG, & Simons LS. Myofascial Pain and Dysfunction: The Trigger Point Manual. Vol. I, 2nd ed., Baltimore: Lippincott, Williams & Wilkins, 1999. Pp. 141-- 142, 505, 509-510, 514-518, 688, 690-693, 699-700, 702-705, 715-715, 728-729, 743-744, 753-757, 764-766.
2. David C. The Trigger Point Therapy Workbook: Your Self-Treatment Guide for Pain Relief Oakland, CA: New Harbinger Publications, 2001.
3. Prudden B. Pain Erasure. New York: M. Evans & Co., 1980.
By CLAIR DAVIES, NCTMB
Mr. Davies is nationally certified in therapeutic massage and body work (NCTMB). He can be contacted at 3005 Arrowhead Drive, Lexington, KY 40503.
E-mail address: email@example.com
Web site: www.triggerpointbook.com.
Copyright American Chiropractic Association Jul 2002
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