It is a nice idea that symptoms will lead you clearly down one path or the other, but nothing screws up a great idea like a few facts. In reality, the process is often messy, with two or more possible reasons for any presenting symptom. Pursuing one without conflicting with the other is not always easy.
Her message sounded alarming: severe cramping, pain, and numbness in her arm and hand. I had seen her son for severe trigger-finger work, which turned out very well, so she called me for help with her own pain.
When I met with Ms. C., she pointed to the back of her right index finger and thumb.
“I have been having terrible cramping and pain in this area for several days. It comes on intermittently, and it’s awful. I read online that massage might help, but the area is so sensitive, I can’t even think of massaging it right now.”
“Where exactly do you feel it?” I asked, trying to get a clear sense of the possible causes.
“Right here,” she said, pointing to the dorsal side of the thumb, index finger, and possibly the middle finger. “The cramping doesn’t go above the wrist,” she added.
“Is there anything you think might have caused this? Is there anything you can do to relieve it?”
“I can’t think of any reason why this is happening. Bending my wrist back like this seems to relieve it, if I keep it there for a while,” she said, putting her wrist in extension.
I mentally reviewed the possible causes of pain at the dorsal aspect of the thumb. I could think of three right away: de Quervain’s syndrome, radial nerve entrapment, and possibly a referral coming from the extensor carpi radialis muscles. Direct treatment of the local issue was clearly out of the question; Ms. C. was extremely apprehensive about letting me touch the area of pain. Directly addressing the area of symptom presentation isn’t smart if it is highly sensitive. If you suspect there might be a snake in the bushes, kicking the bushes isn’t the best way to find out.
 “Are you sure the cramping and numbness is only on the back of your hand?” I asked, trying to explore whether this could be a radial nerve issue.
“I can’t be sure. When it hurts, it just hurts, and I have to admit that I really do not know,” she relayed with some embarrassment. This point was important, but made the situation even more unclear. The radial nerve serves the back of the hand, while the median nerve serves the palmar side of the thumb and index finger. Her description was not going to help me determine which nerve might have been involved.
The fact that wrist extension decreased her symptoms could indeed point to the radial nerve, as that nerve is slackened by extension of the wrist. However, this position also slackened the wrist extensors, making it difficult to discern whether it was the nerve or the muscle that was relieved by wrist extension.
“What if we stretch the wrist in the opposite position?” I asked, taking her wrist into slight flexion.
Ms. C. gave me a look of fear, as though I’d asked her to run across a busy interstate. “On second thought, let’s not do that,” I said.
I was now officially stuck. The tests to implicate muscle versus nerve are provocative—not a great choice when symptoms are so active.  
Faced with two diverging roads—one muscular and one neural—I decided to take both. I would address it in a way that would alleviate nerve entrapment with no possibility of irritating it. On the muscular front, I would treat the extensor carpi muscles while being careful not to irritate the nerve by stretching it or putting pressure on the nerve itself. That meant not stretching the muscle or putting direct pressure anywhere near where the radial nerve is located.  
I treated the tricep first, as the radial nerve lies between the muscle and the bone. The treatment was just a lifting compression to avoid putting pressure on the nerve. The supinator was next, using pressure with no stretch and carefully avoiding the area where the radial nerve might be. I performed fascial release, stopping before I approached the area of symptoms near the wrist.
On the muscular side, I treated the extensor carpi muscles with careful slow friction in the direction of muscle fibers. I did this with the wrist in extension to keep the radial nerve in a slackened position.
Ms. C.’s symptoms were much improved by the third half-hour session. It became clear the problem wasn’t the radial nerve after all; it was the extensor carpi radialis brevis.
The idea that a therapist can precisely narrow down the cause of pain in one session is just that—a wonderful idea. In reality, solving problems is a messy business. It isn’t always clear which path to take. When you aren’t positive, just make sure that choosing one possibility doesn’t aggravate another suspected cause. When the roads diverge (and if it’s possible), take both.

Douglas Nelson is the founder and principal instructor for Precision Neuromuscular Therapy Seminars and president of the 16-therapist clinic BodyWork Associates in Champaign, Illinois. His clinic, seminars, and research endeavors explore the science behind this work. Visit www.nmtmidwest.com, or email him at doug@nmtmidwest.com.