Nerve injuries can be intimidating for massage therapists. However, they don’t have to be if a few key evaluation and treatment concepts are applied. In this installment, we examine a complex case involving a client with neurological symptoms in her hand.
Monica is an aerial silk artist. These performers do complex acrobatic maneuvers while hanging from large silk ribbons. It is an elegant sport that takes a great deal of strength, flexibility, and grace. Three weeks ago, Monica had an accident during practice in which she lost her grip and had to catch herself from falling. The incident had her horizontal and grabbing the silk with her right hand as she fell; her head was thrust in the opposite direction.
About a week after the injury, Monica began experiencing pain— along with pins-and-needle sensations (paresthesia)—in her right hand. She sought massage therapy, hoping it would resolve the symptoms and prevent further problems. Clearly, Monica was having neurological symptoms, and although one might be tempted to immediately refer a client with neurological involvement, it is not always necessary. Initial assessment indicated Monica’s injuries might be primarily soft-tissue related, and so it was determined that massage may be appropriate. Further assessment is crucial for effective treatment in a condition like Monica’s.

Physical Exam/Evaluation
Monica reported delayed upper extremity neurological sensations several days after the accident. The paresthesia symptoms were predominantly on the ulnar side of her hand, but not in her arm. The location of symptoms is one of the most important clues as to where a predominant nerve injury is located. To fully understand how to use this information effectively, let’s first review some key principles of nerve anatomy and physiology.
There are two basic types of mechanical nerve injury that can result from the type of accident Monica experienced: radiculopathy or a peripheral neuropathy. A radiculopathy is an injury to the nerve root. A common example is a disc herniation or spinal tumor pressing on the nerve root. A peripheral neuropathy is a nerve injury that impacts the nerve farther along its path, distal to the nerve root. These conditions produce distinct symptom patterns, but it is not always easy to distinguish between them.
You can have both problems simultaneously: nerve root and peripheral nerve impairment. However, for determining the tissues involved and making good treatment decisions, it is important to be able to make distinctions between the symptom patterns of these conditions. There are two important concepts related to symptom patterns in radiculopathy and peripheral neuropathy: dermatomes and cutaneous innervation. Understanding these concepts is essential to the evaluation process of nerve injuries.
A dermatome is an area of skin innervated by fibers originating from a single nerve root. For example, Image 1 shows the dermatome region for the C8 nerve root (there is a C8 nerve root even though there are only seven cervical vertebra due to an odd naming convention). The C8 nerve root exits below the C7 vertebra, and some of the fibers in the C8 nerve root form the medial antebrachial cutaneous nerve and some become part of the ulnar nerve. Notice that the C8 dermatome covers the ulnar aspect of the hand, but it also extends into the forearm and back side of the arm.
The fibers from the nerve roots branch out into the peripheral nerves. The area of skin that is innervated by a single peripheral nerve is referred to as that nerve’s cutaneous innervation. A peripheral nerve may have fibers that originate from more than one nerve root, but a single nerve root can also branch into more than one peripheral nerve. Because the nerve could have fibers from more than one nerve root, the nerve’s cutaneous innervation could be split across more than one dermatome. Thus, there is no one-to-one correspondence between a peripheral nerve and a dermatome.
Image 2 shows the cutaneous innervation of several upper extremity nerves. In the image, you can see that the cutaneous innervation region for the medial antebrachial cutaneous nerve and the ulnar nerve are both contained within the C8 dermatome. Let’s take a look at the symptom patterns in Monica’s case to see how this anatomical information applies.
The primary location of Monica’s symptoms would indicate involvement of the ulnar nerve, as the symptoms are contained within the cutaneous innervation pattern for that nerve. However, you can’t rule out nerve root involvement completely in Monica’s case because her symptoms are still within the C8 dermatome, even if they don’t extend throughout the entire dermatome.
To determine nerve root involvement (radiculopathy), as opposed to injury farther along the nerve (peripheral neuropathy), tension or compression forces are selectively applied at different locations to assess if symptoms are aggravated. It is not possible to apply those forces at every single spot along the nerve, so there is still some degree of approximation of injury location. If symptoms are increased when the nerve root is stressed, it indicates a likely radiculopathy. Similarly, if symptoms are most aggravated when the peripheral nerve is stressed, nerve injury farther along the branch is more likely.
When examining Monica, none of her symptoms were reproduced with palpation around her anterior, posterior, or lateral neck region. However, numerous neurological structures are deep and inaccessible to palpation, so that does not mean much by itself.
During range-of-motion evaluation, Monica had increased neurological sensations in her right hand with both active and passive lateral flexion of the cervical region. The brachial plexus is stretched in both of these movements. It is feasible that the nerve root or a peripheral nerve could be aggravated with both of these motions. Monica’s symptom pattern increases our suspicion of neurological tissue damage, but it does not significantly discriminate between nerve root or peripheral problems. During active and passive range-of-motion evaluations with Monica, no other neck motion caused discomfort. Manual resistive tests also did not increase symptoms.
One of the most helpful methods for identifying the location of nerve injury in the upper extremity is a procedure called a neurodynamic test. In this test, tension is applied to different regions of the nerve with sequential steps to assess if symptoms are aggravated. If symptoms are aggravated in one particular region but not another, it suggests that nerve injury is more prominent in that region.
Monica’s symptoms are primarily in the ulnar nerve distribution. The upper limb neurodynamic test 4 is the procedure designed to emphasize disorders with the ulnar nerve. It may also give some indication if the nerve root is involved. The video “Upper Limb Neurodynamic Test 4” found in the digital edition of this publication
(www.massageandbodyworkdigital.com) demonstrates the upper limb neurodynamic test #4, which examines for pathology in the ulnar nerve. If symptoms are aggravated most during the motions involving the forearm and wrist, it suggests the pathology is somewhere between the elbow and hand. If symptoms are increasingly aggravated with the motions involving the cervical region or shoulder, there is a greater likelihood that dysfunction is somewhere in the nerve structures in that region.
With Monica, paresthesia symptoms were aggravated during the shoulder abduction and lateral cervical flexion movements. Both movements stretch the upper brachial plexus. If the problem was primarily at the nerve root alone, it would be unlikely that symptoms would be aggravated during shoulder abduction, because that motion does not significantly stress the nerve root. In fact, because the neurological structures of the arm are brought closer to the neck during full shoulder abduction, symptoms of nerve root problems in the cervical region frequently decrease with that movement. Monica’s response pattern pointed toward involvement of the brachial plexus in the neck or shoulder region and not at the nerve root level.
Another procedure was performed with Monica called the Wright’s abduction test. In this procedure, the arm is brought into full abduction as far as possible and held in that position for about 30–60 seconds. (Flexing the elbow during this procedure stretches the ulnar nerve and may make the test more sensitive). If neurological symptoms increase during the test time, there is a greater likelihood of nerve compression occurring in the lower brachial plexus under the pectoralis minor muscle.
The Wright’s abduction test was used to confirm our findings with the neurodynamic test. The test also decreases stress on the nerve root if the nerve is not being restricted in another location. Symptoms are often decreased with this procedure if the nerve root is the sole problem. Monica had an increase of symptoms during this procedure that indicated peripheral nerve involvement.
Monica’s symptom patterns appeared only in the ulnar nerve's cutaneous innervation, and her response pattern to the various physical examination tests pointed to a greater likelihood of lower brachial plexus injury somewhere between the neck and shoulder regions. Due to the nature of her fall, nerves in this area were likely overstretched from the forces and motions involved, and the resultant pattern of muscle splinting is likely further compressing the brachial plexus and causing an increase in symptoms.

Treatment Strategies
Nerve injury treatment poses some unique challenges. The most important strategy when addressing any soft-tissue disorder is to make sure to match the physiology of the tissue injury with the physiological effects of the treatment approach. If the nerve roots are involved, there is little that massage can do to address it, because the structures are too deep. In addition, massage can’t do anything to the nerve directly to help it heal from compression injury. The most important goal is to get pressure off the nerve so that it can heal on its own.
In Monica’s case, it appears that residual muscle tightness or splinting was compressing the nerve and further restricting its free movement, thereby causing symptoms. Consequently, massage treatment focused on reducing tightness in the lateral cervical muscles, pectoralis minor, and associated muscles, which were likely compressing the lower brachial plexus.
Prior to treating the pectoralis minor, it is important to reduce tightness in the overlying pectoralis major muscle first. Once the pectoralis major is relaxed, deeper stripping applications can be applied to the pectoralis minor to reduce tightness or existing myofascial trigger points that might be causing the muscle to bind and restrict the brachial plexus. Be sure to note if the client experiences any symptoms or sensations when working the pectoralis minor to make sure you don’t put additional pressure on the brachial plexus and further aggravate nerve compression.
Deep stripping applications can also be applied to the anterior and lateral neck muscles to make sure they are not binding or restricting the brachial plexus. Special attention should be focused on the anterior and middle scalene muscles, as these are the ones most likely to bind the brachial plexus in the cervical region (Image 3).
One of the key goals of treatment in Monica’s condition is to encourage free movement of the nerve, which might be bound and restricted by muscle tightness. Once the muscles surrounding the nerve have been somewhat relaxed with the massage techniques described above, you may use a neural mobilization technique. The technique used with Monica uses the same positions as the neurodynamic test described earlier. The arm is then gently moved in and out of the stressful position in order to reduce adhesions that might have bound or restricted the nerve. This technique attempts to move the nerve through its range of motion. You can see a demonstration of the neural mobilization technique for the ulnar nerve in the digital version of this publication, www.massage andbodyworkdigital.com.
Monica required once-a-week sessions for six weeks. Nerves are slow to heal, and though Monica saw immediate improvement, the nature of her art form and activities meant that there was previously existing tightness in her upper body musculature that complicated her situation. Monica performed stretching activities at home as well. She also stayed off the silks completely for two weeks, which was critical for her to stop the progression of the condition. However, after that initial period, she was able to gradually and gently resume her routines.

Conclusion
This case with Monica is an excellent example of the importance of a comprehensive assessment for creating a treatment plan. Though a client may see another health-care professional, your assessment and evaluation skills are crucial parts of successful treatment for these types of cases. Though nerve injuries cannot be directly treated with massage, the surrounding tissues are often involved and there are indirect approaches that can help tremendously in solving these potentially complicated cases.

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