Thank goodness for the thumb. Its unique opposability allows us to grasp, hold, squeeze, and manipulate; its enormous strength gives power to our grip; and its unmatched sensitivity helps us feel the minutest differences in texture, pressure, or size.

Thumbs are so good at so many things that they are very commonly overused, causing tissue and joint irritation, pain, and eventual damage. For example, the increasing use of small-device keyboards means thumbs are more active than ever in the awkward, repetitive movement patterns needed to type out emails, texts, and tweets (Image 1). Some in our field have taken this as a business opportunity, catering to their clientele with “Blackberry thumb” massages—hand treatments designed to ease the strain and pain of excessive thumb keyboarding. 

But manual therapists are themselves vulnerable to thumb overreliance—in our Advanced Myofascial Techniques seminars, we see practitioners in every workshop who are dealing with the effects of thumb overuse, sometimes severe (see A Few Rules of Thumbs on page 116 for a few ways to avoid excessive thumb use).

The structure of the thumb lends it special qualities, along with unique vulnerabilities. The thumb’s joints are the most mobile of all the digits’, allowing the thumb its distinctive opposability and adaptability. As with the fingers, articular ligaments provide some stability; but because of its highly mobile joints, the thumb gets most of its stability from coordinated active muscular tension. The muscles of the thumb are arrayed in all directions around it, much like guy-wires around a pole or mast (Image 2). And these muscles stay busy—because so much of the thumb’s stability comes from the tension of these muscles, most thumb muscles are active during most thumb movements.¹ No wonder our thumbs get tired.

The origins of the word “thumb” go back to the Old English word thma, from Indo-European tum, or “swelling” (which also gave us “tumor” and “thigh”). The swelling in the thumb’s case is thought to be its round shape, or the thumb’s rounded thenar eminence (the muscular portion of the palm at the base of the thumb). It is here that I’ll focus our discussion, as the thenar eminence often takes the brunt of thumb overuse and repetitive strain. There are at least two reasons for this:

1. Because the thenar eminence contains the primary muscles of finger-to-thumb gripping, activities or occupations that involve repeated or prolonged use of small instruments or fine tools (dentistry, electronics manufacturing, handwriting, etc.) can be associated with thenar- eminence fatigue, pain, and overdevelopment. 

2. Since its three constituent muscles (abductor pollicis brevis, flexor pollicis brevis, and opponens pollicis) are some of the thumb’s bulkiest, the thenar eminence also provides the lion’s share of palm-to-thumb grip strength (for example, when using large tools such as hammers and shovels, or in massage techniques involving squeezing or kneading).

THE CARPAL TUNNEL CONNECTION

Overuse of the thenar eminence is also intimately connected to neurovascular compression and the symptoms of carpal-tunnel syndrome (such as hand, palm, or wrist pain, numbness, and tingling). Because all three of its muscles have direct connective tissue continuity with the carpal tunnel’s flexor retinaculum (Image 3), repeated or heavy use of the thenar muscles can contribute to tension, strain, or shortness of this carpal ligament, which may narrow the carpal-tunnel space and compress its contents. 

This thenar-eminence/carpal-tunnel connection works in both directions—thenar muscles can contribute to tunnel compression, and tunnel compression can cause thenar pain. While most palm muscles are innervated by the ulnar nerve (which does not pass through the carpal tunnel), the muscles of the thenar eminence are typically innervated by the median nerve (which does pass through the carpal tunnel, Image 3). It is compression of this median nerve that is most often responsible for the pain of carpal-tunnel syndrome (see “Working with Wrist and Carpal Bones,” Massage & Bodywork, May/June 2009, page 122). In fact, thenar-eminence pain is one of the most common effects of median nerve compression, and atrophy of these muscles (particularly the flexor pollicis brevis, Image 4) is a possible long-term result of unresolved carpal-tunnel neurovascular compression. Direct myofascial manipulation of the thenar eminence has been anecdotally observed to lessen carpal-tunnel compression symptoms, but if you notice atrophy accompanied by pain here, referral to a rehabilitative specialist is probably indicated.² It is also important to remember that median nerve compression symptoms can be related to compression anywhere along the median nerve’s length, such as at the cervical nerve roots distally through the brachial plexus, or in the arm, elbow, or forearm, not just in the hand or wrist.

THENAR EMINENCE TECHNIQUE

While it’s important to keep a global perspective with respect to carpal-tunnel symptoms, these symptoms aren’t the only reasons to work the thenar eminence. Most anyone who uses his or her hands will truly appreciate focused local work with the structures of the thumb’s base. 

The first variation of the Thenar Eminence Technique (Image 5) uses the practitioner’s thumbs to feel into and release the various layers of the palm. Be sure to use your own thumbs in a way that is comfortable and sustainable for you. Especially avoid any hyperextension by maintaining a little bit of flexion in each of your thumb joints. 

Work from the center of the palm outward, starting superficially with the palmar fascia, then working deeper, layer by layer, until you’re deep within the thenar eminence. Although there is some sliding involved, we suggest not using oil or lotion as the friction will actually lend therapeutic stretching to the palmar and muscular fascias; it should not be uncomfortable if you work slowly enough. As always, be sure your pressure isn’t too painful for your client. If he or she is gripping or contracting elsewhere in the body as a result of your pressure or speed, you’re working against yourself. Slow down and let the layers melt away. The thumb figures large in the brain—an outsized proportion of the sensory homunculus is dedicated to processing thumb sensations. Think about how much of the brain’s sensory cortex this little area occupies; why rush it?

Once you’ve engaged a layer, ask for slow, active client movement, directing the client to “Let your hand open, and close” or “Open your thumb.” This will slide and differentiate the tissue layers under your pressure, and give clients control over the technique’s intensity. Work thoroughly all through the thenar-eminence fascia and the palmar side of the thumb itself, from superficial to deep layers in each place.

The second variation of the Thenar Eminence Technique (Image 7) is similar, but uses the knuckles of the practitioner’s soft fist rather than the thumbs. Note that a soft fist is open, not closed. A soft fist is more sensitive and adaptable than a hard, closed fist. In a soft fist, hand stability is achieved by aligning the arm, carpal, and metacarpal bones rather than by gripping the muscles. This means that the wrist must be in a neutral or very slightly flexed position but, like the thumb joints, never extended. 

With your nonworking hand, cradle your client’s hand from below (Image 7). This will allow you extra sensitivity and control, as you can tune the position of your client’s hand to allow the soft fist to engage just the right layer. 

The release is performed with your soft fist’s metacarpal phalangeal joints (the most proximal of the knuckles, at the base of the fingers). Use these knuckles to feel into the hand’s layers, as in the first variation. With the broader tool of the fist, you can anchor larger sheets of palmar fascia, again asking your client to actively open his or her hand once you’ve anchored into the desired layer. As in the first variation, be patient and thorough, and include this technique within a whole-limb, whole-body, and whole-person perspective. 

If symptoms continue to be troublesome, a shift in your approach or in the client’s habits is probably indicated. Given that thumbs are so active, you may find that clients with occupations or activities that demand a lot from their thumbs may need this kind of work regularly in a maintenance and prevention capacity. 

Of course, the soft-fist version of the Thenar Eminence Technique is especially suited to bodyworker self-care—just lay your own hand down on the table at the end of your day and lean into your thenar eminence with the knuckles of your soft fist (or your elbow). Slowly open and close your “client” hand, releasing any thumb tension and fatigue. This would be a great time to say a silent thank-you for the wonder of thumbs—thank goodness we have them. 

Notes

1. N. Austin, “Chapter 9: The Wrist and Hand Complex,” in Joint Structure and Function: A Comprehensive Analysis, P. Levangie and C. Norkin, eds. (Philadelphia: F. A. Davis Company, 2005).

2. S. Goodwin and J. Burch, “Carpal Tunnel Syndrome and Repetitive Stress Injuries,” Massage & Bodywork, December/January 2003, 66.

  Til Luchau is a member of the Advanced-Trainings.com faculty, which offers distance learning and in-person seminars throughout the United States and abroad. He is a Certified Advanced Rolfer and the originator of the Advanced Myofascial Techniques approach. Contact him via info@advanced-trainings.com and Advanced-Trainings.com’s Facebook page.

A Few Rules of Thumbs

Here are some principles of sustainable thumb use:

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The best way to save your thumbs is to use something else instead. The most sustainable thumb alternatives are boney projections such as your forearm, soft fist (Image 7), or knuckle. With practice and creative positioning, any of these tools can be as sensitive and specific as your thumb.

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Avoid hyperextension at any of your thumb joints (Image 6). Hyperextension may feel stable, but this stability relies on stretching your articular ligaments and joint capsules to their maximum length, which will cause them to slacken over time. This leads to less stability and eventual pain. 

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Neutral joint position is good; even better is to keep a small amount of flexion at each thumb joint. Engaging the powerful flexor muscles of your palm will support your thumb joints and ligaments. If this positioning isn’t familiar, you may need to practice it gradually as you develop the necessary flexor strength. You don’t actually need much strength, but you do need a little, and if you’re not accustomed to working with slightly flexed thumb joints, the muscles involved may be quite weak.

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Pain or discomfort is a sign that something is wrong. If your thumb or hand hurts when doing a technique, do it a different way. This sounds obvious, but many of us forget about our own comfort when we’re focused on that of our clients.

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Some practitioners have found handheld tools or thumb splints useful. I haven’t, but you might. When using 

a handheld tool, be sure you’re acutely attuned to your client’s verbal and nonverbal signals since you have less direct tactile feedback with a tool. 

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Save your thumbs for the few places where they excel and are truly irreplaceable. After several thumb injuries unrelated to bodywork, and after 30 years of manual therapy practice, I still use my thumbs quite comfortably (knock on wood) in a few areas. In addition to the Thenar Eminence Technique, I use my thumbs for working the iliolumbar ligaments, knee (meniscal ligaments, infrapatellar fat pad, and patellar tendon), and sacrotuberous ligaments (“Working with Sacrotuberous Ligaments,” Massage & Bodywork, September/October 2012, page 114), but hardly anywhere else—that’s the way I’ve found to make them last.