K. visited me for help with her right index finger, which had not recovered mobility after a minor injury.
“How long ago did this happen?” I asked.

“About seven weeks ago. The doctor said there was nothing broken or torn, but the joint was clearly swollen. As you can see, it still looks different than the other side,” she said, pointing to the metacarpophalangeal (MCP) joint. “The doctor said I could splint it, but she wouldn’t necessarily recommend that approach. Her suggestion was to move it as much as possible, which is what I have done. The problem is, I still cannot move it completely and the finger just doesn’t feel right.”

“What was the mechanism of the injury?” I asked.

She looked sheepish, but finally told me the story. While rushing to the bathroom at a conference, she had jammed her hand against the toilet paper holder.

“Wow, we need a new story. We’ll get to that later,” I couldn’t help saying. “Show me what movements you can or cannot do.”
She made a fist, revealing full flexion range of her index finger. The damaged finger’s extension, however, was clearly limited in comparison to the other fingers of both hands.

“Mostly, I notice that I do not have strength in this finger. When I try to press on anything, such as a spray bottle lever, my finger is really weak. I’ve painfully learned how much I use my index finger,” K. revealed.
 
I reviewed the game plan. “There are three areas of concern: the finger flexors, the extensors, and the ligaments at the joint itself. What I am going to do is reason through each of these possibilities until we understand where the problem lies.

“You have full flexion range. That means that the extensor muscles will allow the motion, even though you don’t have strength. But your extension range is reduced, which could be caused by flexor shortness or extensor weakness.
“Another possibility that would explain both the reduced extension and the reduced strength is something called arthrokinetic inhibition. This is a protective mechanism in which an injury to the joint sends a message to the muscles that cross it to not contract fully. Muscles can heal relatively easily, but joint injuries can last a lifetime, so the brain will always sacrifice a muscle to protect a joint. When muscles contract fully across a joint, it increases joint pressure, so after an injury, the contractile capacity of those muscles may be shut down to prevent any further damage.”

At this point, I began by carefully examining both the flexor digitorum superficialis and profundus muscle and tendon associated with the index finger. While K. had full range of motion, there were some surprisingly tender areas in the muscle belly.

“Wow. That really is tender. Is it very tight?” she asked.

“Not tight, but injured and inhibited. Muscles essentially do one thing—they contract. When they are injured, they do that one thing less well, which you experience as weakness. So it looks like my goal here is not to increase range, but to increase strength. What about this muscle?” I asked, palpating the extensor indicis.

“That pain is even worse,” she replied. “What role does that muscle play?”

“This muscle is the one that pulls your finger backward, like you showed me in the beginning. I am beginning to think the problem isn’t the flexors being too tight to allow full extension, but this extensor muscle being too weak.”

“So both of these muscles were inhibited by the injury to the joint,” K. summarized. “And now the flexor muscle is so weak that pushing on a bottle of hairspray is hard, while the extensor muscle is too weak to pull the finger backward to the same distance as the other fingers.”

“Exactly. The system is very functional in the short term. The joint injury sent a message to the muscles to shut down to prevent further injury. Unfortunately, when the joint was no longer at risk, the muscles didn’t get the memo that it was safe to resume full activity. This could go on indefinitely without treatment.”

For the next 20 minutes, I alternated treating the extensor and flexor muscles of the index finger using moderately deep, unidirectional friction movements in the direction of the muscle fiber. I also did cross-fiber friction of the ligaments at the MCP joint.

When K. returned a week later, the swelling was visibly less and the finger’s extension was just shy of normal.
“It is much stronger,” she stated happily. “The biggest difference is that I find myself using this finger during daily activities again.”

“I’m thrilled it is much better,” I told her. “Now, one more thing: I just want to be very clear about how you injured your hand. When you dove in front of the oncoming car, reaching out with your right hand to save the child who had just wandered out into the street ...”

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.

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