Chapter 10: Upper Limb

This is a Chapter 10 summary of “Clinical Neurodynamics” by Michael Shacklock.

Thoracic Outlet Syndrome (TOS)

When discussing TOS pathoneurodynamics, you must talk about breathing. The brachial plexus passes inferolaterally between the first rib and clavicle. When inhalation occurs, the plexus bowstrings over the first rib cephalidly. So breathing dysfunctions can contribute to one’s symptoms. Excessive scapular depression can also contribute because the clavicle approximates the plexus from above.

Clinically, TOS often presents as anteroinferior shoulder pain, with some cases passing distally along the course of the ulnar nerve.  A resultant upper trapezius/levator scapula hyper or hypoactivity can occur that may affect the neural elements.

Treating the Interface

Level 1 – Static Opener with breathing

Level 2 – Static opener with rib mob during exhalation; progressing with scapular depression.

Level 3 – Rib depression with sliders and tensioners.

Pronator Tunnel Syndrome

This syndrome consists of pain in the anteromedial forearm region with or without pins and needles. Symptoms are usually provoked by repetitive activities such as squeezing, pulling through the elbow, and pronation movements.

From an interface perspective, pronator syndrome deals with excessive closing. So we will use openers to treat.

Level 1 – Static opener combining 60-90 degrees of elbow flexion with forearm pronation

Level 2 – Dynamic opener

Treating neural components depends on the present dysfunction. There are the following possible dysfunctions:

  • Distal sliding dysfunction – symptoms decrease with contralateral cervical flexion.
  • Proximal sliding dysfunction – Symptoms increase with contralateral cervical sidebend and finger flexion.
  • Tension dysfunction – Symptoms increase with contralateral cervical sidebend and finger extension.

We treat the distal sliding dysfunction by progression sliders from large to small distal movements, with the reverse occurring for proximal sliding dysfunctions:

Tension dysfunctions are going from anti-tension to tension mechanisms

You can also combine interfaces and neurodynamic treatment utilizing acupressure during a nerve mobilization:

Supinator Tunnel Syndrome

This syndrome involves anterolateral elbow and forearm pain with possibly pins and needles. There also can be isolated wrist dorsum pain. Symptoms are provoked by activities such as squeezing and pulling through elbow flexion and supination movements.

Interface treatment is very similar to that of pronator tunnel syndrome.

You can also have distal (improve with contralateral cervical sidebend) and proximal (worsen with contralateral cervical sidebend and wrist extension) sliding dysfunctions, which are treated in a similar fashion as the pronator tunnel syndrome. So too with tension dysfunction; the goal is to build up the test.

You can also perform neurodynamic massage over the supinator.

Carpal Tunnel Syndrome (CTS)

Treating CTS is an often underutilized area that can be of much benefit. We can mobilize the transverse ligament as an interface technique.

You can also treat the neural structures with different methods depending on the dysfunction.

Proximal sliding dysfunction – use a median nerve slider starting with distal components then adding proximal components

Distal sliding dysfunction – Use Median nerve test 1 and slowly add distal components.

The best slider for the median nerve is in fact the tensioner. This is because when you extend the wrist, the tendons and the nerve move in the same direction. Adding contralateral cervical sidebend slides the median nerve in the opposite direction of the tendons.

Tensioning dysfunction is just utilizing your basic tensioner.