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Need advice for client with forearm pain

I have a client who is in dental school who presented to me with pain in his forearm extensor and flexor muscles, some symptoms of carpal tunnel, with some tenderness around the medial and lateral epicondyle. I have used various techniques on him from general stripping of the muscles to trigger point to deep kneading. He is typing a lot, using dental instruments, etc. and cannot just stop doing these activities as he is in school for quite a while. He is icing the areas at least a couple times per day.

I worked on him a 2nd time and now his forearms are more achy and one of his doctors told him that he could go through some discomfort thru the healing process.

Any insight you could give me would be greatly appreciated here.

Replies to This Discussion

Permalink Reply by Greg Lewerenz, LMP, LAc on April 8, 2010 at 6:22pm

From a massage perspective it sounds like you are doing what I would do. In addition to the local work, have you investigated the possibility of nerve impingement at the neck or shoulders? For example, does he have a rounded posture (tight pecs impinging nerves) or has he been in a car accident where a neck injury is the source of pain? I am also an acupuncturist and, from a Chinese medicine viewpoint, I had a few other ideas:
- Depending on how long his forearms have been bothering him (e.g., weeks vs. months) you could suggest heat therapy instead of ice. The longer pain has been around, the more appropriate it is to use heat to move the stagnation vs. cold which can exacerbate existing pain. I'm sure to get some debate on this, but I've seen positive clinical results from warming a painful area that had previously been iced to no end.
- 701 plasters (available in Chinese pharmacies) are great. Just cut a piece that fits the painful area and stick on at night, removing in the morning. If there is any redness or irritation he can skip a day between applications or stop using altogether, of course, if he is reacting negatively to the herbs.
- Qi gong exercises: consult a local qi gong teacher for movements that can get things flowing through the shoulders, arms and fingers; this can alleviate tightness and thus reduce pain.
- Acupuncture: find someone who practices Tong/Dong style acupuncture in your area. There are two points on the lower leg in the Tong style which can be phenomenal for this type of pain. Unfortunately, they aren't as effective when simply pressed as in acupressure as they are needled very deeply. If he went for an acupuncture treatment and then came to you the same day for massage to follow up, that would be ideal.

Good luck!

Permalink Reply by Terry Craddock on April 8, 2010 at 6:45pm

Donna,
A simple test to check for TOS is sit your client on a stool. locate the pulse point on the affected side at the wrist. Have client hold thier arm striaght out in front of them and then have them move the arm to the lateral side and if possible to posterior side. If at any time in that movement you lose the feeling of the pulse in the wrist..you might want to consider treatments for TOS.
just a thought..good luck.

Permalink Reply by Donna C. Agrinsonis, LMT on April 8, 2010 at 7:30pm

Hmmm. I wondered about TOS at some point but forgot how to test for it. Thanks I will look into this.

Terry Craddock said:

Donna,
A simple test to check for TOS is sit your client on a stool. locate the pulse point on the affected side at the wrist. Have client hold thier arm striaght out in front of them and then have them move the arm to the lateral side and if possible to posterior side. If at any time in that movement you lose the feeling of the pulse in the wrist..you might want to consider treatments for TOS.
just a thought..good luck.

Permalink Reply by Donna C. Agrinsonis, LMT on April 8, 2010 at 7:31pm

Thanks you are making me think now.

Greg Lewerenz, LMP, LAc said:

From a massage perspective it sounds like you are doing what I would do. In addition to the local work, have you investigated the possibility of nerve impingement at the neck or shoulders? For example, does he have a rounded posture (tight pecs impinging nerves) or has he been in a car accident where a neck injury is the source of pain? I am also an acupuncturist and, from a Chinese medicine viewpoint, I had a few other ideas:
- Depending on how long his forearms have been bothering him (e.g., weeks vs. months) you could suggest heat therapy instead of ice. The longer pain has been around, the more appropriate it is to use heat to move the stagnation vs. cold which can exacerbate existing pain. I'm sure to get some debate on this, but I've seen positive clinical results from warming a painful area that had previously been iced to no end.
- 701 plasters (available in Chinese pharmacies) are great. Just cut a piece that fits the painful area and stick on at night, removing in the morning. If there is any redness or irritation he can skip a day between applications or stop using altogether, of course, if he is reacting negatively to the herbs.
- Qi gong exercises: consult a local qi gong teacher for movements that can get things flowing through the shoulders, arms and fingers; this can alleviate tightness and thus reduce pain.
- Acupuncture: find someone who practices Tong/Dong style acupuncture in your area. There are two points on the lower leg in the Tong style which can be phenomenal for this type of pain. Unfortunately, they aren't as effective when simply pressed as in acupressure as they are needled very deeply. If he went for an acupuncture treatment and then came to you the same day for massage to follow up, that would be ideal.

Good luck!

Permalink Reply by Randy Miller on April 8, 2010 at 8:02pm

Hello, You might try some joint glides at the elbow in conjunction with your muscle stripping. Brian Mulligan suggests blocking the lateral humerus with one hand, while with the other hand grasping and providing a lateral glide of the forearm. While maintaining this glide the client flexes and extends the elbow and makes a fist and relaxes the fist repeatedly at the same time. This generally will decrease discomfort. You may also use Kinesio tape to maintain a slight rotation of the forearm on the humerus, usually a Internal Rotation of the radius and ulna on the humerus. Hope this helps.

Permalink Reply by Tom Florio on April 8, 2010 at 8:08pm

Did your client find any relief immediately after either treatment? If so, I believe you are probably on the appropriate treatment track. If he had no relief, or minimal, the problem may be outside the forearm.

Was the onset of symptoms sudden or progress over a period of time? If sudden onset, nerve and/or disc problems should be investigated. TOS or cervical impingment/compression are certainly possibilities.

Additionally, Trigger Points in the triceps, pec major, pec minor, serratus, and supraspinatus can cause referral pain in the forearm and elbow. Also, check for weakness/pain with resisted forearm pronation and supination.

Hope this helps!

Permalink Reply by Donna C. Agrinsonis, LMT on April 8, 2010 at 8:29pm

His problems started gradually after he kept working with his hands repetitively back in January. I am starting to think that I may have spent too much time on his arms and been a little bit too aggressive. I am going to back off and limit time on his arms and use more general techniques for his next appointment. I will also do tests for TOS to make sure I know if there is something else going on. On his end he is going to keep using ibuprofen and icing. I will be sure to investigate all possibilities to be sure I am treating the right thing. Everyone's responses have certainly forced me to think more objectively about the situation.

Tom Florio said:

Did your client find any relief immediately after either treatment? If so, I believe you are probably on the appropriate treatment track. If he had no relief, or minimal, the problem may be outside the forearm.

Was the onset of symptoms sudden or progress over a period of time? If sudden onset, nerve and/or disc problems should be investigated. TOS or cervical impingment/compression are certainly possibilities.

Additionally, Trigger Points in the triceps, pec major, pec minor, serratus, and supraspinatus can cause referral pain in the forearm and elbow. Also, check for weakness/pain with resisted forearm pronation and supination.

Hope this helps!

Permalink Reply by Joan Annunziata on April 9, 2010 at 6:04am

Sometimes pain in the forearm and into the hands is related to the Scalenes.Sometimes it appears as carpal tunnel but really is TOS.
Joan

Permalink Reply by Dan O'Clair on April 11, 2010 at 10:29pm

Donna,
You've gotten some really good thoughts here and yes you may have worked too aggressively your first session, backing off and looking at the larger picture is always a good idea.

I have found cross-fiber friction to be highly effective especially for the extensors, even more so than stripping. Moderate pressure (not inducing pain but maybe slightly irritating) for 2-4 minutes works wonders for loosening tight, over-stretched extensors. Strengthening exercises (opening the fingers against resistance) is excellent homework too.

Think about the body mechanics of dental workers (hairstylists too), arms elevated, hands gripping and performing tedious maneuvers. That means scalenes, levator, traps, pecs (M & m), supraspinatus, infraspinatus, teres (M & m), subscap, serratus posterior superior and rhomboids are all involved as well as other neck muscles (forward head posture) and the upper arm too.

Let us know how you and your client progress through this!
Dan

Permalink Reply by David Burrows on May 18, 2010 at 6:18pm

I didn't find any relief for my own forearm discomfort, which was in the flexors from working at post office, and also from being a musician, until I started using the stretching and strengthening exerices in a book titled FRAMEWORK.
I had neuromuscular massage and chiropractic and PT and just about everything done on my arms. In the end my own self repair through exercise fixed me up. I did have Massage therapist who really dug into my arms only to make them feel worse and PT's who worked me to death and put me in constant pain.
I agree with the other comments about checking out trigger points in the scapular area and pec minor---where there are referral patterns that run respectively down the flexors and extensors. Having a Chronic condition myself in the forearms, I understand how frustrating the experience can be. I suffered with it for 16 years before following the protocols in FRAMEWORK, written by an MD. I guess I needed to heal myself!! And to realize the power of pinpointed stretching and strengthening!!

David Burrows, Massage Therapist

Permalink Reply by scott DOUGlas shields NCLMT on June 9, 2010 at 8:00pm

Donna

I believe the indications show this to be TOS or Cubital Problems, but how is the client/patients' sense of touch (extreme, non-exsistant, or a feeling of "glue"wrapperd) ?

Permalink Reply by Maggie Fritzke on July 13, 2010 at 11:06pm

I have found that hot/cold stone therapy has worked to relieve pain. Possibly get better results with gliding, cross fiber, and pressure points.