Legs & Arms Unit 2 - Beyond Trigger Points



Welcome to Beyond Trigger Point Seminars Legs and Arms Unit

Module 4 on the Hand Extensor, Brachioradialis, Extensor Digitorum and the Flexor Carpi Radialis and Ulnaris muscles. This is Cathy Cohen. In this lesson you will be studying the muscles enabling us to grasp our client’s flesh in our hands, fasten a tiny safety pin and maneuver a hot drink to our lips. The extensor and flexor muscles of the forearm provide us with a gripping ability most other animals can only achieve with their jaws. As a group, the hand and finger extensors and flexors coordinate their activities to produce not only a powerful grip but also our uniquely human trait of manual dexterity.

When a restorative balance of tension level is achieved through massage and self care; strength, flexibility and fine manual motor skills improve. I attribute the longevity of my massage therapy career to the great work other massage therapists have done on my forearms. I have survived decades of manual therapy and I hope you can too with some of the self help suggestions contained in this module.

Let's go now to page 30 of our student study guide for the extensor’s actions. Generally speaking - the extensor mass of the forearm prevents wrist flexion when the fingers are used for grasping. In other words, the extensors prevent the wrist from curling in towards the palm while the fingers are grasping. Activation of all the hand extensors is essential for a powerful grip. The extensor carpi radialis longus and brevis specifically abduct the hand (radial deviation) and assists flexion at the elbow. So again the three actions of the extensor carpi radialis longus and brevis are to checkrein wrist flexion, wrist abduction and assist in flexion at the elbow.

The extensor carpi ulnaris has the same actions except instead of abduction; it adducts (ulnar deviates) the hand at the wrist.

The brachioradialis' action is flexion at the elbow. Originally it was named the supinator longus on the assumption it supinated the elbow. When stimulation studies showed it functioned primarily as a flexor it was renamed to brachioradialis. Also, when swinging a hammer for example or during other rapid elbow movements, it contracts to prevent the elbow joint from separating.

On the next page of the study guide or page 692 and 693 of the textbook, you'll see four different arms with some distinguishing pain patterns. You are looking at the superficial layer. Keep in mind there are three layers of extensors in the forearm. You are viewing the top layer, which controls hand movement at the wrist.

As always, to help you memorize the pain complaints and the location of each trigger point, draw those patterns now with a colored pen or pencil. All are central TrPs. Looking at the picture though; you may not believe me. Here’s why they are centrally located; when calculating the halfway point in the muscles belly, we do not calculate the tendons length. The extensors all attach on the lateral epicondyle proximately and have long tendons distally. When we forget about the tendons, the half way location is about a 1½- 2” below the crease of the elbow. This is where you want to draw your Xs for the documented TrPs.

The one documented trigger point of the extensor carpi ulnaris refers along the ulnar side of the wrist. The carpi radialis brevis refers onto the dorsal side of the hand and wrist. Finally, the extensor carpi radialis longus also refers pain into the dorsal side of the wrist but its primary pain pattern is along the lateral epicondyle of the elbow. So once again, we meet a muscle referring into the lateral epicondyle of the elbow. The other muscles we encountered in an earlier module with a lateral epicondyle pain pattern were the supinator and triceps brachii.

Now we also see the brachioradialis and by golly it too has a primary pain pattern into the lateral epicondyle region. But look there; it also refers into the webbing of the thumb as well.

The hand extensors have been nicknamed the Painful Weak Grip Muscles. That's what Dr. Travell nicknamed them but I nicknamed it something different. I like to refer to it as the Plastic Mug Morning Muscles. When my kids saw me rubbing my extensor mass after a long week at the table, they’d hand me a plastic mug for my tea because they didn't trust me to hold a glass cup. What I want you to remember is, when tension and trigger points develop in the hand extensors, an unreliable grip ensues.

Now we answer the question on page 32 of your study guide:

What factors activate and perpetuate the hand extensor and brachioradialis muscles?

It's pretty simple. The underlying theme is a repetitive forceful handgrip, especially when the wrist is in an ulnar deviated position. For example:

1. Forceful hand gripping on a large object. The larger the object, the more ulnar deviation of the hand and the more likely the muscle is to develop a problem. When I play tennis with a man’s racquet for example, I feel the weakness in my grip instantly.

2. Backstroke. When you're doing a good backstroke you're really grasping the water and pulling it through.

3. Gardening with a trowel.

4. Repetitive Frisbee throwing.

5. Activities involving writing. I have a client who is an architect so she's been at the drawing table all of her professional life. Now, when she holds a pen in her hand, her wrist becomes weak. It goes into a flexed position. Her doctor diagnosed this as a writer’s cramp. And he's right! She has an imbalance in her forearms because of too much tension in her flexors and not enough strength in her extensors. So we are working on restoring the balance.

I want to mention three tests indicative of hand extensor involvement because before you even put them on the table, you can begin making educated guesses. Let's start with the handgrip test. When a client reports pain and discomfort into their hand, their fingers or maybe into their elbow, you can test their hand strength by simply positioning their hand in a normal hand shake position and have them squeeze your hand. Then test the other side. One handgrip may be considerably weaker. Not like dominate versus non-dominate types of weakness, but a significant in-ability to grasp your hand firmly. Then when you ask them to extend or flex the hand at the wrist, squeezing your hand is more weakened and painful. These are positive signs for a hand extensor, finger extensor or brachioradialis involvement.

Test 2: Lateral epicondyle pain can be tested in a simple manner too. If tapping with your finger over the distal half of the lateral epicondyle is reportedly sore, then you have another positive sign for hand extensor muscle involvement. Tenderness may be due to enthesopathy at the attachment site.

Lastly, if you feel taut bands by snapping over the extensor mass and reproduce the pain pattern by compressing a TrP, then that is a positive sign too.

What are the corrective actions for the hand extensors?

The obvious answer would be to:

• Avoid forceful gripping activities especially when combined with ulnar deviation.

What we're trying to educate our clients on, as well as ourselves, is to be in the habit of moving and rotating our hands from our shoulders and torso and not from our wrists.

• Use wrist supports as needed. This helps protect the wrist from hand flexion or ulnar deviation. We'll talk more about the use of splints and wrist supports as we move on.

• Another corrective action for the extensors is stretching.

So wherever you're at right now just settle in for a moment. Have a seat. Put your pen down. Allow one forearm to rest on your thigh. We're going to stretch both the hand and the finger extensors. So with your palm facing the floor, flex your wrist and bring your fingers towards your forearm. The middle finger extensor is the only extensor not completely stretched in this movement. You need to individually curl your middle finger by gently pushing on it with your other hand while you're flexing your wrist. Go ahead and do that now and try to bring your middle finger toward your forearm while you flex at the wrist.

If you haven't already, switch and do the same with the other forearm. I hope you create a habit of stretching your extensors daily.

Let’s move now to page 34 of our student study guide or page 715 of the textbook where you see the extensor digitorum muscles. The three muscles forming the extensor digitorum lay between the extensor carpi ulnaris and the extensor carpi radialis. Its primary action is to extend digits 2-5. The pain pattern arising from a trigger point in the middle finger extensor, one of the extensor digitorum is fairly common. The primary pain pattern is felt most intensely over the dorsal side of the middle finger. There might also be pain and stiffness in the joints of the finger. The ring finger extensor pain pattern can be felt from the ring finger, up the forearm and into - there it is again - the lateral epicondyle. Make sure you draw and memorize those patterns.

If you place your left hand onto your right extensor mass and strum cross fiber over the middle finger extensor, you will probably feel a taut band. The middle finger extensor is the most common muscle in the body to develop a taut band. Do you feel the taut band over the extensor side of your right forearm? If you're strumming firmly over the middle finger extensor an inch and a half or so down from the elbow, you may cause your middle finger to snap-up. That's how you know you're correctly placed. Okay go ahead and find the middle finger extensor on the other arm too.

The next fill-ins on page 33 Forceful, repetitive overuse of finger movement activates and perpetuates the extensor digitorum muscles. Some examples: pianists, carpenters, mechanics and massage therapists who apply force with their fingertips can create problems in their forearms.

In the next question, let’s see if you can list 5 muscles involved with lateral epicondyle pain. This is your opportunity to really cement this into your memory bank. I’ll innumerate them in the order of highest to least amount of prevalence. The supinator is the most common muscle harboring a TrP referring pain into the lateral epicondyle. The brachioradialis is next followed by the extensor carpi radialis longus, the triceps brachii and finally the ring finger extensor you just drew.

Do you see the picture at the bottom of page 33? That's illustrating a middle finger extensor restriction because by definition a trigger point restricts range of motion. So when the metacarpophalangeal joints are held straight and the fingers are flexed, an inability to place the middle finger pad firmly onto the palm of the hand is a positive test for a middle finger involvement. Those of you who have taken the scalene class have seen this test before. But remember with the scalene muscles all four finger pads fall short of touching the palm.

What are the corrective actions? I’ll list 4.

1. Stretching (like what we just did) and strengthening exercise.

We'll be learning many more stretches particularly for our fingers in the workshop. For a complete listing of the workshop content, dates and locations, visit courses.

2. Neutral sleeping position. Train you and your client to keep the wrist in a neutral position while sleeping. To discourage curling the wrist, Dr. Travell suggested wrapping a towel around the forearm and wrist and anchoring it in place with an ace bandage. This keeps the wrist in a comfortable soft brace that’s non-injurious to anyone in bed!

3. Take frequent breaks. Moving the fingers out of the holding patterns our occupation puts them in encourages less tension to develop.

4. Become more ambidextrous. By working with both hands we reduce the wear and tear on the dominate hand by half.

Let’s look at the flexor side of the forearm now. On page 35 of the study guide and page 756 of the text, we see the documented TrPs for the hand flexor muscles found in the superficial layer. Their two actions are to flex and deviate the hand at the wrist. On the arm scan also found on page 35, draw the one centrally located TrP of the flexor carpi radialis and its referred pain pattern over the palmer side of the wrist region. The flexor carpi ulnaris has a distinct pain pattern to the ulnar/medial side of the wrist region.

Now, with a little more pressure, you would be into the intermediate layer of the finger flexors. For the sake of clarity and time, we are only drawing the superficial layer’s pain patterns. But hear this, if someone presents with finger pain that is experienced beyond the tip of the finger like a lightening bolt shooting through the end of the digit, you may want to explore these deeper layers of the flexors. For those of you attending the workshop, you will perform a cross fiber friction routine that systematically layers from superficial into the deeper layers of the forearm. It’s yummy to receive. Your arms will feel fluffy and plumb.

Answering the question: What are some symptoms of the hand and finger flexors?

Symptoms include difficulty using a pair of scissors or gardening shears. TrPs in the extensor muscles conversely create no problems with scissors. Also clipping on a hair clasp may be difficult when active TrPs in the finger flexors are present. A trigger finger is a painless but annoying phenomenon causing the finger to be stuck in a flexed position apparently due to fascial restrictions near the flexor tendon. So on page 36, symptoms are pain when using a scissor or shears or a hair barrette and the presence of a painless trigger finger.

Factors activating and perpetuating the hand and finger flexors are:

1. Repeated strenuous pulling and twisting movements with the fingers like when weeding.

2. Repetitive or prolonged strong gripping such as when gripping a hand tool or a racquet or a steering wheel too hard. My dad developed a TrP and subsequent wrist pain after a long intense drive down to Florida one year. When the top of the steering wheel is gripped forcefully, the flexors are strained more because the hand is also flexed at the wrist.

Here’s a case study now. A gentleman presented with a pain pattern in his right medial wrist. This was a major calamity for him because he couldn't play golf. It was a major calamity for his wife because she liked her alone time when he went golfing. His story was this. He had history of bilateral rotator cuff problems from multiple baseball injuries to the point where he had to throw an underhanded baseball pitch to his grandkids. Because of the rotator cuff problems, he powered his golf swing from his wrist. He played left handed and if you remember from Module 3 - the power in the arm as well as the forearm comes from the non-dominate hand in the golf and baseball swing; hence a stronger right handed grip on the golf club. He also summered in Chincoteague, Virginia where one of his chores was to fork hay into a barn. He also liked to tinker with his collection of hand tools.

He had been diagnosed with tendonitis in the wrist. The activity that bothered him the most was golfing, lifting and twisting his wrist. Can you guess which muscle was involved? I hope you're saying the flexor carpi ulnaris. He had one trigger point in the flexor carpi ulnaris reproducing his pain pattern into the medial side of his wrist. Within 3 or 4 treatments he had full ROM restored and the pain was gone.

Look at the pictures in your study guide illustrating normal range of motion at the wrist as measured by a goniometer instrument. Our job as soft tissue experts is to restore normal range of motion. Even if you don’t use a goniometer to measure the progress your client is making with your great work, starting tomorrow, you can compare how close your clients are to these pictures.

At the bottom of page 36, another test for the finger flexors is shown. Let's put our pencils down again. Can you place both palms flat together, fingertips pointing upward with the forearms at a nearly horizontal position from elbow to elbow? Picture A shows the starting position. Picture B shows the final position for a completely negative, normal test. Anything less than picture B, is a positive sign for the finger flexors.

Now, I want us thinking about which muscles of the forearm can cause entrapment of different nerves. For those of you interested in sitting for the National Certification Board Exam which, along with some other necessary prerequisites, enables you to become a Certified Myofascial Trigger Point Therapist, there are a number of questions testing your knowledge on nerve entrapment. If you’d like to learn more about how you could distinguish yourself by being a board certified trigger point therapist, visit . Then follow the Certification link to the information on the exam.

The three muscles of the forearm listed on page 37 which are potentially responsible for entrapment syndromes of the ulnar nerve are: flexor carpi ulnaris, flexor digitorum superficialis and flexor digitorum profundus. TrPs in the flexor carpi ulnaris that we just studied is the most likely muscle to cause entrapments of the ulnar nerve for two reasons. First a taut band in this muscle could pull the fascial arch around the elbow tight against the nerve and secondly since the ulnar nerve courses through the flexor carpi ulnaris muscle over a long distance, a taut band might also compress the nerve in the forearm region. So the region of ulnar nerve entrapment is usually somewhere between the cubital tunnel of the elbow and within the first third of the forearm. An EMG would most accurately localize the problem area.

The entrapment of this nerve commonly causes disturbed sensation in the fourth and fifth digits, including burning pain, weakness of the grip, numbness and dysesthesia, which is an impairment of sensitivity especially to touch.

If you place your forearm in your lap, palm up, the first muscle you encounter lateral to the ulnar bone is the flexor carpi ulnaris. Most of us who have been in this industry have a strongly developed muscle here. Do you have any taut bands coming down from the condylar groove of the elbow? Again, the ulnar nerve passes through a groove behind the medial epicondyle. The tendinous arch of the common flexor tendon forms the roof of this cubital tunnel, through which the ulnar nerve passes. Neuropathy occurring around the funny bone is generically called cubital tunnel syndrome. It is the second most common entrapment syndrome diagnosis of this region after carpal tunnel syndrome. Can you sense how increased tension of the flexor carpi ulnaris combined with elbow flexion diminishes the cubital tunnel space? Again, increased tension of the flexor carpi ulnaris combined with elbow flexion narrows the cubital space. Why don’t you massage that area for good measure now!

The two muscles of the forearm potentially responsible for entrapment syndromes of the median nerve below the elbows are: pronator teres and flexor digitorum superficialis. Symptoms of medial nerve entrapment are hyperesthesia and paresthesias of the third and fourth digits and possibly the second finger as well. Paresthesia was best described to me as a feeling of bugs crawling and creeping along the skin.

Now we haven’t located or talked about the pronator teres muscle. That’s because according to the authors of our text and my own experience, the pronator teres is less likely to develop a TrP than other muscles. TrPs are more likely to develop in the other flexor and supinator muscles we’ve studied. Pronation is weaker than supination. (On the aside, screws are designed to be tightened by the power of the right forearm supination muscles.

Let’s move to the next question: What are the differential diagnoses commonly identified when the patient has active trigger points in the forearm muscles? It’s always good to ask which tests have been performed to determine how accurate the diagnosis. Otherwise assume these are blanket diagnoses, which haven’t taken TrPs into consideration.

1. Carpal tunnel syndrome- Involvement of the pronator teres, flexor carpi ulnaris and/ or the brachialis muscles might be diagnosed as a carpal tunnel syndrome instead of a myofascial syndrome due to referred pain from trigger points. An accurate carpal tunnel syndrome diagnoses is given when, and I quote from page 765 of our text, “A median nerve conduction study and examination of the muscles for TrPs establishes if one or both of the diagnoses are accurate.” A true carpal tunnel syndrome is caused by pressure on the median nerve at the carpal tunnel in the wrist. This pressure can come from swelling or anything that makes the carpal tunnel smaller. All of the fingers except the little finger might be affected when the median nerve is compromised. There might be pain and tingling across the wrist and into the forearm initially occurring at night.

In just a moment I will look at why massage therapists are prone to this disorder and what we can do to minimize the impact of our work on our wrists.

But first the other differential diagnoses your client may present with are:

2. Medial epicondylitis- we've referred to this as golfers elbow.

3. C5-T1 radiculopathy- when someone presents with pain, numbness or tingling down their forearm and hand, and I have ruled out TrPs in all the likely suspected muscles, the question I ask myself is, do they need to see a doctor to rule out a neurological problem from their neck?

4. Osteoarthritis of the wrist

5. Thoracic outlet syndrome is a term applied to any disturbance of the fourth and fifth digit. We discuss this in detail during the Upper Torso & Shoulder Unit.

6. Blackberry Thumb is a new term used to describe a repetitive strain injury to tendons in the thumbs. Thumbs may start to ache at night, but as the condition gets more severe, sharp knifelike jabs and intense pain occurs. Blackberry Thumb is caused by overusing the thumbs when text messaging on mobile phone keypads.

What are the corrective actions for the hand and finger flexors?

1. Relax the grip. For my dad this meant opening his fingers around the steering wheel more frequently. Or for someone who rows with a paddle, this means opening the fingers fully on the return stroke. Or for massage therapists this means avoiding any gripping movement involving only the fingertips. Instead, grasp a client’s wrist with your entire hand or use a hook grip involving all the fingers moving towards the palm as when grasping an upper trapezius. or use several fingertips together acting as one tool instead of a lone digit.

2. Keep the wrist and fingers in a neutral position. For a racquet player this means keeping the wrist in a neutral or slightly cocked up/radially deviated angle. For a massage therapist this means keeping the wrist straight. In the same way bending the elbow narrows the cubital space, bending the wrist narrows the carpal tunnel. Be vigilant about maintaining neutral positions of your wrists, because a straight wrist creates a wider opening at the carpal tunnel through which the tendons and median nerve pass thus minimizing friction and degenerative changes to the tendons and fascial sheath.

3. Take frequent breaks and stretch the forearms and individual fingers often. Distortion of any of the small joints in the wrist from overuse of the flexors and extensors can make the wrist more irritated and vulnerable to injuries. So please pace yourself, stretch often and ask yourself now if you are penciled into someone else’s appointment book for a massage.

This brings us to the end of the Legs & Arms Unit. If you have been taking this online program for continuing education credit, follow the link on the student page to direct you to the quiz site. For those of you continuing on with a hands-on workshop, I'm looking forward to meeting you and helping you extend your professional life as a manual therapist with smarter body mechanics, easier strokes and more effortless results through trigger point release and ice and stretch techniques. I am wishing all of you a long and healthy career in massage. Your clients are fortunate to have you as their therapist. I thank-you for participating and stay in touch.

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