I always like to bring you a real case and a real story. I know you, too, will someday probably have that same type of client that needs your help with treatment. This time, I am helping an oral surgeon save his career by saving his hands. When this doctor presented in my office seeking help, he had been looking at surgery on his hands as his only option to save his career. It took him 10 years to complete his degree and 10 years of practicing to almost lose everything he had worked so hard for.

While working with him, it became clear to me that a massage therapist looking to specialize and gain a reputation as the one to seek out for hand dysfunction could have a forever busy practice. Just go to YouTube and look at what small instruments and awkward positions that this profession does on a daily basis. Now, think how many other professions use similar intricate tools. Those professionals need a therapist that can take a no nonsense approach to helping them save the career they have spent so much time and money on to achieve.

Working with hands or feet is very challenging for the massage therapist in terms of how it affects your hands. The work has to be very meticulous and that can be very wearing to your own hands. So I have tried to offer suggestions of how to do treatment in a manner to get the job done and have less wear on you.

Case Study

He presented with aching hands all the time, he was beginning to lose grip strength, his fingers had become stiff feeling and it was affecting his ability to close his hand, he had bilateral thumb pain and bilateral numbness and tingling in the ring and little finger. He had more thumb pain on the right, but said this was due to the fact that three months ago he was playing with his son and his finger had been abruptly pulled backwards. He also complained of right shoulder pain.

How to Start

The first thing we want to do is assess or take a screen of the patient. A screen helps you rule out, should they be in your office or do they need other higher medical care. Just a reminder to stay within your scope of practice, a screen is not to be used as diagnoses, it is to be used as a tool to understand movement quality. You are looking at how healthy or dysfunctional is the individual's joint movement. This helps you determine the complex of muscles and fascia to be treated. When taking a screen, you will want to look above and below the joint being questioned. From the screen, you can develop an organized logical approach to treatment and suggestions of home care.

Screen Number One

Rule out cervical involvement by looking at the quality of cervical motion and asking the question throughout the screen: is there pain or no pain? In this case, he has presented with ulnar nerve involvement. Also ask if they feel any referral pain when going through the range of motion. Cervical flexion: they should be able to touch their chin to chest 45 degrees. Cervical extension: 45 degrees with mouth closed. Cervical side bending 20-40 (watch to see if the shoulder rises indicating how tight the trapezius muscle can be). Cervical rotation 70-90 degrees without pain. See reference.

Specific to this case because he had shoulder pain, I also went through all of the shoulder range of motion tests and he had a positive impingement sign. He also had a very stiff neck. We are addressing all of his concerns from the screen, but for this article I have kept the focus on the hand and forearm.

Screen Number Two

Assess their wrist and elbow range of motion. Wrist flexion: 80 degrees. Wrist extension: 70 degrees. Ulnar Deviation: 45 degrees. Radial Deviation 20 degrees. Supination 90 degrees. Pronation 90 degrees. Elbow extension 0 degrees and Elbow flexion 145. See reference.

Screen Number Three

Muscle test wrist flexion, extension, pronation and supination. Muscle test elbow extension and flexion. Muscle test all the ranges of each digit including the thumb. Each finger may flex, extend, abduct and adduct and also circumduct. See reference.

Treatment

1. To help the thumb you would work with flexor pollicis brevis. Its action is to flex the metacarpophalangeal and carpometacarpal joints of the thumb and assists in opposition of the thumb toward the little finger. (Remember, with his son he hyper extended the thumb so the eccentric load would fall onto any of the muscles that tried to stop this force.) There was a positive muscle test on flexor pollicis brevis. (Manual compression, muscle stripping, massage cupping machine, warm stone tool and PNF.)
2. Then begin to work with the muscles at the base of the thumb and radial hand: adductor pollicis, abductor pollicis brevis, opponens pollicis, flexor pollicis longus, extensor pollicis longus, extensor pollicis brevis, abductor pollicis longus, opponens digiti minimi, abductor digiti minimi and flexor digiti minimi. (Cross fiber friction to the tendon attachments, compression movements along the web, stripping with warm stone tool, machine massage cupping.)
3. Next, work along each digit or the dorsal interossei, palmar interossei, flexor digitorum profundus tendons. (Great place to use a t-bar.)
4. Next, address Palmaris longus and brevis, flexor digitorum superficialis, flexor digitorum profundus, flexor carpi radialis, flexor carpi ulnaris, pronator quadratus, pronator teres, supinator and biceps brachii and brachialis. (Pin and stretch whole forearm, long stripping to individual muscles, stripping with warm stone tool, machine massage cupping and counter-strain while working on the tissue.)
5. Next, on the dorsum of the hand treat extensor indicis, extensor digiti minimi, extensor digitorum, extensor carpi radialis longus, extensor carpi radialis brevis, extensor carpi ulnaris, and triceps brachii. (Pin and stretch to the extensors, individual muscle stripping with t-bar and warm stone tool, myofascial release with massage cupping machine.)
6. PNF stretching of flexion, extension, supination, and pronation.
7. Contrast therapy using some type of cold then incorporating a warm stone or hydroculator pack for increased circulation. The pain reduction theory is that the heat is a vasodilator bringing blood to the area and cold acting as a vasoconstrictor helps reduce inflammation. Variation of hot and cold has a physiological effect on the body's pain gate mechanism. The brain is momentarily distracted away from sending or receiving pain messages.
8. Do a lot of spreading to the area of carpal tunnel and work the flexor retinaculum.

Conclusion

The reason I listed all of the muscles indicates your need to be extremely specific. You want to look at an anatomy book and to the best of your ability treat each and every muscle you see. If you treat fractional inches at a time from the finger tips to the elbow joint, and then from the elbow to the shoulder, slowly along the bone, you won't miss anything. But if you always do an effleurage type of stroke you will miss something. Therapy should be about being specific, not generalized. The hand should not only feel better, but should also have better function. Recheck your range of motion and muscle tests to show the client how much improvement your treatment has made. I mentioned above all the tools I used besides my hands and every few minutes during the session I will trade out and use those tools so I save my own career.

Treatment Tip: I generally follow the thought of contrast first, myofascial second, specific work next, then PNF stretching and repeat. So far, 25 years and still going strong!

So, how is this client doing today? He is doing great and I continue to see him once a week. He has since been able to go back to more intricate work because his body isn't fighting him with pain anymore.

Fun Ring Finger Trivia

Before medical science discovered how the circulatory system functioned, people believed that a vein of blood ran directly from the third finger on the left hand to the heart. Because of the hand-heart connection, they chose the descriptive name vena amoris, Latin name meaning, literally vein of love. Based upon this name, their contemporaries, purported experts in the field of matrimonial etiquette, wrote that it would only be fitting that the wedding ring be worn on this finger.

References:

1. Muscles Testing and Function with Posture and Pain, Fifth Edition, Copywrite 2005, Florence Peterson Kendall, Elizabeth Kendall McCreary, Patricia Geise Provance, Mary McIntyre Rodgers, William Anatomy Romani, Lippincott Williams & Wilkins, Baltimore, MD.
2. Trail Guide to the Body, 4th edition, Copywrite 2010, Andrew Biel, Books of Discover.
3. Travell & Simons, Myofascial Pain and Dysfunction, The Trigger point Manual, Volume one, Upper Half of Body, Second Edition, David G. Simons, M.D., Janet G. Travell, M.D., Lois S. Simons, P.T., Williams & Wilkins.