resourcesABOUT MT AUTHOR GUIDELINES CLASSIFIEDS EDITORIAL CALENDAR MEDIA GUIDE MASSAGE MART SCHOOLS & EDUCATION FEEDBACK
Taking Another Step Toward a Secure Future
In 2008, the Council on Chiropractic Guidelines and Practice Parameters (CCGPP) released a literature review on chiropractic care for low back disorders.
From Antiquity to Modernity: Huang Qin Tang at Yale Medical School, Part 1
Traditional Chinese medicine is a coherent medical system with several unique characteristics: it originated almost 3,000 years ago; in its area of origin, it has been practiced without interruption since its inception.
Yo San University Helps Make LA Communities Healthier
An element of healthcare training often overlooked is the residual benefit to communities served by Acupuncture and Oriental Medicine (AOM) schools nationwide.
The MRI: What to Do With the Results
As I wrote in my previous article on this topic, it is my goal for you, the doctor, to be an expert in interpreting MRI images yourself; and to be able to independently make decisions based upon a combination of clinical presentations and findings, followed by the MRI images.
Is There a Neurological Basis and Correction for Macular Degeneration?
Macular degeneration, aka AMD (age-related macular degeneration), is a common eye disease and a leading cause of blindness in people age 50 years and older, according to the National Institutes of Health National Eye Institute.
Do Doctors Lie to Patients? (Do You Lie to Yours?)
In a previous column ["When Patients Lie (Bribe or Flatter)," Oct. 1, 2015], I discussed the issue of patients lying to doctors, and the many reasons why this can occur.
Asking the Insurance Rep the Right Questions
One of the first or last questions a potential patient often asks is: "Do you take insurance?" An ill-informed or optimistic, "yes" can result in delayed or non-payment. Instead, just say: "Let me check if you are eligible first."
Changing the Cultural View of Medicine
Many hospitals in the U.S. are incorporating integrative clinics that include Traditional Chinese Medicine. Cleveland Clinic has led the charge for adding a traditional Chinese herbal medicine clinic to their existing acupuncture program.
Forgotten Options for Musculoskeletal Health
Challenges with musculoskeletal health are of tremendous concern for many people today.
How to Humanize Your Content to Create Stronger Relationships
Content marketing is about building relationships, whether that is through updates on social media, offers on your website, blog posts, email campaigns, or even printed material. Now days a business needs to make a human connection.
Diet, Nutrition and the Context of Risk (Part 1)
Food and supplement safety is a topic that often comes up when I speak to chiropractors for CE relicensing, even when it is not the advertised subject.
RAND Study Recruiting DCs
Dr. Ian Coulter, RAND / Samueli chair for integrative medicine and senior health policy researcher for the RAND Corporation, has issued a call for participation, recruiting doctors of chiropractic for a practice-based research study that will examine "the impact of evidence, outcomes, costs and patient preferences on the choice of treatment for chronic low back pain and neck pain."
Percussion Therapy: An Experiment
My study of qi began more than 20 years ago — long before my study of TCM, points or pathways. It all started with an awareness in my hands and physical manifestations in the way of blockages while working on clients.
Interprofessionalism: What it Means and Why You Should Care
Interprofessionalism in education and in practice is a growing trend across health care in the United States. The idea that team-based care and collaborative practice can improve health care has been around more than 50 years.
Integrative Medicine Can Shape the Profession
As the AOM profession struggles to define the role of "integrative" medicine within their practices their schools and organizations, students, faculty, alumni and administrators at schools wrestle with discussions of how much, where, how, and what to "integrate."
The Roots of Insomnia
One of the most common clinical presentations is insomnia. Next to digestive disorders, sleep disorders are one of the most common complaints the clinician will encounter in daily practice.
Ethics: The Glue That Holds Us Together
Kudos to the National Certification Commission for Acupuncture and Oriental Medicine (NCCAOM) for creating a code of ethics for the nationwide profession and for deciding to make courses in ethics a requirement for certification renewal.
Window of the Sky Points
The acupuncture points known as Window of the Sky are a modern creation. There is no reference in Chinese medical texts for an acupuncture point category called Window of the Sky.
Chiropractic Around the World: WFC Country Reports December 2015
The following country updates are reprinted with permission from the December 2015 World Federation of Chiropractic (WFC) Quarterly World Report. Information is excepted for space and edited to DC-specific style guidelines.
Billing and Coding for Moxibustion
Q: I am trying to locate a code for cupping and moxibustion, and have had various fellow acupuncturists indicate that they bill using the existing codes for heat, 97010 hot packs or 97026 infra-red for moxa and 97016 vasopneumatic device for cupping.
The Clinical Versatility of Milk Thistle (Part 2)
Evidence is growing that the silymarin complex of flavonolignans from milk thistle can impact serum ferritin and iron overload in various clinical circumstances.
Treating Pain: The Hypermobile Coccyx
When I write about the coccyx, I recognize that I am talking about a relatively small subset of patients. When I write for Dynamic Chiropractic, I am trying to reach 60,000 chiropractors.
Lab Rats (Roaming the Streets)
The title of this article is an accurate description of American consumers (regardless of age) in the modern era.
Enhancing Performance in Cross-Fit Athletes
Cross-fitness centers are expanding in number and increasing in popularity. To remain relevant to this growing portion of society, practitioners need to learn about the exercises and injuries common to this group.
Maybe That's Not Tennis Elbow
Lateral epicondylitis, commonly referred to as tennis elbow, is one of the most prevalent upper extremity overuse conditions. Originally perceived as an inflammatory condition of tendon fiber tearing, it is now recognized to result from non-inflammatory collagen degeneration within the tendon as a result of overuse. Massage can be very effective for addressing this problem because pressure and movement applied to the tendon is one of the most effective methods of encouraging fibroblast proliferation in helping to rebuild the damaged collagen.
However, lateral elbow and forearm pain may come from other causes and can easily be mistaken for lateral epicondylitis. In such a case, the standard treatment protocol for epicondylitis of deep friction massage applied to the lateral elbow region could aggravate the condition and make it worse. If the standard protocol for addressing lateral epicondylitis is ineffective, it could be because the primary dysfunction is something different.
Radial tunnel syndrome (RTS) is commonly mistaken for lateral epicondylitis. It is a nerve compression pathology affecting the radial nerve. RTS is also frequently referred to as "resistant tennis elbow" because the symptoms can be so similar to tennis elbow but resistant to the standard treatments.
The radial nerve courses around the posterior aspect of the upper arm along the spiral groove of the humerus. It then crosses the anterior aspect of the elbow, before continuing down the forearm. Just distal to the elbow the radial nerve divides into its two terminal branches, superficial and deep. The superficial radial nerve is sensory, while the deep branch, which comprises the posterior interosseous nerve (PIN), carries mostly motor fibers. It is the PIN that is involved in RTS.
The supinator muscle has two separate divisions. One comes off the lateral epicondyle of the humerus, and has fibers that also originate from the radial collateral and annular ligaments. The other supinator division originates on the supinator crest and the fossa of the ulna (Figure 1).
The posterior interosseous nerve passes between the two divisions of the supinator muscle as it enters the radial tunnel (Figure 2). The radial tunnel is bordered on one side by the tendons of the extensor carpi radialis brevis, the extensor carpi radialis longus, and brachioradialis. The tendons of the biceps brachii and brachialis make up the opposite wall of the tunnel. The capsule of the radiocapitular (radius and capitulum of humerus) joint makes up the floor of the tunnel.1
Compression of the posterior interosseous nerve in the radial tunnel is known as radial tunnel syndrome. There are several different factors that may cause radial nerve compression in this region. Trauma to the elbow causing displacement of bones in the elbow joint is a common cause. Small cysts or tumors can also compress the nerve in the tunnel. The most common cause of PIN entrapment in the radial tunnel is tendinous bands at the edge of the tunnel that press on the nerve.
The symptoms of other common upper extremity nerve compression pathologies such as carpal tunnel syndrome or cubital tunnel syndrome are dominated by sensory aberrations such as pins and needles, electrical sensations, or sharp stabbing pain. These strong sensory symptoms are predominantly the result of cutaneous sensory fibers within the nerve being aggravated.
Nerve compression in radial tunnel syndrome is a bit different because the posterior interosseous nerve is predominantly a motor nerve and carries very few sensory fibers. However, it does carry sensory fibers from the muscles it innervates and related joint areas so it is not completely devoid of sensory fibers. The pain felt from radial nerve compression is more likely to be perceived in the muscle belly as that is where the sensory fibers are coming from. This pain pattern in RTS is in contrast to that of epicondylitis where the primary tenderness is in the tendon fibers very close to the tendon attachments at the lateral epicondyle of the humerus.
Because the PIN is predominantly a motor nerve, muscle weakness or difficulties with upper extremity dexterity are common. The primary muscles affected are the extensors of the wrist and fingers. Forearm pain may accompany weakness when the extensor muscles are contracted significantly because the sensory fibers in the affected muscles are being stimulated. Keep in mind that motor or sensory symptoms may exist together or without the presence of the other.
The symptoms of RTS may develop suddenly or they may come on gradually. How they develop is mostly dependent on the primary cause of the nerve compression. For example, RTS will often occur as a result of some acute injury where there has been a fracture or dislocation of the elbow joint causing a change in positional alignment of the bones in the elbow. In this case a rapid onset of symptoms could be directly related to the traumatic injury in the region.
In other cases, the symptoms may arise more gradually. For example, when RTS is caused by tumors or tendinous bands in the nearby muscles, symptoms may occur more gradually. Repetitive activities involving supination and pronation of the forearm, especially when done from a position of elbow extension which stretches the nerve, are most likely to produce these symptoms.2
Several pain and symptom patterns that help in recognizing RTS have already been introduced. In addition, pain from RTS is likely to be aggravated with activities like handwriting that cause prolonged isometric muscle contractions in any of the forearm muscles. The pain sensations are also likely to be reproduced with palpation directly on the supinator muscle distal to the lateral epicondyle of the humerus. If fibers of the supinator muscle are compressing the posterior interosseous nerve, resisted supination of the forearm may also aggravate the symptoms.3
Weakness or palsy in the wrist and finger extensors is also a common finding. If the compression is only mild or moderate the client will often demonstrate an inability to extend the wrist or fingers against resistance because they will seem very weak. In addition to weakness, pain in the extensor muscles of the wrist may also be present with resisted wrist or finger extension.
Massage and soft-tissue therapy can play a beneficial role in treating RTS. The practitioner should address other regions of potential nerve entrapment such as the thoracic outlet region, axilla, or lateral neck region in case there is a multiple nerve crush or neural tension problem in some other region that is aggravating the nerve compression symptoms of RTS.
Particular attention should be paid to the wrist and finger extensor muscles in the forearm. Deep longitudinal stripping techniques on these muscles will help free any neural restrictions in the distal region of the radial nerve. Decreasing tension in the wrist extensor muscles may also reduce the symptoms. Deep broadening techniques for the wrist extensors will also be of benefit in this region.
Methods of reducing nerve compression in the interface between the posterior interosseous nerve and the radial tunnel will be helpful. Firm pressure on the proximal region of the supinator muscle while the forearm is being pronated will help encourage elongation in the supinator muscle and may reduce compression on the nerve. However, the practitioner should be careful not to aggravate the symptoms by putting additional pressure on the compressed nerve.
Watch for the symptoms of RTS if a suspected lateral epicondylitis problem is not resolving. Deep friction massage over the lateral epicondyle region is the primary treatment for epicondylitis, and this treatment could aggravate an existing radial nerve compression. Therefore, if a deep friction treatment near the epicondyle aggravates neurological symptoms or pain farther down in the forearm, it is wise to consider the possibility of radial nerve entrapment in this region and modify your treatment approach accordingly.
While radial tunnel syndrome is not a commonly occurring condition, it can certainly be a painful and debilitating problem, especially if it is not adequately recognized. Because its symptoms are so often mistaken for lateral epicondylitis it is wise to have a clear understanding of both problems in order to provide the most effective treatment for lateral elbow and forearm pain.