Repetitive Stress Injuries
Together, our temporary laboratory of massage therapists, participating in an intense life workshop with the bodies of the finest athletes in the world, perpetuated an embryonic idea. We felt that by working with the tendons and ligaments surrounding the joints involved in repetitive movement, we could encourage healing by breaking down fibrous adhesions. It appears we were right.
I would like you to hold up your index finger and take a good look at it. That finger is about the size of the hole in your wrist through which several flexor tendons, lymphatic vessels, arteries, and veins, along with the median nerve, pass. A rower activates the muscles in his back, chest, shoulders and arms which move those tendons in and out of that hole to allow the wrists to stroke the oars through water.
Last week I asked you to hold up your index finger and take a good look at it. Don’t put it down yet, I would like you to look at it again. That finger is about the size of your carpal tunnel, the hole in your wrist through which pass nine flexor tendons, your median nerve, and several lymphatic vessels, arteries, and veins. When you work on your computer, you activate the muscles in your back, chest, shoulders and arms which move these tendons in and out of the carpal tunnel to allow for the tapping of keys on your keyboard.
Recent works of a true pioneer in the sports massage field, Rich Phaigh. His excellent article on upper extremity repetitive stress injuries, published in the Spring 1994 issue of “Massage Therapy Journal,” forms the foundation of our discussion. Quotes from that article are being reprinted here with permission from the American Massage Therapy Association.
More and more we began receiving visits from athletes complaining of pain and numbness in their wrists and arms, along with a loss of grasping strength. These people were doing to their bodies in just days what it has taken ten years for office workers to do by using office computers.
What we had all noticed on these rowers was a swelling in the wrist area. Technically speaking, as Rich Phaigh puts it, in a condition like this, “The synovial sheaths surrounding the flexor tendons show varying signs of proliferation and thickening.” For these rowers, that was an understatement.
OK, lets get anatomical for a few minutes. Most people think that tendons attach to bones and extend out to join together into ligaments, which move on out into muscles, only to turn back into ligaments and tendons again, attaching to different bones at the other end. When you use a relaxed muscle, you cause it to shorten, which pulls on the ligaments and tendons attached to it, which brings your bones closer together. You experience movement.
Sounds good to me. Only one thing is missing. To keep the individual tendons separate from each other in tight quarters like the carpal tunnel in your wrist, millions of years of evolution have resulted in a sophisticated mechanical design. Our tendons are each covered with a smooth sheath which acts, in a way, like teflon does on a pan. When you move each of your fingers separately, the synovial sheathes surrounding the nine tendons passing through your carpal tunnel make sure your little finger doesn’t curl when you curl your index finger, that is, when your body is working the way it was designed.
Millions of years of evolution to perfect the human musculo-skeletal design. Ten years of repetitive computer use to break that design down. Reread Rich Phaigh’s description of the condition of these sheaths in carpal tunnel syndrome suffers. This is exactly what we found on Olympic rowers. Big difference, though: Office workers can take off sick. These athletes had one shot at glory, and only two more weeks of intense work ahead of them to achieve it.
Yugoslavia had a distinct advantage over all other athletes competing in the rowing events. They had been receiving what we called “cross fiber friction” therapy long before they reached America. Their synovial sheathes had been physically
Repetitive Stress Injuries ( contd. )
worked through tactile manipulation to reduce, if not eliminate, the proliferation and thickening seen in other athletes. Their grips were strong, their endurance high, and their Country proud as they won gold medals in four out of their five rowing events.
We are on a roll. For the past couple of weeks, we have been looking at high technology from another view, a more humanistic view. Whether you work on an old IBM PC, or just acquired the new Power PC, you work with a keyboard. Because of this, if you use your computer for extended periods of time, you are a potential candidate for repetitive stress injuries, the most notorious of which is carpal tunnel syndrome.
If you have succumbed to some form of repetitive stress injury, we want to help you understand it, and, before this series is over, give you some ideas for working with it. These rowers, because of the intense repetitive use of their hands and arms in their sport, exhibited an accelerated form of the same basic condition computer operators encounter after years of pecking away at computer keys. The techniques we used to alleviate this condition in rowing athletes, by analogy, may be applicable to anyone experiencing the characteristic symptoms of carpal tunnel syndrome today.
Just what are those symptoms? According to Rich Phaigh in and article he wrote for the Spring, 1994 issue of the “Massage Therapy Journal,” and reprinted here with permission from the American Massage Therapy Association, he states that, “Functional testing shows a shortness in passive wrist extension accompanied by pain, weakness in resisted wrist extension, shortness in passive supination and weakness in resisted supination.” That is, it hurts to flex your hand, and you can’t open it as much as you used to. He goes on by saying, “Advanced symptoms of carpal tunnel syndrome are an aching numbness in the wrist and fingers. The symptoms usually center on the middle and index finger and, to a lesser degree, the thumb. Gripping becomes difficult due to associated weakness of the flexor muscles.” Interestingly enough, the symptoms are worse after a night’s sleep, according to Mr. Phaigh.
It is time to recap. What we know today as carpal tunnel syndrome is a repetitive stress injury happening because of the proliferation and thickening of the synovial sheaths surrounding the nine flexor tendons which pass through an index finger sized hole in your wrist. This swelling within the closed tunnel leads to entrapment of the median nerve. The resulting manifestation of pain, usually in the form of an aching numbness, is a direct result of the compression of that nerve within the carpal tunnel. The thickening of the synovial sheathes also constricts the ability of the flexor tendons to move independently and to their maximum extent. Sufferers notice that moving fingers independently becomes difficult, and full hand extension becomes painful as the moving tendons apply additional pressure to the already compressed median nerve.
So just what did Yugoslavia’s Petar Ciric teach us which sports massage therapists have been perfecting over the past ten years in treating this condition? Petar’s “cross fiber friction” has evolved to the more eloquent “transverse friction massage” technique, and the premise is this:
The flexor tendons of the hand run lengthwise through the carpal tunnel on their way from the middle of your arm to your hand. As Rich Phaigh explains with regard to the median nerve, “In cases of nerve entrapment, the blood-nerve barrier is disturbed with ischemia and resultant loss of nutrition to the nerve. Prolonged ischemia leads to infraction of the nerve, and is directly responsible for the formation of fibrous adhesions in the damaged area.”
Adhesive fibrous formations gum everything up. They cause the flexor tendons the stick to their synovial sheaths, and the separate sheaths to stick to each other. Everything starts moving together, and it hurts. These formations can be broken up, and here’s the gold medal winning technique for restoring flexor tendon movement:
Repetitive Stress Injuries ( contd. )
With the athlete’s hand relaxed and supported, Petar Ciric would apply deep pressure across the inner and outer aspects of the Olympiad’s forearm, just above the wrist. His hope was, by rubbing “across the grain,” so to speak, the adhesion points could be broken and the fibrous formations released. This would restore full longitudinal movement to the tendons again, relax the sheaths, and encourage the movement of fresh blood and nutrients to the median nerve, thereby reducing the numbness and restoring grip strength.
I had never seen anything like it. It all made sense. The normal therapeutic approach of immobilizing the wrist, applying ice to reduce the swelling, and encouraging rest was exactly what you would do if you wanted to grow adhesive fibrous formations. No wonder these athletes felt worse in the morning when left untreated, or treated with ice therapy.
Logic would predict that aggravating an already sensitive area with deep stimulation would worsen, not improve an already bad situation. Such was not the case. Petar’s cross fiber friction, applied only with his trained fingers and thumb, made the difference in Olympic success. It taught me a lesson, too. Always be open for alternative ideas, even new ideas within an already established and accepted method of practice.
Comfortably seated and relaxed, the first thing I do is raise my head and turn it from side to side. I tilt it back and forth a few times, and try and break up the crackling sounds in my neck. Then I fix my gaze at something far away. If I can I get up and walk away from the computer, I will, but usually I just stretch a bit and get back to work.
–I always take time to interlink my fingers and press my palms forward, flexing my hands and fingers back. I know this not only feels good for my hands, but it lengthens and extends the flexor tendons passing through the carpal tunnels in my wrists, my first step in the preventative health care of my hands and arms.
–I shake my hands out vigorously restoring blood to my fingers, and then every half hour or so, and I know I should do it more frequently, but sometimes I forget. Before I leave my office at the end of the day, I try and make time to do a little something in private.
–I lay my left forearm down into my right hand with my palm facing up so my right index finger is even with my wrist. I make sure the back of my hand is supported and that I can see the creases in my wrist. Then I dig in.
–Using the first three fingers of my right hand, I rub gently across the inside of my forearm. I never rub lengthwise, only across. I do that for a half a minute or so, then I prepare myself for some deep work.
–Using my thumb, I dig deep into my forearm, about an inch or so back from the crease in my wrist. I feel around for one of those flexor tendons, and then I wiggle my thumb back and forth across it.
–It hurts a little, but for me, it’s a good kind of hurt. I don’t stay there long, just a few strokes with my thumb pad, then I move on and find another one. Each time I press deep and wiggle my thumb back and forth across the tendon. I try and visualize it as rubbing off a gummy buildup on the shaft of a pencil. It helps me think about what I am trying to do.
–I work all around an area in the inside of my forearm from just above my or tendons. As a final treat, I squeeze my forearm muscles from the middle of my forearm up to my elbow and back down to my wrist. Boy, that feels good.
–I do the same thing for my other arm, reversing the role of my hands. When I’m all done, I shake out my hands, interlock my fingers, and go for one more nice long stretch, palms out. Then I head home. Total elapsed time: about 5 minutes.
Repetitive Stress Injuries ( contd. )
That’s it. No big deal, just some applied deep pressure across the tendons in my forearm. Sometimes I throw in the back side of my forearm for good measure, but not always.
In the evenings I like to reach one hand around the other forearm just above my wrist and squeeze. Silly as it might seem, that simple squeeze helps move blood into and through the carpal tunnel, and that helps provide nourishment to the median nerve. Carpal tunnel syndrome is the most famous computer blamed repetitive stress injury, but it is not the only one. When you work at the same machine, month after month, you are bound to experience all sorts of problems. You’re feeling pain, tingling and numbness in your arms and hands. You’re loosing your grip — not your grip on life — your real grip. Picking up a carton of milk is an effort. You don’t know what to do. You don’t know what’s causing it, although you suspect it might be that one eyed monster at work, your office computer. Whatever it is, it is getting worse every day.
Repetitive stress injuries either are, or will, affect most of the 45 million US workers who use a computer in their jobs. Right now it is estimated that repetitive stress injuries account for nearly 200,000 workman’s compensation claims per year, and the number is
The cost, including lost productivity and medical expenses, is estimated at $7 billion (that’s billion with a B) per year. You see how
your head is tilted back? You’re trying to look at you computer screen through the bottom of your bifocal glasses! You can’t read the words when looking through the top part because that glass gives you good vision at a distance, and the computer screen is right in front of you. Bifocals were a great invention when people used to read books held in their laps. They present a real physiological problem for computer users.
Wait, there’s more:
Your feet are flat on the floor, but your knees are higher than your hips. You’re slouching in your chair, there’s no lumbar support for your lower back, your hands are above your elbows because your keyboard is sitting on the top of a regular desk, not a computer desk. Why, you’re a complete wreck. I’ve got a good idea what you are suffering from. According to Rich Phaigh, in an article he wrote for the Spring, 1994 issue of the “Massage Therapy Journal,” and reprinted here with permission from the American Massage Therapy Association, you just might have “compression of the brachial plexus just inferior of the coracoid process of the scapula.”
Folks, bad computer workstation design can lead to symptoms of carpal tunnel syndrome, when in fact, the problem can be way up in your neck and not even in your arm at all. You can squeeze and rub and shake your hands and arms all you want, and the pain, tingling, and numbness won’t go away. At this point you need help beyond what you can do for yourself. You need the kind of help a trained therapist can provide.
What I just described, by the way, is known in the sports massage trade as the coracoid pressure syndrome. Rich Phaigh, in his article mentioned above adds, “This condition is generally the result of a hypertrophied (short) pectoralis minor muscle which depresses the bony process and closes the small gap through which the brachial plexus passes. Every nerve which innervates the arm may be compressed in this condition.” In layman terms, tight muscles up near your armpit are cutting off the main nerve running down your arm much like when you hang your arm over the back of a chair and it goes to sleep on you.
It hurts in the morning when I get up, in fact, recently the pain has been waking me up. Oh, I don’t know where it is. It’s in my arms, it’s in my hands, it just aches. And it’s getting worse.
Repetitive Stress Injuries ( contd. )
Welcome back. On first glance this could well be a description of carpal the “Massage Therapy Journal,” reprinted here with permission from the American Massage Therapy Association, this could be anterior scalene syndrome. According to Mr. Phaigh, “Common causes of anterior scalene syndrome are the forward head posture, forward shoulder posture, and compression of the cervical nerve roots near the spine.”
Remember the anterior scalene syndrome above? No problem. Proper chair height and monitor placement will remove the tendency to hunch over and compress the cervical nerve roots near the spine. Skilled manipulation of the soft tissues of the neck during a by-weekly visit to “the therapy chair” can release the constriction over time and restore warm blood flow and nourishment to the aching nerves. Problem solved.
Last week we woke up with an ache in our arms and hands, a non-specific pain, but one intense enough to wake us in the morning. We learned it was probably due to the anterior scalene syndrome because we hunch our head and shoulders forward when we are working at our office computers. Sorry to tell you, those same symptoms, along with potentially indicating carpal tunnel syndrome.
Jerry Turner, CMT, LMT
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