Issue link: https://www.massageandbodyworkdigital.com/i/1417136
L i s te n to T h e A B M P Po d c a s t a t a b m p.co m /p o d c a s t s o r w h e reve r yo u a cce s s yo u r favo r i te p o d c a s t s 85 symptoms with lumbar extension, side bending, or rotation, either actively or passively. Prolonged standing, sitting, walking, and rolling are also likely to aggravate superior nerve irritation. Because of their location and lack of mobility, the middle and inferior cluneal nerve groups are not as affected as much during lumbar or hip movements. Palpation can be a helpful tool for identifying cluneal nerve involvement because the nerves are close to the skin's surface. Palpating the region of nerve entrapment will usually reproduce neurological sensations in the gluteal region, such as burning, tingling, or electrical-type symptoms, if the nerve is sensitized from compression. If symptoms increase when the area is palpated, do not continue to place pressure on that area. Additional pressure could further aggravate and sensitize those nerves. Sometimes trigger points are evident in areas near cluneal nerve compression due to the involvement of myofascial tissues. Consequently, it may be challenging to distinguish trigger point pain from nerve compression, as the symptoms of both can be similar, if not identical. TREATMENT Cluneal nerve entrapment is likely underdiagnosed, and there is little published literature on appropriate treatment strategies for these problems. Traditional medical treatments may include gentle exercises that free up the nerve and encourage decreased irritation during movement. Clients should avoid positions of sitting or walking that aggravate symptoms. With nerve compression pathologies, the more symptoms are aggravated, the greater the chance of developing sensitization in those nerves that can spread to other regions. Increased neural sensitization makes the nerves more sensitive, and therefore less irritation is needed to exacerbate symptoms. Nerve blocks or surgical release of the tissue surrounding the nerve may be recommended if conservative treatments are ineffective. I have not found any mention of manual therapy used to address cluneal nerve entrapment in any published literature. However, this is one of those situations where clinical reasoning suggests a beneficial role for massage. Because the nerves are so close to the skin's surface and often entrapped by other soft tissues, our soft-tissue treatments may be helpful. However, be selective in choosing techniques so as not to aggravate the nerve compression further. Deep, specific pressure techniques, such as those performed with a thumb, finger, elbow, or other small contact surface, could further compress the nerve and worsen the condition. A more helpful approach would be broad-contact surface applications, such as those with the palm or forearm. These techniques are more beneficial when there is less lubricant and the pressure is applied across the surface of (tangential to) the skin, instead of pressing directly down into the tissue. Treatment techniques commonly referred to as myofascial release, skin dragging, or dermoneuromodulating are very helpful for addressing cluneal nerve involvement. A key benefit of these approaches is they are relatively easy to perform with self-massage, so you can teach the client how to do this themselves. Sometimes it appears that the nerves respond well to pressure in specific directions. However, knowing which direction is going to work best is discovered through trial and error. Good communication with the client during the treatment is imperative. Give a gentle pull to the superficial tissues and ask the client if there is any relief of discomfort or change in sensation (better or worse). For example, you might begin by applying pressure over the upper iliac or gluteal region aimed inferiorly. Then apply that same type of skin drag medially, then laterally. You might then try doing the same thing in a superior direction. When you find the direction that gives the most relief, hold the position for a few seconds while the nerves adjust to the new sensation. Then gently and easily release the pressure. Often these sensory changes can begin to reduce neural sensitivity. Make sure you thoroughly treat the lumbar and gluteal regions and lower extremities to encourage relaxation and help relieve nerve irritability. Cluneal nerve entrapments are not common, but if not recognized, they can lead to the condition worsening or to poor effects from improper treatment. If you assume someone's low-back or gluteal pain is from muscle tightness or trigger points, there may be a temptation to treat those areas with deep, specific work. This approach could end up aggravating the existing complaint. Our knowledge of a wide variety of orthopedic disorders and their signs and symptoms is a valuable way to make sure we give our clients the very best care. Notes 1. Toyohiko Isu et al., "Superior and Middle Cluneal Nerve Entrapment as a Cause of Low Back Pain," Neurospine 15, no. 1 (March 2018): 25–32, https://doi.org/10.14245/ns.1836024.012. 2. Jay Karri et al., "Pain Syndromes Secondary to Cluneal Nerve Entrapment," Current Pain and Headache Reports 24, no. 10 (August 2020): 61, https://doi.org/10.1007/s11916-020-00891-7. Whitney Lowe is the developer and instructor of one of the profession's most popular orthopedic massage training programs. His text and programs have been used by professionals and schools for almost 30 years. Learn more at academyofclinicalmassage.com. CLINICAL EXPLOR ATIONS