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94 m a s s a g e & b o d y w o r k n o v e m b e r / d e c e m b e r 2 0 1 4 technique CLINICAL APPS Rebuilding Alan's Thumb By Whitney Lowe Clinical massage practitioners are most successful when they don't jump to immediate conclusions, but take the time to fully investigate the nature of a client's problem. In this installment of Clinical Apps, we explore a case in which the client is convinced he has one condition, but in fact it is something else. It is through your developed critical thinking and problem-solving skills that you will find effective solutions to your clients' problems. BACKGROUND AND KEY CONSIDERATIONS Alan recently took a carpentry job in which he uses a lot of power tools. He is suffering hand pain that interferes with his work. He is seeking health care because he is concerned that his symptoms may be a result of carpal tunnel syndrome. Alan's primary complaint is sharp pain around the wrist and base of the thumb. In certain positions, the pain is sharp enough to make him feel like he is going to drop the items he is holding. He reports that this sensation is not so much an actual loss of overall grip strength, but a sudden, sharp pain around the base of the thumb, resulting in an abrupt loss of hand and grip strength. In assessment, the essential rule of real estate applies: location, location, location. Of course, the site of pain does not always correspond with the location of the actual tissue dysfunction, as in trigger-point referral or radiating nerve pain, but pain location does provide a good clue and starting point for evaluation. Carpal tunnel syndrome is common among carpenters due to the job's constant gripping actions and vibrations from power tools. These are key factors causing median nerve compression under the flexor retinaculum. However, just because Alan has hand pain and carpal tunnel syndrome is common in his profession doesn't mean we can jump to the conclusion that it is the source of the present complaint. Other key structures in the area need to be investigated. Multijoint tendons that control the thumb and fingers have several unique factors that can lead to pain complaints in this area. The thumb and finger tendons that cross the wrist all pass under fibrous restraints called retinacula (singular: retinaculum). Each retinaculum plays a key biomechanical role in force transmission for the tendons. Looking at the retinacula, it would appear that their primary function is to hold the tendons in place around the joint. While they do provide a restraining force for the tendons, they actually perform a more critical biomechanical role. There are unique biomechanical challenges for tendons that cross multiple joints, like those of the wrist and fingers. For example, in the distal extremities, tendons often exert their pulling force across a 90-degree angle. Generating force across a sharp angle like this requires a mechanical arrangement like a pulley and rope arrangement (Image 1). The retinaculum acts like a pulley so the tendons can continue to generate a strong force across this sharp angle. Unfortunately there is a serious downside to the retinacula's role as a pulley, which should be apparent. If the tendon is pulling strongly against the pulley (retinaculum), there is a great deal of pressure and friction between the tendon and retinaculum. Increased friction on the tendon can lead to pain and tendon degeneration. 1 Wheel and pulley arrangement of tendons bound by retinacula. Image is from 3D4Medical's Essential Anatomy 3 application.