Massage & Bodywork

JANUARY | FEBRUARY 2016

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Do you recall sitting in a classroom and thinking that one or two students were getting the lion's share of attention when others had things to contribute as well? It seems the world of soft-tissue pain and injury problems shares this metaphor. Take nerve entrapment, for example. As soon as you say the phrase upper extremity nerve entrapment, most people's minds immediately jump to carpal tunnel syndrome. But there are numerous other nerve compression syndromes that also cause significant pain or dysfunction in the upper extremity. In this newly focused column, my goal is to shed light on current pain science, as well as a host of nerve-related disorders that go undetected or misidentified on a regular basis. Massage therapists often admit to limited focus on the neurological system in their basic education. Yet, neurological sensation is a foundational and critical component of every client's experience. In this first installment, I turn attention to problems involving the long thoracic nerve (LTN). This is a tissue many massage practitioners may not be familiar with, but it plays a key role in upper extremity biomechanics and numerous pain complaints. 98 m a s s a g e & b o d y w o r k j a n u a r y / f e b r u a r y 2 0 1 6 technique SCIENCE OF NERVES The Long and Winding Nerve Challenges Involving the Long Thoracic Nerve By Whitney Lowe ANATOMICAL BACKGROUND The LTN originates from nerve roots at the lower cervical vertebrae, usually between C5 and C7. Once the nerve root fibers exit the cervical vertebrae, they blend together to form the main trunk of the LTN. The nerve then passes between the anterior and middle scalene muscles immediately adjacent to the other major fibers of the brachial plexus (Image 1). After passing between the scalene muscles, the nerve courses between the clavicle and first rib. It continues down the lateral aspect of the rib cage to its termination at multiple points along the serratus anterior muscle. This nerve's pathway is quite long, and consequently, there are multiple locations along its path where it is susceptible to compression or traction injury. The primary function of the LTN is motor innervation to the serratus anterior muscle, which has several key functions. The major function of serratus anterior is to hold the scapula firmly against the thoracic rib cage. Accordingly, when there is an interruption of motor stimulus The long thoracic nerve (LTN ) in relation to the brachial plexus. Image courtesy 3D4Medical's Essential Anatomy 5 application. Long thoracic nerve Brachial plexus to the serratus anterior, the common pattern of scapular "winging" is present. The serratus anterior has another important role: upward rotation of the scapula. The movement of upward rotation is a key component of proper scapulothoracic mechanics. Later in this column, I will highlight why this role of the serratus anterior is so important and what happens when muscle weakness from nerve impingement affects shoulder biomechanics. PATHOLOGY Damage or dysfunction can occur with the LTN from either excessive compression or tension, although compression injuries are most common. There are several locations where compression injuries are likely to occur. Compression could affect LTN roots at the cervical spine from herniated discs, bone spurs, tumors, or other obstructions. Moving distally from the nerve root, the next location of potential compression is between the anterior and middle scalene muscles. The brachial plexus courses between the anterior and middle scalene muscles 1 NEW

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