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A B M P m e m b e r s e a r n F R E E C E a t w w w. a b m p . c o m / c e b y r e a d i n g M a s s a g e & B o d y w o r k m a g a z i n e 97 SCIENCE OF NERVES Tinel's Sign A special orthopedic test called Tinel's sign is sometimes used to identify ulnar nerve compression at the wrist. This test is performed by tapping on the potential area of nerve compression with the fingertips and evaluating if it produces increased neurological sensation. Tinel's sign is only helpful for the Type I and III versions of Guyon's canal syndrome, since those have predominant sensory symptoms. Tinel's sign is not considered highly accurate to begin with, and since the Type II (motor nerve variation) of Guyon's canal syndrome is more common, Tinel's sign is not used with great frequency to evaluate this problem. Froment's Sign Another orthopedic test called Froment's sign focuses on the Type II (motor) variation. In this test, the client grasps a small piece of paper between the thumb and fingers. The practitioner attempts to pull the paper out of the client's grasp (Image 7). If it is hard to pull the paper out, this indicates a strong and well-functioning adductor pollicis muscle. If it is easy to pull the paper out, this generally indicates weakness in the adductor pollicis muscle, which is innervated by the ulnar nerve and may indicate compression of that motor branch. TREATMENT STRATEGIES With nerve compression problems, the primary strategy is to decrease pressure on the nerve so that it can heal. Because so many cases of Guyon's canal syndrome involve external compression, a primary treatment goal is to adjust lifestyle activities (like biking ergonomics) to decrease pressure on the base of the hand. Nerve tissue is slow to heal, so it can take a matter of months for symptoms to abate depending on how severe the nerve compression was to begin with. Because treatment should avoid putting additional pressure on the nerve, massage treatment should be applied carefully in this region so as not to further aggravate nerve compression. Treatment of any ulnar nerve compression problem will be most effective if the entire pathway of the nerve can be addressed throughout the upper extremity. That means specific attention should be focused to the medial aspect of the forearm and upper arm. In addition, treatment strategies that reduce hypertonicity in the pectoralis minor muscle and lateral cervical muscles (where the brachial plexus branches exit the thoracic outlet) will be particularly helpful. Any number of massage techniques could be helpful in this region as long as they are aimed at reducing muscular hypertonicity and not putting additional pressure on vulnerable compression sites of the nerve. Some clients will not respond to massage or other conservative treatment interventions. There may be an obstruction in the canal that cannot be addressed through noninvasive procedures and surgery is a likely option. However, a thorough regimen of conservative treatment(s) prior to surgery is always recommended to reduce issues that could further impair the function of the nerve. Greater awareness of less frequently occurring conditions such as Guyon's canal syndrome helps us deliver more effective treatment for our clients. Notes 1. M. J. Brody and R. R. Bindra, "Ulnar Tunnel Syndrome," in Disorders of the Hand Volume 2: Hand Reconstruction and Nerve Compression, eds I. Trail and A. Fleming (London: Springer, 2015): 267–82. https://doi.org/10.1007/978-1-4471-6560-6_15. 2. M. Pecina, A. Markiewitz, and J. Krmpotic-Nemanic, Tunnel Syndromes: Peripheral Nerve Compression Syndromes (Boca Raton: CRC Press, 2001). 3. J. Shea and E. McClain, "Ulnar-Nerve Compression Syndromes at and Below the Wrist," Journal of Bone and Joint Surgery, American Volume 51, no. 6 (September 1969): 1095–1103. 4. M. Lewanska and J. Walusiak-Skorupa, "Is Ulnar Nerve Entrapment at Wrist Frequent Among Patients with Carpal Tunnel Syndrome Occupationally Exposed to Monotype Wrist Movements?" International Journal of Occupational Medicine and Environmental Health 30, no. 6 (2017): 861–74. 5. P. Hoogvliet et al., "How to Treat Guyon's Canal Syndrome? Results from the European HANDGUIDE Study: A Multidisciplinary Treatment Guideline," British Journal of Sports Medicine 47, no. 17 (2013): 1063–70. https://doi.org/10.1136/bjsports-2013-092280. Whitney Lowe is the developer and instructor of one of the profession's most popular orthopedic massage training programs. His texts and programs have been used by professionals and schools for almost 30 years. Learn more at www.academyofclinicalmassage.com. 6 7 Clawing of the hand sometimes presents in Guyon's canal syndrome. Image courtesy Wikimedia Commons. Froment's sign for evaluating muscle weakness.