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102 m a s s a g e & b o d y w o r k s e p t e m b e r / o c t o b e r 2 0 1 4 tissues are stretched, and during resisted lateral rotation when they are contracted, as they are in Emily's case. We now have a good idea of the tissues involved in Emily's shoulder pain, but what about the pain she is experiencing in her neck and down the upper extremity? She reports this pain is aggravated when she laterally flexes her head to the left, either actively or passively. The pain is also reproduced if she adopts the injury position, in which her head is laterally flexed to the left and her right arm is abducted and straight out to the right side. In this position, the nerves of the brachial plexus in the neck region are significantly stretched (Image 3). Emily's shooting pain sensations extend all the way down into her hand and into the palm and first and second fingers. The cutaneous innervation map for the hand indicates that this region is innervated by the median nerve (Image 4). The median nerve is in its most lengthened position when the arm is outstretched, similar to what happened when Boomer lunged ahead. It would then seem likely, based on Emily's symptoms and the motions that further aggravate her pain, that a median nerve traction injury may have occurred. TREATMENT STRATEGIES Now that we have a good idea about the nature of Emily's injury, it's time to consider the most effective treatment options. Starting with the more prominent superior shoulder pain, it appears she sustained a strain to the supraspinatus. The most prominent area of tissue damage is the distal musculotendinous junction (Image 5). The problem with attempting to treat this particular area with massage is that it is mostly inaccessible due to the tissue being underneath the acromion process. Cutaneous innervation of the median nerve. Mediclip image copyright (1998) Williams & Wilkins. All rights reserved. 4 CLINICAL APPS Median nerve distribution The rapid left lateral flexion of her head in combination with the immediate forceful pulling of her right arm away from her body could easily have produced what is called a nerve traction injury. This is an injury in which a nerve is exposed to excessive tensile (pulling) force, as opposed to the compressive forces that are the cause of most nerve injuries. Nerve traction injuries produce identical symptoms to those of a nerve compression problem. However, there are several important considerations that affect treatment solutions for these types of injuries. ASSESSMENT AND EVALUATION As mentioned earlier, there was no visible sign of trauma in Emily's shoulder region, so functional evaluation will be important for determining the tissues most likely injured. She reported the greatest amount of shoulder pain just underneath the acromion process, but reports that it also extends somewhat around the back side of her shoulder. Our focus in physical examination will be on tissues in those regions. During movement, Emily's greatest shoulder pain is with abduction movements, especially when she performs these actions against any type of resistance, such as trying to pick something up and lift it to her side. The pain she feels deep in her shoulder tends to worsen the farther she moves her arm into abduction. She feels this pain both actively and passively in abduction, but it is significantly worse in active abduction. She also reports that the pain is most pronounced when resisted abduction is performed. There is also some pain with active and passive forward flexion, although it is not as strong as the abduction. The fact that Emily feels more pain with resisted abduction than with active or passive abduction suggests a muscle tendon unit is most likely the problem, not a deep shoulder structure like the glenoid labrum. When we consider the initial injury, we can infer the supraspinatus would have been under exaggerated tensile load as her arm was pulled away from her body. This sudden traction force could likely have caused a strain to the supraspinatus muscle tendon unit. It is quite likely that Emily also sustained a minor strain to the posterior rotator cuff muscles (infraspinatus and teres minor) from the sudden traction force. We are also able to reproduce some of Emily's posterior shoulder pain by palpating structures around the posterior humeral head. Similar pain is also reproduced at the far end of active and passive medial rotation tests and somewhat with resisted lateral rotation. Her posterior shoulder pain is not as strong as what she feels just beneath the acromion process. Pain located in the posterior shoulder region could make us suspect the posterior rotator cuff muscles (infraspinatus and teres minor). If these muscles were involved, pain would likely increase at the end of medial rotation as those