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90 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 8 the development of the nerve compression problem. In addition, any occupational or recreational activities they frequently engage in that involve extensive overhead movements of the upper extremity may contribute to neural compression or tension (and subsequent symptom production). All branches of the brachial plexus, as well as the long thoracic and dorsal scapular nerves, are susceptible to overstretch and symptom production in rapid lateral whiplash injuries where the head is rapidly moved to one side. This occurs frequently in side-impact automobile accidents and may also occur in contact sports or other high- velocity movement encounters. When taking a thorough history, identify any factors that might cause these kinds of biomechanical forces in the cervical region, as they could easily contribute to nerve compression pathology that produces pain in the neck or upper-back region. IDENTIFYING NERVE COMPRESSION It is difficult to accurately isolate DSN pathology. The best strategy involves looking for key factors in the client's history, along with potential issues found in physical examination, such as mid- scapular pain, symptom aggravation with reaching overhead, or external loads that could be applying compression or tension to the affected nerve. In a study on DSN entrapment, researchers looked at individuals who had pain between the scapula as a prominent complaint. They found that over 50 percent of those individuals had some evidence of potential dorsal scapular nerve entrapment, indicating the condition may not be anywhere near as rare as once thought. 4 Scapular winging caused by DSN compression can be confirmed by having the client place their hands on their hips and then attempt to move the elbows backward (Image 3). When performing that maneuver, the scapula will often pull off the thoracic rib cage if the muscles innervated by the DSN or long thoracic nerve are weak. There may also be weakness in arm elevation, along with pain felt in the neck, shoulder, or arm during shoulder elevation or reaching overhead. Sometimes rotational movements in the cervical region may cause symptom aggravation if the rotary movement tugs on, or compresses, the affected nerve. DSN compression pathology may also be a causative factor in other conditions of shoulder pain or dysfunction. If the scapular stabilizers are not working properly, this can adversely affect shoulder mechanics and can lead to other biomechanical challenges in the shoulder, such as impingement problems or rotator cuff pathology. The symptoms of these other problems are similar to DSN pathology, so they can sometimes be mistaken for each other. Be cautious about making assumptions in the causes of shoulder, neck, or arm pain; it's not always simple. TREATMENT Pain between the scapulae in the upper back is generally attributed to tight or overstretched muscles in the upper- back region. However, the existence of dorsal scapular nerve irritation causing the same symptoms may be more common than previously thought. While we have yet to see any specific research on massage treatment for this problem, there are several treatment strategies that would seem helpful for addressing DSN pathology. Whenever possible, it is important to match the physiology of the tissue dysfunction with the primary effects of the treatment. We noted earlier that there are three primary causes of DSN pathology. The first involves potential nerve compression in the cervical region where the nerve actually perforates the middle scalene muscle and curves around the posterior scalene before making its way into the upper-thoracic and mid-scapular region. Thus, hypertonicity in the scalene muscles may contribute to nerve compression producing the upper-back pain. Gentle pulling and applying longitudinal traction to the scalene muscles without Evaluation test to identify potential scapular winging. 3 4 Gentle superficial work on the scalenes can reduce compression of the DSN.