Repetitive Stress Injuries and Structural Integration: A Certified Hand Therapist’s Perspective
Kelly Clancy
Kelly Clancy received her BA from Colorado State University in occupational therapy (1987) and certifications in hand therapy (1994), Bowenwork from the Bowen Academy of Australia (2006), structural medicine through the Institute of Structural Medicine (2011), and board certification in structural integration, BCSICM (2011). Kelly teaches classes on the treatment of repetitive stress injury (RSI), myofascial length testing (MFLT), and manual therapy,
nationally and internationally, and is on faculty in the University of Washington’s rehabilitation department. Kelly founded and practices at the Seattle Center for Structural Medicine (www. scfsm.com) in Seattle, WA, an integrative wellness center of holistic health care professionals.
She can be reached at [email protected].
Abstract
Combining a structural integrator’s knowledge of fascia with the experience of a certified hand therapist, the author presents a model for treatment of repetitive strain injuries of the upper extremity utilizing new objective measures and providing structural integration as a first-line therapy. Traditional medical approaches to the treatment of these conditions, and drawbacks to those treatment modalities, are discussed, and a new paradigm of alternative treatment approaches affecting the connective tissue matrix is explored. Current and new treatments for epicondylitis, carpal tunnel syndrome, rotator cuff tendinosis, and thoracic outlet syndrome are described in detail.
Our upper extremities (UE) are an extension of our creativity and practicality, designed to provide interactive sense-perception of both our environment and practical experiences to meet our survival needs. Because of their near-constant functioning, our UE are susceptible to trauma, overuse, and dysfunction, especially if the rest of our system is out of balance. In the rehabilitation model of traditional Western medicine, treating such injuries has been the role of physicians, physical therapists (PT), occupational therapists (OT), and certified hand therapists (CHT). Yet, despite our years of training and the vast accumulation of knowledge in our fields, we often are unable to see lasting change and healing in our patients with injuries related to cumulative trauma and repetitive stress. The fascial system is rarely, if ever, considered as the driving force of the pathology. This is why traditional treatment often fails for individuals suffering from these conditions. Nerves may be decompressed by surgical intervention, diseased tendon fibers may be excised, tunnels may be modified, tendons may be transferred, and joints may be replaced, but the medical community is not looking at the driving force of the dysfunctional positioning—the fascial system.
My new paradigm of treatment in the UE is to untwist and derotate along the lines of fascia, in a three-dimensional fashion, organizing the underlying structures back to their original positioning in order to restore the balanced tensegrity of the whole structure and to produce lasting change and healing in the patient’s body. Only when the original, optimal rotation or spiral is restored in the tissue will such lasting healing be possible. I draw upon my clinical knowledge as an OT and CHT to use the tools of those trades— providing hands-on treatment to a client with repetitive stress injury (RSI) who may or may not undergo surgical intervention, modifying a client’s approach to activities of daily living, and encouraging a change in work or recreational habits.
Here, I present my model for treating clients with repetitive stress injuries by utilizing new objective measures and providing structural integration (SI) as a first-line treatment which I follow with movement lessons, postural and at-home exercise programs, and ergonomic evaluations. In addition to this standardized model for the treatment of RSI, I describe the role that fascial dysfunction plays in common pathologic conditions of the UE related to RSI: elbow and forearm pathologies, including medial and lateral epicondylitis; wrist injuries, including carpal tunnel syndrome, carpometacarpal (CMC) arthritis, de Quervain’s tenosynovitis, and triangular fibrocartilage complex (TFCC) tears; and shoulder pathologies, including rotator cuff tendinosis and thoracic outlet syndrome (TOS). Traditional approaches to the treatment of these conditions, and drawbacks to those treatment modalities, are summarized, and alternative treatment approaches affecting the connective tissue matrix are described.
To clarify some terminology before beginning this discussion, I refer to what is commonly called tendinitis with the more accurate term of tendinosis. Several scholars and medical professionals have argued for the use of tendinosis, or tendinopathy, over tendinitis. Khan, Cook, Kannus, Maffulli, and Bonar (2002) provided an overview of the differences between tendinitis, an acute, inflammatory pathology, and tendinosis or tendinopathy, a painful overuse tendon condition with a non-inflammatory pathology which does not respond to NSAIDS and takes months, not weeks, to resolve. Additionally, Bass (2012, p. 14) wrote that:
Tendinitis is the inflammation of the tendon and results from micro-tears that happen when the musculotendinous unit is acutely overloaded . . . tendinosis is a degeneration of the tendon’s collagen in response to chronic overuse; when overuse is continued without giving the tendon time to heal and rest, such as with repetitive strain injury, tendinosis results.
For these reasons, I refer to rotator cuff tendinosis, rather than tendinitis.
Background
Common orthopaedic therapeutic approaches to treating these conditions of RSI routinely involve concentrating clinical efforts on the localized site of pain, strengthening the involved muscles, or stretching an involved joint. What this traditionalist approach ignores, and what practitioners of structural integration know firsthand, is the role of fascia and the imbalance of tensegrity in the entire UE leading the way to dysfunction. Levin (2012) wrote that “the fascial system is a continuum, a structure that evolved hierarchically from the one cell embryo to the organism, and it is constantly adapting to new stresses to meet the structural demands of the organism” (p. 137). If the balance of tensegrity in the upper body is altered, then the upper extremities will never hold their most efficient, most balanced shape. Myers described this in Anatomy Trains: Myofascial Meridians for Manual and Movement Therapists (2009, p.149):
Figure 2. Arm Lines myofascial tracks and bony stations.
This figure and Table 1 were published in Anatomy Trains: Myofascial Meridians for Manual and Movement
Therapists, 2nd ed., Thomas Myers, pp. 150 and 151, Copyright Elsevier. Reprinted with permission.
Common postural compensation patterns associated with the Arm Lines lead to all kinds of shoulder problems, as well as arm and hand problems, usually involving the shoulders being protracted, retracted, lifted, or rounded. These compensations are often founded in the lack of support from the rib cage, which leads us to look to the cardinal lines as well as the Spiral and Deep Front Lines for a solution. Carpal tunnel, elbow and shoulder impingements, and chronic shoulder muscle or trigger- point pain emerge over time from these postural and support faults.
Utilizing Myers’ Anatomy Trains® lines as a roadmap to therapeutic intervention (see Figures 1 and 2, and Table 1), we can see how the functional lines and superficial and deep front and back arm lines all play important roles in promoting balance, length, tensile strength, and coordination for everyday functional movement patterns.
When the alignment and tensegrity balance of rotation is altered in the UE, the nerves that lie within the fascial matrix may become tractioned, compressed, or both. Often this tractioning will not appear on diagnostic studies, such as EMG testing, because there is no particular location of compression within a localized tunnel. CHTs hear complaints of “roving” symptoms that are located anywhere within the UE, neck, head, scapula, and thorax. The symptoms often do not follow a particular dermatomal or referred pain pattern.
In traditional therapeutic intervention for clients with RSI, treatments are aimed at each of those presenting independent symptoms, attempting to reduce the nerve compression, the tendon or musculoskeletal complaints, or the lymphatic swelling. In treating conditions of the elbow and wrist, the traditional, reductionist approach taken by OTs, PTs, and CHTs is to stretch the forearm in a linear direction either passively, actively, or manually.
Localized treatment of these conditions ignores the dysfunctional spiral pattern of fascia that exists throughout the UE, which is the origin of these structures’ tendinous insertions being pulled abnormally and out of balance. An imbalanced pattern of fascial positioning almost always produces pain, inflammation, and dysfunction. If this imbalanced pattern is not addressed globally, lasting improvement will not occur.
Myofascial Length Testing
Treating painful conditions of the UE is a complex, multi-step process which often involves multiple practitioners from different areas of specialization. Structural integrators are perfectly suited to provide holistically-minded, fascially-focused treatment to clients with problems in their UE because the root cause of UE issues is rarely simply in the UE or upper quadrant (UQ).
The treatment of inherently complex disorders of the UE is best guided by the use of practical tools for assessment, specifically myofascial length testing (MFLT). MFLT objectively tests the myofascial restrictions within the body. Developed by Donna Bajelis, PT, CHP, SMS, the founder and owner of the Institute for Structural Medicine, MFLT combines physical therapy principles of muscle testing with proprioceptive neuromuscular facilitation (PNF) patterning and tests the fascial lines to determine where primary restrictions may be located, and identifies the compensatory patterns that have developed within the body (Bajelis & Duben, 2012). By utilizing a formal objective assessment technique for both pre- and post-treatment testing, the practitioner is able to determine exactly where the restrictions are located within the structure and can target treatment to these areas, thus making treatment more efficient and cost effective. MFLT provides a practitioner with objective testing to use in documentation, which allows greater communication to the referral source, insurance companies, and other providers working with the client.
Table 1. Arm Lines: Myofascial Tracks and Bony Stations (see Figure 2)
Testing such as MFLT becomes paramount when treating UE injuries because it tells the practitioner the precise capacity for the arm lines to rotate in relation to each other in both internal and external rotation at the shoulder and upper arm, and in supination and pronation at the forearm.
This rotational ability lies at the heart of normal functioning of the UE. When their rotational functioning is altered, the structures within the arms, including the muscles, tendons, ligaments, nerves, vascular, and lymphatic systems, all become altered, resulting in the complex UE disorders that we see in our clients.
MFLT is conducted after a standing postural assessment and is done by the practitioner, with the client passive. First, the ability of the scapula to organize itself in depression and inferior angle protraction, to allow the glenohumeral joint to flex correctly, is assessed. This biomechanical pattern is paramount in normal shoulder functioning to create the proper scapulohumeral rhythm in overall mobility. The scapular mobility is 100% dependent upon the thoracic alignment because of its floating position on the rib cage. Once the scapula’s ability to “seat” is evaluated, meaning its ability to depress, then MFLT procedures for the superficial back and front arm line are performed.
For the superficial back arm line, with the scapula placed in its end-range depressed position, the arm is passively flexed and horizontally adducted while maintaining end-range external rotation and forearm supination. This tests the total end-range capacity of the fascial fibers of the superficial line. The end range of the client’s SBAL flexibility occurs when the client’s elbow reaches the bridge of the nose, or at 140 degrees.
Figure 3. Superficial Back Arm Line testing.
Likewise, the superficial front arm line is tested with the scapula seated, while maintaining the external rotation and supination components of the “wind up.” The practitioner ensures that the client is not positioning the elbow in valgus to achieve this orientation. The arm is then passively moved into shoulder extension at approximately 30 degrees of abduction. In Figures 3 and 4, the client’s available range, in both external rotation and supination, is limited, and so the practitioner is unable to move her into the absolute end range of her SFAL.
The deep front and back arm lines are tested in the same fashion, except the shoulder is positioned in full internal rotation and with the forearm in pronation. By evaluating the rotational ability of the UE, the practitioner is able to determine where within the arm line the deficits lie and can direct the treatment accordingly.
Often, the regions most restricted in mobility translate into hypermobility above or below that segment. It is critical that the practitioner be able to evaluate these areas of rotational restriction because it is often at these locations that the client compensates into another plane of movement or becomes hypermobile just proximal or distal to that site. The areas of compensation or hypermobility are often the same sites where the client presents with pain, as the structures at that site become irritated, inflamed, tractioned, or compressed. In traditional orthopedic treatment, it is at these sites that the physician, PT, or OT addresses the client’s concerns of pain and dysfunction, but this may not be where the origin of the problem lies. Without utilizing objective measures that test fascial length and strength in their full rotation and spiral, such as MFLT, practitioners and medical professionals in any specialty will be unable to identify with certainty the origin of fascial restriction and imbalance that results in the client’s presentation of pain and dysfunction. Additionally, without measures like MFLT, the client’s progress cannot be tracked with precision.
Figure 4. Superficial Front Arm Line testing.
Standardized Treatment of RSI
The model I follow in my own clinic has four discrete steps. I recommend employing this model in the treatment of any client who presents with RSI. Before beginning treatment, I conduct testing via MFLT, and use MFLT as an objective measure to test the client before and after each session to track progress and to direct further structural integration work. Then, I provide SI series work, movement lessons, postural and at-home exercise programs, and ergonomic evaluation. Finally, I treat the client for specific RSI diagnoses of the UE.
Step 1: SI Series
For structural integration sessions with a client who presents with RSI, my training as a CHT and OT leads me to recommend providing more than the standard SI series because of the complex nature of RSI itself and the anatomically complicated nature of the fascial arm lines, which play an inextricable role in disorders of the UE.
In their treatment of clients with RSI, I recommend that structural integrators begin their work with a full SI series, continue with multiple sessions of structural integration on the arms alone, and finish by revisiting the series to evaluate and treat where fascial imbalances may still exist in the whole structure.
When I provide a client with a 10-session series of structural integration, I use the approach taken by the Institute of Structural Medicine, which I find very effective in my treatment of clients with upper extremity RSI. The following sessions are especially relevant:
Provide several sessions of structural integration on the arms alone. Let MFLT be the guide here. Test the direct lines which encompass the location of the client’s pain and dysfunction, and then test the secondary lines that influence those directly involved lines. Using objective measures such as MFLT provides the practitioner with guidance on what path to take and how to prioritize each client’s unique treatment. In my experience, taking subjective pain reports from the client, observing a standing postural assessment, and utilizing palpation testing does not provide enough precise guidance on where I should direct further treatment for my clients with RSI. Especially in evaluating clients with RSI, the arms must be wound up in testing via MFLT, and subsequently, in treatment, the client’s tissue needs to be brought closely to its end range or spiral rotation to influence the whole line.
During these multiple sessions on the arms alone, the focus of the work should be to balance the normal spiraling of the arm, making sure that the spiraling is equally distributed in external rotation and supination, and in internal rotation and pronation. The dysfunction usually happens when the arm loses that full excursion between the two.
In my clinical practice, I can see that the linear orientation of the fascial arm lines changes into a spiral orientation once the client initiates movement. My observations of these pattern changes arose from my knowledge of proprioceptive neuromuscular facilitation (see Scifers, 2004), which is a therapy technique that helps restore neuromuscular function in diagonal and spiraling patterns of movement, namely, the diagonal 1 (D1) movement pattern of external rotation and supination while crossing the midline, and the diagonal 2 (D2) pattern of internal rotation and pronation while crossing the midline.
PNF treatment principles normalize functional movement, and PNF patterns depend on the normalized length of fascial lines.
As I trained in structural medicine and specifically MFLT, I began to understand that the diagonal patterns of PNF are tested to their end range with MFLT, specifically assessing the client’s ability to assume end range D1/D2 patterning, which stretches the whole fascial line.
In movement the fascial arm lines effectively wrap around the arm in spirals and therefore must be evaluated, treated, and restored to their original length within a spiral orientation. The excursion and the directionality of the spiral will depend upon the function of the activity, such as reaching, weight bearing, brachiating, or independent positioning.
During treatment, this derotation of the fascial arm lines reduces the tensional patterns that are created and exacerbated by RSI. The derotation untethers multiple anatomical structures including nerves, lymphatic system, vascular supply, muscles, endons, and ligaments, which become tractioned by fascial imbalances as a result of prolonged, complex issues in the UE. As these structures are addressed, the underlying root causes of RSI pain and dysfunction begin to improve, permitting lasting change and healing.
Once the arm tensegrity has been normalized, revisit the SI series and see where fascial imbalances continue to exist throughout the client’s whole body structure, again letting MFLT be the guide to treatment. New problems may develop in a client’s structure as their UE or UQ is reorganized. For example, the reorganization of the client’s arm lines may require that the arm lines borrow fascial tissue from the back line, and as a result, a client’s back may “go out.” Yet another reason to use MFLT is that clients with similar RSI issues may present those issues in different ways throughout the fascial lines of their whole body. As an example, two clients with rotator cuff tendinosis may require different special interventions in order to balance their whole body structures. One client may need the front line worked out and released all the way to the toes, but a second client may not need that at all. Only with an objective measure used regularly in addition to the client’s subjective pain reports, standing postural assessment, and palpation testing will a structural integration practitioner gather enough information to accurately guide the detailed, multistage work of rehabilitating a client with RSI.
The fascial arm lines in function effectively wrap around the arm in spirals and therefore must be evaluated, treated, and restored to their original length within a spiral orientation.
Step 2: Movement Lessons
After completing the first, standard series of structural integration, adding additional sessions focused only on the arm lines, and progressively adjusting the client’s tissue tension, based on testing, to balance all of the client’s fascial lines, it is appropriate to provide or prescribe movement lessons for the client.
If the SI practitioner is qualified to provide movement lessons, then working with the client with RSI in any modality of gentle movement will further the integrating work of SI and reduce the likelihood of reoccurring RSI symptoms. Some schools of movement lessons that, in my experience, have effectively supplemented other fascial work for clients with RSI include:
Such movement lessons help integrate the changes encouraged by manual therapy throughout the whole body. Therefore, the client should receive movement lessons during and after structural integration work has been completed.
MFLT plays an important role at this point in the client’s recovery from RSI as well; its objective measures provide a way for the structural integrator to direct her own efforts or to make a referral for movement lessons as accurate and informative as possible. When making such a referral, any issues in the client’s possible range of motion and end-range positioning should be communicated to the movement practitioner. Communicating the testing results to the client and movement practitioner ensures that the client does not fall into compensatory patterns, which may develop due to any remaining limitations in motion. The results of testing should be part of any referral made out for movement lessons during the SI series and beyond. The more familiar the client is with his existing compensatory patterns, the more likely he will be able to reverse them.
Step 3: Postural and At-Home Exercise Postural and at-home exercise programs should be developed and directed by an OT, PT, or a CHT who is a specialist in the UE and is familiar with the fascial system as a whole. In addition to structural integration and movement lessons, a guided exercise program is warranted to counterbalance the effects of repetitive movement in the client’s body. For example, computer users can balance the forward position required by their jobs through scapular stabilization exercises. This kind of localized exercise is important for computer users, because the daily activities of their jobs will continue to imbalance their fascial lines, even after their structure is integrated. A second example can be found in the bodies of structural integrators who develop RSI. I recommend that they also exercise in a localized way to counterbalance the activities of their job as manual therapists.
Step 4: Ergonomics
Finally, ergonomic assessment is warranted either through client education or through one-on-one evaluations of a client’s work or home environment. Ergonomic assessments could be performed by a practitioner specifically trained in ergonomics such as a CHT, OT, PT, SI practitioner, or ergonomist.
Treating Specific RSI Diagnoses of the Upper Extremity
After providing the client with the previously described standardized treatment model for clients with RSI, I continue to treat my client with specific RSI issues as follows.
Elbow and Forearm Pathologies Elbow positioning is influenced by both the superficial and deep arm lines. In the case of epicondylitis, the superficial front and back arm lines are involved.
Medial and Lateral Epicondylitis
Medial epicondylitis produces pain on the medial aspect of the elbow and involves the common flexor tendons. Abnormalities within the superficial front arm line (SFAL), which includes the latissimus dorsi, pectoralis major, medial intramuscular septum, and digital and wrist flexors, contribute to this condition.
Lateral epicondylitis produces pain at the origin of the extensor tendons at the lateral elbow. The superficial back arm line (SBAL), which includes the trapezius, deltoid, lateral intramuscular septum, forearm, and digital and wrist extensors, is implicated.
Conventional treatments for medial and lateral epicondylitis include the following localized interventions:
Many of these localized treatment approaches may temporarily reduce pain and dysfunction in the elbow, because they may reduce local inflammation and irritation, but they rarely produce lasting change and healing. In addition to only producing temporary gains through the current medical model, some of the treatments listed above can cause additional pain and dysfunction. For example, forearm bracing is designed to relieve tension at the elbow. However, such bracing often compresses the radial and median nerves at the supinator and pronator teres, adding additional nerve compression to the pre-existing conditions in the elbow. Often, we see clinically that the elbow symptoms resolve with localized treatment, only to flare up somewhere else, proximal or distal to that joint, and be perceived as a “new” pathology.
Pathologies within the deep front arm line would include diagnoses of bicipital tendinosis, radial nerve impingements at the forearm, and thumb-related disorders. These specific conditions can present in isolation or in combined pain complaints in relation to the altered tensegrity of the deep front arm line itself and its relationship to the other fascial lines within the arm. Because the end-range test positioning of the deep arm lines involves an internal rotation and pronation pattern, we often see deep structural imbalances within this line affecting the anterior labrum of the glenohumeral joint, the deep rotation patterns of the forearm, and subsequently the alignment of the carpals within the wrist and thumb.
Wrist Pathologies
Carpal Tunnel Syndrome
Carpal tunnel syndrome directly involves the SFAL which begins proximally at the latissimus dorsi and pectoralis major, and extends into the medial intramuscular septum to the wrist and digital flexors. The structure of the carpal tunnel forms a passageway for nine flexor tendons, two to each finger, one to the thumb, and the median nerve as they pass through to the hand. Whenever there is asymmetry in the carpal bones, or an inflammatory process that involves the tendons or outlying structures, the pressure increases in the carpal tunnel, thereby compressing the median nerve as it passes beneath the flexor retinaculum. This median nerve compression leads to paresthesias or numbness in the first three digits of the hand. Compression of the median nerve may be at the wrist itself, or the site of compression may be proximal to the wrist, based on the orientation of the fascia and the structures influenced by the SFAL. Traditional diagnostic studies to rule out or rule in the diagnosis of carpal tunnel syndrome include electromyogram (EMG) studies, provocative percussion testing such as Tinel’s test, and compression testing such as Phalen’s and Durkan’s test. These tests can determine if there is a localized site of compression at the carpal tunnel but will not determine if there are other sources of tractioning or nerve irritation that may be contributing to the distal symptoms.
Current traditional OT and PT treatment approaches to carpal tunnel syndrome include localized treatment strategies such as:
When traditional OT and PT interventions fail, then surgical intervention is applied. The carpal tunnel is enlarged by transecting the transverse carpal ligament, creating a larger space for the median nerve and flexor tendons to glide and thereby reducing compression of those structures. Again, the tensional patterns of the UQ that may have contributed to the localized inflammation and irritation more proximal to the site have not been evaluated or treated, limiting the successful outcomes of surgical interventions and often only partially relieving symptoms.
In some severe cases where the rotational forces are too restricted in the deep layers of the fascia for conservative management such as targeted structural integration, surgical interventions like fascial releases at these proximal sites may be warranted.
This requires a skilled surgeon who is familiar with the fascial matrix and detailed anatomy, and is experienced in treating the proximal postural components of this condition. In my clinical experience, I know of only one upper extremity surgeon, Dr. William B. Ericson, Jr., FACS, FAAOS, who is familiar enough with the fascial matrix to routinely include considerations of fascia in his surgical interventions. Dr. Ericson practices at the Ericson Hand and Nerve Center in Seattle, WA, and he presented his initial findings about proximal median nerve entrapment as a poster, “Median nerve entrapment in the forearm: Diagnosis and treatment,” at the American Society for Surgery of the Hand (2004) and more recently on “Dual oblique skin incisions for proximal median nerve entrapment” at the Scandinavian Society for Surgery of the Hand (2010). Dr. Ericson continues to practice surgical fascial interventions and collaborate with other specialists to research and present findings in his field.
CMC Arthritis, de Quervain’s Tenosynovitis, and TFCC Tears
When the deep front arm line is restricted, the client loses the ability to fully extend the elbow due to biceps shortening, and the elbow is forced into a valgus position with abduction of the lower arm. Forearm end-range supination is lost, and compensatory patterns at the wrist are reinforced leading to overuse of the CMC joint at the base of the thumb, de Quervain’s tenosynovitis affecting the thumb extensor and abductor, and triangular fibrocartilage complex (TFCC) disruptions in the ulnar wrist. Traditional treatment strategies would be site specific, addressing the inflammation or irritation at these sites. When conservative management fails, then surgical intervention is provided in the following forms:
Clinically, it is not uncommon to see clients who have multiple surgeries of the UE in an attempt to alleviate the myriad of symptoms they present due to these spiral asymmetries.
Shoulder Pathologies
Pathologies within the deep front and back arm lines include proximal issues related to the rotator cuff musculature and distal issues in the thumb and carpals. Tensegrital imbalances affecting these lines affect all of the muscular balancing at the glenohumeral joint, elbow, and wrist. The deep back arm line includes the levator scapulae, rhomboids, infraspinatus, supraspinatus, subscapularis, teres minor into the triceps, ulnar periosteum to the ulnar wrist, and hypothenar musculature. When these imbalances occur proximally, the deep external rotators cinch the posterior capsule and shear the anterior humerus forward. Limitations will be present in abduction, flexion, horizontal adduction, and external rotation.
Rotator Cuff Tendinosis
The rotator cuff is a complex of four stabilizing muscles and tendons, the infraspinatus, teres minor, subscapularis, and supraspinatus, that naturally hold the humerus in the glenoid fossa, allowing the joint to be stable and mobile for three-dimensional movements of the UE. When the tensegrital balance is altered—whether due to scapular dysfunction, postural asymmetries such as a forward head posture or kyphotic thoracic positioning, trauma, or surgical intervention anywhere within the system that may directly or indirectly affect this balanced state—then dysfunction will be present.
The rotator cuff musculature normally provides an equal circumferential positioning of the head of the humerus into the glenoid fossa by its tensional compression forces and distraction forces. This requires that all of the rotator cuff musculature and surrounding structures of the thorax and scapula be balanced in length and strength. When these balancing pulleys and struts become asymmetrical, the joint becomes dysfunctional, leading to irritation in any structure that is within the joint space, including the bursa and tendons. Eventually, with enough changes in alignment, boney changes occur, causing spurring which eventually leads to fraying of the tendons. With bone spurs, partial- or full- thickness tears occur, the latter requiring surgical intervention.
The muscles of the rotator cuff are all involved with stabilization and mobility of the humerus in the glenoid fossa. The subscapularis and the superficial anterior structures of the latissimus and pectoralis muscles are internal rotators. These muscles, which lie within the deep and superficial arm lines, proximally from the neck to distally into the hand, are at the mercy of the positioning and tensioning of the whole line. When fascial tensegrity is compromised, the joints are no longer balanced.
Rotator cuff impingements most often affect the supraspinatus based on its vulnerable positioning along the superior aspect of the glenoid fossa. When the tensional balance is altered due to abnormal scapular positioning or alterations in the balance of the rotator cuff musculature, the humerus rides up too superiorly in the fossa, creating an impingement of the vulnerable tendons within that space. Symptoms of rotator cuff disorders include shoulder pain, weakness, and stiffness, most often on the front and side of the shoulder and upper arm.
Tendons of the rotator cuff can become irritated, and fraying and tearing can occur. Magnetic resonance imaging (MRI) with contrast can help determine the percentage of tear within the joint itself. The restoration of proper tensional alignment is paramount in both conservative and post-surgical management of these conditions.
The deep front arm line includes the pectoralis minor, subclavius, coracobrachialis, biceps into the radial periosteum, and thenar musculature. The biceps tendon, which lies within the deep front arm, also becomes irritated, sheared, and eventually torn if the anterior shearing forces are prolonged due to restrictions in the deep back line. Another cause for irritation, shearing, or tearing in the biceps tendon is repetitive activities involving shoulder flexion, abduction, or rotation. Because the long head of the biceps blends into the labrum anteriorly, the labrum is often disrupted, and the patient is diagnosed with a superior labrum anterior to posterior (SLAP) lesion. Symptoms of a SLAP tear may include anterior shoulder pain, a sense of instability, or clicking in the shoulder. These disruptions in tendon and joint health are caused by the abnormal shearing forces that are created by the imbalance of tensional forces, both intrinsic and extrinsic, affecting the shoulder joint.
Impairments such as SLAP lesions and rotator cuff impairments involving pain within the shoulder joint are diagnosed with provocative testing in the clinic by therapists and physicians. Some of these tests may include a Hawkins-Kennedy Impingement test, Speed’s test, Yergason’s test, anterior/posterior shear test, and Neer’s test, each designed to determined where within the joint the greatest restrictions or instability lie. Confirmation through diagnostic testing is then also performed, including MRI studies with arthrogram, which involves an injection of dye in the joint space. This allows the physician to easily see contrast on the film which would confirm damage to a tendon.
When partial thickness tears, bursitis, or small spurs are present, conservative management is often warranted. In traditional treatment settings involving physical and occupational therapists, rotator cuff stabilization exercises are emphasized in an attempt to normalize the stability of the glenohumeral joint. Unfortunately, it is rare that connective tissue asymmetries and abnormal tensional patterns of the fascial lines are taken into consideration. If the intervention is strictly strengthening, then the compensatory patterns will remain. Symptoms may persist or be translated somewhere within the lines of fascia—either proximally or distally. Injections with corticosteroids may temporarily alleviate the localized symptoms but will not create long term resolution of the imbalances.
Impairments further down the chain of the deep front and back arm lines include elbow joint misalignments, limitations in forearm rotation, and subsequently asymmetries at the wrist and hand.
These imbalances of fascial lines cause an imbalance in the ability of the forearm to fully supinate and pronate, compromising the nerve structures as they extend from the cervical spine distally to the hand. Often, weakness occurs into the finger flexors and thumb musculature, leading to compensatory patterns involving overuse of the wrist extensors and abnormal pinch patterns. Distally abnormal patterns will develop radially in the form of CMC arthritis at the base of the thumb, tendon inflammation, and synovitis such as de Quervain’s tendinitis or, if left untreated, tendinosis. Ulnar joint compressions along the wrist will progress, including ulnar impaction syndrome, TFCC tears, or ulnar nerve compressions at the wrist.
Again, with these disorders, typical localized treatment interventions involve:
These treatments can lead to temporary reduction in symptoms but again will not heal the postural dysfunction. Balancing the fascial tensegrity is the only way that the tension and compression forces can be restored and lead to long-term resolution of symptoms. Often, when localized modalities and treatments are applied, we either see a temporary change in symptoms that is short-lived, or we see a translation of symptoms proximally up the fascial line into the elbow, glenohumeral joint, posterior thorax, or neck.
. . . clients with UE dysfunction and pain achieve lasting health and healing at the hands of a practitioner who treats them holistically, with the organ of fascia being the primary intervention.
Thoracic Outlet Syndrome
Thoracic outlet syndrome (TOS) is a condition most often seen in populations where UE repetition is involved. Previously, it was seen in patients who performed overhead activities in a sustained fashion, such as drywall installers, painters, or machinists.
More recently, there has been a dramatic increase in incidence in computer users who also are experiencing nerve compression, pain complaints, and loss of function throughout the UE. These clients can be more complex to diagnose and treat based on their multiple symptoms and complexity related to postural asymmetries, ergonomic factors, and the demands that our society places on interfacing with computers for work, social networking, and entertainment.
The anatomy involved classically includes the anterior and middle scalenes, where the neurovascular bundle to the UE lies. This neurovascular bundle houses the nerves, veins, and arteries that continue into the UE; the bundle continues distally beneath the pectoralis minor and then bifurcates into the upper and distal arm. Anywhere along this pathway, these nerves can become tractioned, compressed, or a combination of both. Symptoms may include: numbness in the fourth and fifth digits, with numbness into the other digits if the middle trunk of the brachial plexus becomes irritated; diminished coordination, including frequent dropping of items; loss of dexterity; and pain anywhere from the neck, parascapular region, shoulder joint, axilla, upper arm, forearm, and into the hand. If the irritation is severe enough, vascular changes, such as color changes, and lymphatic symptoms, such as swelling of the hand and digits, is seen.
Usually, the pain starts in a vague, isolated pattern anywhere in the arm, and if the irritating factors remain, this pain pattern spreads and becomes more diffuse and increases in intensity. It may disrupt sleep, make home and work duties difficult, and interfere with normal daily functioning.
This disorder can be quite frustrating for the patient and healthcare provider who may not be well versed in this syndrome. Misdiagnosis is very common and medical interventions, such as surgeries to remove the anterior and middle scalenes, first rib resections, nerve decompression at the elbow, carpal tunnel surgery, Botox and lidocaine injections, and pharmacologic treatments, are often implemented to no avail in an attempt to alleviate symptoms. Many of our current diagnostic studies, such as nerve conduction studies and clinical examination, do not detect the source of the nerve compression, thus making diagnosis and intervention even more difficult.
Thoracic outlet syndrome does not respond well to traditional physical and occupational therapy interventions such as strengthening. Symptoms can sometimes but not always respond to stretching routines that honor the neural tension patterns within the system. Current standard therapy programs performed for TOS patients include the following treatments to the neck, shoulder, and shoulder blade:
Localized treatments like these often fail to alleviate symptoms because of their reductionist approach, attempting to treat only the symptoms while ignoring the overall postural patterns which lie at the core of this condition.
The majority of TOS origins lie in poor posture, poor ergonomic work practices, and overuse. There are some diagnosed cases that are due to an extra cervical rib, enlarged transverse cervical processes, or Pancoast tumors, but they exist in small numbers.
Most often, the TOS pattern starts in the ribcage and its relationship to the pelvis. Because of poor ergonomics, excessive workload, anxiety in the workplace, previous injuries or surgeries, trauma, or general deconditioning, changes in pelvic and thoracic alignment are present and shallow inhalation and exhalation breathing patterns develop due to poor excursion of the diaphragm. Consequently, the muscles of secondary inhalation, the scalenes, levator scapulae, upper trapezius, sternocleidomastoid (SCM), and levator costarum, begin to take over. When this occurs, there is a narrowing of space between the head and the shoulders due to the vertical nature of the breathing pattern of the ribcage, instead of the normal three- dimensional expansion present in normal breathing. The yoke, being the region bordered by the clavicle anteriorly, the spine of the scapula posteriorly, and the head medially, becomes altered and is no longer positioned horizontally with reference to the floor. The yoke narrows in width and/or depth and tilts anteriorly or posteriorly based on the positioning of the thorax. Subsequently, this yoke space, which houses important vascular and nerve structures including the brachial artery and the brachial plexus nerve bundles, becomes altered in either compression, tractioning, or both. The head often comes forward based on the alignment of the arms and a sometimes posteriorly tilted thorax. The scapula is then forced into protraction based on the rib cage positioning, and the glenohumeral joint is forced to internally rotate.
Due to the load now being placed on the secondary inhalation muscles to become the primary breathers, they increase density and strength. Their length will adjust to meet the demands of primary breathing to sustain the life of the organism. These length and girth changes will then further affect the postural positioning of the surrounding bones, muscles, nerves, and lymphatic system, often creating more changes such as nerve compression and/or cervical disc herniation.
These asymmetries in postural alignment and tension patterns often translate both proximally and distally, creating imbalances down the whole arm and into the head and neck, further tractioning and disrupting the normal positioning and function of the nerves, blood supply, and lymphatic system.
Conclusion
As an occupational therapist, certified hand therapist, and structural integrator, I am aware of the gap in paradigms associated with the treatment of UE injuries between traditional therapists, physicians, and bodywork disciplines. I know firsthand that clients with UE dysfunction and pain achieve lasting health and healing at the hands of a practitioner who treats them holistically, with the organ of fascia being the primary intervention.
My hope is that structural integrators, occupational therapists, physical therapists, and physicians will continue to collaborate, bringing knowledge about the organ of structure—fascia—into mainstream medicine. As we all find deep satisfaction in helping our clients find long-term healing, I look forward to the fascial community working towards integration of these concepts, sharing the knowledge of our backgrounds as often and directly as possible. If the allopathic community, at all levels, could begin to understand the role of fascia in the body, clients experiencing pain and dysfunction would be treated more quickly, effectively, and with the best possible outcomes.
Resources
Alexander Technique (www.alexandertechnique.com) Aston-Patterning® (www.astonkinetics.com) Continuum (www.continuummovement.com) Feldenkrais Method® (www.feldenkrais.com) Gyrotonic® (www.gyrotonic.com)
References
Bajelis, D. F., & Duben, I. (2012). Myofascial length testing: Practical assessment tools for the myofascial therapist. [Ebook.] Retrieved from www.structuralmedicine.com/ store.html
Bass, E. (2012). Tendinopathy: Why the difference between tendinitis and tendinosis matters. International Journal of Therapeutic Massage & Bodywork, 5(1), 14–17. PMCID: PMC3312643.
Ericson, Jr., W. B. (2004, September). Median nerve entrapment in the forearm: Diagnosis and treatment. Poster presented at the American Society of Surgery of the Hand 59th Annual Meeting, New York, NY. Retrieved from www.wbericson.org/downloads.html
Ericson, Jr., W. B. (2010, May). Dual oblique skin incisions for proximal median nerve entrapment. Poster presented at the 23rd Scandinavian Hand Society Meeting, Visby, Sweden. Retrieved from www.ericsonhand.com
Khan, K.M., Cook, J.L., Kannus, P., Maffulli, N., & Bonar, S.F. (2002). Time to abandon the “tendinitis” myth. British Medical Journal, 324(7338), 626–627. PMCID: PMC1122566.
Levin, S. M., & Martin, D.C. (2012). Biotensegrity: The mechanics of fascia. In R. Schleip, T. W. Findley, L. Chaitow, & P. A. Huijung, Fascia: The tensional network of the human body (pp. 137-142). Edinburgh: Elsevier.
Myers, T. W. (2009). Anatomy trains: Myofascial meridians for manual and movement therapists (2nd ed.). Edinburgh: Elsevier.
Scifers, J. R. (2004). The truth about PNF techniques. Advance for Physical Therapy and Rehab Medicine, 15(26), 40.
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