Carpal Tunnel

Syndrome, Ulnar
Nerve
Entrapment, &
Thoracic Outlet
Syndrome
By: Alyssa Garcia, SPTA
 Carpal Tunnel Syndrome
● The Carpal Tunnel is a small space in the wrist between the carpal
bones and the the transverse carpal ligament. Carpal Tunnel
syndrome is then caused by the compression of the median nerve
being compressed in the tunnel space.
● This can be due to inflammation, adhesion, or other compromising of
the contents in the tunnel

Symptoms: Pain, numbness, and/or tingling in the thumb, index and middle
fingers, lateral half of the ring finger, wrist, and palm of the hand.

Symptoms may worsen with movement or by sleeping with a flexed wrist

position.
Causes

Causes: Median nerve entrapment is caused by reduced space in the carpal

tunnel
● The reduced space can be attributed to bony ailments like dislocation,
abnormal bone growth, cysts, and tumors
● It can also be influenced by soft tissue changing size due to
inflammation, hypertonicity, fibrotic tissue build up, trigger points,
tendinopathy, scarring, sprains, and strains
● This can all happen from trauma, pathologies, and most commonly
overuse due to work occupation
Involved Structures of Carpal Tunnel Syndrome

Muscles: Flexor carpi radialis, Flexor digitorum superficialis, Flexor digitorum

profundus, Flexor pollicis brevis, Flexor pollicis longus, Palmaris longus,
Pronator teres, Pronator quadratus, Opponens pollicis, Abductor pollicis brevis,
and 1st and 2nd lumbricals of hand
Nerves: Median nerve which arises from the brachial plexus ( C5-T1)
Ligaments: Transverse Carpal Ligament
Massage Protocol
1. Static contact and superficial stroking for acclimation and relaxation as well as warming
and desensitizing of the area. We will be working with the arm from the shoulder down
focusing on the forearm and hand. ~1 Min
2. Skin rolling at the wrist by the tendons of flexor carpi radialis, palmaris longus, and flexor
digitorum superficialis, upward toward the elbow ending by the medial epicondyle which
detects fascia distortions. When distortions are detected apply myofascial release which
treats the distortions. ~3 mins
3. Trigger Point Protocol Set up: Find trigger points along the length of the flexors, Palmaris
longus, pronator teres, pronator quadratus. Begin effleurage to increase circulation and
move fluids, follow with petrissage, in this case kneading with the thumbs/knuckles to
soften tissues and increase pliability, then stripping and strumming which realign and
separate fibers making them soften up~ 3 mins
Massage Protocol cont.
4. Trigger point protocol treatment: apply specific compression on found trigger points which
relieves the points, deactivates muscle, and increases circulation. Note that you don't want to
hit above 3-4 on pain scale or the muscle will tighten up. Follow up with stripping and
strumming, and then petrissage with the thumbs. Repeat 3-4 times. ~5 mins
5. Trigger point protocol closing out: Effleurage, petrissage, stripping and strumming, then follow
with a light stretch of the flexors. ~2 mins
6. Ice massage on the transverse carpal ligament, the opponens pollicis, flexor pollicis brevis,
and 1st and 2nd lumbricals to reduce inflammation and in the carpal tunnel area and reduce
pain in the affected hand muscles allowing for more specific targeting. ~5 mins
7. Myofascial release on the thenar and hypothenar muscles moving medially and laterally away
from each other on the palm.~3 mins
Massage Protocol Conclusion
8. Stripping and strumming the Opponens pollicis, 1st and 2nd lumbricals. ~1 min

9. Petrissage on the aforementioned muscles. ~1 min

10. Effleurage beginning at the 1st and 2nd lumbricals working back up the forearm to the
medial epicondyle. ~1 min

11. Hot pack with at least 6 layers on the forearm avoiding the carpal tunnel area to increase
nerve conduction velocity and muscle ROM for the pronator teres, pronator quadratus, and the
flexors. ~15 mins

*It’s important to note not to apply direct hard pressure on the tunnel area and check in with
patient throughout process as this can actually irritate the carpal tunnel symptoms further*
Ulnar Nerve Entrapment (Cubital tunnel
syndrome) Causes:
● Excessive leaning.
A condition where ● Repeated bending. (Flexion)
● Fluid buildup in the elbow.
there is compressed ● Current or previous injury to the
neuropathy anywhere inside of the elbow. (Dislocation)
● Arthritis.
along the length of ● Swelling.
the ulnar nerve Symptoms:
typically at the cubital
● Pain, numbness or tingling in the
forearm and the fourth and fifth
tunnel of the elbow. fingers of the hand.
● Weakness and tenderness in the
hand and elbow.
● Loss of hand grip.
 Structures involved with Ulnar Nerve Entrapment
Muscles: Flexor carpi ulnaris, flexor digitorum profundus,
abductor digiti minimi, adductor pollicis and the triceps. It
also innervates the intrinsic muscles of the hand such as the
palmaris brevis, lumbricals, hypothenar and interosseous
muscles.
Ligaments: Osborne’s ligament. (This ligament encloses the
cubital tunnel of the elbow), Ulnar collateral ligament that
runs on the inner side of the elbow.
Nerves: Ulnar nerve that is associated with the brachial
plexus and this is also the area typically called the “funny
bone”. (C8-T1)
 Massage protocol part 1

● Static contact [relax and acclimate] and Superficial stroking [relax and
desensitizes the area] -1 minute (working my way up from the hand at the 4th
and 5th fingers to the medial aspect of the forearm, medial triceps, and up to
the pec minor and major.)
● Apply heat pack [to increase nerve conduction velocity] to surrounding muscles
going up the arm -15 minutes.
● Skin roll along the medial portion of the arm to [detect fascia distortions]. -1
minute
● Perform myofascial release to any areas detected. - 2 minutes
 Massage protocol 2

● Locate trigger points going along the inner portion of the forearm and up. -2 minutes
● Effleurage [increases circulation and mobility] and Petrissage [improve circulation and
relieve knots] -2 minutes
● Stripping and strumming [to lengthen and reduce myofascial trigger points] -2 minutes
● Specific compression using thumb [relieves trigger points] -1 minute
● Stripping and strumming [to lengthen and reduce myofascial trigger points] -2 minutes
● Petrissage [improve circulation and relieve knots] -1 minutes
● Repeat this trigger point protocol [3-4 times]. - 5 minutes each
 To close out the massage

● Pin and stretch [to relieve scar tissue and bring muscle through full range of
motion] -2 minutes (Pec muscles and the extensors and flexors of the forearm)
● Apply a cold pack to the ulnar nerve entrapment at the cubital tunnel. -5 minutes
[produces sedative effect and relieves nerve pain as well as reduces any
inflammation]

*It is important not to keep the arm flexed as this will worsen the symptoms of the
entrapment.
 Thoracic Outlet Syndrome

● TOS is a group of disorders that occur when there is

compression, injury, or irritation to the nerves and/or
blood vessels (arteries and veins) in the lower neck and
upper chest area.

3 Types of TOS:

1. Neurogenic TOS- Abnormalities of the bony and soft

tissue in the lower neck region that compress and irritate
the nerves of the brachial plexus, complex of nerves that
supply motor and sensory function to the arm and hand.
2. Venous TOS- This condition is caused by damage to the
major veins in the lower neck and upper chest. It develops
suddenly, and often after unusual and tiring exercises of
the arm.
3. Arterial TOS- This is the least common but most serious
type, caused by congenital bony abnormalities in the
lower neck and upper chest.
 Symptoms and Causes

Symptoms:

●Neurogenic TOS: weakness or numbness of the hand, decreased size of hand muscles (occurs on one side of body), and pain, tingling, prickling,
numbness and weakness of the neck, chest, and arms.

●Venous TOS: swelling of the hands, fingers, and arm, as well as heaviness and weakness of the neck and arms. The veins in the anterior chest wall may
appear swollen.

●Arterial TOS: cold sensitivity in the hands and fingers; numbness, pain or sores of the fingers, and poor circulation to the arms, hands, and fingers.

Causes: The causes are typically not well understood, but it is known that when the blood vessels and/or nerves in the tight passageway of the thoracic
outlet are abnormally compressed.

TOS can be a result of an extra first rib or an old fracture of the clavicle that reduces the space for vessels and nerves.

Some things that may increase the risk of developing TOS is

●Sleep disorders
●Tumors or large lymph nodes in the upper chest or underarm area
●Stress or depression
●Participating in sports that involve repetitive arm or shoulder movement (baseball, swimming, volleyball)
●Repetitive injuries from carrying heavy shoulder loads
●Injury to neck or back (whiplash)
●Poor posture
●Weight lifting
Structures involved with Thoracic Outlet Syndrome
Muscles: The anterior and middle scalene and the subclavian, since they all insert on the first rib TOS
can cause narrowing of the muscles and compress them.

Nerves: The lower two nerve roots of the brachial plexus, C8 and T1, which then can cause pain to the
ulnar nerve.

Artery: Subclavian Artery, that runs alongside of the brachial plexus

 Massage Protocol

Apply heat pack to surrounding muscles of the brachial plexus; pec major and minor, upper trap, and SCM
to relax and open up the nerve. -15 minutes
Myofascial release (treat fascial distortions) starting at upper neck area just lateral to the transverse
processes of the cervical region, working your way down to the base of the neck - 1 minute ,2 times
Picking up/muscle squeezing (increase pliability) of the upper trap, holding the muscle and allowing the
tissue to soften/loosen between the fingers- 1 minute, 2 times
Myofascial release (treat fascial distortions) of the SCM, starting close to the mastoid process of temporal
bone and working my day down to the clavicle- 1 minute, 2 times
Myofascial release (treat fascial distortions) of the pectoralis major starting medial and working lateral- 1
minute, 2 times.
Picking up/muscle squeezing (increase pliability) of the pectoralis minor, holding the muscle and allowing
the tissue to loosen. Can also do slow arm circles while holding muscle to help stretch it - 1 minute, 2 times
Finish off with stretching, holding down shoulder of affected side and laterally flexing the neck to opposite
side, allowing muscles and nerves more flexibility - 30 seconds, 3 times.
In Carpal tunnel syndrome: Pain and numbness down the thumb, index, middle, and lateral half of the
ring finger.

In Ulnar nerve entrapment: Down the inner elbow, the ring finger and pinky finger is where most of the
pain and sensations occur.

In Thoracic outlet syndrome: Pain in shoulders and neck and numbness in fingers

They all stem from the brachial plexus and include entrapments that produce similar symptoms in
neighboring areas of the upper extremity.
 Common Massage Goals
To reduce inflammation and pain, relieve trigger points as well as fascia
distortions, return ROM, strengthen muscles, and help relieve nerve
entrapment.