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Dr. Andrew Gutierrez' Corner #3 - All About the Neck and Upper Extremity

This issue is brought to you by Dr. Andrew Gutierrez, DC., CCSP

Upper extremity conditions are commonly seen in our office. Sometimes they are neck related, sometimes they are not. I wanted to go over some common upper extremity conditions that we often see, and discuss it's anatomy, causes, presentation, diagnosis and treatments.  


Quick Summary:

  • The upper extremity includes the shoulder, arm, elbow, forearm, wrist and hand.
  • All movement and feeling in the upper extremity is controlled by nerves that arise in the neck.
  • Nerves can be affected/entrapped/pinched as they come out of the cervical spine or outside of the spine.
  • "Pinched" nerves can cause pain, numbness, tingling, burning, or weakness.
  • Most upper extremity conditions can be treated by chiropractic and physiotherapy

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CAUSES OF UPPER EXTREMITY NUMBNESS

The sensation of numbness and/or tingling in the arms or hands has numerous causes and can often be difficult to decipher. It can be a sign of a life threatening condition such as a stroke or heart attack. It can also be a symptom or complication of serious health problems such as diabetes, neurological conditions such as multiple sclerosis, or a side effect of chemotherapy. The most common causes are musculoskeletal in nature, due to a pinched or irritated nerve(s) in conditions such as: carpal tunnel syndrome, cubital tunnel syndrome, thoracic outlet syndrome, “burner” syndrome and cervical disc injury. 

 

UPPER EXTREMITY NERVE ANATOMY

To understand the different musculoskeletal causes of upper extremity numbness, it is essential to be familiar with the brachial plexus. The brachial plexus is a group of nerves that control the muscles of the shoulder, arm, forearm, and hand. These same nerves also provide sensations of the whole upper limb. The brachial plexus nerves begin as “roots” off of the spinal cord and exit the spinal column between the vertebrae. These roots are labeled C5, C6, C7, C8 for the cervical vertebrae and T1 for the first thoracic vertebra. These nerve roots supply the multiple peripheral nerves of the upper limb, but the main two for our purposes here are the median and ulnar nerves. 

 

CARPAL TUNNEL SYNDROME

There is a space in the wrist called the carpal tunnel where the median nerve and nine tendons pass from the forearm into the hand. Carpal tunnel syndrome occurs when narrowing and/or swelling in this tunnel puts pressure on the nerve. The numbness or tingling most often takes place in the thumb, index, middle and ring fingers. The symptoms usually are felt during the night but may also be noticed during daily activities such as driving or reading a newspaper. In bad cases, sensation and strength may be permanently lost. This condition is not very common in athletes but is much more prevalent in the workplace, usually due to repetitive hand motions (i.e. typing, grasping, hammering, etc.); however; it does occasionally appear amongst cyclists, golfers and racquet sports. 


CUBITAL TUNNEL SYNDROME

Cubital Tunnel Syndrome is a condition that involves pressure or stretching of the ulnar nerve, which can cause numbness or tingling in the ring and small fingers, pain in the forearm, and/or weakness in the hand. The ulnar nerve runs in a groove on the inner side of the elbow often referred to as “the funny bone”. These symptoms are often felt when the elbow is bent for a long period of time causing a stretch on the nerve, such as while holding a phone or while sleeping. Other causes are direct pressure (like leaning the arm on an arm rest), or repeated snapping of the nerve over a bony bump in the elbow which irritates the nerve. Cubital tunnel syndrome is usually seen in throwing athletes and results from either acute trauma or repetitive activities, such as baseball players (particularly pitchers) and javelin throwers. 

 

THORACIC OUTLET SYNDROME

Thoracic outlet syndrome (TOS) is a group of disorders that occur when blood vessels or nerves in the space between your collarbone and your first rib (thoracic outlet) are compressed. This can cause pain in your shoulders and neck and numbness in your fingers. Common causes of thoracic outlet syndrome include physical trauma from a car accident, repetitive injuries from job- or sports-related activities, certain anatomical defects (such as having an extra rib), poor posture and pregnancy. Basketball players and other athletes performing repetitive overhead arm movements such as swimmers, tennis, baseball, softball and volleyball players are at increased risk for this condition. 

TOS can be difficult to diagnose because it can present similar to other conditions. It is often diagnosed by ruling out other more common conditions and can be difficult to decipher the exact cause. 

 

BURNER (STINGER) SYNDROME

A “burner” or “stinger” is an injury to the brachial plexus that results in paralysis and paresthesia (loss of sensation) of the entire arm. “Stingers” are well known and common in the sport of football but are rarely seen in any other sport. It is common to have a football player run off the field with his/her arm hanging limply to the side during a practice and/or game. Although frightening for the athlete, the transient paralysis and paresthesia usually resolves quickly within minutes. However, more serious stingers can result in damage to the nerve itself with neurological deficits lasting up to one year. These types of injuries are graded from 1 to 3 based on the severity of damage that occurs to the nerve. Although stingers have several mechanisms of injury, the most common is when the brachial plexus is stretched due to the head being forced to one side while the opposite shoulder is depressed. They can also be caused by a direct blow to the side of the neck/shoulder or injured when the neck is extended while the shoulder is arm is moved up and to the side of the body. During this type of positioning of the head and shoulder, the brachial plexus can be compressed between the clavicle and first rib. 

 

CERVICAL DISC INJURY

Cervical disc injury, also referred to as bulging, ruptured, slipped, herniated or displaced disc, is a common disorder of the spine. A herniated disc occurs when part or all of its protective outer layer tears and some of the inner gelatinous material leaks into the tear. A herniated disc typically causes the most pain when the nucleus pulposus (gelatinous material), which contains inflammatory proteins, leaks out of the disc and onto a nearby spinal nerve root. Less commonly, a herniated disc may leak onto the spinal cord. The pain can range from an aching in the neck, arm, and/or hand to electric-like pain that radiates into these same areas. Arm or hand numbness and weakness may also be present and are typically felt in one arm or the other. While a cervical herniated disc may originate from some sort of trauma or neck injury, the symptoms often start spontaneously (most likely a result of chronic bad posture or repetitive stress syndromes). These injuries are most prevalent in contact sports but are common in sports where there is a high risk of falling on the head. High risk sports include: football, wrestling, gymnastics, rugby, hockey, snow sports, cycling and equestrian. In our office we see these injuries both from sport injuries and as a result of trauma from auto accidents.

 

DIAGNOSIS AND TREATMENT

The conditions above can be quite debilitating and are often difficult to distinguish between one another. A thorough examination and history can narrow down the cause of upper extremity numbness/tingling or pain and help to pin down a likely diagnosis. 

Diagnostic testing such as Magnetic Resonance Imaging (MRI), Nerve Conduction Velocity (NCV) or Electromyography (EMG) studies can be done, but this test are both expensive and can be invasive, and are generally reserved for patients with severe  symptoms or for patients who have failed previous conservative care.  
 

CAN WE HELP?

Yes. Most of this conditions unless they are far advanced can and should be treated conservatively first.  We see most of this conditions in our office with a high rate of success. Treatment for this conditions include the following modalities:

  • Chiropractic manipulative therapy
  • Myofascial release
  • Class IV laser therapy
  • Corrective exercises and stretching
  • Postural training 
 

Check back next month for more information from the world of sports medicine.

If you have any questions or would like to set an appointment please don't hesitate to contact the office at 310-993-8482.

Dr. Andrew Gutierrez, DC CCSP

Santa Monica Chiropractor

Bay Chiropractic & Rehabilitation

310-993-8284

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