Neural Tension (Nerve Entrapment) Physio for Rock Climbing
Neural tension, or nerve entrapment as its sometimes referred to occurs when the stretch capacity of nervous tissue within the body is limited. Lack of nerve mobility can be caused by compression from tight, swollen, or scarred surrounding tissues. When a nerve becomes entrapped it can no longer move smoothly through surrounding tissue. The resulting pressure and tension on the nerve can cause a variety of symptoms including numbness, tingling, burning, and pain. It’s important to recognize the signs and symptoms of nerve entrapment because it often misdiagnosed as other common climbing injuries such as lateral and medial epicondylitis (tennis and climber’s elbow).
What is the anatomy of Nerve Entrapment?
There are three main nerve branches that can become entrapped and cause issues for climbers. These nerve branches are the ulnar, radial, and median nerve. All three of these nerves have a common origin at the spinal cord and branch off into three separate nerves at the brachial plexus (a network of nerves at the shoulder). After branching into the three distinct nerve fibers at the brachial plexus, they move through different areas of the arm and innervate different muscles all the way down to your fingers.
What is the Median Nerve?
The Median nerve originates from both the cervical and thoracic spine at the levels of the C6, C7, C8, and T1 vertebra. From the spinal cord it travels through the brachial plexus and descends down the inner part of your arm, just beside the brachial artery. In the arm the median nerve will pass through a structure known as the antecubital fossa and then between the deep and superficial heads of the pronator teres muscle. The nerve will travel down the middle of the forearm and innervate the thumb, index, middle, and half of the ring finger.
The median nerve can potentially become entrapped at four locations around the elbow:
1. The distal humerus by the ligament of Struthers
2. The proximal part of the elbow by a thickened connective tissue surrounding the biceps
3. The elbow joint between the superficial and deep heads of the pronator teres muscle
4. The proximal forearm by a thickened edge of the flexor digitorum superficialis muscle
What is the Radial Nerve?
The radial nerve also has roots from the cervical and thoracic spine, C6, C7, C8 and T1. It travels down the backside of the humerus or upper arm before moving to the anterior or front aspect of the outside of the elbow. The radial nerve splits through the supinator muscle between the deep and superficial heads then runs to the backside of the hand where it innervates the back of the thumb, index finger, and middle finger.
The radial nerve has five main sites of entrapment:
1. The head of the radius bone by fibrous bands between the brachioradialis muscle and joint capsule
2. Just beyond the radial head by the leash of Henry (a fanning network of radial vessels).
3. The tendinous edge of the extensor carpi radialis brevis muscle,
4. The arcade of Frohse (a fibrous band at the most superior part of the superficial layer of the supinator muscle)
5. The distal aspect of the supinator muscle.
What is the Ulnar Nerve?
The ulnar nerve only has branches from C8 and T1. It runs down the medial or inside of the humerus until it enters the posterior aspect as it nears the elbow. The ulnar nerve passes posterior to the medial epicondyle of the humerus in the cubital tunnel (a narrow space beneath the medial epicondyle of the elbow). The nerve exits the cubital tunnel to enter the medial part of the forearm and runs down into the hand to innervate part of the ring finger and pinky finger.
The main site of ulnar nerve entrapment is the cubital fossa at the side of the elbow. When we bend our elbow fully, for example when performing a high lock-off of holding the top portion of a pull-up) the pressure within this cubital tunnel increases and causes compression of the ulnar nerve.
What are symptoms of Neural Entrapment?
Symptoms of neural entrapment can be difficult to diagnose because of varying presentations and location of the symptoms. Neural entrapment often initially presents with mild tingling or decreased sensation but can become more advanced with symptoms of burning, numbness, tingling, and a constant dull ache. Symptoms can often be position-dependent, meaning they may come and go quickly based on the position of your arms, shoulders, and neck. Symptoms may present in the upper arm, but they most often occur at the elbow, wrist, or hand.
Symptoms of Ulnar Nerve Entrapment occur at the inner aspect of the elbow, on the inside of your wrist, or to your ring and pinky fingers.
The radial nerve may cause symptoms on the outside of your elbow and can travel down the outside of your forearm to your wrist and into your thumb and possibly the back side of your hand and index finger.
The median nerve may present with symptoms on the inside and anterior / front part of your elbow and forearm. It may travel down the forearm and go into your palm and fingers.
The exact location of symptoms will vary between individuals because everyone’s anatomy and nerve distribution is slightly different. Symptoms may occur in one spot, or a combination of the locations listed above.
How do physiotherapists treat neural tension?
The primary focus for treatment of neural tension is to focus on nerve mobility. This is done through techniques known as nerve gliding and nerve tensioning.
Nerve Gliding:
Nerve Gliding involves gliding the nerve through its pathway to help reduce any possible adhesions, sites of entrapment. This is also referred to as “nerve flossing.” With nerve gliding, you pull one end of the nerve while relaxing the other, and then vice versa. Nerve gliding smooths out internal surfaces, breaking up any scar tissue or sites of entrapment. The more you perform nerve glides, the smoother the nerves pathway becomes and the fewer symptoms you should experience. Nerve glides are a non-aggressive form of treatment. You may feel a stretch or some tension while performing them, but you should not have any numbness or tingling – if this occurs, back-off and perform the movements through a smaller range of motion.
Median Nerve Glide:
1. Raise your arm out to the side with your elbow straight until it is parallel to the ground (90 degrees of abduction)
2. Rotate your arm until your palm is up
3. Depress your shoulder down (opposite of shrugging), while keeping your chest/torso upright
4. Extend your wrist, point your fingers behind you while simultaneously bring your head towards the same side (if you are moving your left arm, move the head to your left)
5. Bring your hand back to neutral while simultaneously moving your head away (towards the opposite arm).
6. Repeat 10 times
Radial Nerve Glide:
1. Rest your arm by your side with your elbow straight
2. Rotate your arm so that your palm faces backwards
3. Extend your arm about 10-15 degrees behind you
4. Reach your hand down towards the ground, while keeping your chest/torso upright
5. Flex your wrist, pointing your fingers behind you while simultaneously bring your head towards the same side (if you are moving your left arm, move the head to your left)
6. Bring your hand back to neutral while simultaneously moving your head away (towards the opposite arm).
7. Repeat 10 reps
Ulnar Nerve Glide:
1. Raise your arm out to the side with your elbow straight until it is parallel to the ground (90 degrees of abduction)
2. Rotate your arm until your palm is down
3. Depress your shoulder down (opposite of shrugging), while keeping your chest/torso upright
4. Bend/flex your elbow, extend your wrist, and bring your head towards the same side (if you are moving your left arm, move the head to your left)
5. Reverse: Straight your elbow, relax your hand, and move your head away (towards the opposite arm).
6. Repeat 10 times
Nerve Tensioning:
Nerve tensioning is a slightly more aggressive form of treatment compared to nerve gliding which creates a tension or stretch of the nerve as you perform the exercise. Nerve tensioning is meant to aggressively mobilize your neural network and attempt to improve mobility while reducing adhesions. Since nerve tensioning is more aggressive, ensure that you are being cautious and working within a tolerable range to avoid irritating the nerve and increasing symptoms. Begin with only 4-6 repetitions of nerve tensioning exercises and hold the stretch for no more than 5 seconds. Performing nerve tensioners is similar to gliders, except you will move your head the opposite way (away from the side being mobilized) which will increase the tension at the nerve.
Median Nerve Tensioner:
1. Raise your arm out to the side with your elbow straight until it is parallel to the ground (90 degrees of abduction)
2. Rotate your arm until your palm is up
3. Depress your shoulder down (opposite of shrugging), while keeping your chest/torso upright
4. Extend your wrist, point your fingers behind you while simultaneously bring your head towards the opposite side (if you are moving your left arm, move the head to your right)
5. Bring your hand back to neutral while simultaneously moving your head to the other side
6. Repeat 4-6 times
Radial Nerve Tensioner:
Rest your arm by your side with your elbow straight
Rotate your arm so that your palm faces backwards
Extend your arm about 10-15 degrees behind you
Reach your hand down towards the ground, while keeping your chest/torso upright
Flex your wrist, pointing your fingers behind you while simultaneously bring your head towards the opposite side (if you are moving your left arm, move the head to your right)
Bring your hand back to neutral while simultaneously moving your head towards the arm in motion
Repeat 4-6 times
Ulnar Nerve Tensioner:
Raise your arm out to the side with your elbow straight until it is parallel to the ground (90 degrees of abduction)
Rotate your arm until your palm is down
Depress your shoulder down (opposite of shrugging), while keeping your chest/torso upright
Bend/flex your elbow, extend your wrist, and bring your head away from the arm you are performing the exercise with (if you are moving your left arm, move the head to your right)
Reverse: Straight your elbow, relax your hand, and move your head towards the moving arm
Repeat 4-6 times
Prognosis:
Most cases of nerve entrapment should improve fairly quickly with proper treatment, however, the time it takes to fully recover will vary from person to person. If your symptoms are mild, you can continue climbing and performing your normal exercise and activities, however if symptoms become more severe, it’s a good idea to take a break from climbing and seek advice form a physiotherapist until the issue resolves.
Differential Diagnoses:
As mentioned above, nerve entrapment is difficult to diagnose because the location, signs, and symptoms mimic those of other common musculoskeletal disorders that climbers experience such as lateral epicondylitis (tennis elbow), and medial epicondylitis (golfer’s/climber’s elbow).
Climbers elbow causes pain at the medial elbow and sometimes when the symptoms are bad it can be in the anterior forearm as it follows the muscles of the wrist and finger flexors. Similarly, median nerve entrapment causes pain at the inner elbow can cause symptoms down the front forearm.
Tennis elbow causes pain at the lateral elbow and when irritated can cause symptoms on the backside of your forearm. Radial nerve entrapment can cause similar symptoms at the exact same location.
Regardless of whether you have nerve entrapment or a tendinopathy such as lateral or medial epicondylitis, the first step to recovery will be an accurate diagnosis so that you can begin an appropriate treatment protocol to alleviate your symptoms. If you think you might be suffering from any one of the conditions it’s a good idea to book an appointment with a physiotherapist who can help get you on track to doing all the sports and activities you love, pain free.
Visit our Main Street physiotherapy clinic in Vancouver BC to learn more!
Original Article by Rachel Rubin-Sarganis
Photo by Yunus Polat