Arm pain is a very general term but, underlying many of the conditions of the upper extremity, is an irritated or frankly pinched nerve root in the neck; it's called a brachial neuralgia.
In its acute phase this is probably one of the most disabling conditions faced in the chiropractic clinic. The deep, penetrating ache is relentless and it is difficult to find a position which lessens it. It's often especially bad at night.
A characteristic finding is the so called shoulder abduction relief sign. Raising the limb above your head brings a measure of relief as it takes the stretch off the nerve. Conversely, carrying a bag of groceries will increase the traction on the tethered or irritated fibres, exacerbating the ache.
The definitive examination for a pinched nerve is called the upper limb tension test; see the video lower down showing you how to discover if you have a irritated root that is causing causing the ache.
Neck problems are a common reason why people visit their chiropractor. Typically it doesn't start from a single injury, though it may; a car accident or a fall from a horse, for example. Instead, the condition usually develops over time from the stress and strain of daily activities, which includes the traumas that almost everyone experiences.
Plus, there is much confusion and disagreement even amongst the experts.
This week we have a letter from a person with three months of severe arm pain whose neurologist told her that she had a thoracic outlet syndrome because raising her arm relieved the ache. Normally, that would increase the tingling and discomfort, but would relieve things in a tethered nerve; the so called shoulder abduction relief sign, is associated with a root impingement, and TOS patients get increased paresthesias, not relief, when raising their arms.
Sports injuries such as blows to the
head in boxing and diving into shallow water are a frequent cause of injuries to the cervical spine; and neck and shoulder trauma as in rugby and falls from horses are often the cause of an acromioclavicular joint syndrome. These whiplashes are often the underlying cause of arm pain.
Let's face it, getting up in the morning is dangerous. If we want to avoid all injuries, then it's better to stay snuggled up under the blankets; only, more people die in bed than those out enjoying a full life.
Grasping this neck anatomy is vital if you want to gain a real understanding of what's happening. The cervical spine is formed by seven vertebrae, to which we should add
the upper two or three thoracic bones, as they are often involved. The whole structure is stabilized by the facet joints, ligaments and muscles.
Through a small foramen the nerve root escapes on its way to the upper extremity.
Each vertebra is formed by a round block called the body, and a bony ring which surrounds and protects the spinal cord.
the cord travels from the skull down through the spine, it sends
out branches between the bones; they are called nerve roots. This is where much arm pain begins as these fibres follow a hazardous journey beginning in the brain and ending in the finger tips.
These roots form the nerves that go to the arms and hands, passing via a small bony tunnel; it's called an inter vertebral foramen.
As the nerve emerges from between the vertebrae via the foramen it may become irritated and or pinched by a slipped disc, swelling from the facets or arthritic changes within the canal. More commonly, it has now been proved that fixated joints release noxious chemicals that stimulate so called nociceptors, causing tingling and pain in the arm.
At the entrance to the foramen stand the joints of Luschka like guards protecting the nerve root from a slipped disc. Only sometimes they are turncoats, becoming arthritic after whiplash, and then sending pincer like projections into the canal.
For more information about the chiropractic subluxation and how they cause arthritis in joints, see here;
An intervertebral disc is made up of two parts. The centre, called the nucleus pulposis , is like egg white. It provides most of the ability to absorb shock. The nucleus is held in place by the annulus , a series of strong rings of cartilage. If the gel in the nucleus tears through the annular fibres, then you have a slipped disk which may pinch the nerve and cause arm pain.
There are two facet joints between each pair of vertebrae, one on each side of the spine. The alignment of the facet joints of the cervical spine allows freedom of movement as you bend and turn your neck. They are the most common cause of neck pain. Should a piece of the capsule become entrapped, then you have the classical stiff neck that we in chiropractic help on a daily basis. Bread and butter. If allowed to become chronic, then irritating chemicals may be released which inflame the nerve causing tingling or pain in the arm.
What is a brachial neuralgia?
The arm is innervated by nerves that emerge from the lower neck. Their function is two-fold: To bring information to the brain from the arm (such as pain, should your fingers be burnt by hot oil for example), and secondly to send information to the muscles of the arm, enabling you to rapidly move your hand away from the source of pain (the boiling oil!)
These nerves emerge from the neck via the tiny neural foramen seen in the picture above, travelling through the armpit, via the elbow and to the forearm and fingers.
Irritation of these nerves is what causes most of the painful conditions of the shoulder, elbow, wrist and fingers.
frank pinching of the nerve root in the neck is what we call a brachial
neuralgia. It may cause extreme arm pain, tingling, numbness and even
weakness of the muscles, most usually the triceps. Less severe arm pain,
and especially tingling may be caused by noxious chemicals released
within a fixated joint as the cartilage starts to degenerate.
Read more about immobilisation arthritis.
Joints of Luschka
Protecting the nerve root from a slipped disc is a small "uncinate process" that makes up the Joint of Luschka, aka an UncoVertebral Joint. After a whiplash type injury this joint becomes arthritic, particularly in people who click their own necks, and because it is immediately adjacent to the nerve root it may begin to irritate the nerve. This is major reason for cervical spine surgery. Prevention is the the key when it comes to the uncovertebral Joint Luschka.
the shoulder muscles, the capsule, the ligaments and fascia are supplied
by nerves from the neck, a chronic irritation of the nerve is usually
the underlying causes of many shoulder syndromes, such as
Frozen Shoulder Syndrome …(a capsular condition) - at this page you'll find some vital frozen shoulder exercises on You Tube.
... and a
Rotator Cuff Syndrome which is a muscular condition. The hinge joint between your collar bone
and the shoulder blade, the AcromioClavicular Joint, is central to normal shoulder function. For
more information about how chiropractic helps the muscles, joints and nerves, the shoulder anatomy, click here:
SHOULDER ANATOMY. If you are a woman, take your spouse with you and everybody will be more at ease. Your chiropractor may have to address a muscle deep in the armpit, right adjacent to your breast, making you both uncomfortable; sexual advances chiropractor are not common, but just to be safe, take hubby.
For more information about Rotator Cuff strengthening exercises, click here: ROTATOR CUFF STRENGTHENING.
Pain running down the arm is a serious condition. It's often EXTREMELY PAINFUL and is one of the conditions that will likely make your chiropractor running late.
Moving down the arm, should the nerve
supplying the extensor muscles of the wrist (they are found around the
elbow), then you become prone to tennis elbow, and golfer's elbow too. For more information about how chirorpractic helps these conditions, click here:
TENNIS ELBOW ...
Carpal tunnel syndrome
There is much anecdotal
evidence that carpal tunnel syndrome, but it remains to be
scientifically proved. Because it usually falls into the so-called
"double crush syndrome" we find CTS responds well to chiropractic. The
nerve may be irritated in the neck, and in the forearm and the wrist. Typically you have tingling in the
thumb, fore and middle fingers. CARPAL TUNNEL SYNDROME ... Read more …
Included in this Carpal Tunnel Syndrome page you will find a short questionaire that will enable you to measure just how bad your CTS is, and whether the Chiropractic treatment was effective or not in the treatment of your hand and often arm pain that accompanies CTS.
Note: CTS NEVER affects the pinkie.
A fairly common
condition is the irritation of the nerves causing arm pain by a
subluxated first rib in the neck. If it also affects the artery
supplying the arm, then it is called a
Thoracic Outlet Syndrome; the
classic sign is increased pain and tingling in the lower arm as you
raise your arm above your head, as in hanging the washing. Not to be
confused with a slipped disc in which case raising the arm reduces the
tingling in the arm.
ADSON'S TEST FOR TOS
The classic test for Thoracic Outlet Syndrome examines the effect that moving the head and first rib have on the artery running down the arm to the hand.
The "thoracic outlet" is made up of a space behind the clavicle (collarbone) and above the first rib which is shown but not labelled above. Through this space three important structures pass on their way to the arm.
Two of these structures, the brachial plexus and the subclavian artery, but not the vein, first escape from the chest cavity via a narrow triangle known as the "inter scalene triangle".
This triangle is bounded by the
Very occasionally an extra rib, CERVICAL RIBS may invade the so-called inter scalene triangle through which the artery and nerves to the arm must pass. Only about 1/ 1000 people have a cervical rib and in the vast majority they are too small to be clinically significant. But occasionally it may cause severe pain and tingling in arms and hands, especially when the arms are lifted as in holding the telephone to the ear, or hanging the washing.
See how a large cervical rib can cause pain and tingling in the arms and hands and even effect the artery. In this cervical rib casefile the patient had absolutely no palpable radial pulse in the forearm. Little wonder the arm ached with use.
Medicine likes to remove the offending rib surgically. A patient this week had the procedure some six months ago, and it made absolutely no difference to his arm pain, but I have seen no research showing how effective the surgery is.
Chiropractors adjust the subluxated rib, I think very
successfully, though once again I have no stats for you. Certainly it is
much simpler than the grisly operation which is done through the armpit. The anaesthetic itself is not without dangers...
For more information about Anaesthethic Alzheimers disease (memory loss after an anaesthetic) click here. ANAESTHETIC ALZHEIMERS ...
Chiropractic neck pain treatment
Your Chiropractor may use a variety of techniques to free up the tethered nerve root causing your arm pain. Most of them involve manipulations, what we call an adjustment. In the hands of an experienced practitioner it's a very safe procedure, only very, very occasionally causing serious problems. A lot safer than anti inflammatory drugs that kill thousands. Literally.
Treatment may also include stretching of the neck, treatment of the muscles of the neck and an array of physiotherapy devices.What is surprising is that even in the most degenerative neck, with huge arthritic spurs surrounding the nerve root, adjustment of the vertebrae above and below the arthritis relieves the arm pain.
Rotating the arm like a windmill sometimes helps a brachial neuralgia, but will aggravate a rotator cuff syndrome.
Sleeping with your hand under the head may relieve the pain of a pinched nerve in the neck.
Simple traction devices can be very useful in the treatment of a brachial neuralgia. Follow this link for an My mind's made up, so DON'T CONFUSE ME WITH THE FACTS!
A survey of a large number of studies concerning traction for arm pain came to the following conclusions:
BACKGROUND: Neck pain is a frequently reported complaint which can be disabling and costly to society. Mechanical traction is often used as an adjunct therapy in outpatient rehabilitation.
OBJECTIVES: To evaluate the effectiveness of traction for cervical spine conditions.
RESULTS: Of the seven selected trials, six clearly set out to prove what they already "knew to be true", or in research lingo only one of the randomised controlled trials had a low risk of bias. It found no statistically significant difference between continuous traction and placebo traction in reducing pain or improving function for chronic neck disorders with radicular symptoms.
I have used this traction device for home use of arm pain with great effect, as an adjunct to chiropractic treatment. However, there is no hard evidence that it is effective when used on its own, or as an adjunct to physiotherapy. There simply is only one good trial concerning traction used and it neither proved it effective, nor refuted its effectiveness in the treatment of arm pain.
If you have two right hands (Dutch proverb) you might like to make this home traction unit.
From the chiropractic coalface
Mr S, is a 43 year old Dutchman after my own heart. He's a motor cycling fanatatic. Only he has a problem. Two years ago he set off on a trip across Europe and within two hours had to return home: severe pain in the neck, radiating down the left arm. For over a year he was unable to ride his motor cycle. Literally. Within ten minute he would have severe neck and arm pain.
I won't pretend his case has been easy. His neck was technically difficult to adjust, but within six months of chiropractic treatment, with the aid of his home traction unit he was motor cycling again. Last night he had dinner with us, and took me for a ride on his new BMW 100, ah sublime. Next week he leaves on 10 day ride through the former Soviet republics. Estonia, Latvia... Chiropractic PLUS his home traction unit pictured above have enabled him to return to his favourite pasttime. Motor cycling. Mine too. Traction may not help on its own, but as an add-on to chiropractic, I highly recommend for radiating arm pain from the neck.
Update: Mr S had a very successful trip with minimal neck or arm pain.
Occasionally, this arm pain will not respond to conservative treatment. If the arm becomes weakened, and the nerve pain in the arm remains relentless, surgery may have to be considered.
It can be very successful, though it is a dangerous procedure with a relatively high rate of morbidity and complications. Sometimes there is no other option.
As you can see, when removing bony arthritic fragments and disc material from the foramen, the surgeon is working perilously close to the nerve.
Are you a musician and suffering from neck, shoulder and arm pain? From Learn Theory Music you can pick up some very useful tips about musicians health. Musicians' health ...
In the Quick Dash questionaire mentioned below there is a specfic questionaire for musicians.
Arm pain case histories
Arm pain case histories do not constitute scientific evidence of the
efficacy of any particular treatment, but they do give an inkling of
what can be achieved ...
ARM PAIN CASE HISTORIES ...
50 percent less pain
With all Chiropractic Conditions - what we treat on a daily basis …, medical conditions too, I presume, you want to be very careful when the pain is about half. That's the dangerous time, we often see setbacks, sometimes serious ones: 50 percent less pain ...
Another case history
Mr S, a physically fit and strong man, a builder by trade decided to go to the gym. After lifting weights he developed severe pain between the shoulderblades, and then his left arm started to tingle when he turned to the left or looked up.
Various treatments didn't help, finally after four months he decided to try chiropractic, after a personal friend, a medical trauma specialist surgeon said only surgery in the region of the first rib would relieve the pain.
On examination, there were several serious findings.
There is no doubt about it; had he consulted a neurologist first, he would have been under the knife within the week.
I made no promises; this is probably the most difficult condition facing the chiropractor. Deep upper back pain due to a pinched dorsal scapular nerve is problematic; add weakness, an ache and tingling in the arm and you have a great challenge on your hands.
Nevertheless, to be totally pessimistic also means that one is likely to have lost the battle before the first shot was fired. I was guardedly optimistic. There was also doubt about the diagnosis; was it a problem in the inter scalene triangle causing nerve and arterial pressure, or arthritic spurs invading the foramena, or both?
He consulted me this evening for the seventh visit. He has minimal pain, the strength has returned completely to the triceps muscles, but there remains some weakness of opposition in the hand. Range of motion of the neck is normal, with no radiation to the arm, but some discomfort between the shoulder blades in the rhomboid muscles, supplied by the dorsal scapular nerve. Spurlings and upper limb tension test test were both negative.
He feels 90 percent cured, and wanted to return to the gym, the original cause of the problem. Alas, no, was my reaction. And to be very careful with looking up.
All in all, we are both very pleased. The future? Neither of us are sure.
I'm not looking here for funny stories. That we'll find a place for elsewhere, and you can find an abundance of them in my books at Bernard-Preston.com. James Herriott genre books.
Here I'm looking for things that you particularly love / hate about a visit to the chiropractor. Share it! If we get too many, and we probably will, we'll split them.
Are there things you hate about a Chiropractic consultation? Let's hear about it. Hopefully even more stories about things you love.
You see, we Chiropractors can learn from your feedback, both positive and negative.
Click below to see contributions from other visitors to this page...
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