Causes of Hand and Arm Numbness Beyond Carpal Tunnel

This is session number 59 of the Performance Place Sports Care podcast. In the words of Albert Einstein, insanity is doing the same thing over and over again and expecting different results. Welcome to the Performance Place Sports Care podcast, where you can learn about sports injury theory, rehab, diagnosis, and how to understand the doctor lingo you didn't understand at your appointment. And now, your host, Dr. Sebastian Gonzales. Hey, everybody. It's Dr. Sebastian Gonzales again with the Performance Place Sports Care podcast. I thought the Einstein quote, actually, I thought it was somebody else, honestly. That insanity quote, I've been saying it for years. I actually use it a lot of times in my first encounter with patients at my office because a lot of times you have to really figure out if they're willing to change and look at things from the outside. And a lot of times people, me included, when I have a condition, I'm too close to the condition.

I'm too close to the injury to really logically think about what are the missing parts. And I always ask them, like, you know, what if you tried? Is that working? Has it helped at all? Like, and if so, I think we need to change things up a little bit. And I ask them directly, what is the definition of insanity? And a lot of them will know this quote. So that's kind of where I start with a lot of people. So today's session here, we're actually going to have a guest on. His name is Dr. Matt Fontaine. And we're going to be talking about some things that are common with, I'm sure you probably know one or two people with this if you don't have it yourself.

Causes of arm hand numbness. And we're going to target it more towards an athletic population, although it can happen with anybody. And we're actually going to go through some suggestions and things that we've found that have worked at the office. So Dr. Matt Fontaine is going to be going through the different types of things that will create this. And the important takeaway with this is that there's a lot of things that can create arm and hand numbness. And there's, depending upon what the actual thing is, means that you pick the appropriate correction. So some of the stuff that he's going to drop, those little bits of knowledge in regards to like, I don't want to say DIY, but stuff that technically you guys could do, which you shouldn't do because you haven't been examined yet.

Those things would be only for certain types of cases. But I'll see if I can get him to do some videos correlated to this. And if so, I'll drop it on the show notes. So just a little bit about Dr. Fontaine before he comes on. He's been practicing for about 17 years. He's in North Virginia area. His practice is called Potomac Physical Medicine. But he mainly specializes in working with athletes. So he works on muscle, joint pain. He utilizes deep tissue work, such as active release, sports chiropractic, which actually can use, uses a lot of different modalities, corrective exercise, and things of that nature.

But he actually does have, he does work on a spring training baseball team. Sorry, I'm losing my mind right now. So it's the Alexander Aces. That's a collegiate Cal Ripken League team. He's actually a contributing author for Triathlete Magazine, as well as the American Chiropractic Association and StrengthCoach.com. So these are things that are kind of hard to write on, at least getting your name and information in there. So he has some really, really good stuff to share. And he is active within triathlete communities, within baseball players, and CrossFit communities. And he's actually a volunteer firefighter, too, an EMT. So he's an interesting guy. Interesting guy.

So without further ado, let's talk to Dr. Fontaine about hand and arm numbness and what we can do about it. All right, everybody, this is Dr. Matt Fontaine. So everyone say hi. And Matt, say hi. How you doing, guys? Good to be on. I'll answer for them. Excellent. We're doing well. So you're going to talk to us about hand-arm numbness. Sound good? Outstanding. Okay. Tell us a little bit about yourself and, like, how you know so much about hand-arm numbness. Well, like you, I'm a sports chiropractor. I've been doing it for a little around 17 years now. I'd say the last 12 or so as an active release provider.

So I practice in northern Virginia. I had a practice in Florida for about 10 years. And, you know, basically over that time period, I've had the opportunity to work with a lot of athletes. And you just tend to see a lot of different things come in. And nerve-related entrapments are very, very common. We'll definitely get into that in a little bit. And so, you know, as an ART provider, as I'm sure you know, we do get a lot of specialized training on how to detect what's causing these issues and, more importantly, like how to address them. So that's kind of, you know, a high level. I've been doing this a while.

I had the opportunity to work with two major league baseball teams back, you know, in the latter part of the 2000s. And I've done a lot with Ironman. I've worked in the active release Ironman provider team at several Ironman events. So working with the triathlete and endurance athlete, you just tend to see a lot of different things from upper and lower extremity, spine, and a lot of nerve entrapments. I know we're going to talk mostly upper extremity, but you do see them in the lower extremity as well. And, you know, the symptoms can be pretty clandestine unless you know kind of where to look.

Well, do most people, when they get something like this, do they, I mean, are they, do they understand that it's a nerve-related issue or do they think it's more of like, let's just say we're talking about the hand, do they believe it's a hand muscle or structure issue down there? Do they have any comprehension of it typically? I think you would agree it really depends on the person. But generally speaking, I think people tend to put things into one of a few categories. You know, do I have a pinched nerve in my neck? I think inherently people kind of know if they're having paresthesias, you know, burning, itching, numbness, tingling, they kind of know, hey, my, you know, my hand feels like it's going to sleep.

And a lot of patients will kind of gravitate towards, you know, it feels like it's a nerve issue. And I think that's about as far as it goes. Certainly there's people that come in and think it's maybe a structural issue. And a lot of times there is structural problems with the wrist or the forearm, elbow, even up into the shoulder and neck. And I think a lot of people just kind of work through it. They probably haven't seen anybody for it. Sometimes yes, sometimes no. But we tend to see a lot of people in clinic where they haven't really seen anybody successfully for it, don't really know what's causing it.

And then we end up doing an evaluation. And if you can isolate where the nerve's entrapped, you know, that's 90% of your battle right there. And then apply the appropriate treatment, we tend to have pretty good success. So I think it's a syndrome that really keeps people, you know, I just don't think that they have a lot of answers for it. And a lot of people, I think, just feel like they have to live with it. And they try to work through it. But I think it perplexes a lot of people. And I just don't think there's a lot of really good answers out there for a lot of people until they get to see the right provider.

Yeah, I totally agree. I actually had a patient before that he had. He was someone who played on one of my teams, actually. And he came in, I want to say like two, three times. Like he had some type of numbness into the hand. It was in the ring in the pinky finger. And he just kind of disappeared off the map. I didn't talk to him about a year. And he popped back into the office one day. And his hand was just eaten away. And I'm like, what the hell happened to your hand, you know? And he's like, well, it's been numb for a while. I'm like, dude, no shit. Like we talked about this. But that's the kind of thing I feel like that I don't think people realize if you let this go on, it can create that type of thing, you know?

Yeah, I mean, I think, you know, that's, and I think you'd agree, right? That's kind of a fairly progressive. At that point, you've got enough compression of the nerve that it's affecting the motor portion. You're starting to get atrophy in the hand. So, you know, we can talk about where that typically occurs. But I think, you know, the issue is that a lot of people, they just kind of ignore it for quite a bit of time until it becomes, you know, progressive to that point. So, you know, the other thing, too, is I think a lot of people have really heard of carpal tunnel, and they tend to want to throw their syndrome into these few kind of buzzword umbrella terms, you know, thoracic outlet, carpal tunnel.

I mean, it's been written about enough, and a lot of primary care doctors diagnose people just kind of pandemically with it. And even, you know, orthopedic and neurologists, you know, that's a very common diagnosis. It's not very specific, though. And I would say that true carpal tunnel is pretty rare, I think, in 17 years. I mean, I can think probably on two hands the amount of cases I've had where they really had true carpal entrapment of the median nerve where they required a surgical release to, you know, decompress the nerve. Atrophy, you know, it does happen, but I don't think it's by far the most common thing we see.

I think we see a lot of smaller sensory neuropathies where maybe the motor component has not taken place yet. They don't have true weakness. They don't notice that they have weakness in their grip or fine finger movements. And, you know, I tend to see that a lot more with disc patients in the neck, you know, just because of the nature of if you have a disc herniation, it tends to, you know, either create enough inflammation around the nerve or direct compression. And, you know, those tend to be a little bit more severe cases. But the peripheral nerve entrapments, I think a lot of what we're seeing are sensory neuropathies where they've got, you know, numbness, tingling.

A lot of times the symptoms are worse at night. And I always tell patients one of the big reasons for that is because part of your natural physiology, the blood pressure slows down at night. Your body's trying to kind of shut the engines down and rest and recover. And so if you have an area where there's, you know, a lot of tightness and you're not getting good blood flow, blood pressure naturally dropping is going to make that worse. And so those symptoms tend to be more dramatic at night for a lot of these people. Interesting. I actually never knew, like, I know with disc injury people, like, we say that the fluid increases in the disc, it inflates a little bit.

But I actually never knew why, like, people, like, you know, they have, like, cramps in their foot at night and things of that nature. I had no idea. So with... Yeah, I mean, it makes sense from a basic science standpoint, you know. I mean, we can get into soft tissue stuff. But, you know, basically an area that's tight, it's just not getting good blood flow because the tightness in the muscle, it actually creates a somewhat of a tourniquet effect. And so, you know, the nerves have their own blood supply, and these nerves are, you know, blood vessels are extremely, extremely small, right? They're called, like, the vasovasorum and very small capillary beds that basically provide blood flow to the nervous tissue.

And it's very easy for those small blood vessels to become compressed. So now you're getting decreased blood flow to the nerve. It's pretty easy to get these peripheral nerve entrapments in areas the nerves are traveling through, and you're having, you know, compression against the nerve or there's friction. Nerves are very, very sensitive. So you don't even need to have direct compression. You can have, you know, some stretch or some friction, and the next thing you know, you have symptoms. And so, you know, at night, that blood pressure drops down, and things are kind of shutting down. And so those symptoms tend to be a little bit more dramatic, not to say that they can't happen during the day, because they certainly do.

But I find oftentimes you'll ask people, and they'll just come out and tell you, you know, hey, my hands go numb at night. So it's fairly common that we see. Okay. So you talked about compression of a nerve, and it doesn't take much. I know that I've had a lot of patients ask before, like, this, it just started bothering me yesterday. I woke up with this. Or, you know, like, they're kind of searching for some type of reason why it started today, and they didn't do anything. Nothing happened to them, and so on. Is there some type of compressive, like, threshold that a nerve would have? Well, what I always try to tell people is that you've got to respect the process, not the event, right?

I mean, I think if you take out the acute sports setting injury, you know, the torn ligament, ruptured tendon, et cetera, broken bone, the majority of the things that we see in the office are chronic, repetitive motion, postural syndromes. They happen kind of insidiously over time. I tell patients I might, you know, typically the patient who goes to the hospital with an acute heart attack, there were things going on for a long time before that happened, and the next thing you know, you just kind of cross thresholds. So very often you'll see that, you know, when you examine these patients, you're going to find areas of restricted tissue and scar tissue, and unfortunately the syndromes can't come on abruptly, and so it's very misleading to the patient.

They figure, I didn't do anything different. I'm doing my same training regimen, and oftentimes it's hard to get them to connect the fact that it's a simple math equation where, you know, the injury builds up over time. You know, in ART they always talk about the injury equation, you know, and it's number and force of repetitions over time, and so, you know, poor posture, you know, 100 miles a week on the bike, you know, you're working out lifting, doing CrossFit, and tissues can get repetitively tightened down over time, and eventually all tissues will fail at a certain threshold. So, you know, if you mechanically overload a tissue, you're going to get breakdown of the tissue and wear and tear.

And so these repetitive motion injuries, that wear and tear is occurring on a very micro scale over a long period of time, as opposed to the acute sports setting where there's a definite event, I get injured. And so the thing that they also fail to realize is that as the tissues are getting tighter and they're getting more restricted mobility, the threshold of those tissues goes down. Meaning the tissue is tight, it's less flexible, it's hypoxic, meaning there's not good blood flow to certain areas of that muscle, and that lends the tissue to be much more vulnerable to injury. So its threshold actually drops, you know.

So the runner who's used to doing X miles a week, all of a sudden now 5K becomes really traumatic. And it's because as the tissues wear down, they're more vulnerable and they tend to break down at an accelerated rate. So it's one of the hardest things we deal with, I think, right? Patients come in, there's that disconnect, I don't know what I did, and now we're trying to kind of, you know, we're behind the power curve, but we're trying to tell them, here's what happened, it happened over time. And I think, I don't know, I think just inherently people tend to, you know, with other things like diabetes, I mean, I think most people kind of realize, you know, if you get diagnosed with that, they realize that didn't just happen today.

And I think some of the other things that we just kind of take for granted, when it comes to soft tissue and joint injuries, people want to kind of hang their hat on a specific event. And for the most part, that's just not the case. Yeah. There was, I did a whole podcast section actually on, I had someone that had come in and I think he had a knee injury, I forget. But either way, like I asked him, like, you know, when did the injury happen? He said, I'm not injured. And I'm like, why are you here? You know? And, or why am I examining you in the first place? But yeah, they don't, they don't equate the word.

You did say that, so the amount of volume, you said cycling, you said lifting, crossfitting, all these things. Does the repetition, is it dependent upon load or how hard the person is, you know, hammering or so on? Or can it be small movements? Because I think there's a lot of people that, you know, like you're, like you have your, your, your desk workers. Can they still develop these types of things regardless of they're not exercising? Absolutely. I mean, I think, you know, the thing that I always try to get through to my patients is that, you know, when you look at elite athletes, they get the same injuries the rest of us do.

The difference is they're extremely adaptable. That's why they're elite athletes. Genetics are on their side, et cetera. They, they can compensate. The body is an adaptive machine. It'll continue to compensate movement patterns and try to move in certain ways that don't stress tissues that are injured. Pain can come and go. You learn new movement patterns and they do an exceptional job of being able to hide that. When they break down, they tend to break down on a much more dramatic note. You know, the athlete who's out for the season with a torn ACL, et cetera. But if you're sitting at a computer for eight, 10 hours a day, I think everybody kind of understands that computer posture is not ideal.

There's a lot of stress on the neck, on the muscles, the shoulder girdle. And so those slow kind of, you know, insidious postural strains on the muscle add up over time, eight hours a day, five days a week, months, you know, et cetera. And so all those things can, can contribute to that. And then of course, you know, the computer worker is usually working out, you know, however many days a week, cycling, running, swimming, lifting weights in the gym, and all of those things are cumulative. So it's really unfair to blame an exercise or to blame a sport. We really have to look at the process and say, Hey, you know, I'm spending 40, 50 hours a week on the computer.

I'm sitting in a car driving to work. And on top of that, I'm going to the gym, I'm lifting weights, and it's all cumulative over time. So two of the biggest things that can, can create load on the system is, you know, posture and movement. Do you have good posture? Do you have good movement? Then you're probably going to be able to tolerate your particular sport much longer before a breakdown occurs. There's other things at play that a lot of people have that tip the scale in favor of injury, meaning if you have soft tissue, tightness, you know, adhesion in the muscle, if you have any kind of degenerative arthritis in a joint, and any kind of joint dysfunction, those things can weaken the system, which sets you up for a higher likelihood of injury.

And I think that's kind of where most people kind of fall into. I would say 95% of people we see tend to have poor movement in one or more body regions, stiffness in one or more joints of the body, including the spine, hips, shoulders. And they try to take that less than optimally functioning system and go into the gym lifting weights, or they try to get out and pound the ground with running, cycling, swimming. And so that's really the biggest thing. And I think, you know, the buzz is out there. We know that, you know, correcting movement really helps to clear up a lot of these things. And, you know, I think just today, people are, you know, in healthcare, I think even strength and conditioning and athletic trainers are much more cognizant of looking for poor movement and trying to correct that.

And I think that we're doing a better job of being able to correct a lot of these muscle and joint pain syndromes that people have based on looking at movement rather than just trying to look at an isolated area in the body. So you said muscle and joint pain syndromes also, I'm guessing too, so the neurological stuff can also be an end result of moving poorly and repetitious load, you said, just to clarify for everybody. Yeah, I think one of the biggest things that's a take home, and it's pretty tried and true for most cases, is that there's usually a joint, muscle, and a nerve, right? You have some joints that are stuck and not moving, some joints that are maybe moving too much.

We need to stabilize those. Usually that comes in the form of some corrective exercise. And you have some muscle tissue that's stuck and glued down. It's tight. And then you have some other muscles that aren't working well enough. And again, we need some exercises to kind of get those muscles more active. And then, for the most part, the nerve is pretty much just along for the ride, you know? So it depends on where the nerve entrapment occurs, but I think it's important for people to understand that the nerves come out either of the neck or the lower back, and then they travel out. You have this bundle of wires, so to speak, that are traveling through the upper extremity, the arm, shoulder, hand, elbow, and down into the foot in the lower extremity.

And so, as these nerves kind of wind through the muscle, sometimes they travel in between muscles. Sometimes they actually pierce through a muscle. What a nerve entrapment really is, is if you imagine if we took a piece of scotch tape, taped it over the nerve at a certain spot, we've tacked down the nerve at that spot. So, as you go to do a normal range of motion, some motions may be unaffected, but motions that cause that nerve to have to slide through that area that's tacked down, now you're going to have potentially symptoms because the nerve is not going to slide, and the nerve is going to be stretched.

It's going to get irritated. And that's really what drives, I would say, 80% to 90% of the nerve-related symptoms that we see. I like the analogy, the tape one. I think I'm going to make that at the office here just to show people that's good. Yeah. So, with... One of the things that I learned a long time ago was the fact that nerves don't stretch. They have, I'd say, less than 10% or 15% stretch. So, I always tell patients, you know, if you think of, like, fishing line, you know, there's different fishing lines. Some have more stretch, some have less, but by and large, fishing line, monofilament doesn't really give too much.

Put it under too much strain, it'll break. So, the nervous tissue really doesn't tolerate stretch at all. What happens is when you move your arms or you flex your neck or your back, the nerves have to slide, and they slide like dental floss through teeth. And so, if you have an area where the nerve is restricted and it doesn't slide, it will be forced to stretch. And so, beyond 10% stretch on a nerve, we go back to we're affecting that blood flow to the nerve and you have symptoms. A lot of these symptoms are dynamic. Patients will tell you, hey, when I do this movement, you know, I get numbness in my hand or if my arm is sitting at my side driving or I'm working at the computer, that's when I have symptoms.

And so, you know, a lot of it is trying to troubleshoot, okay, what anatomical structures are at play there. Again, it all comes back to kind of knowing where the nerve entrapments are. You know, using anatomy and trying to get very specific as to where those nerve entrapments are is a big part of being able to, you know, accurately tell where the problem is and then apply some effective treatment to it. Okay. I do want to get into the different major nerves of the arm, but before we do, you mentioned slide and stretch. And I feel like I got to ask with nerve flossing protocols, because I feel like probably people think, well, I'm stretching it with that.

Why, why is it not affecting it or something that I think there's some confusion what nerve flossing actually is. Can you explain a little bit or? Sure. I mean, are we talking about prescribing exercises where we get patients doing a movement that should floss the nerve or we're actually talking hands-on manual treatment? No, we can go with both, because I bet a lot of people look up and they find videos on nerve flossing, and I know I've always had a concern with that, you know? Yeah, I mean, you know, Butler is probably one of the more famous guys, and I think, you know, there's obviously manual techniques where people learn how to position the arms or legs in a position that will shorten the nerve.

I mean, again, the nerves kind of slide, so you can put slack in the system. It's just like a string if you push on it and kind of bunch it up. And then they take through specific movements designed to bias certain nerves. You know, we can go through this series of kind of stretching the arm out, extending the wrist, extending the fingers. And in theory, we should be mobilizing that nerve. That's great. Problem is, if you have a nerve entrapment where there's scar tissue around the nerve, and that typically means the muscle tissue has glued down and the nerve's traveling through there. So now you have the nerve actually tethered to the muscle.

When you do those nerve flossing movements, the parts of the nerve that can slide will, but we still have that area that's tacked down. So you're never going to fix that with just a nerve flossing movement. You need to apply a manual compression intention to that area, release that scar tissue, and then get the patient doing those movements at home to reinforce that sliding. Then it can become really effective. Okay. Do you ever caution patients with, you know, we don't want to stretch the nerve from both sides or creating more than that 10% stretch if they're, I never really, I don't give a ton of nerve flossing at home protocols.

We do some in the office here. Yep. But I think the getting them to realize what's slack and what's not, it concerns me that they'll create tension. I don't know if you have any tips on this. Yeah, you know, I think, again, it depends on how, you know, how in tune with the body the patient is. Some patients have better kinesthetic awareness where they're just, they're more in tune with things. But I do caution them, you know, if we're working a sciatic nerve in the hip, that nerve is extremely big. It's about the size of your thumb. A lot of times people will get concerned of sitting on a lacrosse ball, rolling around.

Am I going to irritate the nerve? And I tell them, look, that nerve's pretty robust. It will tolerate some pretty good abuse. That being said, you know, you don't want to get direct pressure on that nerve because once it gets irritated, it's really hard to get in front of that. So we, you know, we do some nerve flossing, but again, I'm with you. We don't typically do a lot of it. We will get people laying lengthwise on a foam roller and just have their arms outstretched. And we find that, you know, just moving the head back and forth, you can get some pretty good stretch on the nerves. And again, a lot of times putting patients in these positions recreates their symptoms.

So, you know, with, with nervous tissue and flossing, I think you just have to kind of caution them to just go through the movements easily, try to breathe, try to take it more of a, like a yoga approach, because if you're too aggressive with it, the other thing too, it's difficult to tell the difference between nerve tension and muscle stretch. It feels the same. So a lot of patients, you know, case in point, they'll come in and say, well, I can't, I can never bend over and touch my toes. And they think they have tight hamstrings when, and a lot of times it's not a hamstring issue. It's because the sciatic nerve is entrapped in the, in the hip.

And so as they're stretching, bending forward, that nerve doesn't slide. And now it's being stretched. It creates almost the same sensation as, as a pulling hamstring. So, you know, with the nerve flossing, we may show them a move or two to just get in and try to, you know, stretch some of these tissues. Basically, you're, I don't like to use the word stretching, but more mobilizing. We're trying to get things moving and sliding. And so, you know, I think stretching can be a little bit misleading, kind of lends people to be a little bit more aggressive where they're really, you know, they might be doing a lot of bouncing and ballistic movement, which is never a good thing.

So, but, you know, as far as going through flossing movements, when we do nerve release in the office, we are taking advantage of those movements to move the nerve through a full range of motion. And that's usually done when we do active release, long nerve track, and we're actually applying to manual compression directly where the nerve is entrapped. And compression is a bad word because we're really using more tension. We're trying to get as close to the nerve as we can. Again, the nerves are very sensitive, so a lot of compression can irritate it. So, you know, you just have to kind of use caution when working on these things.

Yeah. You mentioned that study about nerve movement earlier, not in the podcast, but before, for the ulnar nerve. Can you tell us about that a little bit? Yeah, I mean, I'm sure we'll post it up in the notes, but basically it was a study that was done in the Journal of Hand Surgery. And what they did was they looked at how much sliding does occur at the ulnar nerve. So, for everybody listening, your funny bone, that's the nerve that you hit when you strike the inside part of your elbow. The nerve is extremely superficial. Pretty much you have skin covering it, then there's the nerve, and then bone.

So, what they did is they looked at through different ranges of motion. If we think about bringing your arm just from your side all the way out, bringing your arm directly overhead, biceps right up to the ear. They actually measured the excursion, how much sliding does the nerve have to do to accommodate that movement. And what they found was pretty substantial. You know, if you think about 30 degrees out to your side all the way to 110, which is, you know, just slightly higher than straight out at the side, you know, they found that the nerve actually had to move about four millimeters just in that movement.

Now, four millimeters really isn't a lot. But when we look at total range of motion, and we include wrist extension, elbow straightening, which, again, is extension, the nerve, in order to get your arm all the way up overhead, it actually has to move at the wrist and the elbow combined. It's a combination of about 23.2 at each spot, millimeters, which that's roughly an inch at each spot. So about two inches of sliding that that nerve has to accommodate, basically from the neck all the way out to the fingers as you're moving the arm. Yeah, that's a bit of sliding. It's a bit of a piece of stance on it.

Yeah. Especially if it's duct taped down. If it's, yeah, if it's duct taped down somewhere, you can see how you can lose a lot of that range of motion. And as you're raising the arm overhead, the symptoms you might get might be numbness, tingling, or you may just have a severely restricted range of motion where you feel like a rope-like sensation down the arm. There's just a lot of tension. In the office, we do nerve tension tests where we can bias the radian, you know, radial nerve, median nerve, ulnar nerve. Those are the three major nerves in the arm. And we can bias based on different movements to see, is there normal sliding movement with those three nerves?

And then from there, we can detect a lot of issues and get in and try to find that. But that's one of the most common things you'll see is people will have restricted range of motion and they'll feel this kind of cord-like pulling down the arm and they don't really know what to make of it. And most of the time, it's due to a nerve entrapment somewhere in the arm. I can't help but think about, actually, I had a friend that happened. She had a breast implant because she actually had a mastectomy and she was telling me about how you had to get massaged of the cordage up there. And I'd never heard of it before, actually, after having breast implants, but I'm like, that sounds like a niche job right there.

Are they basically working on the, is there a nerve entrapment with that or is that just the tissue that has been repaired, if you know? I mean, it's interesting. I've had a couple of patients who've undergone, you know, breast reduction, astectomy, some for cancer. Cording is a fairly common side effect or, you know, sequela to like when they do lymph node resection. And depending on the stage of cancer, they do that quite a bit. I've seen it mostly with cancer patients. And so cording, I mean, for those of you who don't know, it basically looks like in the armpit area, a string of peas. And it's essentially just a bunch of scar tissue around the lymph structures because they do lymph node resection and they take some of the lymph nodes out.

Obviously, they try to leave what they can. Depending on the stage of cancer, it can be pretty extensive in terms of what they take out. And so essentially, again, it's scar tissue. And I think a lot of people struggle with what exactly is that? I mean, the simplest way to think about it is that the body tissues, when they're injured or they're repetitively used over time, the body will lay down this fibrous tissue. There's cells in the body called fibroblasts. And their job solely is to glue tissue back together for tissue repair. There's fibrin in blood clots. Obviously, you're creating a clot.

In scar tissue, it's kind of a similar process. So the anatomy is very complex in the armpit. And there's a lot of nerve and blood vessel structures that travel through there. And they travel right in front of the muscle, in front of the shoulder blade. If you just kind of jam your fingers up in there and kind of feel around, you can usually feel kind of like these stringy, worm-like things. You're getting some lymphatic chain in there. You're getting some nerve structures. Usually, if you compress on it, you'll actually get the symptoms into your hand. So there's a lot of nerve structures in there.

The brachial plexus is still kind of a tangle of nerves in there. They haven't really differentiated into the three major nerves that come out into the arm. So they're technically still considered cords at that point. There's a posterior, a median, and I forget the other one. Do you remember? I don't. But essentially, what they are is, if you think about electrical wires coming in from the street to the circuit panel, they're bigger towards the spine, and then they start to get smaller as they go out. But in the armpit, they're actually, the cords are still bundles of nerve. And then they kind of separate out as they get a little bit further.

So with this cording, you'll actually see a lot of times the nerves get tethered down to that scar tissue, and they'll have severely restricted range of motion. They can't reach their arm behind their back or putting a shirt on, combing their hair, washing their hair. And you do see a lot of manual therapy being targeted towards trying to release that scar tissue, which basically means if you think about trying to break the bond between two pieces of Velcro, you're trying to get your hands in between there, create some movement of the arm, which helps separate the tissue. That's really what's going on when we release scar tissue, that scar tissue is not getting broken down and eaten up by the body.

It's just we're getting the tissues to unglue so they can separate. That's really a better way to think about it. Once you do that, the nerves should be free to slide, and we should be able to restore some range of motion. Yeah, good point with the separating of the Velcro because I've had a lot of people say or ask, like, because we generally use the term breakup, the scar tissue, and they're like, well, where does it go? Does it get reabsorbed and so on? It's like, no, we're just getting better slide mainly. But, yeah, that's a popular question. I'm thinking about all your blogs you can write now.

I know. Well, we just did a clinic last night at the CrossFit gym I work with, and that was one of the questions that one of the coaches asked. He said, you know, can you talk a little bit about scar tissue and breaking it down and, you know, what exactly is going on there? And I think a lot of people confuse the scar tissue that occurs in the muscles and fascia with scar tissue they typically get in a surgical case, and it's a little bit different. But I think the conception is that what happens to the scar tissue when it gets broken up? Where does it go? It's not like an infection in the body where the body will just kind of wall that off and it eventually will get flushed out through a lot of different, you know, avenues.

But if you think about that Velcro on Velcro, normal healthy tissue should move like silk on silk. When you have scar tissue, the muscles glue together, and the most effective soft tissue treatments, whether it's instrument-assisted or it's active release, really should be aimed at trying to restore gliding and getting in and ungluing those layers of tissue. You know, the scar tissue just basically gets broken up, meaning it's like pulling a Band-Aid off of your skin, right? You're just separating those two layers. Yeah, I think a lot of people, I feel like over the years that scar tissue has become the bad guy when it's a normal process, but we just don't want it to stick things together.

You know, like you said, it repairs the area, so why would you want to get rid of it completely? You know, it's repairing a spot that got damaged. Yeah, I mean, it's an imperfect system, but, you know, if you have soft tissue injury where the muscle gets broken down and strained, I mean, when you work out and you have muscle soreness, you know, that type of trauma, typically the body can just repair that with good nutrition and good sleep, and the muscle grows back stronger. But when you have repetitive strain that goes beyond that, the body's default, and it only has one default, and it's to place fibrous tissue down to just glue everything together, and that becomes a permanent deformity until you have that released at some point in the future.

So, you know, it does a good job to heal the tissue. The problem is the end result is tissue that's glued together, and it's very inelastic. You lose the natural elastic properties of that tissue, and then you have to restore that with proper treatment down the road. So, going back to the nerve-related stuff, you said the major nerves of the arm, and I know this is a major miscommunication with a lot of patients, especially when self-diagnosing. I mean, they don't always understand the different distribution pattern between nerve roots versus the three peripheral nerves, the major ones, at least into the arm, and then they kind of bucket everything together as I have carpal tunnel.

And I'm guessing you see a ton where you have to differentiate the fingers and the forearm sensations and so on. Can you kind of break down each one and just give us an example of how maybe treating each nerve is kind of unique? You have to know which one is which before you treat it? Yeah, I mean, I think, you know, the best way to think about it is, you know, you've got all these nerves coming, traveling through the arm, and they travel in different areas, right? So, if you have an electrical problem in your house, and there's something going on in the wall, you can't see the wires, you get an electrician out, well, they kind of know the schematic and where the wires are running.

They can kind of troubleshoot it from the panel out, and they can find out where that arc fault is. And it's based because they know how the wiring is set up. They kind of know the blueprint of it. So, the biggest thing from get-go is the functional anatomy. If you know the course of where the nerves travel and you appreciate what happens to these nerve entrapments, and they're not just limited to the carpal tunnel. I mean, that's one of the most common, but it's the most common diagnosed, I would say. A lot of doctors like to just throw that out as an umbrella term, and it doesn't really specify the real problem.

A lot of these patients that have been diagnosed with carpal tunnel have negative nerve conduction studies. One of the major reasons for that is that nerve conduction studies just are not that good at diagnosing small sensory neuropathies. And we talked about that earlier, that a lot of patients don't have enough compression to cause motor weakness. So, their symptoms are kind of flying under the radar. The tests we have, the neurodiagnostics, the EMG studies that we do, electromyographs, where they stick a needle into the muscle and they can tell, is the muscle firing? A lot of these tests come back normal.

And neurologists and family practice doctors kind of shaking their head. They don't know what to make of it. A lot of these patients get put on different drugs, Lyrica, Neurontin, and they're basically trying to attenuate the nerve symptoms. And they just, at the end of the day, continue to have symptoms. So, when you know where the potential nerve entrapment spots are, there's a far more common entrapment site in the forearm, and there's a muscle called the pronator teres. The median nerve actually travels through that muscle. It's extremely vulnerable to repetitive movements. And a lot of nerve entrapments will happen there.

Certainly, you can see a lot of nerve entrapments in the neck. The muscles of the neck tend to be really tight and glued down. There's several spots in the shoulder where different nerves can be entrapped. And, you know, part of going through the active release training is doing the long nerve tracks where they really start to go over the specific anatomy and how to bias these nerve tension tests where you can detect, okay, there's tension on the median nerve when I move the arm. And now I'm going to look at the different spots where that nerve can be entrapped. And so, really, it's kind of like an electrician chasing from the electrical switch on the wall back to the panel.

Where is the problem? Because until you actually find where the problem is, your option is to turn the power off at the panel so now you have no power. And that's kind of what these drugs do. I mean, you're basically numbing the nervous system. Some of these drugs have actually been shown to lower pain threshold. So, over time, you know, you become more sensitive to things that should really not be painful. So, it really all comes down to being able to find out where do I possibly have a nerve entrapment. And a lot of patients have nerve entrapments in more than a few different spots. The double crush syndrome then?

Yeah, exactly. Yeah, I thought the long track protocol for active release was one of their better ones, actually. I really did enjoy it. I used a protocol yesterday for the sciatic nerve. But I think it's interesting. I mean, you said that you're basically shutting the power off at the source with the drugs. Because for an evaluation standpoint, if you don't really have anything, like, you can't troubleshoot. There's nothing to troubleshoot. The patient doesn't have symptoms anymore or they're numb to it. So, you can't really get anything out of the exam, or at least that's what I feel sometimes, you know?

That's right. So, you wrote a thing on, actually, I was reading your blogs the other day. You wrote one on fascia, actually. So, I pulled a quote out of it. I like this one, actually. Bones being islands of tension floating in seas of tension. Islands of tension floating in seas of tension. When it comes to nerves, how do... I know that we always talk about nerves being entrapped within the spine, within the muscles or tunnels, or things like that. But can it get entrapped within fascia? And what is fascia? Yeah, huge. So, you know, I wish I coined that term. That was actually taken from Buckminster Fuller, I guess.

And he's the one who's famously quoted for realizing that kind of structural integrity. And basically, this thing called tensegrity. And it's basically, if you think about a series, you know, if you think about the Epcot Center Globe, it's kind of this struts and wires that hold this structure in place. And that's basically the way our body is put together. You know, you have all these long bones of the skeleton, and they're held in place by muscles and ligaments. And that's not really the structural integrity. What keeps that system together is the fascia. So, most of the time, patients look at you.

They may have heard it. They don't really know what it is. The easiest way to think about it is to think about that silvery stuff on a chicken breast or, you know, when you cut up a chicken or a steak, that kind of silvery lining on the muscle. We have it all over the body. It's fiber, individual muscle groups. You can have groups of muscle. It's intertwined. It is a structural component. It's kind of the shrink wrap of the myofascial system. And the really important thing, what's come out in the last decade, they did the first World Congress on fascia back in 2004. I think it was at Harvard. And since then, I think they've done several.

They're probably on their third. I know they did one, I think, in Amsterdam. And so, soft tissue injuries, if we take over the last 25 years, they've really been downplayed. Doctors really don't, you know, appreciate them for what they're really capable of creating. You know, and it's really been kind of downplayed up until about the last 10, 15 years. And so, the research that's come out on fascia has been really phenomenal. And the physical medicine world, because it really gives us a good, hard science to why we do what we do and why these things are problems. So, the fascia is actually more of a nervous organ than it is a structural integrity organ.

So, there are small networks of nerves that travel through and within all of this fascia all over the body. And its primary job is to be able to signal the brain in what position your body's in. All the joints of the body have what's called proprioceptors and mechanoreceptors. And they're nerve receptors inside the shrink wrap of the joint that send signals back to the brain via spinal cord as to what position your joints in. That's what helps you with balance, fine motor movement, gross motor movement. And so, when you have an injury to a tissue, whether it's an acute sports injury or it happens over time, and we're starting to glue down these tissues, the fascia gets restricted.

And that can now affect the signal transmission back to the main computer. And so, that can cause compensated movement patterns. And a lot of times, it ends up causing dysfunctional movement over time. And so, the fascia, you know, from a clinical standpoint, it really needs to be thought of more as a nervous organ as well as just a structural component. I think that's pretty interesting in that, you know, this stuff has all come out in the last 10, 15 years. And it's starting to kind of, you know, give us, you know, more backing to things that we've always kind of known in physical medicine. And anybody who's done any manual therapy, we kind of inherently know that these treatments work.

But we're now able to kind of detect why that is. So, I know there was a seminar, actually, I watched probably, it was probably more than five years ago. I remember it was at a, it was at Perform Better Summit, and someone had come out with, there was a fascial, there was the fascial trans book. That was the, one of the main ones with Myers, right? Yep, yep. So, they came out. Anatomy trains. That's what I call fascial trains. So, they, they came out with, they mimicked stretching, just static stretching based upon the nerve track, or the, sorry, the, the fascial tracks. I haven't seen anything from that sense, but I just bring it up just because if there's fascial restrictions, do we, do we address this differently than muscle or nerve ones to get the body moving better so we can then have better movement and not have all these compensatory things that happen, such as nerve irritation?

Do you have any suggestions on how to free fascia up? Well, I mean, I think there's, there's a couple things. So, you know, there, there is certification in fascial manipulation. I haven't actually taken any certification in that specifically. Some of the ART docs that I know have done it. And I think treatments like instrument assisted, whether it's Graston or any kind of a, of a tool you're using to scrape into the myofascial system, you're going to affect the fascia. I know in, you know, like Dr. Warren Hammer, he's a, he's a big, big soft tissue guy. He's got, you know, a textbook that's, you know, considered one of the most prominent in a lot of the schools.

And it's in, I don't know how many editions it's in now, but, you know, they talk a lot about a lot of the different techniques in the myofascial world, you know, strain, you know, strain, counter strain, PNF stretching, active release, Graston. I mean, there's a lot of different ways of getting about to treating the fascial system. And this fascial manipulation, I think it started in Italy. I'm not quite sure of the doctor's name. I'll probably botch it if I try to say it. And not having taken the certification, I don't know a lot of the ins and outs. It seems to me that it's kind of more along the lines of strain, counter strain, where you're applying kind of compressive forces to different areas of the fascia.

And you're kind of holding that. So, you know, in ART, we treat capsule a lot, right? And so when you treat capsule, you treat it much differently than you do the muscle and the fascia. And we're really getting in and taking a lot of tension. We're holding that tension for a prolonged period of time. Sometimes one to two minutes or longer. And that's because of the properties of that specific connective tissue. It needs to have some kind of a deformative force for a prolonged period of time. Whereas a muscle, you can get in, compress it, stretch it through. And really, it's like taking pasta through a pasta maker.

You're kind of thinning it out. You're getting the tissue to release. So, I haven't taken any of the new fascial courses out there. I think one of the things with instrument-assisted that's actually occurring, in addition to just the mechanical, we're breaking up those cross-linked fibers that are glued together, is you are actually stimulating that fascial network of nerve tissue. And I think that's one of the positive things that you'll get out. You know, Dr. Hyde, he talked with Graston for years. And they used to really get into doing a lot of this, you know, factor. And it's, you know, you're basically combining this Graston movement while the patient's moving.

And so, you're trying to break up and release the soft tissue scarring. At the same time, you're trying to stimulate the nervous system. It's a truly integrated state, you know, and the body systems work together. They don't work in isolation. So, I think there's a lot of validity to some of the fascial stuff out there. I think at the end of the day, it's all of these techniques are creating an awareness that, hey, a lot of the things we see in physical medicine and even orthopedics are driven by these dysfunctions in the myofascial system. And the joint system. And so, unless you're getting manual therapy, manipulation, soft tissue treatment, you can do all the exercise you want.

But it's not a truly integrative program at that point. Yeah. You know, something you said earlier that I want to come back to as well is that I know we had talked about, like, the miscommunication of what an injury is versus, like, an overuse condition. But also, too, with, you say, movements or exercise, and then we say, well, like, just cycling or just lifting won't take care of it. Do people understand that to correct sometimes movements or these injuries, the rehab is different than just going for a run? You know, is there, because I think that's a miscommunication I have a lot of times with my patients is, I'm like, well, we've got to get you stronger.

They're like, well, I lift. And I'm like, well, I mean, endurance. They're like, well, I run. I'm like, okay, fine. Just trust me. We're going to do some stuff, okay? Yeah. But do you have any feedback on that? Well, I think it's one of the hardest things that we struggle with in practice, right? The misconception, misinformation. I mean, how many patients do you see come in and, you know, they've seen various other providers and, you know, it's a knee problem or whatever. And they told me my quads are weak, my glutes are weak. Yet this is a CrossFitter that squats well over 300 pounds. How weak can the glutes really be, right?

So I think typically the paradigm has been to throw everything under, hey, this is weak. Let's strengthen it, right? And so you really need to kind of reverse engineer that. And I take the approach of if you have tight, restricted tissues, you need to restore mobility. So, yes, we need to have mobility in certain areas of the body and you need to have stability in other areas. And some body regions, you need to have both, like the foot. You know, the foot needs to be flexible at certain points of the gait cycle. But it also needs to be very rigid when you strike the ground. So, you know, the runner who, you know, says, well, you know, how can I be weak?

I'm running. What they fail to realize is that, you know, if you have tight, restricted tissues, those tissues are going to be inhibited. They're going to have a lower fatigue rate, meaning they're going to fatigue much sooner than would be healthy tissue. Therefore, i.e. weak, if you want to use that term. A better term, I think, would be to say that the muscle is inhibited. So, I tell patients, look, if you think about how your muscles work under the guidance of the nervous system, it's like being on a dimmer switch. You can have the dimmer switch all the way up. The light is on 100% or it can be down slightly.

So, the muscle is firing, but it's not firing on all cylinders, right? So, that might be, you know, hey, 5, 10 miles into a run, stuff starts to go awry, and it's because muscles are kind of shutting down. Now, I've got other muscles that have to compensate for that. So, the whole weakness thing, typically, I just kind of scoff off because I think, you know, generally speaking, a lot of people have had a bunch of exercise prescribed to them. And, hey, we need to strengthen XYZ, and where I think we fall short is there's not enough people looking at joint structure and function. Where are the joints not moving?

Because if you have a joint that is restricted or compressed, it will cause weakness of the muscles that cross that joint. And this is a hard science, basic science called Hilton's Law. You know, we learn about it in school. You can pick up several anatomy books. Moore's Clinical Anatomy talks about it. And Dr. Hilton, he described this law back in the 1860s, and it basically says that the nerve that innervates a joint also innervates the muscle and skin that crosses that joint. So, to sit there and say, oh, these muscles are weak, or you're having spasms in these muscles, we need to always go back and look at the joints and the soft tissues.

You know, a lot of times what we see as a tight muscle could be protective guarding from a damaged joint, an arthritic joint. You could have an arthritic condition in the hip that's causing the glutes to just be on all the time. And so they will get tight and scarred down. And if you sit there and say, well, we just need to hammer out more strengthening of the glutes, I mean, good luck. And you're pounding your head against the wall. So you have to get in and do some joint mobs. You have to get the joint moving. And then if you're able to do that successfully, you can kind of decrease a lot of this.

You know, they call it increased gamma gain, where the nervous system to these muscles gets turned on hyperdrive because the brain is trying to protect a damaged joint. And I think that loss on a lot of patients, they don't really understand how the body really works in an integrative state. And I spend a lot of time, I'm sure you do, in the office trying to educate them on, hey, this is why we're doing what we're doing, right? We're doing joint manipulation because you have a joint that's stuck and not moving. There's only one way to fix that. You have to put your hands on people and get that joint moving.

We can reinforce that with some good mobility drills. A lot of the elastic bands that we use, you know, they're very effective at creating joint traction. But you also have to deal with the soft tissues. And then you have to round all that out with a corrective exercise that's properly prescribed. But you can't just come in off the top and say, you have a bunch of weak muscles, let's just strengthen them. It just doesn't work. You know, it's a failed recipe. You need to have a multi-pronged approach, joint, soft tissue, and functional rehab. And that's really kind of, you know, at the end of the day, what tends to make the most profound impact in clearing up these syndromes.

Good. You're like bringing it home almost to a close. So, as we start to close it down, can you, if someone had a, give me a couple steps, if someone had a numbness into the hand or elbow or forearm, what do you think they should do? Roughly. I know it's a very broad topic, but for the listener. Yeah. I mean, they're always kind of broad. You know, I think the important thing to look at is if it doesn't go away within about two weeks of trying to, you know, do some mobility. Again, it depends on, you know, what your skill set is. Hopefully, everybody out there has been exposed to some mobility practice-type things using a lacrosse ball, foam roller.

You know, try to get on a foam roller, increase some mobility in your upper back. We tend to see a lot of stiffness in the upper back. That being said, if, you know, you can get in and try to do some of these things over the course of a few weeks, if it's not getting better, it's not going to get better. And at that point, I would say, you know, get in, find a sports chiro, get in to see an active release doc. That's probably one of your best bets to be able to, you know, get somebody to be able to troubleshoot, you know, what's going on. And if you really are having numbness and tingling, if it's just joint pain, again, I mean, you know, the nerve stuff tends to be kind of a little bit specialized.

But, you know, a good sports chiro is doing some soft tissue. You ought to be able to handle, you know, these issues. And that's kind of what I talk about when we do clinics. You know, hey, if you're doing some things to try to fix it on your own and in two weeks' time it's just not getting any better, you know, the easiest way to prevent a chronic problem is to get in and have it fixed sooner than later. Yeah, totally agree. You can't wait. You can't get a haircut over the phone, right? Yeah. So as we close up, how can everybody contact you? Let's see. The website is PotomacPhysicalMedicine.com.

We're located in northern Virginia, just outside of Washington, D.C. Website, blog, Facebook, it's all there at PotomacPhysicalMedicine.com. If you want to reach out to the office, you can email staff at PotomacPhysicalMedicine.com. Phone numbers on the website, all that good stuff. That's probably the best bet. We have a YouTube channel that's got some decent exercise videos on there. It's kind of an evolving thing. We're trying to add content as frequently as we can. The blog has some good, interesting content on soft tissue injuries and a lot of different things as they pertain to running, CrossFit, endurance athletes, and we get into kind of a deep dive on how these injuries happen, what you can do about them.

I think that covers it. I don't know if you're planning on making a YouTube video anytime soon, but if we did a correlated one to this podcast, I would imagine some nerve flossing might be or some type of, I don't want to say DIY. Yeah, we could definitely do that. That's one thing that we don't have on there. There are some things you can do to get a tennis ball, and you can kind of use it up in the front part of the neck, and you can go through some arm movements kind of up against the wall that help to free that up. And, you know, I think that's one of the things that we need to shoot for a video.

We do have some good shoulder mobility videos where we show you how to use a lacrosse ball for kind of that top part of the neck, shoulder, and unglue some of that. A lot of patients get nerve entrapments in the shoulder girdle. Talk about how to use a foam roller to get in on a lat and just open up some of this stuff. So those are good starting points. Whether or not you end up having to go see, you know, a physician, these are things that you're going to need to be doing anyway. So, you know, get in front of the power curve, start doing some of this stuff if you're not already. So we do have some of those on YouTube.

But, yeah, I'll try to get in and shoot some video this next week, and I'll shoot you an email when we get it posted up. Okay. Yeah, and I don't like getting the notes, everybody. So that'll definitely be in there, as well as all the contacts and everything. Cool. Then let me close it up for everybody and just hang on, and I'll talk to you after we're done. Sound good? Cool. Sounds good. Okay, everyone. That was Dr. Matt Fontaine. Again, he is in Virginia, northern Virginia area. If you are looking to submit a question to the podcast or suggest another guest or speaker or some other topic that you guys actually want to hear about, just reach out.

On the website is p2sportscare.com. If you want to find all the podcasts, it's on slash podcast. And if you want to leave a voicemail on there, there is a voicemail button actually on the main site. It is through SpeakPipe. You've got about a minute and a half to leave your case, your questions, your topics, your suggestions, and everything. So I do look for constructive criticism. Constructive, please. I haven't gotten any bad comments yet, but I want to make this show better so everyone can continue to learn and get better through their athletic ventures. So I will speak with you guys soon, and have a good week.