Case of the Week 5-7-12: Stubborn Peripheralization | Modern Manual Therapy Blog

Case of the Week 5-7-12: Stubborn Peripheralization

The patient was a 68 yo female with chronic cervical and radiating UE pain to below the elbow.

History: Insidious onset of right cervical pain years ago which progressed and peripheralized into median nerve distribution below the elbow. Her complaints were constant and rated moderate to severe, affecting all of her ADLs using her arm. No c/o loss of sensation or weakness. Sx worse with sitting, when still, with cervical forward bending and rotation to the right.

Fair sitting posture with forward head, right scapula elevated and anteriorly tipped compared to left.

Cervical ROM

  • WNL with PDM during flexion
  • mod loss with cervical SB and rot to the right
Myofascia: mod limits in right cervical paraspinals, scalenes, SCM, upper trap, levator scapula, pec minor, medial upper arm, anterior radial bony contours of forearm

Neurodynamics: moderate loss of median nerve, reproducing Sx with elbow extension and wrist flexion (as final components)

Assessment: Signs and Sx consistent with cervical dysfunction and neurodynamic dysfunction with median nerve bias

Treatment focused on

  • IASTM to cervical paraspinals, right > left upper trap, levator scapula, right medial upper arm, right bony contours of the radius
  • functional release of pec minor
  • postural correction, sitting with a lumbar roll
  • education on hourly cervical retractions and prayer stretch for median neurodynamics

After 4-5 visits with adding repeated scapula setting to inhibit upper traps, she was about 80% better and centralized, except in the 1st two digits, which still had moderate paraesthesia. Most of her cervical pain was gone except some mild end range pain with extension and SB to the right.

Visits 6-7 added deep cervical flexor strengthening and functional release to the pronator teres which only temporarily reduced the right hand paraesthesia.

On visit 8, which I told her would be her last visit and she may have to live with the 80% improvement (according to her), I modified the neurodynamics to more shoulder abduction, ER, elbow extension, full supination, wrist extension, and digits 1-3 alternating finger wiggles and digits 1-2 repeated opposition. She felt this was a "huge" stretch for the area which also after performing 3-4 sets of 60 second oscillations, the symptoms were abolished!

This is one of my favorite progressions for stubborn centralization and for passive neurodynamic tensioners, I often just mobilize the first 3 digits for median nerve, first 2 for radial, and last 2 digits for ulnar nerve. Makes for a great progression of treatment!

She called 4 weeks later and was still better, fully centralized with no pain at rest or cervical movement.


  1. Would love to see this as a video when you get the chance.

  2. I'll film and post it sometime this week. Thanks Ben.