T Nation

3 Months Post Shoulder Op Nagging Bicep Issue


#1

T-Nation,

What's up guys,

Well I'm 3 months out from a sub-acromial decompression surgery on my left shoulder. I started PT the week after my surgery and I'm still going and while I'm making good progress, I still have this nagging bicep issue that I really want to resolve and can't seem to pin-point how to make it better.

I might be slightly confused since I've been reading a lot of Cressey's stuff lately, but I believe I had an External Impingement since I had a huge bone spur on my acromion and a type 2 hooked process. The surgery got rid of the spur and shaved down my acromion to a type 1 flat process.

Prior to the surgery the only time I felt pain in my shoulder itself was during any over-head pressing, shrugging movement. From reading Cressey's stuff this leads me to believe I had an AC Impingement. Range of motion was always excellent and I definitely could hear an audible "crack" when abducting the shoulder past 90 degrees.

I've learned a lot about correcting posture, foam rolling, stretching tight pecs, thoracic extension, prone y, t, ws etc.

However as I mentioned I still have a nagging dull ache on the inner part of my elbow, just below my bicep and just above my forearm on the effected side.

Here are some of the symptoms I notice in that bicep area:

-as mentioned dull ache, usually gets better once I do my stretching (sleeper stretch)

-pain (throbbing) in one of my rotator cuff tendons. feels like its right on top of my left shoulder blade, and just inside my left lat. I know referred pain down the arm is common with some of the cuff muscles (supraspinatus) so this might be connected, since doing the sleeper stretch for my posterior capsule tends to alleviate both the posterior throbbing and the ache below the bicep.

-lack of blood flow in the left arm and obvious weakness

-when doing direct bicep work with very light weight for high reps (in therapy) the muscle gets tight sometimes and fatigues very quickly in relation to my good side


Now I've been through the ringer with this situation. Prior to my surgery I was in PT, but had a terrible therapist so I didn't make much progress. I saw a guy who does Graston, but was only able to see him a couple times. He did Graston on the bicep and said there was a lot of scar tissue in that area.

I went back for my one month post op appt with my Ortho who is a shoulder specialist. I kept telling him about the ache just below my bicep and he kept telling me he was puzzled by it since bicep pain and the impingement I had are totally unrelated??? Everything I read in literature says the LHB tendon is often impinged when the shoulder is injured.

My ortho even had me get a nerve test where I got hooked up to this machine and everything came back normal?

To make matters more confusing my therapist thinks it could be one of two things:

a) she says it is likely nerve irritation. She said often times nerves can get compressed especially when there is a shoulder injury. This makes sense, but I still have no clue how to make it better?

b) she said there is a possibility that you might have a partial tear.

My MRI prior to the surgery said the following:

-Left Supraspinatus rotator cuff tendinopathy with a partial thickness tear of the superior fibers. Left AC Joint hypertrophy with a downward sloping acromion process

Now obviously the spur was removed and the acromion was shaved down. When I asked my doc about the partial tear, he said there was no tear, all the cuff muscles were in excellent condition. I'm imaging perhaps there was only some fraying?

I apologize for the length of this, but really want to get to the bottom of this...

Lastly I will say, that perhaps in time this issue will resolve itself, considering i'm only 10 weeks out from a pretty big surgery?? However I feel like that's wishful thinking.

Any help would be greatly appreciated!

Thanks,

Sunny


#2

Cliffs Version:

-Hurt my left shoulder doing heavy flat dumbbell presses, had bad form and felt a sharp stabbing pain in the front of my shoulder (impingement was the diagnosis)

-After a stint in therapy started having pain in the inner bend of my elbow, just below the bicep

-Originally this pain was only noticeable during lifting, but started to hurt all the time

-Had ART, a few visits to my Ortho and even nerve testing to find the source of the pain

-MRI revealed type 2 acromion, bone spur and partial RC tear, also showed long head bicep tendon was in the groove

-surgery nearly 3 months ago; in PT ever since

-shoulder pain is almost completely gone, however ache in the inner part of my elbow remains

-when doing any bicep work (light weights) the arm feels weak, lack of blood flow and sometimes gets tight

-accompanying pain in one of my rotator cuff muscles, located just inside my left lat

-when I do sleeper stretches the rotator cuff pain and to a degree bicep pain reduces greatly

-currently doing lots of foam rolling, pec stretching, prone y, w, t's, thoracic extension etc

Wondering if this bicep issue is nerve irritation as my therapist suggests, perhaps a partial tear of the short head, or simply will take time to feel better since its clear the long head bicep tendon was being pinched by my acromion situation. Prior to the surgery I had been through extended bouts of PT twice (therapist sucked) and my main symptom was this dull ache below my bicep.

I don't get any tingling in my fingers, but I still wondering if this is ulnar nerve compression or something in that direction?

Thx


#3

I strongly believe the pain you are having is related to the shoulder issue. In other words, anyone who tells you it's just a coincidence is someone I personally would not listen to.

If your current PT sucks, drop him (her) and find another one immediately. There are some god-awful PTs out there (like any other profession) and the sooner you give yours the pink slip, the better your chance of finding a good one before you use up all your visits.

Re: sleeper strech. Mike Reinold wrote a fascinating article on why he doesn't care for it. Visit his site and do a search.

Re: prone Y's. If you're doing the old-fashioned way (ie head not supported), your upper traps may be kicking in. Remember, the upper traps elevate the scaps; the lower traps (which the Y's are supposed to target) DEPRESS the scaps. A better option is to do them unilaterally with your head resting on the non-working arm which itself is resting on an incline bench (so it looks like you're making half a Y). The W's IMO are best done with light band in a vertical position; again, you don't want the upper traps dominating the movement when its the teres minor, infraspinatus, mid traps, rhomboids major/minor should be stimulated

Remember - more muscles connect at the elbow than any other joint. You mention that one of the people you saw felt a significant amount scar tissue there. If this is the case, you will need to proactively address it.

Also, you state the shoulder pain is "almost completely gone" Perhaps, and this is just my theory, your body began to move in such a manner to compensate for the shoulder issue. This most likely started a while pre op but it certainly manifested post. Get a highly skilled individual to do further assessments. Also, have a highly skilled trainer check your form on your lifts.

You'll hate me for saying this. Even after they shaved the spur, certain movements will be considered high risk for you moving forward: overhead pressing; behind the neck pulling/pressing; upright rows (which are awful for even someone with healthy shoulders). You will need to fall in love with movements that strengthen the scapular retractors and depressors. Also stretch the upper traps on a regular basis.


#4

All very true. 15 months post-surgery and I still can't OHP.


#5

As mentioned, going back to the ortho tmmrw and going to get to the bottom of this some how. Will see him and follow up here. I've pretty much narrowed it down in my head mentally to either a partial distal bicep tear or (more likely) some type of nerve compression from the initial shoulder injury.


#6

^^^Great to hear. Keep us posted.


#7

Well went to my ortho, he said he spoke to my therapist prior to my visit to collaborate and try to figure out this distal bicep deal. He mentioned that I had the distal bicep MRI last summer with the other ortho I saw which came back negative. Although if anyone wants to chime in here since the that other ortho I went to was TERRIBLE, the MRI was only in the area of my inner elbow; nothing up in the bicep and nothing in the forearm area. I'm wondering if perhaps my whole bicep was MRI'd if something else would show up???

Anyways as of now, I will be going to see an ART/Graston guy starting the first week of September to see if he can resolve this issue. But also will be pursuing with my current ortho to try and get the bicep MRI'd as well.

Its also interesting to know that I get some pain in my posterior cuff area when the distal bicep area acts up, right now as I type this, the posterior cuff is aching a bit.

Will update when I know more.


#8

Another piece to the puzzle.

Re: MRI - I'm not up to speed on the latest MRI technology (that's not my job). The last I checked I don't believe muscle strains will always show on a MRI. If I'm wrong, someone please correct me.

The bicep long head originates at the supraglenoid tubercle and the short head originates at the coracoid process of the scapula. Therefore, it could be possible that, post op, your glenohumeral rhythm shifted in such a way that the tendon of the bicep long head (and possibly the short head) was pulled superior (maybe) and posterior (most likely).

I'm inclined to think the shift was more posterior - which explains why the sleeper stretch (which, after reading the Mike Reinold piece, I am not a huge fan of) offers relief.

Just a theory but could it be that this superior/posterior shift in the scapula has manifested into pain at the distal tendon? In other words, the location in which the both of the bicipital tendons originate is pulled back (and possibly up). This, in turn, places the bicep in an abnormally elongated position. And this results in pain where the biceps attach at the radius and the brachial fascia.

You said the original MRI was "elbow area" This should have shown any pathology - IF one existed at the time. Remember - as I stated in my very first post, this bicipital tendon issue may have manifested post op. If this is the case, it stands to reason it may have also manifested AFTER the original MRI.


#9

Thx for the reply bro and all your help in figuring this out.

Had my first appt with the Graston/ART therapist today. He evaluated me and did some manual arm testing, and poking around in the area.

After testing, eval etc, he mentioned that I have a bit of scar tissue right at the distal bicep area, also showing signs of bicep tedonitis, pronator teres syndrome and compression of brachial plex nerves. Also mentioned I show signs of tennis elbow lateral and medial along with tight tight scalenes.

He pressed around in my bicep, arm, wrist and forearm this morning and as I sit here and type this, my hand, elbow and forearm are throbbing.

I also got a new script for an elbow MRI, but will hold off on that to see if this therapy with ART etc will resolve the issue.

This condition is definitely not something that manifested post op, as I started having these symptoms just after my first bout of therapy back in late summer of 2009.

I go back Saturday for my first treatment and will keep you all updated on my hopeful progress and return to the gym.


#10

Aha - I did not realize this was a symptom that started back in 2009. This information was not presented in your earlier posts. Therefore, the algorithm I ran in my head came to a different set of possible causes.

Nevertheless, my very first post in this thread mentioned addressing adhesions in that area. I'm glad to see that advice may prove beneficial. Feel free to keep us posted and remember the contraindicated exercises I mentioned.


#11

Basicaly had the same surgery in 09. It is going to take time. You are only three months out from surgery. I still had that dull ache in my shoulder, bicep, and scapular area for 12 months. Focus on strengthing your scapular area. Lots of rows, face pulls etc. Those muscles are weak and need to be re trained on how to fire properly after compensating for your injury for so long.

Once I strengthend my scapular muscles and upper back the pain went away in the bicep area as well as the shoulder. I also noticed, at least my wife did, that my posture was better as well. Stretching, massage, and rolling out the tight areas with a lacross ball are also your friends. I am back 100% with that shoulder and then some. Just give it some time and be diligent with your rehab. In fact I still do a lot of my rehab exercise as a form of prehab to this day. Good luck


#12

Yeah been with me for a while; its MUCH better since the surgery as I have no doubt that the huge bone spur was impinging my bicep tendon. I'm very excited as I feel like I'm FINALLY going to be close to getting back to 100%. 2 years of being pretty much out of the gym, I've lost a lot of size and def some of my confidence with it.

Will def keep you posted and as mentioned really appreciate your help throughout all of this 56!


#13

Thanks for the reply Clint.

Did you have the bicep pain prior to your surgery? In my case the pain started just after I initially hurt my shoulder and has been with me ever since. I've talked to several people that have had this surgery and almost all of them said they never had a dull ache in their distal bicep/forearm area. My ortho has repeatedly told me that I shouldn't have any bicep pathology distally from my shoulder situation; he said if it was long head it would be more understandable.

I was very diligent with my rehab, never missed a day and went at it for 4 months.

I hear you on it taking time, I fully realize that docs give very generous recovery estimates, most likely not taking into account that we are athletes looking to use the shoulder, arm etc for heavy lifting. I'm just past 4 months post-op now and just ended my physical therapy. ROM is the shoulder is excellent, I have absolutely no pain in the shoulder itself, but do still get posterior cuff tightness from time to time and the arm pain.

I just started going back to the gym last week and basically just do legs, abs and my rehab routine. Lots of serratus work (ball push-ups), mid/lower trap strengthening with Y T W circuits, and face-pulls, rows etc. Also incorporate lots of stretching of the pec minor, ROM work on my shoulder and I use a Rumble Roller for my total body a few times a week.

Like you, people have mentioned that my posture has improved quite a bit since all this, as I had the classic rounded shoulders from a severe front/back strength imbalance. Looking back thinking I knew how to lift back then makes me laugh now.

Not sure if you caught my earlier message, my new therapist feels like I have tennis elbow, tight scalenes, pronator teres syndrome and scar tissue in the area. This likely IS related to my shoulder issue due to over-compensating as you and 56 mentioned. So its definitely going to take some patience as work to get back to normal.

I'd like to hear more about where your bicep and shoulder pain was pre and post op.


#14

Another Update:

Had my first official session of PT this morning specifically for the arm issue. However I was seen by a different therapist this morning since my normal therapist was away at a conference. Today was the only day he will be gone during my ensuing therapy, but the therapist today was also very knowledgeable and provided a lot more info to this case.

I walked in, as she was reviewing what my evaluation appt notes had said. I filled her in on the whole background (impingement in '09, one round of therapy, which resulted in clearance to return to the gym. Then immediately after the dull ache in the arm started, therapy 3 more times, negative MRI of elbow etc etc; surgery and here I am with arm pain still present though improved and posterior shoulder tightness and pain from time to time.

Instead of focusing on my arm, this therapist immediately wanted to look at shoulder function. Mentioned how shoulder dysfunction could be the source of all the pain, which I agree with....

Right off the bat, mentioned I display some scapular winging on my left side, which I was not surprised to hear since my previous therapist had mentioned this as well. However, also mentioned that I have a much more prominent winging on my right (good) side, which I was shocked to hear. Said it was most likely due to over-compensation and duration of time with this dysfunction.

Internal, external rotation and ROM were noted to be very good, so the focus is on the winging. Mentioned that the winging is the reason I'm getting major tightness in my sub-scapularis (armpit area) and pain in my posterior cuff (teres major , minor and sub-scap).

Gave me 5 exercises to work on at home, wanted me to do them 3x a day everyday and monitor my progress.

I have my next session on Tuesday.

Its hard for me to say when the winging occurred; I know I have always had an issue with poor posture, forward head and lifting hard has most likely magnified this issue with the rounded shoulders, likely muscle imbalance from front to back sides and then the impingement took it over the top.

The home exercises they want me to do are:

Prayer stretch type stance: I am on my knees, elbows locked; shoulders retracted. From this position I slowly go back with the use of only my arms, keeping my core tight and back flat until my butt touches my feet.

Wall Slides: Pretty much text book here, focusing on serratus activation by extending as far as I can at the top and concentrating on not being upper trap dominant on the way down.

Scap push-ups against wall: Protraction & Retraction

Prone Scapular Adduction: Very similar to the protraction/retraction; hands are bent by my head, focusing on squeezing the shoulder blades together, without using the low back or upper traps at all.

Supine Wall Slides: Keeping fingers against the wall, elbow tucked in and low back flat against the wall with knees slightly bent.

More or less what this means to me is my Serratus Anterior is completely shut down; which I guess is typical with shoulder dysfunction. Was told that my rhomboids are also weak, so these home exercises should address that.

Was also told to avoid doing anything in the gym for now until the winging is corrected; which sucks, but I totally understand and agree with.... I've been out of the gym for over 2 years now so I'm use to it.

Was also told to focus on posture, but not be so concerned with shoulders back and down; just to focus on keeping shoulders back.

Also mentioned I display some lower body posture issues which could be part of the reason for the upper body posture issues.

Overall I was very impressed with this therapist, focuses on not only PT but movement analysis and really liked his methodology since it helps get to the root cause of the issue, rather than just doing manual therapy and sending you on your way without any explanation.

Will keep everyone posted as I progress and would love to get feedback from those who have had similar issues and have had success correcting it.

I'm specifically interested in knowing the time frame for correcting winging, although I imagine it likely depends on whether its strictly due to poor posture or if its being caused by the long thoracic nerve being impinged or irritated.

Thx


#15

Nice to see that you're making progress.

(also nice to see that many of my original observations have been validated)

Your PT sounds like a smart cookie. I will, however, disagree regarding her advice about just keeping the shoulders pulled back. What can often happen for many is that they will often recruit the upper traps and this creates retraction (which is good) but also creates elevation (not so good). So the advice of pull the scaps back and push them down will better serve you, IMO. Also, be sure to perform static stretches on the upper traps for 30 seconds or so. This will help down regulate the upper traps so the scap depressors (the lower traps) can better do their job.

Obviously, when you're back in the game and need the upper traps to fire maximally as in the dead lift, you don't want to use this protocol.

As far as the exact healing time, you'll have to discuss this with your PTs as they are the ones who have seen you in person.

When you're back in the game, you're welcome to PM me and I'll be happy to help design a program that bridges the gap between rehab and that Valhalla where you're stronger and healthier than you've ever been. That's my area of expertise. As for the rehab, it appears that you're in good hands.


#16

Hey 56: Just a little update for you and any others who may be following.

Been seeing the ART/Graston therapist for a couple weeks now. The first four sessions were more just soft tissue stuff (ART), postural observations and the home exercises to work on correcting the scapular winging which was previously discussed.

In the course of it all I have done lots of reading on posture stuff and realize I also have tight calves, hips and display some anterior pelvic tilting. So I'm working on all of it and feel like I will be functionally sound and ready to break some PR's when I get back to full strength.

I haven't had any Graston done, just ART as mentioned and we started working on some rehab exercises at the clinic. The posture stuff I work on with a therapist that works there a couple times a month. My main therapist is the Graston/ART/CSCS guy. This past week we started working on some rehab exercises:

1) Crab walks: pretty self explanatory; continually working on activating and strengthening the serratus.

2) Push ups on peddle: hard to explain but they have a cardio machine, but I get in push up position over the pedals and focus on keeping good push up form, while pedaling for a minute forward and backwards.

During the week I work on the Serratus program I listed in my previous post as well as a small program I put together to help with pelvic positioning. I do:

Some static stretching as you mentioned: hip flexor, piriformis in addition to the scapular stuff: upper trap, levator etc.
Also do some bridges, in addition to foam rolling my quads, ITB, gluteus, psoas, and my lats and thoracic extension.

What I've noticed is my lats, infraspinatus, teres minor/major area get tight and some what painful every other day or so. When I do push-ups, crab walks it immediately feels better. My therapist said that's a good sign that it feels better with exercise and likely indicates that with time and strengthening that issue should disappear.

Additionally and this is a huge point, when my lats, teres minor and infraspinatus get tight and a little painful is when I REALLY notice the pain in the inner part of my elbow and sometimes into my bicep.

So I'm hopeful that as you and I have been thinking since day one that this is def all related. Once I correct winging completely, strengthen the area and keep up with stretching that the referred inner arm pain and tightness should go away.... fingers crossed.


#17

Sounds like you're making great progress.

Teres minor and infraspinatus are external rotators. When they are "tight and a little painful" as you describe it, they are most likely in a fatigued state. Those two are the only muscles that externally rotate (supraspinatus and subscapularis do not perform this function).

This, in turn, effects the glenohumeral rhythm (keep in mind the main function of the rotator cuff is to center the humeral head on the glenoid fossa). The change in the glenohumeral rhythm then manifests into the elbow and bicep irritation.

So yes, your recent discoveries are confirming what we had suspected since this thread started. And, of course, the in-person visit with a qualified therapist uncovered new information (which is why myself, LevelHeaded, and BBB are always telling people to see a qualified individual in person).

It's also nice to see that your taking a more comprehensive view of the entire kinetic chain as opposed to individual links (although that certainly has its applications).

Down the road, it may not be a bad idea to eventually work on strengthening the Posterior Oblique Subsystem (includes the lat and contra lateral glute). I have recently been implementing my own flavor of a Mike Boyle movement on a client who has suffered from chronic lower back pain that often masks itself as sciatica (which I'm certain she does not have). Just finishing up a month with her and she is now pain free (and happily wants to focus on body comp). And, of course, we are doing other things re: her back; I am a huge believer in the synergistic effects of several protocols (it's the exact formula that varies from person to person).

Anyway, I mention this because the current line of thought regarding the strengthening of the Posterior Oblique Subsystem is to treat lower back pain via the stabilization of the SIJ. However, the more I prescribe this movement to other clients as well as perform it myself, I am beginning to suspect that the SPECIFIC manner in which it is performed can have more global ramifications. When you're done with the current treatment, and when I have gotten more mileage with this particular variation, we can go over it.


#18

Thx for the great info 56!

Had another session of PT yesterday and asked him to work on my neck since everything on my left side is somewhat tight in relationship to my right. So he focused on doing ART on the scalenes, a little painful, but felt good afterwards.

Started doing some heavy rope battling and man I'm SO WEAK on them right now obviously since the shoulder and bicep are in a de-conditioned state. Are the fatigued teres minor and infraspinatus playing a role in this? I've been out of the gym for a while so I expect weakness.

Secondly what if any type exercises can I do to get better at the heavy rope battling? I was weak all the way around, couldn't really move the rope in as tight of waves as I'd like and fatigued big time within 15-20 seconds. I did 3 sets of 30 seconds; by the 2nd set I was fatiguing after 10-15 seconds.

Keep in mind I had done 5 sets of crab walks and 2 sets of a plank variation using the pedals on the elliptical like bike while I held the push up position prior to doing the ropes.

Trying to stay mentally strong, but sometimes I have my rough spots since I still haven't heard an actual diagnosis on this? Most likely multiple things going on, but my curiosity is killing me sometimes. Some of the PTs I have worked with have said it sounds like I might thane nerve irritation or compression (long thoracic). My current therapist said he thinks its simply weakness, scar tissue etc. So I guess my frustration lies in not knowing exactly what I have at times.

For a bit I was thinking perhaps it was due to the winging, but then was told I have more pronounced winging in my right side than my left. I have no arm pain in my left side. So that narrows it down to the dysfunction I had with the left shoulder.

Another thing I wanted to ask you is my ortho has said he will write me a script for a MRI whenever I want. I had a complete MRI of my shoulder when I found out about the bone spur and hooked acromion. He also told me I have an abnormally large space AROUND my labrum, but no tear there.

Any suggestions on what aspects of the body I should get an MRI on? Posterior capsule area? In addition to my whole arm? Of course this is IF and WHEN I get the MRI. I'm going to give therapy another month or so before I consider an MRI.

So far I have realized that when I bend the arm and have it in hard internal rotation with any type of weight in it, I get the dull ache in the inner elbow, but not always. Its very intermittent. Also too much computer use, def tightness the posterior capsule.

I've started stretching my pec minor again on the wall and foam roll. Additionally stretching my bicep and continuing doing the serratus rehab a few times a week.


#19

Yes, I suspect the teres minor and the infraspinatus are involved. And I would have to watch you perform the movement to know what is the weak link in the chain. Sounds like your serratus, delts, triceps, rotator cuff complex gets plenty of work before you get to the battling ropes.

That said, if the battling ropes is a part of your rehab, I think worrying about what exercises will make you better at it may be a case of not seeing the forest for the trees. In other words, let's not get caught up in hitting PRs in a rehab movement - especially one that's done towards the end of the session. Sure, you want to see performance go up; that indicates the rehab is working. However, this isn't a case of "what accessory lift will get me a PR on my dead lift."

Yep - it's the not knowing that eats away at you. The theory about the scar tissue matches my initial assessment back when the thread first started. Whether or not it's the case, you and your therapists will now have to explore one hypothesis, prove or disprove it, then move on. As you mark off what it is not, you should get closer to what it is.

Continue with the therapy, smr, and also keep a journal. Jot down anything, no matter how trivial it may seem, regarding what causes pain, fatigue, discomfort. And write down details such as what you were doing when the pain took place, the time of day, etc. There's no guarantee; however, you may see a pattern that could help solve this.

When the month of therapy is done, and you (hopefully) have a better sense of the matter, you can determine if a MRI is necessary and on which part of your body it should be done.


#20

Posted a reply this morning but I guess it didn't go through for some reason.

Def not trying to set PR's in any rehab or conditioning exercise, I was more curious on what I can do to get better at them considering I've got winging I'm working on and this inner elbow pain.

Here's the reason this not knowing exactly what is going on is killing me; because it creates some self doubt in all the treatment I have received from all the other therapists I have seen thus far in regards to my inner elbow. Don't get me wrong I have been lucky to have some great therapists work on my shoulder, help me realize how it works, what to strengthen, the importance of proper posture, the effects of sitting at a desk all day on the kinetic chain etc.

But at the same time many of them, just like any other industry are in it simply to make money and their bed side manner and communication skills are very poor. I realize that the average joe is not going to know what pronator teres syndrome is or thoracic outlet etc, but at least explain what you are thinking and what your plan of treatment is.... alright rant off.

I think I am starting to get closer to solving this mystery.

I started keeping a log and also had the head therapist at the clinic I work at take a look at it. He evaluated me, assessed my history and feels very strong that I have median nerve entrapment . My symptoms based on my log over the past couple days tend to agree with that. The pain as I mentioned before is concentrated primarily in the inner elbow right where the median nerve runs through.

Well since I started doing this log I realized I get a "heart beat" like pain in my hand just below my middle finger and sometimes it goes closer to my thumb as well. I looked t some median nerve anatomy and see that it runs through the middle, ring fingers as well as the thumb.

I will communicate all this to my therapist and the next step for me is to figure out where the nerve is entrapped and possibly get an EMG of the area. I had an EMG of my shoulder last year which came back negative, but feel like a closer look at the thoracic outlet & brachial plex area might show something.

This would also run consistent with the reduced grip strength I have in the hand, weakness when doing an sort of arm flexion and intermittent pain I feel there.

Let me know what you think 56.