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Hey there, El Paso! This is Dr. David Middaugh, specialist, physical therapist over at El Paso Manual Physical Therapy, and I'm your host of the Stay Healthy El Paso Podcast. Today we're going to talk about misdiagnose plantar fasciitis, and specifically how to figure out your heel pain. Because if you really don't have plantar fasciitis then what the heck is it? What's going on? And how do we feel?

Get this out so that you can get back to being normal, get back to being active, healthy, and mobile in your foot and ankle without having to rely on pain medications, injections and of course, dreaded surgery.

Let's get into some specifics about how plantar fasciitis is typically diagnosed, what healthcare professionals are looking for, as far as symptoms, signs that that are classified or diagnosed as plantar fasciitis. And then what kind of treatment options are out there. I'm going to get into the controversial stuff, the misdiagnosis, and how we look at it here in the clinic at El Paso Manual Physical Therapy, and how we find misdiagnosed plantar fasciitis.

Almost every time we see a plantar fasciitis patient, somebody that comes in saying they got plantar fasciitis. So let's get into it. First off, the biggest symptoms that people have, whenever they go to see their physician, or their foot doctor, or whoever it is they are seeing as a healthcare professional for their heel pain.

When doctors, physicians, foot specialist diagnose plantar fasciitis, the number one sign they are looking for is when you get up in the morning. Your first few steps, if you have sharp stabbing pain in the heel, that tends to get better as you walk around more, but maybe never goes away or maybe it does if it's not that severe. But the classic telltale sign is that sharp stabbing pain with your first few steps in the morning.

That is often called plantar fasciitis. And there may be some associated limping that goes on. If you can't walk normal. You have to walk very, very carefully, holding on the furniture, holding on to things as you get up. And then some people report swelling as well. They get swelling around the heel area.

They get a different sensation. At the bottom of their foot, on the heel side of their foot, and some people perceive it as swelling. The last patient we had in here with these kinds of symptoms said that she felt like the pad at the bottom of her of her heel was flat. Like it lost its air, like a tire on a car. Like she said, she was like I have a flat tire and I'm stepping on the bone, instead of the cushion, the meat of the foot under the heel. That's kind of the description people have. And it can get better and worse without ever really knowing or understanding how it happens.

As far as treatment, once you tell a physician that you have this, and then they are going to automatically start writing down plantar fasciitis treatment. There are tons of ways to go with this. Of course, physical therapy is one of the treatments. I'll talk more about that later. But let's talk about other treatment options that people go towards if they have plantar fasciitis.

The simplest easiest one that people do is ice, they start icing their heel.

They will just get a bag of ice or some sort of cold thing that you can buy the story to those, those gel packs. The other thing that's commonly done is they will get a water bottle that they freeze. So it's like a cylinder shaped ice block essentially. And they will roll it on their heel and the arch of their foot. And that can be quite beneficial.

Actually, the reason for that is because it numbs the tissues, and everything under the foot and can be relieving, but it doesn't solve the root problem. Which I'll get into more about what the root problem is. But let's just go through these treatment options.

The next one is braces.

People often try all kinds of braces, the ones that you lace up the ones that have struts, metal struts or hard plastic struts on the sides. There are braces that you just wear at night. Those are called night splints. You may not use anything during the day. But there are special plantar fasciitis braces that you wear at night.

The reason why they are special is because they typically have this fabric strap that hangs off the end of the toes that is attached to the shin area of the brace. So it holds your foot and toes up, like you're lifting your toes up, and it puts a stretch on the bottom of the foot into the heel. And some people report they feel a little bit of relief with that.

Another more invasive treatment option is injections. Injections are commonly done for plantar fasciitis symptoms, specifically cortisone or corticosteroid injections because that drug is an anti inflammatory and pain reliever. The thought is that the plantar fascia, which is a tissue, and I'll go more into it in a second. It it's inflamed, and so if we inject anti-inflammatory medication, then it would help with the pain and with the long-term outcome.

The problem is that the plantar fascia is made of connective tissue. And corticosteroids are known to degenerate connective tissue with prolonged use. So, it's very much a short-term solution. And then, in extreme examples, you can have surgery. There are plantar fascia release surgeries where a surgeon will go in there and cut the plantar fascia to relieve pressure.

Now I'm not 100% sure on exactly how this is done, as far as if they cut the entire plantar fascia or a portion of it. This isn't a common surgery. So it's not something that I know a lot about because we just rarely see it. I've seen it in two people before and where they cut it on the scar, it looks like it's only a partial cut not a complete cut of the plantar fascia. I think that's how they are doing it is he just cutting an edge of it to lengthen it a bit. Just to relieve some pressure. But they will cut it the whole way is my is my hunch.

Anyway, as far as the way I think about the body mechanically, I doubt that a surgeon would completely cut the plantar fascia. In most cases when they are going where they are looking to do surgery on the plantar fascia.

Okay, so we're going to get into the PT treatment discussion about what is done in physical therapy for plantar fasciitis. But real quick, let's visit what plantar fasciitis is, physiologically, what's going on in the body so that listeners can understand how this all works.

Let's start off with the plantar fascia itself. The plantar fascia is connective tissue that attaches from the heel of the foot. And if you want a visual of this, it's easy to just go plantar fascia, Google will probably autocorrect if you have trouble spelling it. Because it is a little difficult to spell and click on the images tab, and you'll see tons of pictures of plantar fascia. It's all over the internet.

Anyways, it's a white tissue, a connective tissue. It's white because it has a low blood supply. And its job is to help maintain the arches of the foot. There are actually three arches in the foot. The main one that everybody talks about is a medial longitudinal arch, but there are a lateral longitudinal arch and a transverse arch. But its job is to primarily help hold up the medial lateral longitudinal arch.

The theory, and I say theory because this is this is not proven. This is how most healthcare professionals are operating. The theory is that plantar fasciitis develops because it's getting overly stretched out. So if you have flat arches, it's tensioning the plantar fascia. And if you do that too much, then it begins to irritate the plantar fascia at the insertion point at the heel. And that's why it's tender at the heel. And that's why people get these symptoms when they first stand up, it hurts a lot right in the heel.

That's why the treatment options are such that's why they do the surgical, the plantar fasciitis releases, that's why the braces The idea is that it's too short and needs to get stretched out as well at the heel. That's the thought process with normal plantar fasciitis. But what most healthcare professionals don't think about, that I need you to be aware of, is that the plantar fascia is not the only structure in the heel, which means it's not the only thing that can cause pain or discomfort or some problem.

You also have a pretty substantial fat pad, under the heel. There are bones there, the calcaneus in the heel bone. And there are tendons that pass in the area. Tendons are what connects the muscles to bones. They help to transfer forces to pull on things and make them move. And then the biggest culprit of heel pain in my opinion is nerves.

Nerves cover our entire body. And specifically, in the heel. There are several nerve branches that cover the heel and there is one that runs right over the insertion point of the plantar fascia. So when I do my testing, when I have a plantar fasciitis patient here in the clinic, one of the first things I do is, I do something called a wineglass test and I do a modified version of it. I'm looking to put some tension on the plantar fascia. And then I have to poke on it. And now what we'll do is we'll poke on it without tension and poking it with tension.

The idea here is that if it is truly plantar fasciitis, if it is the plantar fascia that is affected when we put tension on it because it's connective tissue, it's designed to maintain some tension to hold certain body parts together, in this case, the arches of the foot. It stresses the tissue a bit, and then if we apply pressure on it, that stresses the tissue a bit more. It should theoretically hurt most at the plantar fascia. If we apply tension to it and put pressure on it with it with the finger versus if we take tension off, we put it on slack and then apply pressure it should hurt less consistently.

When I get a patient with plantar fasciitis, I do this one last test and it is negative. In other words, it shows that the plantar fascia is not the culprits. And then I'll cross references tests with the nerve tests, where we feel and tension and affect the nerves that run into the heel. And those tests become positive. I have to make the call the diagnosis with the patient that the heel pain is not plantar fascia driven. Its nerve driven.

Now this changes everything because if its truly plantar fascia driven, then the treatment is going to look different. Now we have to ask the question of if it's a nerve problem, do we need to be stretching? Do we need to be splinting it? Do we need to be bracing it? Is injections going to help? Is doing a plantar fascia release surgery going to be effective for a nerve problem in the heel?

I always ask the question of, did the doctor that diagnosed you with this plantar fasciitis do these tests? And it's always no because they just aren't aware. It's just not something that they are trained to do or have figured out to do. And I don't expect it of other healthcare professionals. This is our profession as a manual physical therapist. So it's our specialty.

But we can figure out if it's truly more nerve or more plantar fascia or something else, there are issues in the joints of the foot that can also contribute to heel pain. And we looked at that and then there are also a situation where you can have a combination of things. So we have to judge that scenario as well and then make the proper treatment recommendations for the patient moving forward.

But what we'll settle on here is about nine times out of ten, when we get a plantar fasciitis diagnosis here in the clinic, patients coming in saying I saw a doctor, they told me about plantar fasciitis. I googled the symptoms and all over the internet, it says heel pain, limping and swelling or symptoms. So I'm Dr. Google's confirm for me and a real doctors confirm for me and I have the paper here from the doctor saying that I have a plantar fasciitis syndrome, then I'm thinking to myself, I'm not going to I'm going to take this with a grain of salt. I'm going to check it for sure, but let's check the nerves too and other things so that we can know exactly how to treat this.

Now, if it's plantar fasciitis, if it’s true plantar fasciitis, physical therapy treatment is usually focused on improving the arch. Which makes sense, because you want to take pressure off of the plantar fascia using muscles and other structures in the foot to alleviate the pressure on the plantar fascia.

But if it's not plantar fasciitis, and if it's a nerve problem, and we're doing a treatment that's treating plantar fasciitis to better support the arch, we're going to miss the boats and people can experience a situation where they go through physical therapy. Do all the foot and ankle and toe exercises, they typically will do heel raises, calf raises is another name for it, whether tippy toeing, they might do it in different ways, maybe seated to do a live version of it standing to do a harder version of it, with weights to do an even harder version of it, on a foam pad to add a balance aspect to it single legged.

They will do ankle stretches where they stand against a wall and push their heel back and put a stretch to the achilleas in the foot and the heel. They will do toe exercises as well. A common one is where they have to scratch up a towel with their toes, or pick up marbles with the toes, or I've seen some people have to pick up pins or other objects with their toes and it always makes people feel like a monkey because you're having to use your toes like fingers.

It can help to alleviate some of the symptoms, even if it's a nerve driven problem. Simply because we're just getting more motion to the foot and the heel. Motions that haven't been done before. But to truly fix the problem for the long term, so that it's not coming back in three months, or six months or a year, we've got to look at the entire length of the nerves that end up in the heel, and typically it's the sciatica nerve.

One of the questions here is the misdiagnosis that I'm talking about. One of the questions that I have to ask every patient, whenever they come in with heel pain, is do you believe you have, or do you have minor amounts of sciatica or low back pain? Because the nerve that ends up in the heel that is commonly affected, it's a branch of the plantar nerve, which is a branch off the tibial nerve, which is a branch off this sciatic nerve which starts up in the back.

So, do you have pain in your butt area, your thigh, your calf? Do you have any cramping that occurs in the calf and the thigh up in the hip? Do you have any shakiness? Have you had any back problems? Or maybe it's not really painful now but in the past have you had issues?

I'm also looking at the way their back moves, any other muscle imbalances that might be further up the chain. And I'm putting all this together to formulate the best diagnosis which will then lead us to the best treatments. And time and time again, it happens where we find an issue we, find a some sort of back pain, and usually the heel pain is so intense and so limiting that our patients often forget that they have back pain. It's not something that they are worried about.

And if they are on pain medication for the heel, that lower level sciatica pain, or back pain kind of diminishes, and they just don't even think about it. They are completely focused on getting rid of the heel pain. That they just don't pay attention to the back or thigh pain that they've been having. But have to dig there. And then I'll do some nerve tests. And once we do those nerve tests that are biased and tensioning nerves into the heel, if those tests are positive, if they create some sort of symptoms, then it's absolutely a nerve driven problem.

Then the treatment for that is completely different. We're doing some foot exercises, some foot, hands on treatments, that I have to look at the knee, we have to look at the hip, the thigh and the lower back. And oftentimes, we're doing treatment on the low back, hips, and knees in addition to the foot and that's what truly clears up the heel pain. I wouldn't even call it plantar fasciitis at that point.

The last client that we had with this, she came in and she's been having heel pain for a while. She is an active individual. She's in her 60s, late 60s I believe. She loves to do housework, gardening work. She takes care of her elderly mom, who's gone through some health conditions. She is active and wants to vote. She's a grandmother and is trying to spend time with her family. She's not really a couch potato. And she's been doing that for a long time. She helps out her husband with a business and is on her feet quite a bit for that.

So this active individual all of a sudden was put down by this heel pain and she just kind of muscles through it, but it has to grit through pain and discomfort all the time. And the biggest problem she had was when her mother was at her sickest, she's gotten better. Thankfully. Her mother was waking up at night often and our patient would have to get up to go check on her at night often, and it was just killed her, it would hurt her heels so much to have to take those first few steps at 1am and then at 3am, again at 5am again. And so it was just so painful and aggravating.

When you're in that much pain and that much discomfort, you just don't want to get up, you lose focus, you aren't thinking clearly, you want to take medications, you're grumpy. It's just a bad situation. What she found is that wearing shoes helped. It didn't completely take away the pain. Wearing shoes, it had a little bit of a heel helped.

It also didn't take away the pain though. And she tried doing normal physical therapies, she tried doing ice. She hadn't done injections or surgery and thankfully. She tried braces and splints. And it all kind of helped but didn't really solve the problem. So that's why she ended up visiting us. And once she saw us, she was convinced it was plantar fasciitis. A doctor told her it was plantar fasciitis and she's googled it, and it was plantar fasciitis.

She has all the symptoms and when I look at everything on her, I found that she had a significant back condition that is going to put pressure on nerves and can mask a plantar fasciitis symptom, but it really is a nerve symptom. So as we've gone through treatment for a nerve symptom, not plantar fasciitis. She's done phenomenal. Her getting up in the in the middle of the night is less of a problem and getting up in the morning isn't a big deal.

Now where she's at, we're about a little over a month in. She is really only getting pain or discomfort after she's been on her feet after a long day. Which is a great place to be because now it's just a matter of getting stronger in certain muscles. In her specifically, the biggest weakness that she's got wasn't in the foot. It wasn't in the lower leg anywhere near the heel. It was her abdominals. By strengthening her abdominals, what I determined is that we can take pressure off her back, because that's where she's getting the most pressure on the nerve.

So, by strengthening her dominance properly and having her use them throughout the day properly, that alleviates pressure in her back, which unintentionally, the nerves beginning at the roots in her back, which then will allow more nerve freedom all the way down into the heel. So far we've been successful and I know she's going to be fantastic as she continues to strengthen, and then doing her busy, active lifestyle, gardening, taking care of the house, taking care of family members won't be a thing for her. It won't stop her this heel pain.

That's how plantar fasciitis is often misdiagnosed. It's just taken for words from the healthcare professionals that have its heel pain, if it hurts in the mornings, especially if there are some limping or swelling going on. Then it is plantar fasciitis. But it's not dug into more than that simply because most doctors or physicians, foot specialists just are not specialists looking at the nerve aspect of this.

And if you're out there, you have heel pain and you tried the braces, the splints, you've tried taking over the counter pain medication, maybe even prescription strength pain medication, or worse yet, you've had injections or maybe even a plantar fasciitis release surgery, and you still have the problem. I'm willing to bet that you've probably got a nerve problem that hasn't been addressed. And you've been misdiagnosed, unfortunately, with plantar fasciitis when really you have what I call radiating nerve pain. That's what that means.

And no amount of orthotics or insoles will fix this problem either. It'll help, don't get me wrong. I'm not against orthotics or braces or splints. It will help but I'm talking about long term resolution of this problem. We've got to address a number of symptoms and we've got to look all the way up the chain of joints and muscles, and oftentimes it ends up being in the back and the hips.

So that's our podcast episode for today. I hope you learned a lot if you have plantar fasciitis symptoms, heel pain, and you suspect that this problem might need a deeper look into it. You can definitely reach out to us here at El Paso Manual Physical Therapy, and we're happy to talk to you about it to see what can be done about it, if it can be helped, if we're the right people to help you for that.

We can we can begin that conversation. You give us a call at 915-503-1314 and we're happy to hear about your heel pain story and want to learn more about it and see if we can help out. I hope you have the best day ever today. Bye.

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Hi El Paso, welcome to the Stay Healthy El Paso Podcast. I'm your host, Dr. David Middaugh, specialist physical therapist over at El Paso Manual Physical Therapy. I'm going to be talking to you today all about pinched nerves in the neck and shoulder.

We get clients asking us about this all the time. Sometimes they come in for treatment specifically for a pinched nerve problem. It's just gotten way out of hand and they don't know what else to do.  At times, it just is a pester that bothers people from time to time. It's not really something that they are looking for treatment for. They are actually in here for a foot problem or knee or back problem. But they still ask, Hey, I've got this issue, this pinched nerve that bothers me from time to time.

I wanted to answer the questions of what is it? Why does it happen? And what does it feel like. Then we'll go into some other tangents likely, why does it need surgery and how to relieve it. So stay tuned, you are going to hear all the details about pinched nerves and the neck and shoulder.

What is a pinched nerve?

Let me talk to you about the anatomy just a bit here. The spine is made of a ton of bones. It starts in your tailbone and goes all the way up to the base of the skull. The top seven bones right below the skull are the cervical spine on the side of those bones, between them actually, there are little holes where the nerves come out that go all the way down into your arm. And those holes are called transverse framing.

But were all those nerves come out, they all bundled together after they come out of the spine. And then they separate again and muddled together, they go through this area called the brachial plexus, which is right behind your collarbone on either side. Then once it passes that area, the nerves split up in a bunch of different directions, and they go down in your arm. Some make it all the way down to your fingertips.

The reason for those nerves is, of course, to provide the connection to the muscles so that you can use your arm and hand and everything. They also provide sensation to the skin, and they do a bunch of other things too, that aren't normally talked about. They control the blood vessels in your body, they control all kinds of other things that just aren't normally talked about and people don't really need to know in depth about unless that's your specialty.

But anyways, when we talk about pinching a nerve along the pathway, all the way from the neck to the fingertips, there are several opportunities for the nerve to get compressed or pinched. And if that happens, then it impedes the function of the nerve. It may not shut it off completely, you may not, sever the nerve or you won't cut it off. It will just usually put some pressure on it. And the way that it feels, to most people, is a low level of discomfort or pain and achiness. Sometimes it's a burning sensation. And then if they move in a specific way that they may not always know, it really bites them. I

t's a 10 out of 10 pain and just jolts the individual and they snap to stop what they are doing for moments, and then it usually starts to wear off over the course of a few seconds, maybe a few minutes at most. That's the typical presentation for pinched nerve.

If you've ever had that experience, you likely just had it once in a while here and there, but then for some people it becomes more frequent, it starts to happen more often, to the point where it happens daily, multiple times a day. Then people start to pinpoint “every time I reach out to grab the laundry from the washing machine, or to put something in the dishwasher. When I go to open the car door. I just know it's going to bite me and I'm not looking forward to it. Or if I'm in bed and I pull up the covers, it just bites me when it's a heavy blanket.” Another one is picking up a pot of coffee, or certain times when exercising, it can really set off that pinched nerve sensation.

That's typically what it feels like. And when it's really bad, when it's happening very frequently. It can be debilitating. I mean, it won't let you sleep at night, just little simple movements start to become painful, they start to set off a pinched nerve, and then that low level of discomfort, becomes a medium level of discomfort. and then eventually I high level of constant discomfort.  Because that pinched nerve is just getting irritated and more irritated over time. And it doesn't get a chance to calm down and normalize.

Why does it happen?

Let's talk about that next. How do the passageways for the nerve become compressed? Because usually there's no injury involved in most people, they just start to have this. There wasn't an accident, there wasn't a car accident, they didn't fall or get hit somehow. It just started to gradually happen.

Well, some of the most common places to pinch a nerve is right where the nerve comes out of the spine, right between the bones where that hole is the transverse frame, and if you have arthritis issues in your neck, you've had a history of neck problems. Because that hole is made up of the top half is one bone, the bottom half is another bone. If the disc between the two spine bones begins to change, shorten or lose its height, then that hole can also shrink.

Another thing is if your postures chronically not great, over time that can also cause that hole to be smaller. They call that pyramidal stenosis, this is when any hole becomes smaller in the body like you hear about spinal stenosis, that's what that would be, spinal pyramidal stenosis. So that's one way to pinched nerve.

Another one that's less talked about, but I see here all the time, is if your upper body is pretty weak, especially around your neck and shoulders, your collarbones can sink down. And because those nerves eventually bundled together and pass behind the collarbone, they can put some compression on the nerves.

Occasionally, you hear doctors diagnose patients with something called Thoracic Outlet Syndrome. And what they are talking about is that space behind the collarbone, where those bundles of nerves pass, and the bundle of nerves by the way is called the brachial plexus. If that gets chronically compressed, it can impede the function of the entire arm. Everything below the nerves there can begin to become affected.

Now what happens with people that have not the greatest posture, weak upper body, they begin to use some muscles on the sides of their neck for stability that they are not supposed to be using. They are called the scalene. The scalenes are some interesting muscles they attach from the neck to your first rib and your second rib, which are right behind your collarbone.

A lot of people don't grasp that your ribs go that high. They always think of the ribs being around their torso area, but your first and second rib are way up right at the base of your neck. Because these scaling muscles can become overused at times when they shorten, they can actually yank the first and second rib upwards. And those nerves that I was telling you, at the brachial plexus, they come right over the first and second ribs. If those ribs are getting pulled up, and then your collarbone is sunken down, it creates a sandwiching effect on your poor brachial plexus on those nerves that go down the arm.

That's another place that people often get a pinched nerve sensation. Now, to just make it worse, those scalene muscles that I was telling you about, you have three pairs in your body. You have an anterior scalene, middle scalene, and posterior scalene between the anterior and middle scalene, the front of the middle one is where the brachial plexus passes out from the spine and begins to go under your collarbone. So if you are chronically overusing your scalenes, just like any other muscle, if you use it and use it and use it, it gets bigger.

Those scalenes can get really hard and begin to compress on the nerves as well. Basically, you'll get a triple effect on those poor nerves in the in the brachial plexus area. You can get the collarbone sunken down, the ribs yanked up, and then compression from the scalenes. When we see that, it's a monster to fix, and it's not an easy task, but it can be fixed.

What it feels like?

Typically, people just get this jolt of pain when they turn a certain way. They can't get comfortable at night, they always have this low level of discomfort that runs to their neck and shoulders. They may also get knots in the area, especially around the neck and the upper trap are on the back of the shoulder. They'll get lumps. Wen those ribs pop up, they can feel really hard. They can feel like really hard lumps that be rubbed out, but they never really go away. It's because it's bone. Usually it doesn't go away. It just needs to be shifted down and those muscles need to be calmed down so that they aren't perpetually yanking the ribs up. It's a it's a process for sure.

Another common place, and this will be the last one I'm going to go into, because I can just go on and on. The last on is in the shoulder itself at the ball and socket joint. So those nerves, the brachial plexus, once they pass about the shoulder joint, they start to turn into a bunch of different other nerves. They label them differently because they go to different parts of the arm and connect to different muscles.

The big ones are the radial nerve, the ulnar nerve, the median nerve, and the muscular cutaneous nerve. That's the one that goes to the bicep. All these nerves can get pinched around the ball and socket joint. If your ball and socket joint is having problems moving, if you have issues with it. Issues like a rotator cuff tear, a biceps tear, subacromial impingement, or shoulder impingement is the more common term for it.

Those issues usually mean that the ball and socket joint is not moving normally, and because it's not moving normally, it doesn't allow for normal movement of the nerves which can begin to pinch them. What I often find, that clients are not really aware of, and I guess because this is what I studied and trained in, and live, sleep and breathe all this physical therapy stuff. But nerves move.

If you think about it, your nerves, like I said go from your neck to your shoulder, and all the way to your hand. And every time you move your arm around or your leg around, the nerves within that body part are moving along with it. And it's healthy for your nerves to move, it's necessary. It actually is vital to the health of the nerve that you get in some movement.

This is another reason why exercise is so important. But anyways, if that ball and socket joint is not moving normally or you are babying the shoulder because it's injured, it can begin to also pinch your nerves, and that can feed into that pinched nerve sensation.

When we see people here in the clinic that are coming in directly for a pinched nerve problem. Oftentimes I tell them that this is a massive problem. It's not just a one or two visit deal. We are going to see it for a couple of months likely, potentially longer, as we fix problem by problem. We have to go one step at a time.

The analogy that I like to use is, if you visualize a water hose, it comes out of your backyard, and you turn on the faucet where the hose is attached to the side of your house or the front of your house. And water is flowing through the hose and you see water coming out at the end. Well visualize, somebody's going to go step on the hose a bit, not hard enough to completely cut off the flow, but enough to impede it.

Then they put their other foot on it a little further down the hose and it impedes it just a bit further. So now you have less water flowing at the end of the of the hose. And then let's say two more people come down further the hose, and they step on it and put both feet on it. Eventually you have six spots where the hose is being impeded. Now you got just a trickle at the end, and nobody's even pressing that hard. It's just enough to cut off the flow little by little.

It's the same idea within nerves. Nerves, when they get pressure, then they can still function, but their function is impeded. It's not going to work. Normally it's reduced function. You are going to get pain of course, because that's the nerve telling you “Hey, I'm hurt!” or something's not right. But then you are also going to experience some weakness.

Eventually, if you don't take care of that you can run into other problems like a rotator cuff tear, or further an arthritis problem, or some sort of strain or sprain. Oftentimes, we see muscle spasm because the muscles freak out because the nerve connection from where it's getting pinched is not normal.

The muscle can sometimes react in a way where it spasms. It can cause that spasming. A milder sensation that people get is something called facilitations. But that's muscle twitching. A lot of people when I bring that up, they are like, Yes, I get that. I've been getting that for a while now. I'll be sleeping at night, or I'll be sitting down at work, or watching a movie or something. And all of a sudden, my tricep is just going crazy. It's just twitching, and I can't make it stop, I have to shake my arm out for it to go away. But then next time I sit down again for a while, it starts to twitch again.

That's just the muscle freaking out, it's getting pinched a bit. So those are common sensations people get and that's how we have to approach the problem. By taking one foot off the hose at a time, then taking the next foot off, and it's always a process.

In the description that I outlined for the common ways that this happens. We have to free up the neck joints to make sure that the holes in the side of the spine are open enough to allow free mobility of the nerve. We have to calm down those spaces and muscles, which can mean a combination of massage, and, of course, moving the neck joints so that they free up better. Moving the rib joints, and then also training the person on how to have better posture, and how to exercise in a certain way to calm down the scalenes.

Then we have to look at the upper body strength and find the weakest parts of that. To strengthen that, you have to look at any joints that aren’t moving well. Sometimes a lot of times the shoulder blade isn't moving very good, the collarbone isn't moving very good. The upper back joints in the spine aren’t moving very good, and all the ribs associated with that, we have to get that moving.

Sometimes we have to look at the chest muscles as well and see how flexible, or how strong those are. The ball and socket joint as well, we’ll look at how well aligned that joint is, and how the quality of motion within that joint, and then all the muscles that control it. Of course, the rotator cuff muscles are the big one. But there are a bunch of other muscles that contribute to its mobility that we have to look at.

It's a big long process and it's not even a direct treatment for the nerves. This is all indirect. But there are even times where we have to do specific techniques to the nerves to get them to begin to operate more normally. That's a whole other ballgame. But the good news with all this is that rarely does anybody need surgery.

Usually, when people get surgery for this type of problem, they are getting a surgery in their neck where they, I say this in air quotes, they clean it up, they clean up the neck. Where I said that there are holes in the side of the neck, and you can get stenosis where the hole narrows a bit. They can go in there and widen the holes surgically. But I always tell people that are looking to get that procedure done, it's probably going to close again if you don't fix your posture or address your strength. But you have to consider what got you to close the hole in the first place.

Because if you begin to undo that, maybe you have a shot at opening it up on your own naturally, without having to go in for a surgery that may only last for a year or two, before it closes down again. And then you are going to be stuck with, I'm going to have to have another surgery or go through physical therapy anyway, like I should have the first time potentially.

Now there are cases where it's severely pinched. And usually this person has of course, immense pain, but they also will have lost completely loss of strength, like they can't use your hand. The muscles in one hand look completely different compared to the other, the bicep will be weak, the tricep will be very weak. I mean, you can tell a notable, massive difference. Most people have some minor differences. If they take their shirt off and look in the mirror, they just look at their arms and they'll notice a small difference in muscle size from one side to the other.

But when it's pretty massive, when it's obvious, and other people can tell pretty easily. There's usually either a chronically pinched nerve, and when I say chronic, it's probably been years, potentially decades, or it's just been so hard that it has almost no nerve input. And it's just gotten weaker and weaker over time, very, very quickly. Over the course of a few months, it's lost all its strength.

That's a situation where you might actually need surgery. But to my knowledge, I don't know surgeons that will operate on the first and second rib to put it down. That's something that's done by hand here in the clinic. And then to increase mobility in the spine. That's a combination of hands on work from a specialist physical therapist, and then also exercise that a patient has to go through, that's guided by a specialist physical therapist as well.

But I, to this date, I've never worked with a client that ended up having surgery for a pinched nerve, we've helped everybody just fine. The good news is it gets better. We have an awesome success rate with these clients, and they get tremendously better. They get to the point where they are exercising, if that's what they wanted to do, they are sleeping fantastic.

We know we have to talk about posture, so they are sitting better at work, they are driving better whenever they are in the car, they are having a meal much more comfortably, and most importantly, they have the confidence to move without that fear that something is going to bite them in their neck and shoulder area. So, it's extremely fixable.

Thanks for listening today. I hope you learned a lot. If you want to learn more information about neck and shoulder problems, there are tons of blog articles on our website. Our YouTube channel is very active if you want to get notified right away when we release a new YouTube video, go to our YouTube channel El Paso Manual Physical Therapy and hit subscribe, and you'll get all our latest information about the neck and shoulder as well as other body parts.

I hope you have the best day and if you are out there with a neck and shoulder pinched nerve problem, please get some help as soon as possible. Don't let it get really bad.

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