Good morning. Happy Monday. I have neural coffee in hand and it is perfect. All right. Coming off a very solid weekend. Very busy day today. Digging straight into today's Q&A. This is with Taya. Taya had a question that comes up a lot when we're talking about elbows. This has to do with nerve issues, some mobility issues, some extensibility issues, but all of this comes down to position and then adaptations that may be associated with those positions. So whenever we're talking about something that's in the distal extremity, we always have to be concerned with our proximal orientations and we have to work our way out. So shoulder girdle matters, elbow orientation matters, wrist orientation, and of course the hand, especially with ulnar nerve, because she describes two different scenarios in regards to ulnar nerve symptoms, both of which can be determined in regards to the greatest influence as to where we'll see the most tension. And so we can use our neurodynamic test under these circumstances to help us identify where that may be. And then that can help us drive our decision making in regards to which orientation has the greatest influence. So thank you, Taya. Great question. Lots of information in this video for those of you that may be dealing with medial elbow symptoms, ulnar nerve symptoms, or even wrist symptoms. If you would like to participate in a 15-minute consultation, please go to askbillhartman at gmail.com. Askbillhartman at gmail.com. Please put 15-minute consultation in the subject line so I don't delete it. We'll arrange that at our mutual convenience. Everybody have an outstanding Monday, and I'll see you tomorrow. Thank you.

My question is regarding the ulnar nerve hypermobility. I just have a client that has a problem with the ulnar nerve, especially the sensation in the hand. So I just wanted to run my thought process by you just so if I understand the whole thing correctly.

Yes.

So when you have this issue, you have the whole humerus oriented into ER, as well as the upper forearm, while the lower part of the forearm is in pronation. So in this case, the pistol test is positive. Yeah, and the cubital tunnel gets more flat, which puts more pressure on the ulnar nerve when the arm is flexing. Okay.

Yeah, go ahead. Keep going. Sorry. You're fine.

So this occipital tunnel gets more flat, which puts more pressure on the owner nerve when the arm is flexing. Okay.

Okay. So with the hypermobility, are they sensing that the nerve is clicking across the elbow? Do you know what I'm talking about?

One client, yes; the other one, no. The other one just feels the sensation like here and in the hand.

Okay, because now you're going to have to look at your hand orientation as well because the issue might be the differential between the hand and the wrist, right? Where the nerve runs through the tunnel of Guyon. Okay, so the tunnel of Guyon is through here. And as it goes through there, there might be a curve that it has to go around, which can cause some compressive forces that would cause numbness and things, or is it pain?

Yeah, yeah.

It's just numbness. Yeah. Okay. So if it's just, if it's just here, then you've got a hand to wrist orientation. It doesn't mean you have to clean. You, you have to ignore this. It just means that it might be more local here. Whereas up here, you've got the shape change where the, where the, uh, the nerve comes, comes through the cubital tunnel there, right? So again, you might have two different representations here. You're going to have to clarify the hand position and then the humerus elbow position in both cases. And you may have to do the same thing. I don't know. But the thing I want you to recognize is where do you have the biggest differential might be where you spend more of your time. So this is a bony band. This is a bony band here. This is, this could just be like a relationship of, of hand pronation to the, to the wrist orientation.

Yeah.

So again, you might have two different representations here. You're going to have to clarify the hand position and then the humerus elbow position in both cases. And you may have to do the same thing. I don't know. But the thing I want you to recognize is where do you have the biggest differential might be where you spend more of your time. So this is a bony band. This is a bony band here. This is, this could just be like a relationship of hand pronation to the wrist orientation.

That's what I wanted to check. So if the problem is in the wrist, it just means that the hand is more pronated relative to the forearm.

Most likely. Okay. How can you tell?

With the apple test.

Okay, so those tests are really, really helpful, but there's a cool little test that you can actually identify where the greatest tension in the nerve is. This. Ah, very good. Perfect. Okay, so but what I would say, do you know how to do it? Do the, uh, the, the neurodynamic test yourself on them? Do you know how to execute that test segmentally?

Segmentally, I just have to check probably the flexion first and then like this. If they're ready.

If you have them do it actively, you will not be able to tell where the greatest tension on the nerve is.

I know if the flexion is in the elbow, it's the uh the occipital tunnel. If I'm not mistaken, but if it's, but if they don't feel the sensation just flexing, okay.

You have to execute the test on them. Okay. Because you'll be able to feel where the tension increases as you're executing the test. So you want to look at all-nerve neurodynamic tests, okay? You have to be able to execute it because you'll be able to feel the resistance at the elbow, you'll be able to feel the resistance at the wrist, and then you can correlate that to number one, the tension that you're feeling and number two, the symptoms that they may have at the time. You need a before and an after test other than the symptom because if they have some sensitivity, you might be successful with your reorientation but they still may have symptoms. Nerves are funny, they take a while to change, right?

Okay, so regarding the presentation that leads to this occurrence of sensations. The first step would be to untwist the arm. Oh, the anterior expansion.

You need axial position. You need shoulder position. You need elbow position. You need wrist and hand position.

Yeah, I was just wondering. So I'm guessing first you need AP expansion and then.

So Relye, are you measuring the shoulder? Yes. So rely on your test to guide what you need. Chances are you're going to have external rotation orientation approximately here. Chances are. So you're probably right that you're going to need both anterior-posterior expansion. But again, trust your measurements. Don't guess. If you're measuring directly, you should be able to determine what you need to do first. Because if you reorient this to allow the anterior-posterior expansion and you get your external rotations and internal rotations back approximately, this might be gone.

Okay, but if it's not.

Then you keep going. Yeah.

Yeah, I'm just wondering since the VISTA forum is in pronation, so is it like right to assume that I would drive supination and humorous internal rotation.

At some point. Your first goal is to get everything to match. If I'm oriented into ER, if I have humeral ER, if I have proximal radius ER, I want to turn everything into IR first. So I get IR, IR, IR, IR, IR. So now it all matches. Now I go back and I turn it back over and now I teach them how to supinate at the same time and ER at the same time. Do you understand? Much easier to compress everything into IR first, and then orient them back into ER.

And just as I was watching also your video on the elbow valgus presentation, is this the same as the ulnar nerve hypermobility presentation?