If You Think You Have Carpal Tunnel, You Probably Don't

Every year, over three million cases of carpal tunnel syndrome (CTS) are reported in the United States (Mayo Clinic). True CTS results from irritation or inflammation of the median nerve as it passes through the tunnel in your wrist. This tunnel is a narrow passageway of ligaments and bones at the base of your hand. Pressure can build up in this tunnel, resulting in numbness or tingling in the hand. Continued strain can lead to severe pain in your wrist, making work and daily activities uncomfortable to accomplish.

However, symptoms such as numbness, tingling, and wrist pain are oftentimes resulting from musculoskeletal dysfunction (meaning: tight muscles), and not true CTS.

Sometimes, thickening from the lining of irritated tendons or other swelling narrows the tunnel and causes the median nerve to be compressed.  The result may be numbness, weakness, or sometimes pain in the hand and wrist, or occasionally in the forearm and arm.  CTS is the most common and widely known of the entrapment neuropathies, in which one of the body’s peripheral nerves is pressed upon.

Many cases of Carpal Tunnel Syndrome are misdiagnosed for several reasons.

• We don’t truly understand the causes of Carpal Tunnel. It seems to be aggravated by overuse and strong evidence that by correcting daily movement you can make significant improvement.

• While the Median Nerve is implicated in CTS, it actually begins from the spinal cord and rooting through your neck and out almost every vertebrae before running down towards your fingers.

• Given that the Median Nerve crosses many muscles on the way to your fingers. It’s no wonder that any number of factors might cause CTS-like symptoms like a tight muscle in your neck or shoulder may cause “tingling” in the fingers. And while it’s similar it isn’t necessarily CTS.

• It goes misdiagnosed because most doctors aren’t necessarily well versed in understanding soft tissue related dysfunction. This leads to a general diagnosis of “tendonitis” which often will call for you to rest.

  • Do seek a second and third opinion if the doctor wants to inject you or schedule you for surgery.

Fortunately, carpal tunnel-like symptoms can often be easily managed with soft tissue work performed on the scalenes, pec minor, coracobrachialis, and several other upper extremity adhesion sites at the cervical spine.

Two very common suggestions to relieve CTS are cortisone injections in your wrist, or surgery to cut the transverse carpal ligament to release pressure.

While it may seem like a quick fix, I am strongly against cortisone injections as they have been shown to speed up degeneration of damaged ligaments and cartilage.

Do I Have Carpal Tunnel Syndrome?

Many cases of CTS are often misdiagnosed but can be resolved with soft tissue work and improving every day movement. The following tests will help gauge if you should seek help from a medical professional:

1. Phalen's Test

1. You can perform this seated or standing.

2. Passively let your wrist flop into a flexed position as shown in the diagram above.

3. Hold this position for 60 seconds or until symptoms are reproduced.
   Positive response: numbness and tingling occurs on the palmar aspect.
   Negative response: 3 minutes passing without symptoms reproduced.

(The two hand version above is an alternative way to test, though I prefer the one hand version.)

2. Tinel's Test

Tap where circled

1. Lightly tap over the median nerve as it passes through the carpal tunnel in the wrist.

2. Follow your index finger from the tip, then down the palm and up the forearm looking for any sensation.
   Positive response: A sensation of tingling in the distribution of the median nerve over the hand or in the thumb or first 3 digits.
   Negative response: no sensations.

If either test returns positive, I recommend seeing a doctor. If both tests return negative, great! You most likely do not have CTS and can relieve symptoms without surgery.

What to do if both tests return negative:

1. Correct Your Posture

Great little infograph from The Art of Manliness on standing posture

• Focus on sitting up straight, shoulders neutral, and keep the chin in and head straight. By making sure you're sitting and standing upright, it will take the tension of the muscles that might be causing your CTS-like symptoms in the first place.
  Releated: Thoracic Spine and Breathing to help unlock better posture

• Keep your wrists in a neutral position, not bent backwards. This can help prevent a lot of the tightening of the muscles which can possibly entrap a nerve.

2. Stretch

As stated above, something as simple as poor posture can give you CTS-like symptoms. Here are three main areas of the body and their stretches to relieve poor posture:

• Upper shoulders and neck (upper trapezius, levators, SCM, scalenes)

• Upper chest/shoulders (pectoralis major and minor, serratus anterior)

• Forearm (numerous muscles, including pronator teres.)

Upper Shoulders and Neck (Trap) Stretch: 

1. Reaching your right hand down at your side towards the floor, let your head tip to the left.

2. Slightly vary the angle of your head to feel different versions of the stretch.

3. Hold this to each side for 15-30 seconds and repeat 2-3 times per side.

Chest and Shoulder Stretch:

1. Standing up straight with a tightened belly, reach your arms straight out to your sides at shoulder height (as seen above).

2. Move your arms straight back as far as they’ll go without arching your back. You can do this with assistance from a doorway or wall to help your hands move back.

3. Hold for 10-30 seconds, without pain. Repeat 2-3 times.

Forearm Stretch:

1. With your right arm held out in front of you, use your left hand to stretch the wrist stretching the hand up (shown above).

2. Hold each for 15-30 seconds, 2-3 times. Repeat on other side.

3. Manual Therapy & Corrective Exercise

In conjunction with the improving your posture, wrist position, and stretching, manual therapy from a Licensed Massage Therapist can greatly relieve CTS-like pain. After finding and relaxing the contracted muscles in the above mentioned areas, corrective exercises are performed to offset any problems associated with poor posture and poor breathing patterns.

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Has a doctor suggested wearing a wrist brace for extended periods of time (all day and all night, even when you're sleeping)? Restricting wrist movement isn't a solution and doesn't address the true underlying problem.

If this sounds like you and the tests above show you don't have true carpal tunnel syndrome, schedule a consultation in person or online and get rid of your tingling, numbing, debilitating wrist pain for good.

Lack of Internal Hip Rotation Relates to Low Back & Hip Pain

Improving internal hip rotation is important for a variety of reasons including:

• It allows us to go into a deep squat position safely

• Key contributor to knee and low back pain

• Poor movement for rotation sport athletes like baseball or even golf

• For runners, it doesn’t allow the athlete to extend the hip to engage the glute.

Hip IR should be tested in two positions, because different structures can limit your range of motion depending on whether the hip is extended or flexed. The second test is actually a mobilization for improving hip IR if and when progressed properly.

Testing Seated Internal Hip Rotation

Sit at the end of a table, with your knees bent over the side, and hold onto the table itself.

Now internally rotate the hip, without abducting or side bending, which is a sign of compensating with the lower back.

Generally speaking 35 degrees is good in the general fitness population and 40-45 degrees in competitive athletes.

A quick check to see if you may simply have a "lazy" side if one leg has better hip IR than the other. Perform a side plank on the side that's lagging and reassess. It should improve if it's simply an activation problem, otherwise it helps to narrow down the problem to a structural/muscular or alignment (though not very common) problem. 

Mobilizations to Improve Hip IR

Kneeling Glute MOB

• Set up on all fours with hands under the shoulders and knees under the hips.

• Maintain a slight arch in the lower back and place your right foot on the back of your left knee.

• With your back set sit back into your right hip and hold for a 1-2 count before moving back. Perform 5-10 reps on both sides.

Lying Knee Pull Ins

• Lie on your back with your knees bent and your feet flat on the floor.

• Exaggerate the width between your feet.

• Think about trying to internally rotate your femurs which as a result have your knees touch together while keeping your feet on the floor. Hold for a two count and return to the starting position. The stretch should be felt in the hips and not the knees.

• Perform 8-12 reps before working out.

• Good for those with muscular restrictions.

Prone Windshield Wipers (TEST #2)

• Lie on your stomach with your knees together and feet up in the air.

• Keeping the knees together, let the feet fall out to the sides.

• Hold for a two count and return to the starting position.

• Perform 8-12 reps prior to workout.

• This is great in particular for those with a capsular restriction.

Passive Internal Rotation Stretch

This goodie comes courtesy of Dean Somerset. This is more of an advanced stretch and would be sure to be able to knock out all the above aforementioned ones before using this one to help maintain proper hip IR.

• Sit at the end of a table or elevated step and lift one leg back into internal rotation as shown.

• Progressively work your work close to the table, and hold for 30 seconds.

• Repeat on the other leg.

I hope that this post will help steer you in the right direction to improve your lifts in the gym and your times on the trail.

If you should have any specific questions please shoot me a message and I'll be happy to try and help out. If any of this information was insightful, helpful or funny please share it with a friend!

I'm All In: What Poker Taught Me About Life and Business

The photo above was taken in 2010 I believe while I was playing in the World Poker Tour LA Poker Classic at the Commerce Casino. 

I used to take playing poker very seriously. I spent countless hours playing out hands in my head, reading forums and books to go along with thousands of hours spent playing online (before it was deemed illegal). My best stretch was when I was 22 and cleared a shade under $10,000 in 4 months during a summer. I was pretty good but I really disliked the unhealthy lifestyle that came with playing for 8-12 hours daily to make a living.

Poker is a zero sum game. This means that in order for there to be a winner, there has to be a loser. And at times the best play was to target those who would exhibit signs of addiction as those people aren't playing a sound game, mathamatically speaking, This is not something I feel particularly proud of but that's the game. 

And while I no longer play to pay my bills there were a lot of lessons I picked up playing cards.  Many lessons that translates over to life and business. Here are a few of them.

Expected Value (EV)

In probability theory the expected value of a random variable is the sum of the probability of each possible outcome of the experiment multiplied by the outcome value (or payoff). 

Simply stated EV (in poker) is the amount of money you can win or lose on your average bet. It's often explained by flipping a coin, which is an example of neutral EV. What are the odds it will be heads or tails? Over a small sample size it's 70% tails, extrapolated over 1,000 or 10,000 flips, it will be closer to 50/50. 

No one, not even the best players win every tournament, let alone every single hand they play. Whether you play well or poorly, you'll win some and lose some. Good players are profitable over the long haul because they maximize their spots when they're winning and minimizing losses when cards aren't running their way. They focus on making good decisions regardless of the outcome.

This rings true in business. If you continue to put yourself in the best position by playing the positive percentage plays, more often than not you'll be a winner. 

Which leads me to the next point. 

You can do all the right things and still lose

This one drove me insane. How can I be an overwhelming 95% favorite and STILL LOSE!!!

Because like in life, you aren't in control of everything so anything can happen. Yes you should've won, you should've gotten that business because you're better than your competition, but a'las they've decided to go with Joe-Trainer instead. That's completely out of your control and you need to accept the cards of life as they fall even if they're not in your favor. Move on to the next play.

Always Moving Forward

Piggybacking off the last point, even if you don't get the business, you can't dwell on it for long. Continually beating yourself up for mistakes isn't going to help you change for the better. It's only a complete failure if you fail to learn from your mistakes.

There were so many times I made the wrong move at the table which cost me tournament wins and money! I was angry/sad for a bit but ultimately I would reflect on what I could've done differently. There's no point in being upset with something that's now in the past.

Learn from the past, be in the NOW, and always be preparing for the future. 

Bankroll Management

If I bring in $1,000 and spend $900 of it on going out. I'm not left with much else for anything else. Let alone any unanticipated expenses. 

Knowing how to budget your money is an invaluable skip to learn. You need to stay within your means because you never quite know what might happen. In the case of Poker it might be a few dry months where your cards couldn't hit the side of a barn; in life it could be a car accident or broken appliance you clearly weren't expecting.

It goes without saying again: Always be saving and stay within your means so you can weather the bad times. If you take one too many risks, you might play yourself right out of the game. 

Know Your Numbers

What are the odds of flopping a third Ace when you have two of them in Texas hold em?
Odds of flopping a straight?
How about completing a flush on the river if I only need one last card?

I know these numbers off the top of my head like the back of my hand. I'm not rain man, I just memorized them. But knowing your numbers is just as important in business. 

What's your conversion rate for free consultiations to paid clients?
Run any marketing campaigns? What's your CAC (customer acquisition costs)?
What are your food costs? 

You don't need to know these things at an accountant level, but you should know what's going on behind the scenes. Knowing the lingo helps you communicate with experts and understand what's going on in your business. 

In case you were wondering:
Flopping 3 of a kind 8.5:1 or 10.5%
Flopping a straight about 1%
Completing a flush on the river, assuming you have all 9 remaining cards of that suit, is roughly 18%. 

Understanding basic human psychology

Most people have watched high level poker on ESPN and imagine that pros can detect any facial tick or lean which gives them an edge. While this is sort of true, what great players pick up on are patterns. I would often pay close attention to deviations in patterns:

How did they play after losing a hand?
Does that change if it was "unlucky" versus playing poorly? Do they even think that was a poor play?
Are they more talkative when they're nervous? Do they always take a sip of water when making a borderline decision?

It comes down to understanding how people normally act and if or when there's a change, deciphering what it means. When dealing with clients who are resistant to change, knowing how to pick up on non-verbal cues has been an invaluable skill to have cultivated.

Implied Odds

This is calculating the odds of completing your hand and the future bets you would collect if you do. You need to take stock of the percentage chance you have to complete you hand versus the amount of money already sitting in middle of the table. 

Simply stated: Calculating risks is a little more cut and dry in poker since it's all math. But the same basic principles apply where you need to take stock of what an investment of time or money will cost you, and whether or not it's going to be worth doing. If you make decision"x" what will be your return on investment? And how long will it take for you to break even?

Poker is a game that's easy to learn but hard to master. There are only a few of the lessons I've picked up from this game. I believe poker is a fantastic training camp for those looking to cultivate skill necessary for business and critical thinking. 

Are You Ready For Your First Pull Up

The ability to perform a pull up isn't simply a feat of strength but a byproduct of a structured balanced training program. Before we go on any further lets be specific on what a strict pull up is:

• From a dead hang
• Arms are full extended at the start
• Chest/sternum to the bar
• Minimal swinging

Where To Begin

Can you get your arms in the right position to perform any sort of vertical pulling motion? I would begin here against the wall in a back to wall shoulder flexion screen

1. Begin with your back from head to tailbone against the wall.
2. Flatten out your lower back (slight posterior pelvic tilt)
3. Lift your arms straight out in front of you towards the wall

You pass if you can reach the wall comfortably without losing contact of the wall.

This screen shows us a few things:

• Good core positioning
• Adequate shoulder mobility to an overhead position
  • Limited external rotation (Including short pecs, lats, and subscapularis)
  • Lack of upward scapular motion (including weak lower trapezius and serratus anterior along with synergistic dominance of the levator scapula, rhomboids, and pec minor)
• Poor thoracic spine extension
• Lack of anterior core stiffness

This is important because if you can't get your arms overhead at rest what makes you think you'll be able to under full bodyweight load hanging off of a bar?

If you didn't pass, I would address the soft tissue restrictions listed above and improve mobilization in the thoracic spine and improving upward scapular motion.

Here are a few video to help you get started with that.

Thoracic Spine Extension Do's & Don'ts DONT •allow rib cage to flare up, this puts excessive strain on the low back. •support the neck so you don't end up extending backwards. DO •set the ribs by exhaling which controls the thoracic spine in a better position. •once you move down as far as you can controlled, then practice taking deep breaths without releasing the set rib position. •this then segue ways into adding an overhead motion while keeping the core set.

A post shared by Gary Heshiki Fitness (@garyheshikifitness) on Jun 30, 2016 at 9:08pm PDT

42 Likes, 7 Comments - Gary Heshiki Fitness (@garyheshikifitness) on Instagram: "Thoracic Spine Extension Do's & Don'ts DONT *allow rib cage to flare up, this puts excessive..."

Related: Thoracic Spine and Breathing

If you passed congrats you can physically get into an overhead position safely, but now where do you go from there?

That Pull-Up Machine

Yeah stay away from the counterbalance machine that most commercial gyms have. My main beef with the machine is the lack of stability required to perform this version (hint: it's zero). I've seen it many times, a lifter works their way down to the lightest setting, only to barely be able to get anywhere close to an actual pull up. But why?

The main cause is poor tension throughout the body along during the movement. You spent so much time building strength in a stable position, a free standing pull up is anything but. I would say it's akin to push ups from your knees, you may get the big muscles strong but you aren't stable enough to express your strength.

Which is why I start all my clients with...

Inverted Rows

The inverted row allows you to learn how to properly engage the right muscles while having to actually stabilize your bodyweight. Most every gym has at least one of these TRX straps  hanging in their facility so just about anybody can do these. 

The ability for an individual to get good scapular motion, pull and engage their lats, traps and rhomboids is key to being able to have that carry over to performing a pull up. This move should be the main bodyweight motion until you're able to perform them with your feet elevated.

Really any row variation is great at teaching engagement of the proper muscle, a favorite of mine is the chest supported variety which keeps you honest from momentum. A chest supported T-Bar works well too. 

Negative & Isometric Pull Ups

After some time working on strengthening the proper muscles, I would then begin both negative only motions and isometric holds.

This is an intelligent way to overload the motion because as the muscle lengthens under tension, it is able to produce greater force. Unlike the concentric (think pulling yourself up) the joint is pulled in the direction of that contraction whereas the eccentric (lowering) contraction the muscle slows down the joint at the end of a movement. 

In plain english: Your body is significantly stronger from an eccentric stand point versus a concentric only. 

I would have the client jump up, sternum to the bar and contract the lats, stick the shoulder blades into their back pockets and slowly lower themselves back down to the box. The most important aspect is control. If you can't come down at a 3-5 sec count, then I would go back to inverted rows until you are able to. 

Band Assist Pull Ups

From there I would also incorporate the band assist version. This would be done in conjunction with the isometrics and negatives only. The only problem is not everyone has access to these bands but they are very useful (also they can be a little pricey for a full set of bands).

And then it's simply a matter of patience. Put in the work and soon you'll be knocking out pull ups like a champion. There are many other variations I use with clients but this is at it's simplest the most straightforward progression that most individuals can follow. 

You Get What You Pay For

"I'm sick, can you please direct me to the cheapest doctor that will do the job?"

"My car is making a weird noise, can you recommend the least expensive mechanic?"

"My roof is leaking, will you please call the cheapest repair man?"

"I need a personal trainer, do you know anyone cheaper than the guy at the gym?"

Of the four statements I bet most people would say that number four is the one they would likely think or say. Why is that? 

Standards in Fitness

It's a catch 22--you don't know what to do and you want to hire someone. The problem is that a $30 per hour trainer may not know how to work around your specific injuries, compensations and/or lifestyle so they may in fact do more harm than good. But no one bats an eye after you get hurt because they say it's part of the process. No pain no gain, right? (No, it's not.)

Do you have to seek out the most expensive trainer around? No, and in fact there are fantastic coaches available at all price points if you look hard enough. The problem isn't the consumer being educated but the industry as a whole. Whether you hire a commercial gym trainer or an independent seasoned vet, you should be able to get results and be better off having hired said coach, not worse. Unfortunately this isn't the case across the board.

Why Do Some Trainers Cost $100+ per hour?

Why do some trainers command over $100-150 per hour if all should be qualified enough to help you out with any straight forward goals, like adding on muscle or losing 15 pounds?

It comes down to specialization and likelihood of remaining safe. Price often acts as a filter for quality, though not always the case. 

Lets use a doctor's analogy: If you have a cold, you would likely visit to a general practice physician. But if you have a broken leg and needed surgery, you'd likely go to an orthopedic doctor and surgeon. It makes sense that the person who specializes in that specific area of medicine would be the person to cut you open, not the general practice doctor. But both are doctors! Yes, but one has a bit more knowledge about the matter at hand. And since a surgery is a much more dangerous and intricate procedure, I'm willing to bet they will cost more. 

So can the $30 per hour trainer help your daughter with her ACL post-physical therapy outpatient rehab? Maybe, but I bet that $200 per hour trainer who has testimonials of similar cases and the background to aid her can. Yes, it's a lot more money, but if you want the job done right, you hire once and you hire right. For me, I'd rather spend three months with a more knowledgable, more expensive trainer than 8 months with a less expensive, less knowledgable one if it means I'll get the best results possible. In this scenario I'm also willing to bet you'll remain safer with the $200 per hour coach.

Too often the fitness industry writes articles about how the consumer needs to become more educated, pushing the onus on them. While I don't disagree that a more educated customer is beneficial, I also feel that the industry as a whole needs to take more accountability on raising their own standards of practice.  Only then will telling people you're a "personal trainer" actually mean something more than just a guy who counts reps and grabs you a towel.