Introduction: Median nerve damage caused by trauma is rare, especially after massage therapy. Only one case has been reported with recurrent motor branch of median nerve injury following massage, and there are no report of massage-induced median nerve neuropathy at the forearm. We report uncommon case of median neuropathy after massage in the distal forearm and its associated therapeutic process.
Case: A 61-year man visited our clinic and presented right hand paresthesia and numbness after massage therapy. A month ago, he received a massage on his distal forearm. The massage therapist pressed the distal part of the right forearm strongly using the elbow (figure 1), and the massage sessions lasted from 90 to 120 minutes. A week later, he told the massage therapist the symptoms, but the therapist ignored it and massaged the forearm area again.
In physical examination, there was no weakness of the right upper extremity. Hypoesthesia and paresthesia were checked in the palmar aspect of the right hand and first three and one-half digits. There was no other neurologic deficit, such as cranial nerve dysfunction and cervical radiculopathy. X-ray findings showed no sign of fracture or any other abnormality.
To confirm the injury of median nerve, electrodiagnostic studies were performed. In nerve conduction study (NCS), the sensory nerve action potential (SNAP) of right median nerve decreased to 60% compared to the SNAP of left median nerve. The motor NCS of median nerve was normal. In needle EMG, there were no abnormal findings in muscles like abductor pollicis brevis, innervated by median nerve.
Sonographic examination revealed a hypoechoic swelling of right median nerve at the level of just distal forearm level (above distal wrist crease 4cm). In this level, the cross-sectional area(CSA) of right median nerve was 0.19㎠, and the CSA of left side was 0.09㎠ (figure 2). The Magnetic Resonance Imaging (MRI) findings showed the edema in surrounding fat tissue and suspicious focal defect in epineurium of right median nerve, in distal radius level (figure 3).
The patient was diagnosed with traumatic median neuropathy, distal forearm level. The patient was initially prescribed medication (pregabalin and vitamin B complex) and received ultrasound-guided perineural dexamethasone injection. And, then five additional 5% prolotherapies were performed at 1-week interval. At 1-month follow-up, he showed more than 80 percent improvement in symptoms. Also, in sonographic examination, the CSA of right median nerve was 0.09㎠ and swelling was improved.
Conclusion: This is the first case report of traumatic median neuropathy in the forearm after massage therapy. Our case indicates that massage therapy can induce nerve damage, so the therapist should be cautious if the patient complains of neurologic symptoms.
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Figure 1. The patient received massage in the distal part of the right forearm (arrow). And there was mild swelling in the distal forearm.
Figure 2. Sonographic images (A) right median nerve, (B) left median nerve. The sonographic findings showed a hypoechoic swelling of right median nerve at the level of just distal forearm level (above distal wrist crease 4cm). In this level, the CSA of right median nerve was 0.19㎠, and CSA of left side was 0.09㎠. (C) At 1-month follow-up, the CSA of right median nerve was 0.09㎠.
Figure 3. The MRI images (A) T2 weighted axial view (B) T2 weighted saggital view of the right median nerve. Focal thickening and signal change with normal fibrillay pattern in right median nerve, distal radius level.
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