The Brachial Plexus

and Thoracic
Outlet Syndrome The brachial plexus of nerves and
Understanding Signs and Symptoms the subclavian/axillary artery and
By Joseph E. Muscolino, DC vein comprise a neurovascular

bundle that is often compressed

in the lower neck/upper thoracic

1
Thoracic outlet syndrome is the name given region, causing a condition known
to a set of neurovascular compression
syndromes that affect the brachial plexus of as thoracic outlet syndrome (TOS).
nerves and/or the subclavian/axillary artery
and vein where they outlet from the thorax
into the upper extremity. Note the presence There are actually four different forms
of a cervical rib on the model’s left side. of TOS, each named for the region where
Images courtesy Joseph E. Muscolino. the compression occurs (Image 1). One
Illustrations by Giovanni Rimasti. Photography is called anterior scalene syndrome because
by Yanik Chauvin and Joseph E. Muscolino.
the neurovascular contents are entrapped
and compressed between the anterior and
middle scalene muscles. The second is
called costoclavicular syndrome because the
Middle scalene
C5 entrapment/compression occurs between
C6
Anterior scalene
C7
the first rib (cost is Latin for “rib”) and
C3 the clavicle. The third is called pectoralis
Brachial plexus C8
trunks T1 minor syndrome because the entrapment/
compression occurs between the pectoralis
C6 minor and the rib cage. The fourth type
Cervical
rib of TOS occurs due to the presence of a
Subclavian genetic anomaly that creates what is called
artery
a cervical rib, which is a formation of bone
Musculocutaneous nerve off the seventh cervical vertebra (C7).
Median nerve The first three types of TOS—anterior
Ulnar nerve scalene, costoclavicular, and pectoralis
minor syndromes—are caused by soft-
tissue postural dysfunction and will
1st rib
Axillary nerve respond well to manual and movement
Radial nerve Subclavius
therapy care. Therefore, the emphasis for
anyone in the field of bodywork should
Brachial plexus be placed on these forms of TOS. The
cords
fourth type—cervical rib TOS—being due
to a relatively rare bony anomaly (which
occurs in approximately 1–2 percent of
Axillary artery
and vein the population) is not readily treatable
with manual and movement therapy and is
therefore of less importance to bodyworkers.
Pectoralis minor

60 massage & bodywork november/december 2017

 Brachial Plexus Tree

2
This image is an anatomically correct, yet artistic, rendering of the brachial plexus of nerves, providing a visual touchstone for learning the structures. Leaves represent the muscles
innervated by the branches of the brachial plexus; “½” indicates that muscle is innervated by two different nerve branches. Please see Tables 2 and 3 for a listing of the muscles
corresponding to the abbreviations used in this image.
 Cervical Rib: “True” Thoracic Outlet Syndrome?
Interestingly, the cervical rib version of TOS is often referred to in medical literature as true TOS, which implies
that the other forms of TOS are in some way false. Terming cervical rib TOS as “true” occurs because of the
undue emphasis the medical establishment places on skeletal structure, as well as the lack of importance it
places on soft-tissue dysfunction (the cause of the other three types of TOS). But it should be stated that all
four forms of TOS can cause the signs and symptoms of TOS and, therefore, are all “true” forms of TOS.

SIGNS AND SYMPTOMS OF TOS
A full awareness of the signs and symptoms
of TOS cannot be understood without
a somewhat in-depth knowledge of the
brachial plexus; however, the major concepts
can be addressed and understood. Before
moving forward with this discussion, it is
worth noting that symptoms, by definition,
are subjective in that they must be reported
by the client. For example, only the client
can state if they are experiencing pain.
Signs, on the other hand, are objective
in that they can be measured by the
therapist. For example, the strength of
the client’s pulse is a sign that can be
felt and reported by the therapist.
Neural Symptoms
Almost all peripheral spinal nerves are
mixed in that they carry both sensory and
motor neurons (the only exception is the
C1 nerve root, which is only sensory). In
this sense, they can be likened to two-
lane north-south highways comprising
a northbound lane that carries sensory
information gathered in the periphery
up to the central nervous system, and
a southbound lane that carries motor
information down from the central
nervous system to the periphery. TOS
usually involves peripheral nerve
compression; therefore, the two major
types of neural signs/symptoms result
from sensory compression and motor
compression. And, given that the brachial
plexus of nerves travel to/from the upper
extremity, these signs and symptoms
would manifest in the upper extremity—in
other words, the arm, forearm, and/or
hand. Most often, upper extremity nerve
compression is experienced in the hand.
Compression of a sensory neuron can
cause irritation of the neuron, creating
aberrant sensory impulses resulting in
increased sensation, termed hyperesthesia.
Examples include hypersensitivity to
touch, a feeling of tingling even when
no stimulus is being applied to the skin,
or burning or shooting pain. When the
compression is greater, it can begin to
obstruct axonal flow within the sensory
neuron, resulting in diminished ability of
the neuron to carry impulses. This, in turn,
results in diminished sensation, termed
hypesthesia. This is often experienced as
pins and needles, instead of a full sensation
of touch, when pressure is applied to the
skin. If the axonal flow is entirely blocked,
numbness can result. Any altered sensation,
whether it is hyperesthesia or hypesthesia,
can be termed paresthesia. Because
paresthesia, is by definition, something
the client feels, it is a subjective symptom
and must be reported by the client.
Given that motor neurons are
responsible for directing muscle contraction,
compression of a motor neuron would
affect muscle function. If the motor neuron
is irritated and creates aberrant nerve
impulses, then muscle twitching (termed
fasciculation) can occur. If the compression is
greater, then obstruction of the axonal flow
could result in the inability of the neuron
to direct its muscle fibers to contract. This
would result in weakness, and, perhaps in
time, atrophy of the associated musculature.
Arterial Symptoms
Arterial blood is delivered to the upper
extremity via the subclavian artery, which,
as it travels distally, becomes the axillary
artery, then the brachial artery, and then
divides into the radial and ulnar arteries,
which enter the hand. The various types
of TOS can potentially compress the
subclavian artery or axillary artery pathway
of arterial delivery into the upper extremity.
This would decrease the delivery of
oxygenated arterial blood to all the tissues
and cells of the upper extremity, distal to
the point of compression. In light-skinned
individuals, the skin’s pallor might become
cyanotic (bluish) and is often noticed in
the hand. Decreased arterial flow can be
objectively measured by feeling for the
strength of the client’s radial pulse at the
wrist (it should be emphasized that it is
the strength of the pulse, not the rate
of the pulse, that is assessed). As we will
see later in this article, palpating for the
strength of the radial pulse is the primary
means by which TOS is assessed.
Venous Symptoms
Venous blood is drained from the upper
extremity by veins that are similarly named
to the arteries. TOS can compress the
subclavian and/or axillary vein, which
would result in decreased venous return
and cause pooling of fluid—in other
words, swelling—in the extremities. As
with neural and arterial compression, this
will usually be noticed in the hands.
ORTHOPEDIC ASSESSMENT OF TOS
Given that there are three different forms of
soft-tissue dysfunctional TOS, there are also
three different orthopedic assessment tests.
I like to describe the fundamental concept of

62 massage & bodywork november/december 2017

 3A
3B
orthopedic assessment as “stress and assess.”
If we believe a structure is unhealthy and
causing the client to experience the signs or
symptoms of a condition, then the goal of
our assessment test is to increase the stress
on that structure to see if it reproduces or
increases the client’s characteristic pattern
of signs and symptoms. To do this, we need
to understand the underlying mechanics
of the condition we are assessing. With
anterior scalene syndrome, the underlying
mechanism is tight anterior/middle
scalene musculature; with costoclavicular
syndrome, the underlying mechanism
is a decreased costoclavicular space
between the clavicle and first rib; and with
pectoralis minor syndrome, the underlying
mechanism is a tight pectoralis minor.
Each of these cases results in compression
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Orthopedic assessment
tests for TOS. 3A:
Adson’s test for anterior
scalene syndrome.
3B: Eden’s test
for costoclavicular
syndrome. 3C: Wright’s
test for pectoralis
minor syndrome. 3D:
Alternate Wright’s test
position for pectoralis
minor syndrome.
3C
on the brachial plexus of nerves (or the
subclavian/axillary artery or vein).
Therefore, our orthopedic assessment
tests for these conditions involve increasing
the physical stress on the structures
involved. For whom would we perform these
TOS orthopedic assessment tests? Most
often, it would be for any client who presents
with upper extremity paresthesia or motor
dysfunction. The most common symptom
of TOS is tingling or numbness in the hand.
The three orthopedic assessment tests for
TOS are Adson’s, Eden’s, and Wright’s.
Adson’s Test
Adson’s test for anterior scalene syndrome
places a tension stress on the scalene
musculature by stretching it, thereby pulling
it taut and hard against the neurovascular
contents. Given that the anterior/middle
scalenes are flexors of the neck in the sagittal
plane, lateral flexors in the frontal plane,
and contralateral rotators in the transverse
plane, they would be stretched by asking
the client to move the neck into extension,
lateral flexion to the opposite side, and
rotation to the same side (Image 3A).
It should be noted that if the
client is experiencing TOS due to the
presence of a cervical rib, then because
the compression caused by the cervical
rib occurs at the scalene musculature,
Adson’s test would usually show positive.
Therefore, Adson’s test assesses TOS due
3D
to both anterior scalene syndrome and
a cervical rib. Cervical ribs can often be
palpated, but definitive assessment of a
cervical rib would be made by X-ray.
Eden’s Test
Eden’s test for costoclavicular syndrome
is performed by asking the client to
assume a posture that stresses the body by
decreasing the costoclavicular space. This
is accomplished by asking the client to
push their chest out and pull their shoulder
girdles back, as if standing at attention in
front of a commanding military officer
(Image 3B). This pushes the first rib
anteriorly against the clavicle as the clavicle
is pulled posteriorly against the first rib.
Wright’s Test
Wright’s test for pectoralis minor syndrome
stresses the pectoralis minor by stretching
it. Because the pectoralis minor is a
protractor and depressor of the scapula,
the client’s scapula is brought back into
retraction and elevation, using the client’s
arm as the contact (Image 3C). This tautens
and hardens the pectoralis minor, as it is
pulled posteriorly against the neurovascular
contents. There is an alternative position
for Wright’s test that involves stretching
and tethering the brachial plexus of nerves
around the pectoralis minor by simply
bringing the arm into abduction with
the elbow joint flexed to approximately

(A) Anterior view
90 degrees (Image 3D); this version of
Wright’s test is usually not as sensitive as
the first version presented in Image 3C.
In each case, the therapist assesses the
strength of the radial pulse. The concept is
that because the brachial plexus structures
lie next to the subclavian/axillary artery,
then if the pulse strength is decreased due
to arterial compression, we can extrapolate
that the brachial plexus nerve structures
must also be compressed. If the strength
of the pulse decreases during the test, the
test is considered positive. The test is also
considered positive if the client reports
the reproduction of their characteristic
paresthesia pattern in the upper extremity.
Adson’s, Eden’s, and Wright’s tests are
performed to determine which form of
TOS the client is experiencing. Once the
client is assessed as positive for TOS, it can
then be helpful to determine which nerve
is being compressed. This can be done
by comparing the location of the client’s
paresthesia with a map of the sensory
innervation of the brachial plexus nerves
(Image 4). Note: this innervation pattern
64 massage & bodywork november/december 2017
(B) Posterior view
should not be confused with a sensory
dermatomal map by spinal nerve root.
Determining the specific brachial
plexus nerve that is being compressed
can also be done by performing a series
of orthopedic assessment tests known as
brachial plexus tension tests (BPTTs).
There is one BPTT for each of the
brachial plexus terminal branches that
enter the hand: the median, ulnar, and
radial nerves. Following the concept of
stress and assess, each test is performed
by stressing the nerve by stretching it.
Stretching a nerve is performed in a similar
manner to stretching a muscle; our goal is
to make it longer, and this is accomplished
by knowing which side of each joint it
crosses from the neck down to the fingers,
and then moving these joints to increase
the length of the nerve. Images 5A–C
demonstrate the three BPTTs. In each case,
the test would be considered positive if it
recreates the client’s characteristic pattern
of upper extremity paresthesia. It is worth
noting that these BPTTs are essentially
identical to the positions used when
performing nerve mobilization treatment.
4
Sensory innervation patterns of the terminal
and preterminal branches of the brachial
plexus. A: Anterior view. B: Posterior view.
THE BRACHIAL PLEXUS
Although TOS can involve
neural, arterial, and/
or venous compression,
because nerve tissue is
more sensitive to pressure,
signs and symptoms of
neural compression are,
by far, most common. As
mentioned previously, a full
understanding of the signs and symptoms
of TOS requires a fundamental knowledge
of the brachial plexus of nerves. It is
only by knowing the sensory and motor
innervation patterns of the structures of the
brachial plexus that a full understanding
of the client’s signs and symptoms can be
appreciated and correlated with the TOS
nerve compression that is occurring.
Unfortunately, most students and
therapists are exposed to the brachial plexus
as an exercise to memorize for an exam and
then forget the details, without long-term
understanding of its structure, its function,
and its relationship to TOS. I have learned
and forgotten the structure of the brachial
plexus more times than I can count. After
all, there are roots, trunks, divisions,
cords, preterminal branches, and terminal
branches. Remembering in what order these
structures occur, as well as how they diverge
and converge, their exact names, and what
they innervate, can be a daunting task. One
of the reasons so many therapists, myself
included, struggle with truly learning the
brachial plexus is that most all figures drawn
for the brachial plexus are static and more
closely resemble a metropolitan subway
grid map than the brachial plexus itself.
 Brachial plexus tension tests
(BPTTs). 5A: Median nerve. 5B:
Radial nerve. 5C: Ulnar nerve.
Causes of Thoracic
Outlet Syndrome
The immediate causes of the
various types of thoracic outlet
syndrome (TOS) are clear. Anterior
scalene syndrome is caused
by tight anterior/middle scalene
musculature. Costoclavicular
syndrome is caused by either
a posturally collapsed clavicle
or elevated first rib decreasing
the costoclavicular space. And
pectoralis minor syndrome is caused
by a tight (or perhaps hypertrophied)
pectoralis minor. But the larger
question might be why these
conditions exist in the first place.
Often, two or all three of these types
of TOS occur together as part of a
larger postural dysfunctional pattern
known as upper-crossed syndrome.
Upper-crossed syndrome involves
hyperkyphosis (hyperflexion) of the
upper thoracic spine, protracted
shoulder girdles, and medially
rotated arms at the glenohumeral
joints. It also usually involves a
hypolordotic lower cervical spine
along with a hyperlordotic head
and upper cervical spine, and
a forward-head posture. When
upper-crossed syndrome is
present, it is usually necessary
to address this larger postural
dysfunctional pattern for any lasting
relief from TOS to be attained.
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5A 5B
So, for the purpose of this feature, I
had an illustration drawn of the brachial
plexus that is anatomically correct in its
labeling, but is artistically drawn as a tree
(Image 2). After all, the different named
parts of the brachial plexus are described
as roots, trunks, divisions, cords, and
branches. Having an illustration that
gives expression to the named parts of
the plexus and visually does so as parts of
a tree can offer the therapist a powerful 5C
image, a visual touchstone that can be a
major step forward toward truly learning
and remembering the structural and
functional intricacies of the brachial plexus. TABLE 1
To further aid in learning the structure Brachial Plexus Structures
of the brachial plexus, I have created a
teaching video at http://bit.ly/ABMP-BP Roots C5, C6, C7, C8, T1
that utilizes this brachial plexus illustration.
Given how full and complicated the
brachial plexus as a whole is, it is helpful to
approach it a few structures at a time. For
Trunks Superior, Middle, Inferior
this reason, we will build up our illustration
beginning literally from the ground up.
Superior Anterior, Superior
STRUCTURES OF THE Posterior, Middle Anterior, Middle
Divisions
BRACHIAL PLEXUS Posterior, Inferior Anterior, and
The structures of the brachial plexus, Inferior Posterior
in order, are: roots, trunks, divisions,
cords, and branches. More specifically,
the branches at the ends of the cords Cords Lateral, Medial, Posterior
are terminal branches; there are also
preterminal branches that arise along the
course of the brachial plexus from the roots (Terminal): Musculocutaneous,
to the cords. The structures can be seen in Branches
Axillary, Median, Radial, Ulnar
Image 6 and are listed in Table 1. Note: only
terminal branches are shown and described
in Image 6 and Table 1; preterminal
branches are shown in Image 2 and Table 3.
 6
The main structural components of the brachial
plexus of nerves: roots, trunks, divisions,
cords, and (terminal) branches.

7
The cords of the brachial plexus are named
for their relative position to the axillary artery.

Roots
There are five nerve roots that contribute to
create the brachial plexus. They are the C5,
C6, C7, C8, and T1 nerve roots (Image 6).
Joseph Muscolino is offering his Digital Clinical Orthopedic Manual Therapy
streaming subscription service at a deep discount to ABMP members. This
service contains all his video content, plus new content uploaded each week.
For more information, visit his website at www.learnmuscles.com/abmp.

Trunks
The five nerve roots of the brachial
plexus create the three trunks of the
brachial plexus. They are the superior,
middle, and inferior trunks.

Divisions
Each of the three trunks of the brachial
8
plexus then divides to create an anterior
and posterior division. Hence, there The ulnar, median, and musculocutaneous nerves form
are six divisions of the brachial plexus: a characteristic “M” shape around the axillary artery.
superior anterior, superior posterior, (Note: this image is oriented 180 degrees differently to
middle anterior, middle posterior, inferior Images 6 and 7.)
anterior, and inferior posterior divisions.

Cords
The six divisions of the brachial plexus
then converge to form the three cords.
They are the lateral, medial, and posterior
cords. It should be pointed out that
the cords are named for their relative
positions to the axillary artery (Image 7).

Terminal Branches
The three cords of the brachial plexus then
diverge to form the five terminal branches.
They are the musculocutaneous, axillary,
median, radial, and ulnar nerves.
In a cadaver lab, anatomists look to
identify the cords and terminal branches
of the brachial plexus by locating the
characteristic “M” shape of the ulnar,
median, and musculocutaneous nerves
around the axillary artery. The outer legs
of the “M” are formed by the medial cord
giving rise to the ulnar nerve and the lateral
cord giving rise to the musculocutaneous
nerve. The inner legs of the “M” are formed
by the medial and lateral cords contributing
to the median nerve (Image 8). Once
these cords and branches are located and
identified, the other (posterior) cord and
other two terminal (radial and axillary)
branches are located by looking posterior to
the axillary artery. Thus, this “M” shape is the landmark for locating all three cords and all
five terminal branches of the brachial plexus.
Motor Innervations of the Terminal Branches
Each of the five terminal branch nerves of the brachial plexus divides to form motor
neurons that innervate muscles of the upper extremity. In Image 9, each of the muscles
that is innervated by a terminal branch is represented by a leaf of that branch. Note:
Image 9 also shows that each of the five terminal branches also has a sensory innervation
component; for more detail on these sensory innervations, please see Image 4.
Motor Innervations of the Preterminal Branches
The five terminal branches of the brachial plexus are named terminal because they branch
from the ends of the cords. However, there are also 11 other preterminal branches that
emanate from the brachial plexus before the ends of the cords, either from roots, trunks,
or along the length of the cords. These preterminal branches are shown in Image 2. Leaves
indicating what muscle(s) is/are innervated by each preterminal branch (or whether it is
sensory) are also indicated in this image (for more detail on these sensory innervations, please

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 TABLE 2
Muscle Innervations of the Terminal Branches

Author’s note: The abbreviation listed after each name

corresponds to the abbreviation used in Image 9 (as well as
Image 2).

Coracobrachialis (Cb)
Musculocutaneous
Biceps Brachii (BB)
Nerve
Brachialis (Brach)

Deltoid (Del)
Axillary Nerve
Teres Minor (TMin)

Pronator Teres (PrT)

Pronator Quadratus (PrQ)
Flexor Carpi Radialis (FCR)
Palmaris Longus (PL)
Flexor Digitorum Superficialis (FDS)
Median Nerve Flexor Digitorum Profundus (FDP)
Flexor Pollicis Longus (FPL)
Abductor Pollicis Brevis (APB)
Flexor Pollicis Brevis (FPB)
Opponens Pollicis (OP)
Lumbricals Manus (LM)
Triceps Brachii (TrB)
Anconeus (Anc)
Brachioradialis (Brrad)
Supinator (Sup)
Extensor Carpi Radialis Longus (ECRL)
Extensor Carpi Radialis Brevis (ECRB)
Radial Nerve Extensor Carpi Ulnaris (ECU)
Extensor Digitorum (ED)
Extensor Digiti Minimi (EDM)
Abductor Pollicis Longus (APL)
Extensor Pollicis Brevis (EPB)
Extensor Pollicis Longus (EPL)
Extensor Indicis (EI)
Flexor Carpi Ulnaris (FCU)
Flexor Digitorum Profundus (FDP)
Flexor Pollicis Brevis (FPB)
Opponens Pollicis (OP)
Abductor Digiti Minimi Manus (ADMM)
9 Flexor Digiti Minimi Manus (FDMM)
Ulnar Nerve
Opponens Digiti Minimi (ODM)
The brachial plexus illustration seen in Image 6 now has leaves added to the tree. Each leaf represents
Palmaris Brevis (PB)
a specific muscle that is innervated by the terminal branch from which it emanates (sensory innervation
Adductor Pollicis (AdP)
is also indicated); “½” indicates that muscle is innervated by two different nerve branches. See Table 2
Lumbricals Manus (LM)
for a listing of these muscles corresponding to the abbreviations used in this image.
Palmar Interossei (PI)
Dorsal Interossei Manus (DIM)

68 massage & bodywork november/december 2017

 see Image 4). Thus Image 2 gives us the full nerve branch is being compressed and,
expression of the structure and innervation therefore, direct our manual therapy
TABLE 3 patterns of the brachial plexus of nerves. assessment and treatment. Image 4
Muscle Innervations of the Preterminal illustrates the sensory innervation pattern of
Branches Importance of Motor Innervation the peripheral nerves of the brachial plexus.
The specific muscles innervated by the
Author’s note: The abbreviation listed after each
terminal and preterminal branches of BRACHIAL PLEXUS AND ITS
name corresponds to the abbreviation used in
Image 2. the brachial plexus have been described RELATIONSHIP TO THORACIC
in Images 2 and 9, and listed in Tables 2 OUTLET SYNDROME
and 3. Knowing these motor innervations Although knowing anatomy for anatomy’s
Long Thoracic of the brachial plexus nerves can help us sake is wonderful, ultimately, its importance
Serratus Anterior (SA)
Nerve understand how TOS nerve compression lies in our ability to marry together the
Rhomboid Major (RMaj)
can affect muscular function and assist underlying science of anatomy with our
Dorsal Scapular
Rhomboid Minor (RMin)
us in finding and treating our clients’ hands-on manual therapy assessment
Nerve
Levator Scapulae (LevSc)
dysfunctional patterns. Most commonly, and treatment techniques. By first
TOS will result in compression of learning anatomy (structure), physiology
Subclavian Nerve Subclavius (Subcl) median, radial, or ulnar nerves. Assessing (function) can be figured out. By then
the presence of TOS can then be understanding function, altered function
Suprascapular Infraspinatus (Infra) correlated with motor dysfunction in the (pathophysiology) can be figured out.
Nerve Supraspinatus (Supra) innervation patterns of these nerves. Armed with an understanding of the
mechanics of pathophysiology, our hands-
Medial Pectoral Pectoralis Minor (PMin)
Nerve
The following motor innervation on assessment and treatment tools can
Pectoralis Major (PMaj)
generalizations can be made: then be determined. In essence, a deeper
Lateral Pectoral Pectoralis Minor (PMin) • The musculocutaneous nerve innervates knowledge of anatomy allows for the critical
Nerve Pectoralis Major (PMaj) the muscles of the anterior arm. reasoning skills that then allow for creative
• The median nerve innervates the application of our hands-on manual and
Upper Teres Major (TMaj)
Subscapular muscles of the anterior forearm movement therapy techniques.
Subscapularis (Subsc)
Nerve and the intrinsic muscles of the
Lower thenar eminence of the hand. Joseph E. Muscolino, DC, has been a manual
Subscapular Subscapularis (Subsc) • The ulnar nerve innervates the intrinsic and movement therapy educator for more than
Nerve
muscles of the hypothenar eminence 30 years. He is the author of multiple textbooks,
Thoracodorsal
Latissimus Dorsi (Lat) and central compartment of the hand. including The Muscular System Manual: The
Nerve
• And the radial nerve innervates the Skeletal Muscles of the Human Body (Elsevier,
Medial posterior muscles of the arm and forearm. 2017); The Muscle and Bone Palpation Manual with
Antebrachial Sensory only
Cutaneous Nerve Trigger Points, Referral Patterns, and Stretching
Author’s note: slight exceptions to these (Elsevier, 2016); and Kinesiology: The Skeletal
Medial Brachial
Sensory only
rules exist (see Image 2 for the detailed System and Muscle Function (Elsevier, 2017).
Cutaneous Nerve
muscle innervations), but they are a good He is also the author of 12 DVDs on manual
starting point to learning motor innervation and movement therapy and teaches continuing
patterns of the upper extremity. education workshops around the world, including a
certification in Clinical Orthopedic Manual Therapy
Importance of Sensory Innervation (COMT), and has created Digital COMT, a video
Knowledge of the sensory innervation streaming subscription service for manual and
patterns of the branches of the brachial movement therapists, with new content added
plexus is also extremely important. If a each and every week. Visit www.learnmuscles.
client presents with any type of paresthesia com for more information or reach him directly
(e.g., pain, tingling, numbness) in the upper at joseph.e.muscolino@gmail.com.
extremity, the location of the paresthesia
can direct us toward which brachial plexus

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