1. NERVE GLIDING EXERCISES:
EXCURSION &VALUABLE INDICATIONS FORTHERAPY
SARAH ARNOLD, MS, OTR
HANDTO SHOULDERTHERAPY CENTER
INDIANAPOLIS, INDIANA

2. OBJECTIVES
1. Describe the benefits of nerve gliding exercises
2. Describe the clinical indications for nerve gliding:
 Traumatic
 Non-traumatic
3. Identify key components of a therapist’s evaluation
4. Discuss treatment approaches and apply nerve glides in
your clinical practice

3. WHAT IS A NERVE GLIDE?
Gliding/sliding/flossing
Tensioning
nerve
nerve

4. PHYSIOLOGY OF NERVE GLIDES
h local tissue nutrition
h blood flow
h nerve conduction
h nerve mobility
Photo from: http://voer.edu Cooper, 2014

5. EXCURSION
GLIDINGOFTHE NERVE RELATIVE
TOTHE SURROUNDING NERVE BED
Photo from: www.minneapolishanggliding.com

6. NERVE EXCURSION
Ulnar Nerve
Elbow flexion/extension 14 mm excursion at the elbow Grewal et. al, 2000;
Wright et al., 2001
Wrist flexion/extension 14 mm excursion at the wrist Wright et al., 2001
Median Nerve
Wrist flexion/extension 19.6 mm excursion at the wrist
Wright et al., 1996
Digital flexion/extension 9.7 mm excursion at the wrist
Radial Nerve
Elbow flexion/extension 8.8 mm excursion at the elbow
Wright et al., 2005
Wrist radial/ulnar deviation 4.3 mm excursion at the wrist

7. CLINICAL INDICATIONS
TRAUMATIC

8. ANATOMY… WHY IS IT IMPORTANT?
Ulnar Nerve Median Nerve Radial Nerve

9. CLINICAL INDICATIONS –TRAUMATIC
 Goal: prevent future nerve irritation by initiating nerve
glides early on in the rehab program
 Mobilize the nerve(s) early on to minimize
potential for adherence in scar tissue
(Tubiana & Gilbert, 2005)
Injury/Fracture Possible Nerve Involvement
Proximal humerus Brachial plexus, radial nerve
Mid-humerus Radial nerve
Distal humerus Ulnar nerve
Radius/ulna shaft Median nerve
Distal radius Median nerve

10. CLINICAL INDICATIONS –TRAUMATIC
How do we get some amount of nerve gliding with these
patients to prevent or minimize nerve irritation?
 Can increase nerve gliding by 3-5 mm by
performing exercises with shoulder abducted
(Wright, 2001)
 With ORIF… easier to begin nerve glides
(starting ROM sooner)
 With conservative… more challenging
Prevention is KEY!
Clinical Pearl
Initiate nerve glides early to prevent
nerve from adhering to scar tissue!

11. CLINICAL INDICATIONS
NON-TRAUMATIC

12. CLINICAL INDICATIONS – NON-TRAUMATIC
How long is too long?

13. ULNAR NERVE
AREAS OF POTENTIAL ENTRAPMENT
1. Arcade of Struthers
2. Medial intermuscular septum
3. CubitalTunnel *
4. Arcade of Fascia (Osbourne’s)
5. Guyon’s Canal
* = most common
Cano, 2006

14. MEDIAN NERVE
AREAS OF POTENTIAL ENTRAPMENT
1. Carpal tunnel *
2. Pronator teres
3. Ligament of Struther’s
4. Bicipital aponeurosis
* = most common
Cano, 2006

15. RADIAL NERVE
AREAS OF POTENTIAL ENTRAPMENT
1. Lateral intermuscular septum
2. Arcade of Frohse *
3. Tendinous border of the ECRB
fibrous bands
4. Radial recurrent vessels
at the wrist
* = most common
Cano, 2006; Hazani et. al, 2008

16. THERAPIST EXAMINATION

17. RELEVANT MEDICAL HISTORY
WHO
 DM, hypothyroidism, autoimmune disorders, etc.
 History of neck injury or MVA
WHAT
 Description of symptoms
 Duration of symptoms
 Traumatic vs. non-traumatic
WHEN  Specific activity/motion that provokes symptoms
WHERE  Localized to one area or travelling
WHY
 Why is the patient seeking treatment?
 Do the symptoms interfere with function?
Skirven et. al, 2011

18. THERAPIST EXAMINATION
 Active/passive ROM
 Key symptoms (paresthesias, pain)
 Sensory testing
 2-point discrimination
 Semmes-Weinstein
 Tinel’s sign
 Painful areas along the nerve
 Rule out cervical
involvement
Clinical Pearl
Don’t get stuck on a particular
diagnosis… focus on the symptoms!

19. UPPER LIMB NEURALTENSIONTESTING
ULNAR NERVE
Butler, 2000
Shoulder abduction
Shoulder ER
Elbow flexion
FA pronation
Wrist & digit extension
Ulnar Nerve

20. UPPER LIMB NEURALTENSIONTESTING
MEDIAN NERVE
Butler, 2000
Shoulder abduction
Wrist & digit ext.
FA supination
Shoulder ER
Elbow extension
Median Nerve

21. UPPER LIMB NEURALTENSIONTESTING
RADIAL NERVE
Butler, 2000
Shoulder depression
Elbow extension
FA pronation
Shoulder IR
Wrist & digit flexion
Radial Nerve

22. COMMON NERVE COMPRESSION
SYNDROMES &TREATMENT APPROACHES
Photo from: http://www.monday-8am.com

23. BASIC PRINCIPLES OF NERVE GLIDES
 Emphasize to the patient that it is important to avoid
reproducing symptoms
 Consider frequency and duration – must be based on
the patient’s response
Clinical Pearl
Nerve glides should always be
performed symptom-free!
GOAL
Maximize excursion of the nerve,
while minimizing the strain.

24. BASIC PRINCIPLES OF NERVE GLIDES
 “Sliding” techniques produce significantly more excursion
than “tensioning” techniques
Clinical Pearl
“Sliding” is better than tensioning!
Coppieters & Butler, 2008
Median Nerve
Sliding
12.6 mm of excursion
at the wrist
Tensioning
6.1 mm of excursion
at the wrist
Ulnar Nerve
Sliding
8.3 mm of excursion
at the elbow
Tensioning
3.8 mm of excursion
at the elbow

25. CUBITALTUNNEL SYNDROME
ULNAR NERVE
Photo from: www.moveforwardpt.com

26. ULNAR NERVE – CUBITALTUNNEL SYNDROME
Conservative Management
 Nerve Glides:
 Avoid neural tension at the elbow by keeping the elbow
extended or slightly flexed
 Move adjacent joints (neck, wrist, digits)
 Flexor-pronator mass flexibility stretches
 Orthoses/Protection: elbow pad, night extension orthosis, etc.
 Activity modification: avoid prolonged elbow flexion or resting
elbow on hard surfaces
Skirven et. al, 2011

27. ULNAR NERVE – CUBITALTUNNEL SYNDROME
Elbow extended, wrist & digits flexed Elbow extended, wrist & digits extended
Shoulder adducted, elbow flexed,
wrist & digits extended
Shoulder flexion, elbow extended,
wrist & digits flexed

28. ULNAR NERVE – CUBITALTUNNEL SYNDROME
Post-operative Management
 Nerve Glides:
 Grewal et. al (2000)
 Decompression does not alter excursion of the UN, but does
reduce the elongation in the epicondylar groove
Skirven et. al, 2011; Grewal et. al, 2000
In-situ UN
decompression
Subcutaneous UN
transposition
Submuscular UN
transposition
Position elbow in
extension
Position elbow in
extension
Position elbow in
60-90˚ flexion

29. CARPALTUNNEL SYNDROME
MEDIAN NERVE

30. MEDIAN NERVE – CARPALTUNNEL SYNDROME
Conservative Management
 Activity Modification:
 Avoid repetitive or tight grasping/pinching
 Avoid prolonged wrist flexion
 Avoid prolonged static positioning
Piazzini et al., 2007
Strong
Evidence
Moderate
Evidence
Limited/Mixed
Evidence
Local & oral
steroids (short-
term relief)
Splinting (wrist
immobilization
orthosis)
NSAIDs
Diuretics
Yoga
Laser/ultrasound

31. MEDIAN NERVE – CARPALTUNNEL SYNDROME
1. 2. 3.
4. 5. 6.
Totten & Hunter, 1991

32. MEDIAN NERVE – CARPALTUNNEL SYNDROME
Post-operative Management
 Tendon gliding exercises
 Nerve gliding
exercises
 Scar management &
desensitization
 Patient education on
activity modification

33. RADIALTUNNEL SYNDROME
RADIAL NERVE
Photo from: www.slideshare.net

34. RADIAL NERVE – RADIALTUNNEL SYNDROME
Conservative
Nerve glides
 RN glides (symptom-free!)
Orthoses:
 Wrist immobilization orthosis for
highly irritable nerves
Activity modification:
 Avoid repetitive FA rotation or
wrist flexion/extension
Post-Operative Management
Nerve glides:
 Avoid combined elbow
extension, forearm pronation and
wrist/digital flexion
 Desensitization
 Scar management
Activity modification:
 Same as conservative
Skirven et. al, 2011

35. RADIAL NERVE – RADIALTUNNEL SYNDROME
Elbow flexed,
wrist & digits extended
Elbow flexed, wrist flexed,
digits extended
Skirven et. al, 2011

36. RADIAL NERVE – RADIALTUNNEL SYNDROME
Ipsilateral neck flexion,
elbow extension,
wrist flexion & ulnar deviation.
Then return to neutral
position.
Verbal cue: “Like a turtle
scooping sand at the beach.”
Skirven et. al, 2011

37. CONSIDERATIONS
Precautions
Highly irritable conditions
Recent diagnosis of CRPS
Severe unremitting pain
“Nerve gliding is an extremely powerful treatment
technique that easily can increase symptoms and
irritability if not used very carefully and with good
understanding of the goal.”
Butler 1991
Contraindications
Recently repaired
peripheral nerve
Active inflammatory conditions
Skirven et. al, 2011, Butler 1991

38. CONCLUSION
“TAKE-AWAY POINTS”
Nerve glides/slides serve as a good adjunct to
traditional therapy treatment approaches
«-»
Initiate nerve glides early with traumatic injuries or
post-operatively to prevent adherence in scar tissue
«-»
Always perform nerve-glides symptom-free…
avoid tensioning the nerve

39. REFERENCES
 Butler, D. S., & Jones, M. A. (1991). Mobilisation of the nervous system. Melbourne:
Churchill Livingstone.
 Butler, D. S. (2000). The sensitive nervous system. Noigroup publications.
 Cooper, C. (2013). Fundamentals of hand therapy: Clinical reasoning and treatment
guidelines for common diagnoses of the upper extremity. Elsevier Health Sciences.
 Coppieters, M.W., & Butler, D. S. (2008). Do ‘sliders’ slide and ‘tensioners’ tension? An
analysis of neurodynamic techniques and considerations regarding their application.
Manual therapy, 13(3), 213-221.
 Gerritsen, A.A., deVet, H. C., Scholten, R. J., Bertelsmann, F.W., de Krom, M. C., &
Bouter, L. M. (2002). Splinting vs surgery in the treatment of carpal tunnel syndrome: a
randomized controlled trial. Jama, 288(10), 1245-1251.
 Grewal, R.,Varitimidis, S. E.,Vardakas, D. G., Fu, F. H., & Sotereanos, D. G. (2000). Ulnar
nerve elongation and excursion in the cubital tunnel after decompression and anterior
transposition. Journal of Hand Surgery (British and EuropeanVolume), 25(5), 457-460.

40. REFERENCES
 Hazani, R., Engineer, N. J., Mowlavi, A., Neumeister, M., Lee, A., &Wilhelmi, B. J. (2008).
Anatomic landmarks for the radial tunnel. Eplasty, 8, e37.
 Piazzini, D. B., Aprile, I., Ferrara, P. E., Bertolini, C. A. R. L. O.,Tonali, P., Maggi, L. O. R. E.
D. A. N. A., ... & Padua, L. U. C. A. (2007).A systematic review of conservative treatment
of carpal tunnel syndrome. Clinical rehabilitation, 21(4), 299-314.
 Ross, R.G. (2007).Anatomy of the Forearm,Wrist and Hand. A Guide for HandTherapists
and Allied Health Professionals. Cynthia Cano, OTR,CHT. Denver, CO: C Cano
Illustrations, 2006.
 Skirven,T. M., Osterman, A. L., Fedorczyk, J., & Amadio, P. C. (2011). Rehabilitation of the
hand and upper extremity, 2-volume set: expert consult. Elsevier Health Sciences.
 Terzis, J. K., & Smith, K. L. (1990). The peripheral nerve: structure, function and
reconstruction (pp. 38-72). Norfolk,VA: Hampton Press.
 Totten, P. A., & Hunter, J. M. (1991).Therapeutic techniques to enhance nerve gliding in
thoracic outlet syndrome and carpal tunnel syndrome. Hand clinics, 7(3), 505-520.

41. REFERENCES
 Tubiana, R., & Gilbert, A. (2005). Tendon, nerve and other disorders. Informa HealthCare.
 Wright,T.W., Glowczewskie, F., Cowin, D., &Wheeler, D. L. (2005). Radial nerve
excursion and strain at the elbow and wrist associated with upper-extremity motion. The
Journal of hand surgery, 30(5), 990-996.
 Wright,T.W., Glowczewskie, F., Cowin, D., &Wheeler, D. L. (2001). Ulnar nerve excursion
and strain at the elbow and wrist associated with upper extremity motion. TheJournal of
hand surgery, 26(4), 655-662.
 Wright,T.W., Glowczewskie, F.,Wheeler, D., Miller, G., & Cowin, D. (1996). Excursion and
strain of the median nerve. The Journal of Bone &JointSurgery, 78(12), 1897-1903.