Compression Neuropathies Flashcards
Sites of Radial Nerve Entrapment
High on the humerus
Radial Tunnel
At the wrist
Radial Nerve Entrapment - High on the humerus
Usually secondary to a humerus fracture or compression of nerve near spiral groove
Symptoms: Wrist drop, weakness in elbow flexion (brachioradialis), +/- tricep involvement, pain/numbness
Treatment: Function usually returns in 4-5 months
Radial Nerve Entrapment - Radial Tunnel
Repetitive rotatory movement - rowing, discus, racquet sports
Heavy manual labor
Symptoms: Pain and tenderness 5 cm distal to lateral epicondyle, wrist drop or pain w/ resisted pronation
Radial Nerve Entrapment - At the wrist
Superficial branch (sensory) pinched between brachialialis and extensor carpi radialis longus during forearm pronation
Sensation change over posterolateral hand
Pronator Syndrome
Median nerve
Travels between the humeral (superficial) and ulnar (deep) head of the pronator teres
Worsens when pronating against force and flexing elbow against force
Positive Provocation maneuver
Pain over proximal middle forearm and numbness over palmar surface of thumb and thirst 3 digits
Pronator Syndrome Symptoms
Worsens when pronating against force and flexing elbow against force
Positive Provocation maneuver
Pain over proximal middle forearm and numbness over palmar surface of thumb and thirst 3 digits
Provocation maneuvers
Tests for pronator syndrome and compression of median nerve by pronator teres
Flexion of middle finger against resistance
Causes compression by the flexor digitorum superficialis
Anterior Interosseus Syndrome
Compression of median nerve
No sensory loss
Inability to make “OK” sign
Due to weak flexion ability of the index finger’s DIP and thumb’s IP
Treatment: General treatment and splinted elbow flexion at 90 for ~12 weeks
Cubital Tunnel Syndrome
Ulnar Nerve Entrapment
Compressed at cubital tunnel by medial epicondyle, medial trochlea, olecranon, ulnar collateral liagment
Positive Tests for Ulnar Nerve Entrapment/Cubital Tunnel
+ Tinel Sign at Elbow
Froment sign - pinch paper between 1st and 2nd digit if thumb flexes (+)
Due to weak 1st dorsal interosseus and ADP muscle
Carpel Tunnel Syndrome
Most common compression syndrome - compression of median nerve
Compression as passes under flexor retinaculum
Thoracic Outlet Syndrome and Symptoms
Compresion of the brachial plexus and/or subclavian vessels
Symptoms: Weakness, paresthesia of medial arm, forearm, and hand exacerbation by overhead activities
Testing for Thoracic Outlet Syndrome
Points of Compression that cause Thoracic Outlet Syndrome
Sclene Triangle
Costclavicular passage
Attachment of the pectoralis minor attachment at the coracoid process
Mergalgia Paresthetica and Causes
Compression of the lateral femoral cutaneous nerve under the inguinal ligament as it travels through the inguinal canal
Causes: very intense athletics, obseity, tight belts/gun holsters, seat belt misplaced or post-MVA
Symptoms f Meralgia Paresthetica
Numbness or buring pain on anterolateral thigh
Hyperesthesia over anterolateral leg (can’t put items in pockets)
Trophic skin changes (later)
+ Tinnel’s sign 1 cm medial and inferior to ASIS
Common Fibular Nerve Compression
3rd most common compression neuropathy
Common peroneal nerve is compressed as it wraps around the fibular neck and enters the fibular tunnel
Common peroneal nerve = L4-S2
Causes of Common Fibular Nerve Compression
Leg hooked over a rail (bedridden, post-op)
“Strawberry Pickers Palsy” - spends a long time squatting
Ankle sprain (commonly posterior fibular head SD)
New meditators (sitting criss cross)
Lithotomy position during childbirth
Idiopathic
Symptoms of Common Fibular Nerve Compression
Decreased sensation, numbness, tingling on outer part of lower leg and foot
Foot drop
Slapping gait (where foot is slapping with each step)
Tarsal Tunnel Syndrome
Compression of posterior tibial nerve in the tarsal tunnel behind the medial malleolus w/ the overlying flexor retinaculum
Causes of Tarsal Tunnel Syndrome
Idiopathic 50% of the time
Space-occupying lesion
Trauma to medial malleolus, distal tibia, or calcaneus
Autoimmune (RA, ankylosing spondylitis)
Diabetes
Lifestyle (standing for long periods)
Symptoms of Tarsal Tunnel Syndrome
Pain on plantar surface of foot
Nonspecific burning, tingling, or numbness over plantar part of foot
Gait is usually not effected
Treatments of Tarsal Tunnel Syndrome
Rest
NSAIDS
Ultrasound
PT and Acupunture
OM - Myofascial release and HVLA
Anterior Tarsal Tunnel Syndrome
Compression of deep fibular nerve at the inferior extensor retinaculum
Deep fibular nerve = L4-S2
Symptoms of Anterior Tarsal Tunnel Syndrome
Pain over dorsomedial aspect of foot that worsen at rest
Weakness of extensor digitorum brevis = flexing the proximal and medial phalanges of the 2nd-5th toes
Causes of Anterior Tarsal Tunnel Syndrome
Trauma (recurrent ankle sprain, soccer players)
Talonavicular dysfunction
Prolonged plantar flexion (high heels)
Compression from shoes
Froment’s Sign
Tests for Ulnar Nerve Palsy or Compression
Tests strength of adductor pollicus of the thumb
Compressing paper between thumb and hand with thumb straight - Paper shouldn’t slip
Abnormal - Patient flexes thumb to prevent paper from slipping
Plexopathy Tests
EAST (elevated arm stress test)
Adson - Scalene hypertonicity & first rib/extra rib
Military Brace/Eden’s Test - Clavicle
Wright Test - Pect minor hypertonicity
EAST Test
Elevated arm stress test - Aka Roo’s test
Tests for Thoracic Outlet Syndrome
Abduct 90º and externally rotate arm
Flex elbows 45º
Hold for 90 seconds
Have patient slowly open and close hands
Forearm and hand paresthesia
Adson’s Test
Test for Thoracic Outley Syndrome caused by hypertonic scalene muscle or extra rib which compress the subclavian A.
Arm abducted 30º and shoulder maximally extended
Patient extends neck and turns head towards symptomatic shoulder and asked to take a deep breath and hold
Radial pulse is monitored throughout
(+) = drastic decrease in radial pulse
Military Brace
Eden’s test - tests for Thoracic Outlet Syndrome cause by a depressed clavical
Monitor radial pulse
Shoulder is depressed and retracted
Arm is abducted 30º
Hyperextend neck and head
(+) = increased neurological symptoms on UE
Wright Test
Tests for Thoracic Outet Syndrome cause by a hypertonic pec minor m.
Head flexed while the arm is passively brought into abduction and external rotation to 90º
Elbow is flexed to 45º
Arm is held for 1 min
Monitor radial pulse and monitor patient symptoms onset
Continue to increase abduction until end of ROM
(+) = decreased pulse or worsened neurological symptoms
Pronator Teres Mononeuropathy Tests
Phalen test
Resistance Pronation test
OK test
+/- Tinel test over proximal 1/3 of lower arm
Decreased sensation
Reflexes normal
Meralgia Paresthetica Treatment
Behavior changes: Wear looser clothes, lose weight, tell patient its not serious
Biomechanical: Treat SD of Psoas, sacrum, innominant, anterior thigh musculature
Local MFR to abdomen
L2-L3
Hoffmann sign
Firmly grasping the middle finger and quickly snapping or flipping the dorsal surface
(+) quick flexion of both thumb and index finger
Indicates: Cervical myelopathy (cervical spinal stenosis)
5-Model Treatment for Radial Nerve Compression
Rest
Avoid aggravating behavior
Stretching
NSAIDs
Counterstrain/Muscle Energy
Carpel Tunnel Syndrome Symptoms
Symptoms: Nighttime numbness of lateral 3.5 digits, tingling, wrist pain, grip weakness, thenar atrophy
Caused by repetitive wrist flexion and pregnancy
Treatment for Carpel Tunnel Syndrome
Treatment: Gold Standard EMG
NSAIDs
OMT - Lymphatics (if pregnant), ST, MFR
Testing: XRay is maybe fracture or MRI is soft tissue damage
Rest from repetitive motion and stretching
Wear wrist splint that extends wrist at 30º
Steroid injections if more converative treatments don’t work
Surgical release if other treatments fail
Tests for Carpel Tunnel Syndrome
Phalen’s - flex hands to 90º, reproduce sxs within 60 sec
Tinel’s - tapping over flexor retinaculum and reproduce sx
Two point discrimination - unable to distinguish 2 point touch with calipers less than 5 mm
Causes of Cubital Tunnel Syndrome
Baseball pitcher
Prolonged elbow flexion (during sleep)
External compression against a hard surface (Student’s elbow)
Thickened cubital tunnel retinaculum
Symptoms of Cubital Tunnel Syndrome
Parasthesia of 4th and 5th digit
Medial elbow pain radiating down the hand
Weak intrinsic muscle strength - can’t turn key
Treatment for Cubital Tunnel Syndrome
General treatment (rest, NSAIDs etc)
Paddle elbow sleeve to limit terminal elbow flexion and provide cushioning
