Compression Neuropathy OSCE Flashcards
Shoulder Abduction motor testing
C5
Shoulder abduction muscles
deltoid, supraspinatus
Shoulder flexion muscle
anterior deltoid, coracobrachialis
Shoulder extension muscles
posterior deltoid, latissimus dors
Elbow flexion nerves
C5-6
Elbow flexion muscles
biceps (musculocutaneous)
Elbow extension nerve
C7
Elbow extension muscles
Triceps (radial)
Elbow supination nerve
C6
Elbow supination muscles
supinator (radial), biceps (musculocutaneous)
Elbow pronation nerve
C7-8
Elbow pronation muscles
pronator teres (median), pronator quadratus (anterior interosseous from median nerve)
Wrist extension nerve
C6
Wrist extension muscles
extensors supplied by radial nerve
wrist flexion nerve
C7
Wrist flexion muscles
flexors supplied by median and ulnar nerves
Finger extension nerve
C7
Finger extension muscles supplied by
radial nerve
Finger flexion nerve
C8
median and ulnar nerves
Finger flexion ab/adduction nerve
T1
ulnar nerve
Thumb flexion
C8
anterior interosseous, recurrent branch of median
Thumb extension
C8
posterior interosseous from radial
C4 dermatome
superior shoulder
C5 dermatome
lateral arm over deltoid
C6 dermatome
lateral forearm
C7 dermatome
middle finger
C8 dermatome
ring/little finger, distal medial forearm
T1 dermatome
medial arm
Radial nerve
C6-8
- wrist extension and thumb extension
- sensation on dorsal web space between thumb and index finger
Ulnar nerve
- abduction–little finger
- distal ulnar aspect-little finger sensation
- C8-T1
Median nerve
- thumb pinch; opposition and thumb abduction
- sensation to distal radial aspect of index finger
- C5-8
Axillary nerve
- deltoid
- sensation to lateral arm–deltoid patch on upper arm (superior lateral cutaneous branch)
- C5-6
Musculocutaneous nerve
- biceps
- sensation to lateral forearm (lateral antebrachial cutaneous branch)
- C5-7
C5 reflex
biceps
C6 reflex
Brachioradialis
C7 reflex
triceps
Compression neuropathy
-nerve entrapment by musculoskeletal or myofascial tissue that produces paresthesias int eh area of the distribution of the nerve and creates sensory dysfunction/pain and may also decrease muscle strength
Compression can
cause increased pain by narrowing the neural (intervertebral) foramen, pressure on the facers, or initiating muscle spasm
Compression test
-with head and neck in neutral position add an axial lading force caudally looking for upper extremity pain, paresthesias, or numbness
Spurlings test
- tests nerve root compression/irritation.
- tested with axial force in neutral, then extension, then SB/rotation toward; test of high specificity
- positive test is reproduction of symptoms (pain/neurological symptoms in distribution of nerve root)
Neck distraction test
- relief of pain with cervical distraction, opposite of compression test
- doc places one hand under the patient’s chin and places the other hand around the occiput. the doc slowly distracts the head.
- positive test=alleviation of symptoms indicating central compression or central neuropathy
Valsalva test
- patient holds breath and bears. positive test is increased pain and paresthesia, especially in nerve root distribution
- increased intrathecal pressure. In presence of space occupying lesion in cervical canal, this pressure may cause pain in cervical spine as well as radiation of pain to dermatomal distribution
Thoracic Outlet Anatomical boundaries
1st ribs, 1st thoracic vertebra, manubrium
Thoracic Outlet Clinical boundaries
- ribs 1-2, T1-4 thoracic vertebrae, manubrium
- thoracic duct passes through fascial diaphragm twice (left side); right lymphatic duct drains body’s right upper quadrant
- broken into vasculogenic and neurogenic
- brachial plexus, subclavian vein, subclavian artery
- best though of as 3 possible zones: scalene triangle, costoclavicular space, retropectoralis minor
Roos or EAST test
- compression of subclavian artery in thoracic outlet
- abduct shoulder to 90 degrees and externally rotate with elbow flexed to 90 degrees; doc instructs pt to open and close fist for up to 3 minutes
- positive test is reproduction of symptoms (increased pain at shoulder and down arm, paresthesia, arm pallor, cyanosis and swelling)
Adson Test
- neurovascular bundle compressed by tight scalene muscles or 1st rib in thoracic outlet
- locate radial pulse on affected arm. Patient breathes deeply
- doc abducts, extends and externally rotates the shoulder while palpating the radial pulse.
- head is extended and rotated toward affected rib (1st rib etiology)
- then the patient’s head is extended and rotated away from affected side (tight scalene muscles)
positive adson
loss or change in pulse
-test indicates compression of subclavian artery between scalene, cervical rib, or 1st rib
Wright’s Hyperabduction Test
- NV bundle compressed by tight pectorals minor in thoracic outlet
- doc locates and monitors the radial pulse on the affected side.
- the patient is seated. Stand behind the patient and palpate the radial pulse with one hand. Abduct the patient’s arm above his or her head with some extension
positive Wright’s hyperabduction test
loss or change in pulse; exacerbation of pain/paresthesia
-test indicates neurovascular entrapment by pectorals minor muscle
Halstead Test (Military/Costoclavicular)
- extend shoulder and caudal pressure on shoulder noting change in radial pulse–NV bundle compressed by clavicle and rib 1 in thoracic outlet
- patient seated with doc behind patient. Contact the ipsilateral wrist at the radial pulse, extend the shoulder, with elbow extended and wrist supinated and apply caudal pressure on the shoulder
- positive is decrease in radial pulse; indicates thoracic outlet syndrome ude to decreased space between rib 1 and clavicle
First Rib inhalation somatic Dysfunction Pump Handle restriction muscle energy
- patient supine, doc seated at head of the table. Patient’s neck is bent forward, support by physician.
- doc contacts the superior anterior aspect of the dysfunctional rib with thumb (between the 2 heads of the SCM)
- patient inhales deeply while doc resists. With exhalation, doc follows rib motion inferiorly. doc continues to resist inhalation, and exaggerates motion into exhalation. Repeat until motion of the rib is restored
First Rib inhalation somatic dysfunction bucket handle restriction muscle energy
- patient supine, doc at head of table. Doc contacts the superior surface of the first rib posterolaterally (lateral to the SCM)
- with the other hand, doc flexes the head forward, side-bends toward the dysfunctional rib (relieving tension from the scalene muscles)
- patient takes a deep breath-with exhalation, doc follows the rib down and forward into exhalation. with next breath, doc resists inhalation and follows into exhalation. Repeated until motion is restored
scalene MFR
- side bend had and neck away from affected side (linear stretch)
- provide an additional perpendicular force to the muscle; treat one side at a time
- wait for creep
Pectoralis Minor MFR
- grab both pectorals muscles simultaneously
- provide a cephalad distracting force by leaning backward thereby providing a linear stretch to the pectorals minor muscle and perpendicular to the pectorals major muscle
- alternative position: supine with affected arm abducted 180 degrees with slight distraction (linear stretch) and a perpendicular force into muscle
Most common place for ulnar compression neuropathy
-cubital tunnel
Tinel’s sign for the elbow
- tap ulnar nerve where entrapment/trauma occurs at cubital tunnel (cubital tunnel syndrome)
- postive test is paresthesia, tingling in the ulnar nerve distribution
Froment’s sign
-tests for the strength of the adductor pollicis, which is weak with ulnar nerve palsy
Radial head is palpated by
flexion/extension, supination/pronation of forearm
Posterior glide of the radius is coupled with
pronation and extension
Anterior glide of the radius is coupled with
supination/flexion
Posterior radial head
ease of motion dorsally with restriction of motion ventrally.
-anterior radial head is restricted in motion dorsally and has ease of ventral motion
Olecranon live medially with
an abducted ulnar dysfunction
-associated with entrapment of ulnar nerve between medial epicondyle
Abducted ulnar dysfunction
- increased carrying angle
- test with valgus/varus force one extended elbow
Adduction of the ulnar occurs with
varus force
Abduction of the ulnar occurs with
valgus force.
Abducted elbow is restricted to
distal ulnar adduction,r adiocarpal abduction
Proximal ulnar abduction dysfunction HVLA
- patient seated, doc on dysfunctional side in front of patient
- doc places patient wrist of the dysfunctional extremity between doctors arm and lateral chest wall.
- doc grasps elbow with both hands, thumbs in antecubital region over proximal radius and ulna.
- with the elbow close to full extension, doc applies a varus force to elbow, and take the distal ulna into adduction
- HVLA applied in same vector when doc reaches restrictive barrier
Wrist Tinel’s sign
-tap over flexor retinaculum
Wrist Phalen’s test
- patient forces disarm of hands together (b/l wrist flexion) for one minute
- positive test is reproduction of symptoms/paresthesias in the distribution of the median nerve
Carpal Tunnel MFR
-doc places thumbs over carpal bones, extend the patient’s wrist.
-doc’s thumbs provide a linear stretch over flexor retinaculum
(compression of median nerve)
Carpal tunnel stretching exercise
-have patient hyper adduct and extend 1st metacarpal with wrist extension
Carpal Tunnel Articulatory technique
- goal is to restore physiologic ROM to radiocarpal joints
- doc grasps patients dysfunctional wrist with both hands, with fingers under palm of hand on medial and lateral sides.
- doc’s thumbs on dorsal surface of patient’s hand with pads over carpal bones.
- apply traction and apply circumlocution figure 8 of patient’s wrist then complete by extending wrist as thumbs press firmly downward on carpal bones
Hip flexion
- L1-3
- psoas major, iliac, pectinous, rectus femurs, adductor longus, sartorius
Hip Extension
L5, S1
-gluteus maximus, adductor magnus, hamstrings
Hip Abduction
L5, S1
-IT band, gluteus medius and minimus, performs
Hip Adduction
L1-3
-gracilis, adductor longus/magnus/brevis, pectineus
Hip Internal rotation
L1-3
-iliacus, gluts, IT band
Hip External rotation
L5, S1
-quadratus femoris, piriformis, obturator internus and externus, sartorius
Knee Flexion
L5, S1
-hamstrings, semimembranosus, semitendinosus, biceps femoris, gastrocnemius
Knee Extension
L3, 4
-quadriceps femoris
Ankle Dorsiflexion
- L4-5
- via deep fibular nerve
- tibialis anterior, extensor digitorum longus, digitorum hallucis longus, fibularis tertius
Ankle Plantar flexion
- S1-2
- gastrocnemius, soleus, flexor digitorum longus, flexor hallucis longus, fibularis longus, tibialis posterior
Ankle Inversion
- L4-5
- tibial anterior (deep fibular nerve), tibialis posterior
Ankle Eversion
- L5-S1
- Fibularis longus/tertius, brevis
Toe Flexion
-flexor digitorum longus/brevis, flexor hallucis longus/brevis, flexor digiti minimi brevis, lumbricals
Toe Extension
-Extensor digitorum longus/brevis, extensor hallucis longus
Toe Abduction
abductor hallucis, abductor digiti minimi, dorsal interossei
Toe Adduction
plantar interossei, adductor hallucis
L1 Dermatome
inguinal region
L4 dermatome
-anteromedial leg, patella
L5 dermatome
anterolateral leg
S1 dermatome
5th digit and calcaneus
S2 dermatome
posterior thigh
Lateral cutaneous nerve
L2-L3
-sensation to lateral thigh
Common fibular nerve
L4-S3
- knee flexion
- sensation to lateral leg, dorsum of foot
Deep fibular nerve
- L4-S2
- ankle dorsiflexion, toe extension
- sensation to dorsum of foot, skin between 1st and 2nd toe
L4 reflex
Patellar
-knee extensors
S1 reflex
Achilles
-foot plantar flexion
Posterior fibular head HVLA
-patient supine. place hand in patient’s popliteal crease, with MCP on fibular head. Take the foot into eversion, dorsiflexion and external rotation. exert a rapid knee flexion thrust, and pull fibular head anterior
Posterior fibular head Muscle energy
- patient supine. the foot is placed in eversion and dorsiflexion, which externally rotates LE.
- patient tries to push the foot medially against resistance, relaxes, and the physician further everts the foot and ankle, “pushing” the distal fibular posteriorly which brings the posterior proximal fibular head more anterior. further resist inversion until no new barrier.
Gastrocnemius/soleus muscle energy
-patient prone. flex knee to 90 and dorsiflex patients ankle into barrier. patient tries to platter flex against resistance
Biceps femoris muscle energy
-patient supine. flex patient’s hip with knee fully extended into barrier. patient tries toe extend hip against resistance
Cuboid navicular dysfunction treatment
Hiss whip
Hiss whip
-patient prone. Grasp patient’s foot, with both thumbs on plantar aspect of cuboid/navicular. Plantar flex the ankle and induce a dorsal thrust in a whip-like manner
Extensor retinaculum MFR
-patient supine or seated. Thumbs are placed on the superior/medial and inferior/lateral portions of the inferior extensor retinaculum and then separated to engage the barrier, waiting for myofascial creep until no new barrier is encountered
Anterior tarsal tunnel syndrome
-deep fibular/peroneal nerve compression
tarsal tunnel syndrome
- posterior tibial nerve compression
- Flexor retinaculum; eversion somatic dysfunction of ankle
Flexor retinaculum MFR
-patient prone. physician standing at side of dysfunction. Physician flexes knee to 90. Other hand grasps calcaneus and applies an eversion force while simultaneously pressing their forearm down on the ball of the foot creating a passive dorsiflexion. this position is held allowing for myofascial creep until no new barrier is met
Eversion somatic dysfunction of ankle HVLA
-patient supine. Exert traction through calcaneus, while applying a hyper inversion thrust to the ankle
Meralgia paresthetica
- lateral femoral cutaneous nerve compression
- anterior hip dysfunction; flexion somatic dysfunction
Meralgia paresthetica muscle energy
- flexion somatic dysfunction–patient can be prone or supine. doc can stand on contralateral or ipsilateral side of the table. remember to block linkage. if prone, flex knee to 90 and grasp ankle or knee to lift/extend hip into barrier.
- have patient flex hip against resistance for 3-5 seconds
Meralgia paresthetica MFR
-patient prone. flex knee to 90 and grasp ankle or knee to lift/extend hip into barrier, until myofascial creep is felt
