Nerve Entrapment/ Injury of Upper Quadrant

Question 1

Name the sensory nerve that branches off C2 to feed the posterior scalp and potentially gets caught in the upper trapezius?

Answer 1

Greater Occipital Nerve

Question 2

Thoracic Outlet Syndrome is a manifestation of symptoms resulting from what?

Answer 2

Compression of neuromuscular bundle of subclavian artery, vein, and brachial plexus

Question 3

What are the most common structures that would stress the neurovasuclar bundle and how do they effect it?

Answer 3

Scalenes: Cause entrapment by hypertrophy or spasm
Ribs: If 1st rib is at C7 then nerves have less room
Clavicle: old fx, UT tissues come under rib and clavicle/ pec minor

Question 4

What 4 other causes may stress the neuromuscular bundle?

Answer 4

1. Coaracoid Process: problem for overhead athletes, can impinge those nerves
2. Pec Minor: hypertrophy, same as above
3. Subclavius: hypertrophy
4. Costocoracoid Lig: vascularity runs under and may pinch

Question 5

Name the 4 types of TOS and the percentages at which they occur.

Answer 5

1. Neurologic 94-97%
2. Venous: not listed
3. Arterial 1-2.5%
4. Combined: not listed

Question 6

Which of the neurological TOS is more common? Where would they have plain?

Answer 6

Lower Plexus: causes compression of C8-T1 nerves.

Pain in upper back, into axilla along ulnar nerve to ring and small finger

Question 7

The upper plexus TOS is less common and involves C5-C7. Where would this patient experience pain?

Answer 7

Pain in ear, anterior c-spine, clavicle, chest, and outer aspect of arm (along radial nerve)

Question 8

Give some of the issues found with venous TOS.

Answer 8

Edema, cyanosis of UE
Distended superficial veins in shoulder and chest
Axillary Vein Thrombosis- maybe
Fingers feel like sausages- In subjective hx

Question 9

Which is the least common TOS? What are some of the symptoms?

Answer 9

Arterial: arms get cold and pale, may have Raynauds, can be in pitchers from overuse. Rarest and worst!!

Question 10

T/F: Combined TOS can include pinching of the nerve, vein, and artery simultaneously.

Answer 10

True

Question 11

Patients with TOS usually fall into what demographics?

Answer 11

Middle aged (~45) and women

Question 12

Patient will have UE pain, anesthesia, and weakness. Where would each of these be felt on the patient?

Answer 12

Pain: arm extending to fingers, claudicant slowly increases with activity and is relieved by rest.
Anesthesia/paraesthesia: Ring, middle, and small fingers. Pt may shake hand to relieve symptoms
Weakness in Thenar muscles

Question 13

If a patient feels pain the hand first what could this mean?

Answer 13

It could be the vascular form of TOS

Question 14

What special tests are used to make the diagnosis of TOS?

Answer 14

Adsons
Wright
Costoclavicular 
Roos 
ULTT

Question 15

What is the conservative treatment of TOS?

Answer 15

1. Stretching: Scalenes and Pec minor (stay away from tx which can cause scalene spasm)
2. Strengthen muscles to promote posture
3. Postural re-education is KEY. Cervical ribs and anomalous fascial bands present for a while.
4. MFR: alters resting tone than change non-contractile structures
5. 1st rib mobs
6. Rest
7. Modalities

Question 16

What is the surgical treatment of TOS?

Answer 16

1. Resection of fibrous bands
2. Scalenotomy
3. Removal of cervical rib (only 10% of population)
   * *Sx not generally regarded as having a high success rate**

Question 17

What is a stinger?

Answer 17

Brachial plexopathy; brachial plexus traction injury that is common and is unique to football.

Question 18

What is the mechanism of injury for a stinger? How would you identify and treat this?

Answer 18

Mechanism: Shoulder depression or direct compression on the brachial plexus from poorly fitting pads
S/S: Acute shooting or electrical pain down arm following tackle, weakness, usually C5-C6 that may last from a few seconds to many months
Treatment: Rest and ice, strengthening, check fitting of shoulder pad (use spider), return to football when MMT 5/5, strength deficits may persist for months

Question 19

There are 4 concepts in evaluating a nerve injury that you should keep in mind. What are they?

Answer 19

1. Mechanical interface
2. Nerves are elastic
3. Tension on a nerve increases intramural compression
4. Tension in nervous system by movement is not uniform

Question 20

When evaluating pain from compromise neurodynamics what should you keep in mind?

Answer 20

1. Pain source
2. Area od symptoms
3. Types of symptoms

Question 21

What painful sources should you consider with compromised neurodynamics?

Answer 21

1. Connective Tissue- dura mater

2. Neural Tissue

Question 22

Give the terminology for areas of symptoms.

Answer 22

Jumping: pain in one part, now in another
Lines: pathways of pulling, tightness
Clumps: Areas of pain usually around joints and tension points (ex: head of fibula or lat. epicondyle)
Linking up of symptoms (ex. double crush)

Question 23

Types of symptoms can be _______ and _______. Symptoms include:

Answer 23

Multiple and bizarre; tiredness, aching, burning, heaviness, and vague types of pain

Question 24

What are the 4 treatment principles for a nerve injury?

Answer 24

1. Treat any related jt hypomobility or hypermobility that may be present first.
2. Very careful with irritable patients
3. Start gently with stretching techniques that you used to elevate.
4. Joint should not be stressed during the treatment.