OP

Question 1

Anterior Scalene Syndrome
Costoclavicular Syndrome
Pec Minor Syndrome

MOI

Answer 1

• Generally insidious

Question 2

anterior scalene syndrome
costoclavicular syndrome
pec minor syndrome

key s&s

Answer 2

Paresthesia in digits 4 & 5

May involve pallor or coldness in hands

Possible weakness/clumsiness in hands

Question 3

anterior scaelene syndrome
costoclavicular syndrome
pec minor syndrome

Key Q’s

Answer 3

“Can you tell me about how you’re sleeping and if sleep is affected?

Besides tingling, have you noticed any other symptoms into your hand?

• pallor or coldness > arterial involvement
• swelling or edema > venous involvement, therefore not anterior scalenes
• decreased dexterity indicates motor involvement of the central compartment > ulnar nerve fibres

Can you tell me about any positions or movements which bother you or make things worse?

• complaints related to neck posture or movement likely scalenes
• depressed shoulders/bags indicates likely costoclavicular
• overhead stuff likely pec minor

Question 4

anterior scalene syndrome

assesments

Answer 4

Adson’s

Halstead’s aka Travell’s variation

Scalene cramp test

Scalene MMT

Cervical ROM

FCU MMT

Question 5

anterior scalene syndrome

positional precautions

Answer 5

Avoid excess neck flexion

Avoid unsupported cervical side flexion

Question 6

anterior scalene syndrome

tx

Answer 6

• Decompress pathway

reduce scalene HT
–> kneading/comp @ scalenes

reduce tightness along path of median/ulnar nerve
–> kneading/comp along BB, brach, CB, PT, FDS/FDP, FCU

(arterial) reduce tightness along path of brachial artery, radial/ulnar aa
–> facilitate blood flow to extremities if needed
–> kneading/comp along BB, brach, CB, & anterior forearm

improve smooth cervical ROM that does not compress neurovascular structures between neck mm (scalenes)
–> Pin & stretch scalenes affected side
–> gentle passive stretch scalenes affected side
–> gentle hold-relax strech “

work on surrounding mm that may be affecting scalenes via fascial interaction
–> SCM comp, pickup/squeeze
–> posterior scalene & lev scap “

Question 7

costoclavicular syndrome

assessments

Answer 7

Costoclavicular test

Eden’s Test

FCU MMT

Scalene cramp test (Ddx)

Scalene MMT (Ddx)

Question 8

costoclavicular syndrome

positional precautions

Answer 8

Avoid scapular retraction

If venous symptoms present, bringing blood distal

If arterial symptoms present, taking blood away from hand

Question 9

Costoclavicular syndrome

tx goals

Answer 9

reduce subclavius HT
–> kneading/comp @ scalenes

reduce tightness along path of median/ulnar nerve
–> kneading/comp along BB, brach, CB, PT, FDS/FDP, FCU

(arterial) reduce tightness along path of brachial artery, radial/ulnar aa
–> facilitate blood flow to extremities if needed
–> kneading/comp along BB, brach, CB, & anterior forearm

(venous) reduce tightness along path of brachial veins, radial/ulnar veins
–> facilitate blood flow toward heart as needed
–> kneading/comp along anterior arm, forearm

improve smooth shoulder ROM that does not compress neurovascular structures between subclavian mm during movement
–> Pin & stretch subclav affected side (subclav, upper pec)
–> gentle passive stretch subclav affected side

work on surrounding mm that may be affecting subclav via proximity or fascial interaction
–> upper pec, comp

other techniques (not explicitly stated in goals)
–> pin/stretch other
–> JM other

Question 10

Pec Minor syndrome

assessments

Answer 10

Wright’s hyperabduction

Pec minor length test

FCU MMT

Scalene cramp test (Ddx)

Scalene MMT (Ddx)

GH ROM

Question 11

Pec minor syndrome

positional precautions

Answer 11

Avoid abduction past 90d

Avoid having arm rest overhead

If venous symptoms present, bringing blood distal

If arterial symptoms present, taking blood away from hand

Question 12

carpal tunnel syndrome

MOI

Answer 12

May be due to edema or overuse

Possible secondary to FOOSH if lunate dislocation

Question 13

Carpal tunnel syndrome

key s&s

Answer 13

“Classic sx > night pain and paresthesia

Movement can alleviate pain…self-massage and shaking of the hand common

Still has sensation in palmar cutaneous branch”

Question 14

Carpal tunnel syndrome

Q’s

Answer 14

“Can you tell me about how you’re sleeping and if sleep is affected?
- sleeping with wrist flexion can prolong/exacerbate
- night pain

Can you tell me about any positions or movements which bother you or make things worse?
- wrist movements
- stationary hand especially if in a dependent position becomes uncomfortable
- may have some loss of precision grip”

Question 15

carpal tunnel syndrome

assessments

Answer 15

“Phalen

Reverse Phalen

Pronator Teres (Ddx)

Wrist ROM

ULTT 1”

Question 16

carpal tunnel syndrome

positional precautions

Answer 16

Avoid dependent position in presence of edema

Question 17

Carpal tunnel syndrome

tx

Answer 17

MOBILIZE NERVE – ULTT1 pattern glide

work on surrounding mm that may be affecting FLEXOR RETINACULUM of wrist via fascial interaction
–> thenar/hypothenar mass
(opponens/flexor/abductor/adductor pollicis (brevis)
& opponens/flexor/abductor digiti minimi manus) –> comp, spread, knead/stroke, isometrics

passive ROM wrist/elbow —> to facilitate smooth gliding movement of wrist flexor tendons through the carpal tunnel

gentle isometrics at wrist/elbow —> improve distal forearm flexor tendon tissue health, facilitate strength, improve bloodflow

gentle 1-2 JM @ wrist to loosen capsular adhesions in wrist, improve joint capsule tissue health

gentle cross fibre strokes of flexor retinaculum to decrease adhesions and fascial restrictions

Work on muscles along path of median nerve
–> including pronator teres, FDS/FDP, & Anterior brachial mm

DECREASE TONE in FDP/FDS/FPL since it may contribute to decreased tone/tightness/restriction in distal tendons that run through the carpal tunnel
–> longitudinal stripping mm bellies

HYDRO –> if flareup, cold @ wrist, heat @ brachium & proximal antebrachium

PASSIVE STRETCH – (ONLY IF LIMITED ROM IN FLEX/EXT)

IMPORTANT NOTE: PILLOW FOREARM/WRIST

Question 18

carpal tunnel syndrome

homecare

Answer 18

“ADLs around typing or decreasing compression on the wrist

Contrast arm baths

Prox heat, distal cool with elevation

Stretch wrist flexors

Strengthen wrist extensors

With stretch and strengthen, be careful of end-range or overpressure at wrist”

Question 19

Pronator teres syndrome

MOI

Answer 19

Overuse of elbow

Question 20

Pronator teres syndrome

key s&s

Answer 20

“Achy, tired, heavy anterior forearm
- aggravated by elbow movements rather than wrist movements
- pain with RROM or MMT pronator
- no night pain”

Question 21

Pronator teres syndrome key Q’s

Answer 21

Have you noticed any difference in symptoms between your palm and fingers? (Symptoms in palm suggest pronator teres involvement)

Have you noticed any changes to your skin, or sweating in the forearm or hand?

Question 22

Pronator Teres syndrome

assessments

Answer 22

“Pronator Teres Syndrome test

Pronator Teres MMT

Phalen’s (Ddx)

Reverse Phalen’s (Ddx)

Elbow ROM
“

Question 23

Pronator teres

Tx

Answer 23

reduce pronator teres HT
–> kneading/comp

reduce tightness in mm along path of median nerve in general — since one compression site can increase the likelihood of additional compression sites (leading to double crush syndrome)
–> kneading/comp along BB, brach, CB, PT, FDS/FDP

(arterial) reduce tightness along path of brachial artery, radial/ulnar aa
–> facilitate blood flow to extremities if needed
–> kneading/comp along BB, brach, CB, & anterior forearm
(venous) reduce tightness along path of brachial veins, radial/ulnar veins
–> facilitate blood flow toward heart as needed
–> kneading/comp along anterior arm, forearm

improve smooth elbow ROM that does not cause tight mm to compress neurovascular structures @ pronator teres
–> Pin & stretch pronator teres affected side
–> gentle passive stretch “ affected side
–> gentle hold-relax stretch “

work on surrounding mm that may be affecting pronator teres via fascial interaction
–> Brachioradialis & wad 3 – pickup/squeeze
–> FCR, FDS/FDP “
–> reduce tightness in pronator QUADRATUS
–> which can also contribute to shortened position of pronator teres if it is keeping the forearm pronated

improve long-term pronator teres muscle tissue quality/health
–> gentle, submaximal isometrics (HU flx/pronate)
(seems counterintuitive but this will ultimately increase overall tissue health and reduce likelihood of HT & TrP in long run)

MOBILIZE NERVE – ULTT1 pattern glide

other techniques (not explicitly stated in goals)
–> axial distraction GH/elbow/wrist/hands
–> pin/stretch other
–> JM other
–> wrist passive stretch

Question 24

Pronator teres syndrome

homecare

Answer 24

“Strengthen any weak forearm muscles

Contrast arm baths or other hydro for pain management

”

Question 25

Radial Nerve Degeneration MOI

Answer 25

Fracture or severance injury

Question 26

Radial Nerve Degeneration Key s&s

Answer 26

"Wrist drop Sensory loss dorsum of hand especially between digits 1 & 2"

Question 27

Radial nerve degeneration Key Q's

Answer 27

"Can you tell me about any other care you're receiving? Can you tell me about how it is improving or any function you're regaining?"

Question 28

Radial nerve degeneration Assessments

Answer 28

"Wrist ROM Palpation posterior brachium, forearm, hand MMT Triceps, forearm extensors Sensory testing radial nerve distribution"

Question 29

Radial Nerve Degeneration Positional Precautions

Answer 29

"Make sure affected tissue is pillowed to avoid compression Avoid contralateral cervical side flexion Avoid fully extended elbow, pronation, flexion of wrist and fingers"

Question 30

Radial nerve degeneration Technique precautions

Answer 30

"Do not stretch or traction the regenerating nerve through techniques or movement Do not stretch, drag or work deep on flaccid or affected tissue (including no MFR) Be careful of pressure or temperature on areas of sensation loss"

Question 31

Radial Nerve Degeneration Tx

Answer 31

focus PROXIMAL to lesion site -- use border to prevent drag/traction of lesion site treat muscles surrounding radial nerve (proximal to lesion) --> to reduce tightness around nerve --> to improve blood flow to area to increase metabolism & recovery E.g. triceps brachii, teres mj/mn, brachialis, BR/ECRL, ECRB, supinator, etc. promote relaxation --> GSM around neck & brachial plexus --> axial distraction cervical sp & occiput (BUT NO CONTRALATERAL FLEXION OF C-SP) --> instruct diaphragmatic breathing Improve tissue health DISTAL to lesion (affected tissue) --> GENTLE compressions --> LIGHT stroking (as long as it doesn't stretch nerve) Prevent/decrease contracture in mm opposing denervated tissue --> work Distal to lesion on UNAFFECTED side is OKAY --- as long as affected nerve not stretched --> passive stretch --> wrist ext OK --> elbow ext ONLY can be done up to slight flex (NOT FULL EXT) --> Resisted isometrics/isotonics --> wrist ext --> elbow ext (not to full EXT) contribute to improving neuromuscular function -- I.e. "increase strength" / "encourage motor function" --> resisted isometrics/isotonics --> wrist ext, elbow ext (not to full ext) With neural tapping (facilitatory ROOD) promote joint health --> PROM (without stretching/irritating affected nerve) --> JM (") misc --> treat TrP --> edema (E.g. nodal pumping) --> relaxation

Question 32

Radial Nerve degeneration homecare

Answer 32

"Sensory stimulation in affected area using different textures AROM or AAROM of returning function (eg wrist ext) Modified contrast for tissue health - as long as there are no autonomic symptoms"

Question 33

Ulnar Nerve Degeneration MOI

Answer 33

Fracture or severance injury

Question 34

Ulnar Nerve Degeneration Key s&s

Answer 34

"Claw hand of 5th digit and ring finger, wrist pain, numbness and tingling in 4th and 5th digits. Weakness in buttoning shirts and holding onto or picking items up"

Question 35

Ulnar Nerve degeneration Key Q's

Answer 35

"Can you tell me about any other care you're receiving? Can you tell me about how it is improving or any function you're regaining?"

Question 36

Ulnar Nerve Degeneration Assessment

Answer 36

"Wrist ROM Froment's sign Tinel's test Sensory testing ulnar nerve distribution"

Question 37

Ulnar Nerve Degeneration Positional precautions

Answer 37

"Make sure affected tissue is pillowed to avoid compression Avoid contralateral cervical side flexion Avoid fully flexion of elbow, ulnar deviation of wrist and fingers"

Question 38

Ulnar Nerve Degeneration Technique precautions

Answer 38

"Do not stretch or traction the regenerating nerve through techniques or movement Do not stretch, drag or work deep on flaccid or affected tissue (including no MFR) Be careful of pressure or temperature on areas of sensation loss"

Question 39

Ulnar Nerve degeneration tx

Answer 39

focus PROXIMAL to lesion site -- use border to prevent drag/traction of lesion site treat muscles surrounding ULNAR nerve (proximal to lesion) --> to reduce tightness around nerve --> to improve blood flow to area to increase metabolism & recovery E.g. medial head triceps, coracobrachialis, FCU/FDP, FDS promote relaxation --> GSM around neck & brachial plexus --> axial distraction cervical sp & occiput (BUT NO CONTRALATERAL FLEXION OF C-SP) --> instruct diaphragmatic breathing Improve tissue health DISTAL to lesion (affected tissue) --> GENTLE compressions --> LIGHT stroking (as long as it doesn't stretch nerve) Prevent/decrease contracture in mm opposing denervated tissue ECRL & ECRB --> work Distal to lesion on UNAFFECTED side is OKAY --- as long as affected nerve not stretched --> passive stretch (FCU action) --> Resisted isometrics (no isotonics for now, b/c notes say no ulnar deviation (?)) (FCU action) contribute to improving neuromuscular function -- I.e. "increase strength" / "encourage motor function" --> resisted isometrics/isotonics FCU ACTION With neural tapping (facilitatory ROOD) promote joint health --> PROM (without stretching/irritating affected nerve) --> JM (") misc --> treat TrP --> edema (E.g. nodal pumping) --> relaxation

Question 40

Ulnar nerve degeneration Homecare

Answer 40

"Sensory stimulation in affected area using different textures AROM or AAROM of returning function (eg wrist ext) Modified contrast for tissue health - as long as there are no autonomic symptoms"

Question 41

Piriformis Syndrome MOI

Answer 41

"Hip overuse Postural may include flat feet, hyperlordosis, pelvic changes with pregnancy Absence of significant lumbar load involvement (herniation)"

Question 42

Piriformis Syndrome key s&s

Answer 42

"Radiating pain starting at piriformis along sciatic nerve path - not dermatome or myotome - affects distal to piriformis along sciatic, common fibular or tibial nerve - can extend any length from piriformis down to the foot Often also sharp buttock pain Absence of lumbar pain or significant apprehension to lumbar movement"

Question 43

Piriformis syndrome key q's

Answer 43

"Can you tell me about any positions or movements which are difficult or you need to avoid? - sitting, especially prolonged such as driving, is an aggravator - passive external rotation is relieving - passive internal rotation is aggravating because belly is stretched over nerve - sidelying with leg below parralel (knee below trochanter) is aggravating"

Question 44

Piriformis syndrome Assessments

Answer 44

"Pace abduction Piriformis length test Piriformis test SLR Valsalva (Ddx, neg) Hip ROM Glute max MMT Postural assessment"

Question 45

Piriformis syndrome positional precautions

Answer 45

"Avoid passive internally rotated position If sidelying, make sure thigh is at least level (knee not below level of trochanter) If prone with hyperlordosis, try an abdominal pillow"

Question 46

Piriformis syndrome technique precautions

Answer 46

Direct pressure into the belly of piriformis

Question 47

Piriformis syndrome tx

Answer 47

Reduce tension & HT @ PIRIFORMIS INSERTION (avoid belly / local to sciatic nerve) --> OI technique, GTO release, knuckle comp, kneading Nerve glide, sciatic n (via SLR) --> improve smooth movement of nerve between muscles treat muscles along pathway of sciatic nerve (lateral hip rotators, Glute Max, Hamstrings) & lower QL, thoracolumbar fascia -- sciatic = L4-S3 --> comp, kneading, wringing, squeeze treat proximal tendons of hamstrings (ISCHIAL TUB) --> reduce HT that may contribute to compression of Sciatic n below piriformis hip JM & sacral float/vibrations --> capsular tightness may be contributing to tightness in lateral rotators & other hip mm treat TrP that may mimic or accompany piriformis syndrome pain --> QL, glute max, glute med, glute min, piriformis

Question 48

Piriformis Syndrome homecare

Answer 48

"If sleeping on side, pillow between the legs to avoid adducted position which will stretch over the nerve Strengthen glute max (piriformis often overloaded by weak glutes) ADL modifications around time spent sitting"

Question 49

Meralgia parasthetica MOI

Answer 49

"Surgery or iatrogenic Insidious related to external compression "

Question 50

Meralgia Parasthetica key s&s

Answer 50

Burning pain or tingling lateral thigh

Question 51

Meralgia parasthetica Key Q's

Answer 51

"Do you manage any chronic health conditions such as diabetes? Can you describe for me any movements or positions you regularly do which aggravate symptoms? Is there any part of your job like equipment use which contributes?"

Question 52

Meralgia Parasthetica Assessments

Answer 52

"Hip ROM Prone knee bending test Pelvic compression test Tinel's sign for provocation Postural for anterior pelvic tilt or hyperlordosis"

Question 53

Meralgia Parasthetica Positional precautions

Answer 53

Avoid pressure on anterior proximal thigh

Question 54

Meralgia Parasthetica Tx

Answer 54

reduce fascial adhesions & tightness that may be compressing LFCN --> SKIN ROLLING lateral thigh treat potentially TIGHT muscles that may be compressing LFCN (ILIACUS, psoas mj, Sartorius, Vastus Lateralis) --> comp, segmental NM stripping, kneading, GTO release, wringing --> TrP release if necessary reduce tightness in the inguinal ligament & ITB --> BOWING --> crossfibre strokes facilitate smooth movement of nerve along pathway --> LFCN nerve GLIDE (hip/knee) treat TIGHT muscles surrounding LFCN, but not in direct contact (could be affecting LFCN d/t fascial interconnections) (TFL, glut med/min, rectus femoris) --> comp, segmental NM stripping, kneading, GTO release, wringing --> TrP release if necessary treat potential sources of pain that mimics (or accompanies) meralgia paresthetica --> TFL, glute min, vastus lateralis (TRIGGER POINT) Misc Tx: --> JM hip --> hydro (cool if burning/acute @ lateral thigh) --> axial distraction hip/knee

Question 55

Meralgia Parasthetica homecare

Answer 55

"ADLs around external compression sources (clothes, belts, equipment) Encourage posterior tilt of pelvis to slacken inguinal ligament Lift skin and flex hip standing "

Question 56

Common fibular nerve degeneration MOI

Answer 56

"Severe prolonged compression around head of fibula Fibula fracture Iatrogenic"

Question 57

Common fibular nerve degeneration Key s&s

Answer 57

"Foot drop - loss of dorsiflexors and evertors Loss of sensation in lateral leg, dorsum of foot, in between digits 1 & 2"

Question 58

Common fibular nerve degeneration Key Q's

Answer 58

"Can you tell me about any other care you're receiving? Can you tell me about how it is improving or any function you're regaining?"

Question 59

Common fibular nerve degeneration Assessment

Answer 59

"Ankle ROM MMT tib ant, ext dig longus, ext hallucis longus, fib longus, fib brevis Palpation muscle bulk and sensation anterior and lateral lower leg, tissue health "

Question 60

Common fibular nerve degeneration positional precautions

Answer 60

"Make sure affected tissue is pillowed to avoid compression Avoid hip flexion Avoid plantar flexion Avoid inversion"

Question 61

Common fibular nerve degeneration technique precautions

Answer 61

"Do not stretch or traction the regenerating nerve through techniques or movement Do not stretch, drag or work deep on flaccid or affected tissue (including no MFR) Be careful of pressure or temperature on areas of sensation loss"

Question 62

Common fibular nerve degeneration Tx

Answer 62

POSITIONS TO AVOID plantar flexion hip flexion ankle inversion FULL KNEE EXTENSION (PILLOW UNDER KNEE) strengthen (strength & tissue health) improve neuromuscular function dorsiflexors (isometrics) neural tapping stretch (ROM & tissue health) PREVENT CONTRACTURE plantarflexors (BE CAREFUL NOT TO INVERT) JM (joint health) posterior glide TCJ (for dorsiflexion) NO AXIAL DISTRACTION TO AVOID EXTENDING KNEE tissue health & blood flow light comp (very gentle) on affected mm promote relaxation slow GSM, rocking, DB edema gentle strokes towards heart nodal pumping treat TrP if present treat tight mm proximal to lesion E.g. posterior thigh (biceps femoris, semitend/semimemb)

Question 63

Common fibular nerve degeneration Homecare

Answer 63

"Sensory stimulation in affected area using different textures AROM or AAROM of returning function (eg DF, eversion...it's important it does not involve plantar flexion as the posterior muscles will take over and the peroneals will do nothing) Seated dorsiflexion stretch using towel or something Modified contrast for tissue health - as long as there are no autonomic symptoms"

Question 64

Posterior Compartment Syndrome MOI

Answer 64

Overuse calves, insidious

Question 65

Posterior Compartment syndrome Key s&s

Answer 65

"Deep, achy calf pain Plantar paresthesia Worse when dependent position Occurs with exercise, relieved by rest"

Question 66

Posterior Compartment Syndrome Key Q's

Answer 66

"Can you tell me about your exercise volume at the moment? Do you notice exercise affects the severity? Ways to rule out DVT... - any prolonged immobilisation or travel? Recent trauma or surgery? History of CVD or DVT? Ways to rule out arterial insufficiency - do you notice coldness or whiteness in the feet? Any areas of skin that damage easily or take longer to heal? Does leg position affect it the same as exercise does?"

Question 67

Posterior compartment syndrome Assessment

Answer 67

"Ankle ROM Rule out DVT or stress fracture MMT relevant muscles for weakness or pain, especially tib post"

Question 68

Posterior Compartment Syndrome Tx

Answer 68

MFR posterior compartment --> relieve tension / HT in deep posterior compartment --> superficial posterior leg improve smooth nerve movement --> SLR glides improve muscle tissue health -- SUBMAXIMAL ISOMETRICS (plantar flexion, inversion) improve ankle joint health with prolonged denervation or poor innervation --> JM ankle grade 1-2 (Talocrural AND subtalar) STRENGTHEN posterior compartment (submaximal to avoid exercise induced neuropraxia) STRETCH (prevent contraction) anterior compartment (antagonist) --> AGONIST-CONTRACT stretch for anterior compartment (tib ant, EDL) --> submaximal isotonics for posterior compartment facilitory ROOD during posterior leg strengthening --> neural tapping Treat all compartments of lower leg, as interfascial connections may contribute to TIGHTNESS in posterior compartment --> MFR, wringing, squeezing @ lateral compartment, & anterior compartment

Question 69

Posterior Compartment Syndrome Homecare

Answer 69

"ADL modifications to training surfaces (softer) or cross training (less weight bearing) for a short period of time Stretch triceps surae Contrast foot baths RICE post-exercise Thermotherapy on rest days"