UE & LE Compression Neuropathy (Lecture + Lab) Flashcards
Pathologic changes that occur with neuropathy
Microvascular compression —> ischemia
Thickened epineurium
Myelin thinning distortion
Microtubule closure
Axonal degeneration
Etiologies of nerve entrapment
Increased muscle mass by repetitive activity
Space occupying lesions (cysts or tumors)
Inflammation of surrounding tissues (leads to venous congestion in epineurial and perineurial vascular plexuses —> endoneurial edema -> nerve anoxia)
Posttraumatic conditions — hematoma, fracture, or compression
Systemic causes — pregnancy, hypothyroid, diabetes
3 categories of nerve injury
Neuropraxia (1st degree)
Axonotmesis (2nd degree)
Neurotmesis (3rd, 4th, or 5th degree)
Category of nerve injury involving focal damage of myelin fibers around axon while connective tissue sheath remains intact; limited course (days to weeks); least severe
Neuropraxia
Category of nerve injury in which there is some disruption to the axon itself but myelin sheath remains intact; regeneration is possible, but prolonged (months) without a full recovery
Axonotmesis
Describe 3rd degree neurotmesis and possibility of recovery
Disruption of axon and endoneurium
Recovery through axonal regeneration cannot occur as intraneural fibrosis occurs
Describe 4th degree neurotmesis and possibility of recovery
Disruption of axon, endoneurium, and perineurium (nerve fasciculi); large areas of intraneural scarring at injury site —> precluded axon from advancing distal to level of injury
No improvement in function — surgery is used to restore normal continuity
Describe 5th degree neurotmesis and possibility of recovery
Disruption of axon, endoneurium, perineurium, and epineurium; substantial perineural hemorrhage and scarring occur
Surgery is required to restore neural continuity
Conservative treatment options for compression neuropathy
Activity modifications, use of antiinflammatories, splinting, and/or injections
PT, OMM, pain management
Conservative tx should be pursued for 3-6 months (except with cubital tunnel syndrome — fix right away even in mild cases to avoid nerve damage)
Surgical release is considered when non-operative management fails
Motor, sensation, and reflex associated with C5 nerve root
Motor — deltoid, biceps
Sensation - lateral arm
Reflex - biceps
Motor, sensation, and reflex associated with C6 nerve root
Wrist extension, elbow flexion
Sensation - radial forearm, thumb, index finger
Reflex - brachioradialis
Motor, sensation, and reflex associated with C7 nerve root
Wrist flexion, elbow extension, finger extension
Sensation to middle finger
Triceps reflex
Motor and sensation associated with C8 nerve root
Motor - finger flexion
Sensation ulnar forearm, small finger
Motor and sensation associated with T1 nerve root
Motor - finger abduction
Sensation - medial arm
Possible sites of radial nerve entrapment
High on the humerus
Radial tunnel
At the wrist
Motor and sensory functions of radial n
Motor to triceps brachii, anconeus, wrist extensors
Sensation to majority of dorsum of hand (via posterior interosseous)
Symptoms and treatment of radial nerve compression high on the humerus d/t fracture or compression at spiral groove
Wrist drop, weakness of elbow flexion, possible tricep involvement, +/- tricep reflex diminished, pain/numbness
Tx: function returns in 4-5 mos
What causes supinator syndrome, which involves pain and tenderness 5cm distail to lateral epicondyle as well as wrist drop or pain with resisted supination?
Compression of posterior interosseous branch of radial nerve as it passes under the supinator m. at the arcade of frohse (purely motor branch)
4 possible sites of median nerve entrapment
Ligament of struthers
Pronator syndrome — between superficial and deep heads of pronator teres m.
Anterior interosseous syndrome — just distal to pronator teres, innervates flexors
Carpal tunnel syndrome — flexor tendons under flexor retinaculum
What compression neuropathy?:
Repetitive pronating motions like pianists, fiddlers, baseball players, dentists, weight trainers; c/o achy pain in mid/proximal forearm, aggravated by repeated lifting - may have sensory abnormality in radial 3.5 digits and dx based on pain with resisted forearm pronation
Pronator syndrome
T/F: anterior interosseous syndrome has no sensory symptoms
True
Etiologies of anterior interosseous syndrome
Trauma
Cast pressure
Bulky tendinous origin of ulnar head of pronator teres
Soft tissue masses
Fibrous bands
Tx for anterior interossous syndrome
General tx, and elbow can be splinted in 90 degrees of flexion for up to 12 wks
Pt unable to hold “Ok” sign
Anterior interosseous syndrome
[due to weak flexion ability of index finger’s DIP and thumb’s IP]
Gold standard for diagnosing carpal tunnel
EMG
[others include phalens, tinel’s, and 2-point discrimination where pt is unable to distinguish 2 points on a caliper if closer than 5 mm]
Tx for carpal tunnel syndrome
Rest from repetitive motions if possible, self-stretching
Wrist splinting with 30 degrees of hand extension, usually at night
NSAIDs
Steroid injections if failure of conservative measures
Surgical release if failure other tx
General functions of median n
Forearm flexion and pronation
Wrist flexion and radial deviation
Thumb abduction and opposition
Index and middle finger abduction and flexion
2 sites of ulnar nerve entrapment
Cubital tunnel (medial epicondyle, medial trochlea, olecranon, ulnar collateral ligament)
Guyon’s canal
What compression neuropathy?
Baseball pitchers, prolonged elbow flexion during sleep, external compression against surface, thickened retinaculum
Leads to paresthesia to 4th and 5th digits; medial elbow pain radiating to hand with decreased intrinsic muscle strength (can’t turn a key in door); +tinels at elbow; symptom reproduced with elbow flexion and wrist extension
Cubital tunnel syndrome
What is froment’s sign and what does it indicate
Pt must flex thumb in order to pinch paper between 1st and 2nd digits; must contract FPL (supplied by median n.) due to weak 1st dorsal interosseous and ADP muscles
Indicates cubital tunnel syndrome
Tx for cubital tunnel syndrome
General tx and padded elbow sleeve to limit terminal elbow flexion and provide cushioning
General ulnar nerve function
Innervates skin and muscles of ulnar side of forearm and hand (flexors)
Deep branch in hand —> motor innervation for interosseous mm and adductor policis
Superficial branch in hand —> sensory to ring and pinky
3 major sites of compression involved in TOS
Scalene triangle
Costoclavicular passage
At the pec minor attachment at coracoid process
Motor and sensation associated with L1 and L2 nerve roots
Hip flexion
Sensation to inguinal crease (L1) and anterior thigh (L2)
Motor and sensation associated with L2 and L3 nerve roots
Knee extension
Sensation to anterior thigh (L2), anterior thigh just above knee (L3)
Motor, sensation, and reflex associated with L4
Ankle dorsiflexion
Sensation to medial leg and foot
Reflex — knee jerk (patellar)
Motor and sensory functions of L5 nerve root
Extensor hallucis longus
Sensation to lateral leg, foot dorsum
Motor, sensory, and reflex associated with S1
Ankle plantarflexion
Sensation to lateral foot, plantar foot
Reflex = ankle jerk (achilles)
Nerve roots associated with common fibular nerve
L4-S2
Etiologies of common fibular nerve compression
Leg hooked over a rail (i.e, bedridden, comatose, postop)
“strawberry pickers palsy” — time spent in squatting position
Lithotomy position during childbirth
Idiopathic
What compression neuropathy?
Pain along proximal third of lateral leg, foot drop with slapping gait, sxs exacerbated during plantarflexion and inversion of foot
Common fibular nerve
OMT for common fibular nerve neuropathy
Posterior fibular head HVLA or ME
ME on gastroc/soleus, biceps femoris
Nerve roots associated with deep fibular nerve
L4-S2
What is anterior tarsal tunnel syndrome?
Deep fibular nerve compression at inferior extensor retinaculum
Caused by trauma (i.e., recurrent ankle sprains, soccer players), talonavicular dysfunction, prolonged plantar flexion, and/or compression from shoes
What neuropathy?:
Pain over dorsomedial aspect of foot and worse at rest; weakness of extensor digitorum brevis
Anterior tarsal tunnel syndrome
Tx for anterior tarsal tunnel syndrome
Remove compressive forces
MFR of extensor retinaculum
Traction tug of talonavicular joint
Hiss whip for navicular, cuneiforms, 1st and 2nd metatarsal
Nerve roots associated with posterior tibial n
L4-S2
T/F: Tarsal tunnel syndrome = anterior tarsal syndrome
False!
Anterior tarsal syndrome = compression of deep fibular n. at inferior extensor retinaculum
Tarsal tunnel syndrome = compression of posterior tibial n. in tarsal tunnel behind medial malleolus with overlying flexor retinaculum
What neuropathy:
Pain on plantar surface of foot, vague burning, tingling, or numbness on plantar aspect of foot; gait seldom affected; affects the nerve whose function is motor to plantar foot mm and sensation to plantar aspect of foot and toes
Tarsal tunnel syndrome (posterior tibial n)
Etiologies of tarsal tunnel syndrome
Idiopathic in 50% of cases
Space occupying lesion (synovial cyst, ganglion from tendon sheath, lipoma, tenosynovitis)
Trauma to medial malleolus, distal tibia, or calcaneus (MVAs)
Congenital
Autoimmune (RA, ankylosing spondylitis)
Diabetes
Lifestyle (long periods of standing)
2 OMT techniques used in tarsal tunnel syndrome
MFR
HVLA
Nerve roots associated with lateral femoral cutaneous n
L2, L3
[sensory only of anterolateral thigh down to knee]
What is meralgia paresthetica?
Compression of lateral femoral cutaneous n. under inguinal ligament at inguinal canal
What neuropathy?
Numbness or burning pain on anterolateral thigh, hyperthesia to the point of not placing things in pockets, trophic skin changes, +tinel sign 1cm medial and inferior to ASIS
Meralgia paresthetica (lateral femoral cutaneous n)
Etiologies of meralgia paresthetica
Very intense athletes
Obesity
Tight girdle/belt, tight clothing
Seat belt misplacement or post-accident
Anatomic anomaly (i.e., runs through sartorius)
What part of a nerve contains the fascicles, blood vessels, and CT?
Epineurium
Fascicles of a nerve are covered by ____ and contain groups of axons
Perineurium
Axons are covered in a myelin sheath which are in turn covered by ____
Endoneurium
Most commonly cervical discs rupture ___________, causing compression of the nerve root as it exits the intervertebral foramen
Postero-laterally
New York GianTS’ Defensive end, Jason Pierre-Paul (JPP) Comes to you after 4 weeks of having a club cast on his forearm complaining of an abnormal and dull feeling in his right arm.
Which of the following are you most likely to find?
A. Weakness of long flexor muscle of thumb
B. Weakness of long extensor muscle of thumb
C. Weakness of abductor m. of thumb
D. Weakness of adduction muscle of thumb
A. Weakness of long flexor muscle of thumb
Michael Phelps, an Olympic Swimmer, presents to your clinic complaining of weakness and paresthesia of the medial arm and forearm. He states he noticed it shortly after his last Olympic games when he was training extremely hard and did repetitive butterfly strokes for months. He states that butterfly requires repetitive overhead motion.
Which of the following sites of compression would occur while performing adson’s test and looking toward the tested arm?
A. Scalene muscle(s) B. Sternoclavicular joint C. Sternocleidomastoid muscle D. Rib 1 E. Pectoralis Minor
D. Rib 1
