UE & LE Compression Neuropathy (Lecture + Lab)

Question 1

Pathologic changes that occur with neuropathy

Answer 1

Microvascular compression —> ischemia

Thickened epineurium

Myelin thinning distortion

Microtubule closure

Axonal degeneration

Question 2

Etiologies of nerve entrapment

Answer 2

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

Question 3

3 categories of nerve injury

Answer 3

Neuropraxia (1st degree)

Axonotmesis (2nd degree)

Neurotmesis (3rd, 4th, or 5th degree)

Question 4

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

Answer 4

Neuropraxia

Question 5

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

Answer 5

Axonotmesis

Question 6

Describe 3rd degree neurotmesis and possibility of recovery

Answer 6

Disruption of axon and endoneurium

Recovery through axonal regeneration cannot occur as intraneural fibrosis occurs

Question 7

Describe 4th degree neurotmesis and possibility of recovery

Answer 7

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

Question 8

Describe 5th degree neurotmesis and possibility of recovery

Answer 8

Disruption of axon, endoneurium, perineurium, and epineurium; substantial perineural hemorrhage and scarring occur

Surgery is required to restore neural continuity

Question 9

Conservative treatment options for compression neuropathy

Answer 9

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

Question 10

Motor, sensation, and reflex associated with C5 nerve root

Answer 10

Motor — deltoid, biceps

Sensation - lateral arm

Reflex - biceps

Question 11

Motor, sensation, and reflex associated with C6 nerve root

Answer 11

Wrist extension, elbow flexion

Sensation - radial forearm, thumb, index finger

Reflex - brachioradialis

Question 12

Motor, sensation, and reflex associated with C7 nerve root

Answer 12

Wrist flexion, elbow extension, finger extension

Sensation to middle finger

Triceps reflex

Question 13

Motor and sensation associated with C8 nerve root

Answer 13

Motor - finger flexion

Sensation ulnar forearm, small finger

Question 14

Motor and sensation associated with T1 nerve root

Answer 14

Motor - finger abduction

Sensation - medial arm

Question 15

Possible sites of radial nerve entrapment

Answer 15

High on the humerus
Radial tunnel
At the wrist

Question 16

Motor and sensory functions of radial n

Answer 16

Motor to triceps brachii, anconeus, wrist extensors

Sensation to majority of dorsum of hand (via posterior interosseous)

Question 17

Symptoms and treatment of radial nerve compression high on the humerus d/t fracture or compression at spiral groove

Answer 17

Wrist drop, weakness of elbow flexion, possible tricep involvement, +/- tricep reflex diminished, pain/numbness

Tx: function returns in 4-5 mos

Question 18

What causes supinator syndrome, which involves pain and tenderness 5cm distail to lateral epicondyle as well as wrist drop or pain with resisted supination?

Answer 18

Compression of posterior interosseous branch of radial nerve as it passes under the supinator m. at the arcade of frohse (purely motor branch)

Question 19

4 possible sites of median nerve entrapment

Answer 19

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

Question 20

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

Answer 20

Pronator syndrome

Question 21

T/F: anterior interosseous syndrome has no sensory symptoms

Answer 21

True

Question 22

Etiologies of anterior interosseous syndrome

Answer 22

Trauma

Cast pressure

Bulky tendinous origin of ulnar head of pronator teres

Soft tissue masses

Fibrous bands

Question 23

Tx for anterior interossous syndrome

Answer 23

General tx, and elbow can be splinted in 90 degrees of flexion for up to 12 wks

Question 24

Pt unable to hold “Ok” sign

Answer 24

Anterior interosseous syndrome

[due to weak flexion ability of index finger’s DIP and thumb’s IP]

Question 25

Gold standard for diagnosing carpal tunnel

Answer 25

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]

Question 26

Tx for carpal tunnel syndrome

Answer 26

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

Question 27

General functions of median n

Answer 27

Forearm flexion and pronation Wrist flexion and radial deviation Thumb abduction and opposition Index and middle finger abduction and flexion

Question 28

2 sites of ulnar nerve entrapment

Answer 28

Cubital tunnel (medial epicondyle, medial trochlea, olecranon, ulnar collateral ligament) Guyon’s canal

Question 29

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

Answer 29

Cubital tunnel syndrome

Question 30

What is froment’s sign and what does it indicate

Answer 30

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

Question 31

Tx for cubital tunnel syndrome

Answer 31

General tx and padded elbow sleeve to limit terminal elbow flexion and provide cushioning

Question 32

General ulnar nerve function

Answer 32

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

Question 33

3 major sites of compression involved in TOS

Answer 33

Scalene triangle Costoclavicular passage At the pec minor attachment at coracoid process

Question 34

Motor and sensation associated with L1 and L2 nerve roots

Answer 34

Hip flexion Sensation to inguinal crease (L1) and anterior thigh (L2)

Question 35

Motor and sensation associated with L2 and L3 nerve roots

Answer 35

Knee extension Sensation to anterior thigh (L2), anterior thigh just above knee (L3)

Question 36

Motor, sensation, and reflex associated with L4

Answer 36

Ankle dorsiflexion Sensation to medial leg and foot Reflex — knee jerk (patellar)

Question 37

Motor and sensory functions of L5 nerve root

Answer 37

Extensor hallucis longus Sensation to lateral leg, foot dorsum

Question 38

Motor, sensory, and reflex associated with S1

Answer 38

Ankle plantarflexion Sensation to lateral foot, plantar foot Reflex = ankle jerk (achilles)

Question 39

Nerve roots associated with common fibular nerve

Answer 39

L4-S2

Question 40

Etiologies of common fibular nerve compression

Answer 40

Leg hooked over a rail (i.e, bedridden, comatose, postop) “strawberry pickers palsy” — time spent in squatting position Lithotomy position during childbirth Idiopathic

Question 41

What compression neuropathy? Pain along proximal third of lateral leg, foot drop with slapping gait, sxs exacerbated during plantarflexion and inversion of foot

Answer 41

Common fibular nerve

Question 42

OMT for common fibular nerve neuropathy

Answer 42

Posterior fibular head HVLA or ME ME on gastroc/soleus, biceps femoris

Question 43

Nerve roots associated with deep fibular nerve

Answer 43

L4-S2

Question 44

What is anterior tarsal tunnel syndrome?

Answer 44

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

Question 45

What neuropathy?: Pain over dorsomedial aspect of foot and worse at rest; weakness of extensor digitorum brevis

Answer 45

Anterior tarsal tunnel syndrome

Question 46

Tx for anterior tarsal tunnel syndrome

Answer 46

Remove compressive forces MFR of extensor retinaculum Traction tug of talonavicular joint Hiss whip for navicular, cuneiforms, 1st and 2nd metatarsal

Question 47

Nerve roots associated with posterior tibial n

Answer 47

L4-S2

Question 48

T/F: Tarsal tunnel syndrome = anterior tarsal syndrome

Answer 48

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

Question 49

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

Answer 49

Tarsal tunnel syndrome (posterior tibial n)

Question 50

Etiologies of tarsal tunnel syndrome

Answer 50

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)

Question 51

2 OMT techniques used in tarsal tunnel syndrome

Answer 51

MFR | HVLA

Question 52

Nerve roots associated with lateral femoral cutaneous n

Answer 52

L2, L3 [sensory only of anterolateral thigh down to knee]

Question 53

What is meralgia paresthetica?

Answer 53

Compression of lateral femoral cutaneous n. under inguinal ligament at inguinal canal

Question 54

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

Answer 54

Meralgia paresthetica (lateral femoral cutaneous n)

Question 55

Etiologies of meralgia paresthetica

Answer 55

Very intense athletes Obesity Tight girdle/belt, tight clothing Seat belt misplacement or post-accident Anatomic anomaly (i.e., runs through sartorius)

Question 56

What part of a nerve contains the fascicles, blood vessels, and CT?

Answer 56

Epineurium

Question 57

Fascicles of a nerve are covered by ____ and contain groups of axons

Answer 57

Perineurium

Question 58

Axons are covered in a myelin sheath which are in turn covered by ____

Answer 58

Endoneurium

Question 59

Most commonly cervical discs rupture ___________, causing compression of the nerve root as it exits the intervertebral foramen

Answer 59

Postero-laterally

Question 60

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

Answer 60

A. Weakness of long flexor muscle of thumb

Question 61

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 ```

Answer 61

D. Rib 1