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History:
Mary-Jane, 45 year old nurse, presents with intermittent tingling and pain the thumb,
index and middle finger of her right hand for the last 2 days that started while at work.
The pain is described as 4/10 ‘pins and needles’. The pain is made worse with
computer work and is relieved by shaking her hands. She has been awaken by ‘8/10
pain, tingling and numbness’ in the middle of the night for the last 2 nights and
hanging her hand over the side of the bed or getting up to shake her hands helps to
alleviate it enough to get back to sleep. She has been taking 500g paracetomol with
no symptom relief. She denies any trauma or recent fall.
No fever, fatigue, weight gain/loss, fever, chills or sweating
No headaches, dizziness, nausea, visual changes, hearing loss
No recent illnesses
Unremarkable family history
Unremarkable systems - no GI/ GU/ CardioRespiratory complaints
No rash or other integumentary changes
No history of allergies
Social history good
Exam:
Good posture, no gait abnormality, adequate nutritional state, adequate emotional
state, good communication, no acute distress
Neck – no masses, no lymphadenopathy, thyroid good, no visual deformity, mild
restriction on right active and passive rotation; orthopaedic exam normal; UE DTRs
2+ and muscle strength normal, 5+
Shoulder exam – unremarkable
UE – Positive Tinnel’s sign over the volar wrist, positive Phalen’s test; minor muscle
atrophy at the base of the thumb; muscle strength normal. No swelling or tenderness
to joints
Carpal Tunnel (median nerve entrapment) syndrome most likely. No sensory loss
experienced over thenar eminence. The numbness with pain, positive tinnels sign and
phalens test, no sensory loss more associated with Carpal tunnel syndrome.
EXERCISE 2
39 year old male presents with a burning sensation at the bottom of his right foot. This has been
present for two weeks since he has started jogging to get fit again. He doesn’t feel like he’s
overdoing the training and can’t figure out why his foot hurts. Nothing makes it better or worse. He
has no history of system disorders or illness. He is generally well. Past history is only significant for
fracture of the proximal tibia when he was 25 yo. On examination on the right, the foot is normal
colour. Pulses are strong. There is decreased sensation at the posterior lateral ankle and on the
plantar aspect of his foot. He is unable to flex his toes. Ankle jerk is normal. Eversion is normal,
inversion is 3+. Examination of the left foot is normal
- Tarsal tunnel syndrome and tibial nerve entrapped. Tarsal tunnel occurs when the
tibial nerve is being compressed/entrapped. The tibial never provides sensory and
motor innervation to the leg and foot.
- I would suggest because he has just started running and may have poor foot
mechanics which is a factor in tarsal tunnel syndrome.
29 year old female; 28 weeks pregnant, presents to your office with a burning type pain over her
lateral upper leg of 4 weeks duration, 5-7/10 on NRS (numeric rating). She cannot identify a specific
onset, it came on gradually. She has aching in her low back and SI joint but that comes and goes. No
pain in her leg except the area mentioned. The pain is worse when she’s walking and sitting down
helps to relieve the pain. She is unable to take medications at this time. She has seen another
Chiropractor who adjusted her lower back and SI joint a few times but this did not help. On
examination, gait is normal, lumbar spine and hip ROM is normal. Significant discomfort is elicited on
palpation below the greater trochanter. Orthopaedic testing is generally unrewarding however when
you tap or press firmly over the inguinal region she winces. LE neurologic evaluation is normal. She is
otherwise fit and healthy.
What is your most likely diagnosis?
Meralgia paresthetica (pregnancy, burning sensation over lateral upper leg, pain worsens when
walking and pervious manual adjustment didn’t relieve pain.)
EXERCISE 3
Develop a table that includes the common entrapment syndromes of the UE and similar table that
includes the common entrapments of the LE (lower extremity). Include the following components.
Name of the Nerve or branch entrapped Common and any Test used for that
entrapment outstanding entrapment
symptoms
Pronator (Teres) The median nerve may be Aching pain in the This can be tested for by
syndrome entrapped between the proximal forearm palpating over the area of
two heads of the pronator with weakness/ entrapment and by resisted
teres muscle (originating clumsiness of the testing of the pronator teres
ulnar coronoid and medial hand muscle to see if pain and
epicondyle of humerus) paraesthesia are reproduced.
causing Pronator teres Often begins
syndrome. insidiously. To test the pronator teres,
have the patient flex the
Numbness/ elbow to 60° with the forearm
paraesthesias pronated then the examiner
follow the median apply a force against the distal
nerve distribution forearm into supination which
the patient resists.
Night pain is NOT
common
As sensory findings
are like carpal
tunnel syndrome,
the two conditions
may be confused.
Anterior Interosseous Median nerve branch Because there are Ask the patient to place the
Nerve (AIN) no sensory fibres tips of the index finger and
Syndrome in the nerve, the thumb together. If there is a
patient has no problem with the anterior
sensory complaints interosseous nerve then there
and experiences is a loss of distal flexion of the
only motor thumb and index finger giving
weakness a characteristic ‘pinch sign’.
Weakness with
finger, wrist and
thumb movements
Radial tunnel for compression of the pain in the dorsal A positive "middle finger
syndrome posterior interosseous aspect of the test", where resisted middle
nerve at the lateral upper forearm finger extension produces
intermuscular septum of pain
arm, while "supinator Any weakness
syndrome or PIN described is
Syndrome" is used for secondary to the
compression at the arcade pain.
of Frohse
Tenderness to
palpation occurs
over the area of
the radial neck
Cubital tunnel Ulnar nerve to a tingling Tinnel’s sign at the cubital
syndrome sensation along tunnel (Sensitivity: 0.70,
the 4th and 5th Specificity: 0.98)
fingers of the
hand. Elbow flexion test (Sensitivity:
0.75, Specificity: 0.99)
Guyon’s Canal Ulnar nerve Muscular atrophy direct pressure over the
syndrome canal may reproduce or
caused by direct Muscle sparing of exacerbate the symptoms
pressure on a the thenar group (Guyon canal compression
handlebar (ie. Bicyle test)
handlebar, Sensory loss and
weightlifting, pain
construction
equipment) and
therefore, is
sometimes referred
to as “handle bar
palsy”.
Name of the Nerve or branch Common and any Test used for that entrapment
entrapment entrapped outstanding symptoms
Piriformis Sciatic nerve Deep aching pain in the piriformis muscle is tender, and
syndrome entrapment sacral or gluteal region hip abduction and lateral rotation
remains the most are weak.
common symptom Bonne’s Test
with posterior thigh
pain
Possible trophic
changes in territory of
affected nerve
Ilioinguinal Ilioinguianl nerve (L1- Chronic lower Tenderness may be localised near
neruralgia L2 nerve root) abdominal pain the ASIS where the nerve pierces the
(Sensory Only) fascia.
Burning or shooting
pain in the base of the Atrophy of muscles supplied
penis, scrotum (or (internal oblique & transversus
labium major) and part abdominus)
of the medial thigh.
Aggravated by
extension and lateral
leg movements
(abduction)
Meralgia Entrapment of the Middle aged males Reproduced with Tinel’s sign at site
Paresthetica lateral femoral of entrapment (1 cm medial and
cutaneous nerve Unpleasant inferior to the ASIS helps confirm the
(L2,L3) (or lateral paraesthesia (burning, diagnosis)
cutaneous nerve of tingling, stinging) in
thigh) by the inguinal the nerve distribution
ligament close to
where it attaches to Hypersensitivity to
the ASIS. touch (e.g. clothing)
Decreased pain on
sitting
increased pain on hip
extension and
prolonged walking or
standing
Tibial nerve The tibial nerve is a Sensory changes in the Loss of plantar flexion
entrapment terminal branch of bottom of the foot and Loss of toe flexion
the sciatic nerve toes - burning Weak inverters (tibialis anterior can
formed by branches sensation, numbness, still invert some)
from L4-S3. tingling, or other
abnormal sensation, or
pain.
Common Common peroneal Pain usually appears Tinel’s sign or overpressure at the
peroneal (figular) nerve compression initially in the fibula head may increase
nerve compressed region paraesthesia, aiding diagnosis
entrapment before spreading
distally into the
One of the most common peronal Dorsiflexion paresis and foot drop (in
commonly nerve’s cutaneous severe cases, look for atrophy of
encountered distributions anterior tibial muscles)
lower extremity
mono- Possible radiation of Weakness of foot eversion
neuropathies. pain into the thigh (if
pain is seen in buttock Increased pain with plantar flexion
or posterior thigh, and inversion of foot
think of a more
proximal cause) Pressure over tunnel will increase
pain
Sensory abnormalities
along the anterolateral
leg below the knee and
along the top of the
foot if both superfical
and deep branches
involved
Superficial Superficial peroneal Pain increased with passive inversion and plantar flexion
peroneal nerve nerve inversion while applying pressure over the
point where the nerve pierces the
Sensory loss at lateral deep fascia reproduces the
lower half of the calf symptoms
and dorsum of the foot
Deep Peroneal Causes of injury to pain is often motor loss is variable depending on
Nerve the nerve include aggravated by plantar level of the lesion.
anterior flexion
compartment sensory loss at the web May include weak toe extensors,
syndrome and of the great toe weak tibialis anterior and peroneus
passage under the tertius in a more proximal lesion
extensor retinaculum (may have foot drop)
(anterior tarsal
tunnel syndrome). atrophy of the belly of the extensor
digitorum brevis occurs early and is a
useful sign.
Saphenous Saphenous nerve Sunburned feeling over Pain in the distribution of the
neuralgia the distribution of the saphenous nerve, normal motor
nerve function, and tenderness to
palpation over the entrapment site.
Pain that radiates into Entrapment site tenderness is a key
the medial calf to the feature of saphenous nerve
medial malleolus. neuropathy.
May be paraesthetic or
burning in character
Tarsal tunnel entrapment of the Pain or sensory Tinel's test, which involves gently
syndrome tibial nerve disturbance on the tapping the tibial nerve. If you
plantar aspect of the experience a tingling sensation or
foot pain as a result of that pressure, this
indicates tarsal tunnel syndrome
Patients typically
present with Positive Tinel’s sign
intractable heel pain. sensory changes on the dorsum of
the foot
Burning, throbbing
pain on the sole of the
foot
Aggravated by
prolonged
standing/activity
Pain may radiate up
the leg
tenderness over the
tarsal tunnel (posterior
to the distal tip of the
medial malleolus)
Medial plantar Occurs in the region Pain (burning, Tenderness along medial plantar
nerve syndrome of the navicular shooting, sharp) and/or aspect of medial arch in the region
(Jogger’s foot) tuberosity when the dysaesthesia, of the navicular tuberosity
nerve passes through paraesthesia along
a tunnel formed by medial arch of the foot Positive Tinel’s sign just behind the
the abductor hallicus sometimes to plantar navicular tuberosity ± paraesthesia
muscle and navicular toes in distribution of Neurodynamic signs –
bone medial plantar nerve dorsiflexion/eversion/SLR (structural
differentiation)
Occurs during running
– exercise induced There may be pain with resisted
great toe abduction
Onset of pain often
occurs with use of new Neither flexion of the toes against
arch support or new resistance nor passive toe
shoes without changes hyperextension should increase the
in exercise regime pain – differentiate from flexor
tenosynovitis and plantar fascitis.
Pain will often worsen
with high arch supports No weakness detected easily as long
– especially rigid flexors of foot and toes are
orthoses preserved
Pain is usually
described as piercing
or like an electric shock
May be aggravated by
specific activities, e.g.
skiing after a
predictable length of
time
Pain (‘cutting’,
‘electrical’, ‘sharp’)
and/or dysaesthesia
over metatarsal heads