EXERCISE 1

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

Based on the above history:

• Identify the components of LODCTRAPPA
L- pain the thumb, index and middle finger of her right hand
O- last 2 days that started while at work
D- last 2 days
C- computer work
T- intermittent tingling and pain
R- NA
A- The pain is made worse with computer work and is relieved by shaking her
hands
P- denies any trauma or recent fall
P- taking 500g paracetomol with no symptom relief
A- NA

• Identify the components of GORPOMNICS

G- Normal
O- Good posture, no gait abnormality, adequate nutritional state, adequate emotional
state, good communication, no acute distress
R- mild restriction on right active and passive rotation of the neck
P- no masses, no lymphadenopathy, thyroid good, no visual deformity
 O- Normal
M- muscle strength normal, 5+. Minor muscle atrophy at the base of the thumb
N- NA
I - NA
C- Positive Tinnel’s sign over the volar wrist, positive Phalen’s test
S- Normal

• Is any further investigation warranted? If yes, what might this be?

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

Short Case Histories:

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

What is your most likely diagnosis?

- 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.

Upper extremity Syndromes

Name of the Nerve or branch entrapped Common and any Test used for that
entrapment outstanding entrapment
symptoms

Supracondylar Median nerve (C6-C8,T1)  weakness of the Pressure in the ligament of

process syndrome pronator teres Struthers area leads to motor
muscle and of loss 
those muscles and sensory loss of the 
affected by the median nerve. Initially, the
pronator patient complains of pain and
syndrome paresthesia in the elbow and
forearm; abnormality of
motor function is secondary

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

Anterior Interosseous Median nerve branch  Because there are
Nerve (AIN)
Syndrome  in the nerve, the
Posterior Radial nerve branch The
Interosseous Nerve most common entrapment
Syndrome  neuropathy of the radial
nerve or its branches
involves the posterior
interosseous nerve as it
passes between the two
heads of the supinator
muscle under a thick
ligamentous band known as
the arcade of Frohse (also
called the supinator arch),
may be confused.   
Ask the patient to place the
no sensory fibres tips of the index finger and
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’.
dull, aching pain in The pronator quadratus is
the volar aspect of tested with the patient’s
the proximal elbow fully flexed and the
forearm.  forearm pronated.  
The examiner then applies a
force against the lower
forearm into supination which
the patient resists.
With an anterior interosseous
nerve lesion there will be
decreased resistance.  
Progressive Inspection chronic
paralysis of the compression may cause
posterior forearm extensor
interosseous nerve compartment muscle atrophy
Sensory loss to the Finger metacarpal extension
region of weakness
superficial radial
nerve supply is Wrist extension weakness
seen along with inability to extend wrist in
wrist drop neutral or ulnar deviation
Symptoms The wrist will extend with
insidious onset, radial deviation due to intact
may go ECRL (the extensor carpi
undiagnosed  radialis longus) (radial n.) and
absent ECU (The extensor
Pain in the forearm carpi ulnaris) (PIN). 
and wrist –
location depends resisted supination will
on site of PIN increase pain symptoms
compression.
Pain just distal to
the lateral
epicondyle of the
elbow may be
caused by
compression at the
arcade of Frohse
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)

Pressure provocative test

(Sensitivity: 0.89, Specificity:
0.98)

Card test - Froment’s sign.

Carpal Tunnel Median nerve  intermittent A combination of described

Syndrome  numbness of the symptoms, clinical findings,
thumb, index, long and electrophysiological
and radial half of testing is used by most
the ring finger.  specialists

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”. 

Lower Extremity Entrapment syndromes

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

Pain increases with

sitting and walking,
decreases on lying
supine

Pain and paraesthesia

can radiate along tibial
and/or peroneal nerve
distributions 

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.  

Light touch sensation

in the inguinal area
may be altered and
pain may be
exacerbated by
hyperextension of the
hip  
Obturator Anterior divisions of Altered sensation in Stretching the  pectineus muscle can
Neuropathy  L2-L4 within the the medial thigh that be useful in diagnosing obturator
psoas to emerge at may be paraesthetic or nerve entrapment. 
the lower medial burning 
border of the psoas
at the pelvic brim and May include moderate
passes inferior to severe pain that
through the begins insidiously at
obturator foramen the adductor origin on
the pubic bone and
worsens with exercise
(medial thigh or groin
pain)

Pain may extend to the

knee.(NOT pass the
knee)

Aggravated by
extension and lateral
leg movements
(abduction)

Genitofemoral Genitofemoral nerve Chronic neuropathic Inspection chronic compression may

nerve entrapment   groin pain cause forearm extensor
entrapment   compartment muscle atrophy
Pain and/or numbness
in an elliptical area on Finger metacarpal extension
the anterior aspect of weakness
the thigh immediately
below the middle of Wrist extension weakness inability
the inguinal ligament. to extend wrist in neutral or ulnar
May present as scrotal deviation
pain or labial pain 
The wrist will extend with radial
Increased by thigh deviation due to intact ECRL (the
extension   extensor carpi radialis longus) (radial
Decreased perception n.) and absent ECU (The extensor
of pinprick and touch.  carpi ulnaris) (PIN). 

resisted supination will increase pain

symptoms

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

Motor loss, with higher

lesions only, giving
weakness of foot
eversion and ankle
stability 

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.  

Note – in 72% of people EDB (The

extensor digitorum brevis muscle) is
supplied by the deep peroneal
nerve, 28% by the superficial
peroneal nerve
Sural nerve Sural nerve is a Shooting pain  To perform this test, the patient's
entrapment  sensory branch of  and paresthesia in its leg is grasped by the therapist's
the tibial nerve sensory distribution are hands so that the leg is supported
supplying the skin on diagnostic  and the foot is held in dorsiflexion
the posterolateral  signs. and inversion. The leg is then
aspect of the lower passively raised into hip flexion. This
one third of the leg is usually felt in the posterolateral
and the lateral  calf and/or posterolateral ankle.
aspect of the foot 
  

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

Morton’s Syndrome of forefoot Usually, it is the digital  If a Morton’s 

neuroma: pain originating from nerve between the neuroma is suspected, pressure
Interdigital entrapment of nerves third and fourth toes palpation should be 
Perineural in the metatarsal applied on the plantar aspect
Fibrosis  tunnels Pain, numbness, avoiding counter pressure 
paraesthesia in the on the dorsal aspect
Injury to one of  lateral side of one toe
the digital nerves and medial side of the
next

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

Increased pain with

walking, crouching,
wearing high heals (any
other activity that
causes toe extension)