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Median Nerve Entrapment: Beyond Carpal Tunnel Syndrome

5/29/2014

2 Comments

 
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General Overview

Time and time again, the Occupational Therapists in my clinic get referrals for Carpal Tunnel Syndrome (CTS). In some of these cases, the patients also have cervical pain, shoulder pain, proximal forearm weakness, and/or palmar paresthesias. While these individuals may have compression within the carpal tunnel, many of them are suffering from nerve entrapment proximal to the carpal tunnel. Many develop adverse neural tension caused by postural dysfunctions, muscle imbalances, and systemic comorbidities which cause a breakdown of the nervous system. 

Am I saying CTS is over-diagnosed? That is exactly what I am saying. It has become a blanket term for pain in the wrist and hand just as lateral epicondylagia has at the elbow. Many times, the cause of someone's symptoms is not consistent with the referring diagnosis. In this mini-review, I will break down a few areas of entrapment of the median nerve and how to assess for adverse neural tension within the median nerve. 

Median Nerve Pathway

The median nerve is formed from contributions of the spinal nerve roots C5-T1. After originating from the brachial plexus in the axilla, the medial nerve travels down the arm to the cubital fossa. Next, the nerve travels through the two heads of the pronator teres and between the flexor digitorum superficialis and flexor digitorum profundus muscles. At this point the median nerve splits into the anterior interosseous nerve (AIN) and palmar cutaneous nerve. Finally, the nerve travels through the carpal tunnel space. (Be aware there are many alternative anatomy presentations; this is simply one of the most common ones).

As you can see there are many points of entrapment for the median nerve: the cervical spine, interscalene musculature, between the heads of the pronator teres, and within the carpal tunnel (among other less common ones). The patient's subjective reports and your clinical examination will point you to the correct structure and location of dysfunction. When suspecting neural tension, a clinical examination measure you should utilize is the Median Nerve ULTT. 

Assessing for Adverse Neural Tension & Different Sites of Entrapment

We have discussed adverse neural tension several times before on The Student Physical Therapist (How to assess neural tension, Differential Dx in neural tension). At the Harris Health Orthopedic Residency, I use 3 distinguishing criteria for positive adverse neural tension testing. The symptom(s) must reproduce the patient's primary complaint, it must change by moving a component at a joint proximal or distal to the complaint, and it must be different side to side. To see the full test for adverse neural tension of the median nerve, click HERE. This test will not tell you the exact location of symptoms, but it will give you an understanding of the sensitivity of the nerve.


In addition to performing neural tensioning tests, it is important to perform a thorough assessment of other potential areas of entrapment. For example, if you find muscle wasting in the FPL, pronator quadratus, and/or radial half of the FDP, the involved nerve is likely the AIN being compressed in the proximal forearm. Additionally, if the patient has comorbidities that affect the nervous system, such as a history of uncontrolled DM, this can significantly alter your patient presentation. Several clinicians I work with relate this to a form of double crush injury: the nerve is being mechanically entrapped and is also receiving compression from other intrinsic sources.

Continue to use your differential diagnosis skills to determine the source of one's symptoms. It may save your patient from an unnecessary surgery.

-Jim      

2 Comments

Posterior Interosseous Nerve Syndrome

5/13/2013

0 Comments

 
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Posterior Interosseous Nerve (PIN) Syndrome is a pathology that involves pain and/or motor weakness as a result of nerve compression. In parts of the medical community, Radial Tunnel Syndrome and PIN Syndrome are one in the same, while in other parts they are different diagnoses with the same nerve involvement (Posterior Interosseous Nerve). These health care professionals identify Radial Tunnel Syndrome as pain along the radial tunnel, while PIN Syndrome is marked weakness in the muscles innervated by the Posterior Interosseous Nerve. Due to the fact that both syndromes involve compression of the same nerve, often by the same structures, we will use the terms PIN Syndrome and Radial Tunnel Syndrome synonymously in this review, especially due to the fact that the two are managed identically. CONTINUE READING...

0 Comments

Eccentric Exercises for Lateral Epicondylopathy

8/22/2012

0 Comments

 
While there have been plenty of studies on treating achilles tendinopathy with eccentric exercises, there has been some debate on treating tendinopathy in other parts of the body.

This article demonstrates an eccentric exercise utilizing a rubber bar to be effective in treating the lateral epicondylopathy. It is important to note that the rubber bar is not necessary. Any eccentric exercise that targets the affected muscles will do!
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  • Home
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  • Online Courses
    • Hooper's Knee
    • Physical Therapist Entrepreneur Course
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    • Orthopedic Management of the Cervical Spine
    • Return to Sport Essentials Course
  • Resources
    • Newsletter
    • Business Minded Sports Physio Podcast
    • Day in the Life of a Sports PT
    • Residency Corner
    • Special Tests >
      • Cervical Spine >
        • Alar Ligament Test
        • Bakody's Sign
        • Cervical Distraction Test
        • Cervical Rotation Lateral Flexion Test
        • Craniocervical Flexion Test (CCFT)
        • Deep Neck Flexor Endurance Test
        • Posterior-Anterior Segmental Mobility
        • Segmental Mobility
        • Sharp-Purser Test
        • Spurling's Maneuver
        • Transverse Ligament Test
        • ULNT - Median
        • ULNT - Radial
        • ULNT - Ulnar
        • Vertebral Artery Test
      • Thoracic Spine >
        • Adam's Forward Bend Test
        • Passive Neck Flexion Test
        • Thoracic Compression Test
        • Thoracic Distraction Test
        • Thoracic Foraminal Closure Test
      • Lumbar Spine/Sacroiliac Joint >
        • Active Sit-Up Test
        • Alternate Gillet Test
        • Crossed Straight Leg Raise Test
        • Extensor Endurance Test
        • FABER Test
        • Fortin's Sign
        • Gaenslen Test
        • Gillet Test
        • Gower's Sign
        • Lumbar Quadrant Test
        • POSH Test
        • Posteroanterior Mobility
        • Prone Knee Bend Test
        • Prone Instability Test
        • Resisted Abduction Test
        • Sacral Clearing Test
        • Seated Forward Flexion Test
        • SIJ Compression/Distraction Test
        • Slump Test
        • Sphinx Test
        • Spine Rotators & Multifidus Test
        • Squish Test
        • Standing Forward Flexion Test
        • Straight Leg Raise Test
        • Supine to Long Sit Test
      • Shoulder >
        • Active Compression Test
        • Anterior Apprehension
        • Biceps Load Test II
        • Drop Arm Sign
        • External Rotation Lag Sign
        • Hawkins-Kennedy Impingement Sign
        • Horizontal Adduction Test
        • Internal Rotation Lag Sign
        • Jobe Test
        • Ludington's Test
        • Neer Test
        • Painful Arc Sign
        • Pronated Load Test
        • Resisted Supination External Rotation Test
        • Speed's Test
        • Posterior Apprehension
        • Sulcus Sign
        • Thoracic Outlet Tests >
          • Adson's Test
          • Costoclavicular Brace
          • Hyperabduction Test
          • Roos (EAST)
        • Yergason's Test
      • Elbow >
        • Biceps Squeeze Test
        • Chair Sign
        • Cozen's Test
        • Elbow Extension Test
        • Medial Epicondylalgia Test
        • Mill's Test
        • Moving Valgus Stress Test
        • Push-up Sign
        • Ulnar Nerve Compression Test
        • Valgus Stress Test
        • Varus Stress Test
      • Wrist/Hand >
        • Allen's Test
        • Carpal Compression Test
        • Finkelstein Test
        • Phalen's Test
        • Reverse Phalen's Test
      • Hip >
        • Craig's Test
        • Dial Test
        • FABER Test
        • FAIR Test
        • Fitzgerald's Test
        • Hip Quadrant Test
        • Hop Test
        • Labral Anterior Impingement Test
        • Labral Posterior Impingement Test
        • Long-Axis Femoral Distraction Test
        • Noble Compression Test
        • Percussion Test
        • Sign of the Buttock
        • Trendelenburg Test
      • Knee >
        • Anterior Drawer Test
        • Dial Test (Tibial Rotation Test)
        • Joint Line Tenderness
        • Lachman Test
        • McMurray Test
        • Noble Compression Test
        • Pivot-Shift Test
        • Posterior Drawer Test
        • Posterior Sag Sign
        • Quad Active Test
        • Thessaly Test
        • Valgus Stress Test
        • Varus Stress Test
      • Foot/Ankle >
        • Anterior Drawer
        • Calf Squeeze Test
        • External Rotation Test
        • Fracture Screening Tests
        • Impingement Sign
        • Navicular Drop Test
        • Squeeze Test
        • Talar Tilt
        • Tarsal Tunnel Syndrome Test
        • Test for Interdigital Neuroma
        • Windlass Test