Eric Shamus, PhD, DPT, PT, CSCS, Jennie Q. Lou, MD, MSc
++
+++
CONDITION/DISORDER SYNONYMS
++
++
++
+++
PREFERRED PRACTICE PATTERN
++
++
PATIENT PRESENTATION
Patient is a 35-year-old female who woke up with facial nerve paralysis. Patient presents with facial droop (see image 1). On examination it was found that she had absent brow furrowing, weak eye closure and drooping of her mouth angle. She was provided eye lubricants and guidance on keeping her eye moist. Patient is unable to smile or control muscles on the left side of the face. Patient received direct current electric stimulation during exercises.1
++
Paralysis or weakness of muscles on one side of face
Sudden onset, often overnight
Damage to the seventh cranial (facial) nerve that controls muscles on one side of the face, causing that side of face to droop2
Nerve damage may affect sense of taste, production of tears and saliva
Lower motor neuron (LMN) disease
Diagnosis usually made by history and clinical examination
Afflicts approximately 40,000 Americans each year
Equally likely in men and women
Can present at any age, but less common before age 15 years or after age 60
More prevalent in people with diabetes or upper respiratory ailments, such as flu or cold
More likely in pregnant women
++
++
SIGNS AND SYMPTOMS
Sudden weakness or paralysis on one side of face that causes it to droop (main symptom)
Difficulty closing eye on affected side
Drooling
Dry mouth
Eye problems, such as excessive tearing or dry eye
Loss of ability to taste
Pain in or behind ear
Facial numbness on affected side
Increased sensitivity to sound
Headache
Facial twitch
Inability to smile or make facial expressions
+++
Functional Implications
++
Dry eyes
Eating
Hearing
Psychological impact
++
+++
Possible Contributing Causes
++
The nerve that controls muscles on one side of the face is damaged by inflammation in most cases
Root cause of Bell’s palsy is not clear
Most cases thought to be caused by the herpes virus that causes chickenpox and shingles, or Epstein–Barr virus that causes mononucleosis
+++
Differential Diagnosis
++
Brainstem infarct
Brucellosis
Diabetes mellitus
Guillain–Barré syndrome
Herpes simplex virus
HIV infection
Infections
Lyme disease
Meningitis
Middle ear infection
Ramsay Hunt syndrome3
Sarcoidosis
Stroke
Tumors
+++
MEANS OF CONFIRMATION OR DIAGNOSIS
++
Blood tests
MRI of the head to rule out brain tumor
CT scan of the head to rule out brain tumor
History and physical and neurological examination to check facial nerve function
If cause of symptoms is not clear, other tests are needed, such as:
+++
FINDINGS AND INTERPRETATION
++
Facial muscle weakness or total paralysis (e.g., unable to frown) due to swollen, inflamed, or compressed facial nerve
Drooping of eyelid and corner of mouth on the affected side due to muscle weakness or paralysis
++
++
++
++
Impaired facial expression due to paralysis
Problems eating (food stuck in month or falling out), difficulty swallowing
Hearing impairment
Pain
++
++
++
++
Generally very good, self-limiting disease, may last several weeks.
Symptoms may last longer for some.
Symptoms may never completely disappear in a few cases.
Disorder may recur in rare cases, either on same or opposite side of the face.
+++
ADDITIONAL INFORMATION
++
++
+++
ADDITIONAL REFERENCES
+
de Almeida
JR, Al Khabori
M, Guyatt
GH
et al. Combined corticosteroid and antiviral treatment for Bell palsy: a systematic review and meta-analysis. JAMA. 2009;302(9):985–993. doi: 10.1001/jama.2009.1243.
[PubMed: 19724046]
CrossRef +
Quant
EC, Jeste
SS, Muni
RH, Cape
AV, Bhussar
MK, Peleg
AY. The benefits of steroids versus steroids plus antivirals for treatment of Bell’s palsy: a meta-analysis. BMJ. 2009;339:b3354. doi: 10.1136/bmj.b3354.
[PubMed: 19736282]
CrossRef +
Rahman
I, Sadiq
SA. Ophthalmic management of facial nerve palsy: a review. Surv Ophthalmol. 2007;52(2):121–144.
[PubMed: 17355853]
CrossRef +
Sassi
FC, Mangilli
LD, Poluca
MC, Bento
RF, Andrade
CR. Mandibular range of motion in patients with idiopathic peripheral facial palsy. Brazil Journal of Otorhinolaryngology. 2011;77(2):237–244.
CrossRef +
Sullivan
FM, Swan
IR, Donnan
PT
et al. A randomised controlled trial of the use of aciclovir and/or
prednisolone for the early treatment of Bell’s palsy: the BELLS study. Health Technol Assess. 2009;13(47):1–130. doi: 10.3310/hta13470
CrossRef
Eric Shamus, PhD, DPT, PT, CSCS, Jennifer Shamus, PhD, DPT, COMT, CSCS
++
+++
CONDITION/DISORDER SYNONYMS
++
++
353.0 Brachial plexus lesions
767.6 Injury to brachial plexus due to birth trauma
953.4 Injury to brachial plexus
++
++
++
G54.0 Brachial plexus disorders
P14.0 Erb paralysis due to birth injury
P14.1 Klumpke paralysis due to birth injury
P14.3 Other brachial plexus birth injuries
S14.3XXA Injury of brachial plexus, initial encounter
+++
PREFERRED PRACTICE PATTERNS
++
4F: Impaired Joint Mobility, Motor Function, Muscle Performance, Range of Motion, and Reflex Integrity Associated withSpinal Disorders1
5F: Impaired Peripheral Nerve Integrity and Muscle Performance Associated with Peripheral Nerve Injury2
++
++
PATIENT PRESENTATION
A 22-year-old man presents with weakness and tingling in the right arm after a skiing accident on a trip to Colorado 5 days ago. The patient states he was skiing downhill when his pole got stuck in the snow behind him as he kept moving forward. Since then, the patient reports paresthesias down the right arm, an inability to complete tasks requiring fine motor skills of the right hand, and pain down the right upper extremity at night. The patient exhibits diminished reflexes as well as diminished sensation in the C8-T1 dermatome in the right upper extremity. Manual muscle testing of the right flexor carpi ulnaris is 2/5. Elbow flexion test is positive on the right.
++
Weakness in the arm
Diminished reflexes
Pain in the upper extremity
Motor or sensory changes in the ulnar, radial, and median nerve distribution due to pressure from
Compression
Stretch
Friction
+++
Essentials of Diagnosis
++
Electromyography
Hand clumsiness or weakness
Symptom changes with cervical spine and elbow positions
Reproduction of symptoms during clinical examination
Seddon classification
Neurapraxia (Class 1): First degree
Axonotmesis (Class 2): Second degree
Neurotmesis (Class 3): Third degree nerve fiber interruption, fourth degree epineurium intact, and fifth degree complete transection of the nerve
+++
General Considerations
++
Need to differentiate between more proximal and distal ulnar nerve compression, thoracic outlet syndrome (TOS), ulnar tunnel, and cervical radiculopathy
Nerve compression syndrome in the upper extremity
Wallerian degeneration occurs below the site of injury
Patients with mild electrodiagnostic findings, intermittent symptoms, and no atrophy respond well toconservative management
++
Sports injury landing on the shoulder
Traction injury
Individuals who work for sustained periods with power tools or on computers
Infants, from birth trauma or head traction
++
SIGNS AND SYMPTOMS
Acute or chronic paresthesia
Pain or burning
Sensory changes in multiple peripheral nerves of the upper extremity
Hand clumsiness
Feeling of arm heaviness
Hand weakness; decreased grip-power and dexterity
Intrinsic muscle atrophy
Erb palsy
Waiter’s tip sign
Caused by excessive lateral neck flexion
Loss of lateral rotator, arm flexors, and wrist extensor musculature
Klumpike paralysis
Traction of abducted arm
Lower brachial plexus injury
Damage to C8 and T1
Loss of intrinsic muscles of the hand, wrist, and finger flexors
Wartenberg sign3
Froment sign for ulnar nerve palsy4
Bishop’s deformity
Positive elbow flexion test4
+++
Functional Implications
++
Night pain
Poor sleep habits with arm over head
Feeling of arm going “dead”
Limited hand function during ADLs/IADLs due to hand clumsiness and possible loss of strength
+++
Possible Contributing Causes
++
Infant head traction during forceps delivery
Traction to the cervical spine
Trauma pulling the arm into abduction
Viral infection
Ganglion or space-occupying lesion
Repetitive trauma
Sustained pressure over the thoracic outlet
Clavicle fracture
Glenohumeral dislocation
+++
Differential Diagnosis
++
Carpal tunnel syndrome
Cervical radiculopathy
Distal ulnar nerve entrapment cubital tunnel (Guyon canal)3
Median neuropathy
Other potential entrapment sites
Medial humeral groove
Arcade of Struthers
Medial intermuscular septum
Flexor digitorum profundus
Flexor carpi ulnaris
Just proximal to or within Guyon canal
Sensory and motor involvement between the abductor digiti minimi and flexor digiti minimi
Near hook of hamate: Involves motor only
Distal end of Guyon canal: Involves sensory only
Proximal ulnar nerve entrapment
Radial neuropathy
Thoracic outlet syndrome (TOS)
Wallerian degeneration
+++
MEANS OF CONFIRMATION OR DIAGNOSIS
++
+++
Diagnostic Procedures
++
Loss of evoked sensory potential
Decreased electrical velocities across elbow, <50 m/sec
Electromyographic (EMG): Conduction velocities of ulnar innervated muscles <41 m/sec5,6
+++
FINDINGS AND INTERPRETATION
++
++
++
++
Inability to perform overhead activities, such as swimming, baseball, or tennis
Inability to perform jobs involving repetitive overhead reachingor lifting
++
Disabilities of the Arm, Shoulder, and Hand (DASH) score to assess physical function
Functional reach test
Adson or Scalene maneuver
Elevated arm stress test (EAST) or hand-up test (overhead test)
Provocative elevation test (passive shoulder shrug)
Allen pectoralis minor test
Hallstead maneuver
Hyperabduction maneuver (Wright test)
Costoclavicular/military brace
Roos test
Upper limb tension test
Cervical spine compression test
Pain provocation test
Shoulder pain and disability index
++
Myofascial manipulation4
Shoulder sling
Range of motion exercises to affected areas
Neural mobilization
Activity modification/ergonomic intervention
Soft tissue mobilization
Postural awareness
Strengthen as function returns
++
Patient will
Return to full use of affected upper extremity (UE) during activities of daily living (ADLs) and instrumental activities of daily living (IADLs), such as washing dishes and cooking
Be able to raise their arm overhead to take a plate out of the cabinet
Be able to type for 1 hour at work.
++
Prognosis depends on duration of symptoms andmotor involvement.
Nerve regeneration for full motor recovery may take 6 months to 1 year.
Patients with mild electrodiagnostic findings, intermittent symptoms, and no atrophy respond well to conservative management.
++
1. +
The American Physical Therapy Association. Pattern 4F: impaired joint mobility, motor function, muscle performance, range of motion, and reflex integrity associated with spinal disorders. Interactive Guide to Physical Therapist Practice. 2003. DOI: 10.2522/ptguide.3.1_6. Accessed January 21, 2013.
2. +
The American Physical Therapy Association. Pattern 5F: Impaired peripheral nerve integrity and muscle performance associated with peripheral nerve injury. Interactive Guide to Physical Therapist Practice. 2003. DOI: 10.2522/ptguide.3.2_6. Accessed January 21, 2013.
6. +
Preston
D, Shapiro
B. Electromyography and Neuromuscular Disorders. Clinical Electrophysiologic Correlations. Boston, MA: Butterworth-Heinemann; 1998.
7. +
Dutton
M. “Integration of practice patterns 4f and 5f: impaired joint mobility, motor function, muscle performance, and range of motion, or reflex integrity secondary to spinal disorders, peripheral nerve entrapments, compartment syndrome, and myofascial pain dysfunction” (Chapter). In:Dutton
M Orthopaedic Examination, Evaluation, and Intervention. 2nd ed.
http://www.accessphysiotherapy.com/content/55576493. Accessed January 21, 2013.
+++
ADDITIONAL REFERENCES
+
Dubuisson
AS, Kline
DG. Brachial plexus injury: a survey of 100 consecutive cases from a single service. Neurosurgery. 2002;51(3):673–682.
[PubMed: 12188945]
Thomas Bevins, MS, PT, Eric Shamus, PhD, DPT, PT, CSCS
++
++
++
++
G56.01 Carpal tunnel syndrome, right upper limb
G56.02 Carpal tunnel syndrome, left upper limb
+++
PREFERRED PRACTICE PATTERNS
++
4E: Impaired Joint Mobility, Motor Function, Muscle Performance, and Range of Motion Associated withLocalized Inflammation1
5F: Impaired Peripheral Nerve Integrity and Muscle Performance Associated with Peripheral Nerve Injury2
++
PATIENT PRESENTATION
A 42-year-old woman presents with complaints of paresthesias(tingling and lately burning) and occasional pain and numbness in the right thumb, index, and middle fingers. Symptoms were initially intermittent, but becoming more constant, and the pain now often wakes her at night. In addition, recently she has noticed a loss of grip strength and has dropped objects on occasion. Onset was gradual, and symptoms worsening. She first saw her family physician 3 months ago for the numbness and tingling. The patient is a check-out clerk at a local grocery store. She is right-handed; BMI is 40.
On physical examination, sensory testing shows diminished touch and vibration sensation, and decreased two-point discrimination on the palmar surface of the thumb, and index, middle, and radial half of the ring fingers. Phalen and Tinel tests are positive. Thumb abduction, flexion, and opposition strength are only 4/5. Nerve conduction test done last week shows decreased nerve conduction velocity of the median nerve across the right wrist.
++
Entrapment neuropathy of the median nerve within the carpal tunnel of the wrist3,4
Signs and symptoms typical of neuropathy, including
Symptoms are seen in the distribution of the median nerve in the hand3
++
+++
Essentials of Diagnosis
++
Pain, paresthesias, and sensory loss perceived on the radial side of the palm; the palmar side of the thumb, index, and middle fingers; and the radial side of the ring fingers
Pain may radiate up to the elbow, shoulder, and neck
Waking from pain at night is hallmark of this condition5
In advanced cases, motor dysfunction in thenar muscles may occur, characterized by weakness, atrophy, loss of coordination
+++
General Considerations
++
In entrapment neuropathy, nerve becomes compressed, causing ischemic damage to the nerve
The carpal tunnel is a constrained area at the wrist boundedby the carpal bones and the transverse carpal ligament(flexor retinaculum)3
The median nerve and nine flexor tendons pass through the carpal tunnel
Pathomechanics involve decreased size of the tunnel or increased volume of the contents, causing compression on the median nerve
Often associated with repetitive motions or sustained position of the wrist and hand
Unrelieved compression of the nerve results in neurapraxia with segmental demyelination;6 further ischemic damage results in axonotmesis and Wallerian degeneration5,6
++
Incidence: 3.5 cases per 1,000 in general population5
Prevalence: 2.1%5
Most common entrapment neuropathy5
More common in women than in men (70% of cases are females)5
2.5 times more common in obese individuals5,7
Most common among people aged 30 to 60 years5
Nearly one-half of cases will experience bilateral symptoms5
++
++
SIGNS AND SYMPTOMS
First symptom is usually pain or paresthesias;3most commonly with gradual onset
Pain complaints include numbness (most common), tingling, and burning
Pain or numbness waking the patient at night isvery common
Pain is experienced in distribution of the median nerve in the hand, though may radiate up to the elbow, shoulder, or neck
Tenderness to percussion or pressure over the carpal tunnel
Pain may be worse with extreme wrist flexionor extension
Sensory loss may follow early symptom of pain
Motor involvement (weakness, loss of coordination, atrophy) may follow in more advanced cases
+++
Functional Implications
++
Pain with wrist movements
Difficulty with grasping and manipulation activities
Dropping items from the hand
Impaired sensation
Loss of strength in advanced cases
++
+++
Possible Contributing Causes
++
Most often idiopathic
Genetic structural factors
Swelling of synovial tissues in rheumatoid arthritis
Swelling from conditions such as infection, congestive heart failure, pregnancy
Obesity7
Tumors
Alcoholism
Kidney failure
Menopause
Acromegaly
Displaced fracture or fracture callus
Structural abnormalities of carpal bones
Occupations that require repetitive motion, repetitive stress, sustained positions of the wrist and hand
Direct trauma to wrist
Impaired circulation to peripheral nerves, as seen in diabetes, predisposes individuals to nerve compression symptoms
++
++
+++
Differential Diagnosis
++
+++
MEANS OF CONFIRMATION OR DIAGNOSIS
++
++
++
+++
FINDINGS AND INTERPRETATION
++
++
NSAIDs4
Corticosteroid injection
++
REFERRALS/ADMITTANCE
To radiologist for imaging; X-ray for fracture or displacement
To orthopedist for surgical consult or injection
To occupational therapist to provide splints and instruct patient in joint protection techniques
++
++
Disabilities of the Arm, Shoulder, and Hand (DASH) score to assess physical function
Durkan test (carpal compression test)
Flick sign
Manipulative ability test (nine-hole peg test)
Phalen test (sensitivity 0.85, specificity 0.79)5,9
Reverse Phalen test (sensitivity 0.60, specificity 0.67)5,9
Self-reported symptoms on the Katz hand diagram5
Sensory loss may include diminished two-point discrimination, decreased vibration sense, increased threshold in Semmes–Weinstein monofilament test5
Thenar muscle strength test (lateral pinch dynamometry)
Tinel test for carpal tunnel (sensitivity 0.90, specificity 0.81)5,9
Upper limb tension test 1 (ULTT 1), median nerve dominant4
++
++
Early conservative intervention
Second-stage conservative intervention
Immobilization of wrist with splint; holding wrist in neutral position to reduce compression pressures2
Ultrasound10,11
Median nerve gliding4
Tendon gliding exercises11
Manual therapy11
Magnetic therapy11
Cold low-level laser therapy10,11
Yoga4,11
Address swelling
Ice13
Elevation
Iontophoresis
Post-surgical intervention
++
Patient will have
Improved ability to perform physical tasks, self-care, home management, leisure and occupational activities.
Increased tolerance of positions and activities using the hand and wrist.
Reduced ergonomic risk.
++
Poor: 18% “cure” rate with conservative intervention (anti-inflammatory medication and immobilization).5
Surgical intervention indicated for patients with symptoms lasting >1 year, or those for whom conservative treatment over 3 months has failed.
++
++
1. +
The American Physical Therapy Association. Pattern 4E: Impaired joint mobility, motor function, muscle performance, and range of motion associated with localized inflammation. Interactive Guide to Physical Therapist Practice. 2003. DOI: 10.2522/ptguide.3.1_5. Accessed March 16, 2013.
2. +
The American Physical Therapy Association. Pattern 5F: Impaired peripheral nerve integrity and muscle performance associated with peripheral nerve injury. Interactive Guide to Physical Therapist Practice. 2003. DOI: 10.2522/ptguide.3.2_6. Accessed March 16, 2013.
5. +
Goodman
CC, Fuller
KS. Pathology: Implications for the Physical Therapist. 3rd ed. St. Louis, MO: Saunders/Elsevier; 2009.
8. +
Halle
J, Greathouse
D. Chapter 8. Principles of electrophysiologic evaluation and testing. In:Prentice
WE, Quillen
WS, Underwood
F Therapeutic Modalities in Rehabilitation. 4th ed. New York, NY: McGraw-Hill; 2011.
http://www.accessphysiotherapy.com/abstract/8137649#8137649. Accessed March 16, 2013.
11. +
Muller
M, Tsui
D, Schnurr
R
et al. Effectiveness of hand therapy interventions in primary management of carpal tunnel syndrome: a systematic review. J Hand Ther. 2004;17(2):210–228.
[PubMed: 15162107]
CrossRef
+++
ADDITIONAL REFERENCES
+
Lozano-Calderón
S, Anthony
S, Ring
D. The quality and strength of evidence for etiology: example of carpal tunnel syndrome. J Hand Surg Am. 2008;33(4):525–538.
[PubMed: 18406957]
CrossRef
Stacey L. Frazee, DPT, Eric Shamus, PhD, DPT, PT, CSCS
++
+++
CONDITION/DISORDER SYNONYMS
++
Chronic compartment syndrome (CCS)
Chronic exertional compartment syndrome (CECC)
Limb compartment syndrome
Myofascial compartment syndrome
Volar compartment syndrome of forearm (flexors)
Dorsal compartment syndrome of forearm (extensors)
++
++
M62.2 Ischemic infarction of muscle (nontraumatic compartment syndrome)
M79.A1 Nontraumatic compartment syndrome of upper extremity
T79.6 Traumatic ischemia of muscle
+++
PREFERRED PRACTICE PATTERN3
++
4E: Impaired joint mobility, motor function, muscle performance, and range of motion associated with localized inflammation
++
PATIENT PRESENTATION
A 31-year-old man with a recent forearm crush injury presents with severe unilateral forearm pain that has intensified since his injury. He indicates that his injury was sustained 3 weeks ago. He is currently experiencing tightness in the medial forearm and tingling in the thumb, index and middle fingers. Distal pulses and capillary refill are diminished. He is having weakness throughout the wrist/forearm. There is increased pain with squeezing of the forearm musculature. The patient was referred to the emergency room and his physician was notified.
++
Bleeding or edema leads to increased pressure within the fascial compartment and compromises circulation within that space as well as the function of tissues in that area causing ischemia
Arteriolar compression occurs and causes muscle and nerve ischemia
Acute, sensory changes develop after 30 minutes of ischemia
Acute, irreversible nerve damage in 12 to 24 hours
Acute, irreversible muscle changes (i.e., necrosis) in 3 to 8 hours
++
+++
Essentials of Diagnosis
++
Diagnosis is typically made by clinical examination and compartment pressure measurement
Acute compartment syndrome
Subacute compartment syndrome
Chronic exertional compartment syndrome
Conservative treatment first
Secondary surgery, fasciotomy
Symptoms consistently develop the same point during activity
Stops about 30 minutes following exercise
Symptoms can become progressively worse to constant
Severe pain that is not alleviated by elevation or pain medication
Distal pulses are diminished/absent
Strength and sensation are diminished
Edema in affected limb
+++
General Considerations
++
++
Younger age, high-energy/high-velocity trauma and systemic hypotension associated with increased risk of traumatic accident
High risk patients include
Males <35 years old with a fracture
Soft-tissue injury in males <35 years old with bleeding disorder or receiving anticoagulants
Crush injury patients
Patients with prolonged limb compression
Individuals using circumferential wraps, restrictive dressings, casts, or immobilizer are at an increased risk
++
SIGNS AND SYMPTOMS
First signs
Paresis
Decreased palpable pulses
Pallor of skin overlying compartment, paleness of skin
Severe pain that does not go away with pain medicine or raising affected area
Weakness
Pain when the area is squeezed
Extreme pain when moving affected area
Swelling in affected area
+++
Functional Implications
++
Pain out of proportion top to that expected from the injury
Decreased strength in affected limb
Loss of sensation and 2-point discrimination deficits
Inability to use upper extremity
Fatigue
+++
Possible Contributing Causes
++
Traumatic compartment syndrome
Car accident
Crush injury
Surgery
Complex fractures
Distal radius fracture
Ulnar fracture
Supracondylar fracture
Chronic compartment syndrome
Vascular conditions
Soft-tissue injuries
Anabolic steroids
Creatine supplementation4
++
+++
Differential Diagnosis
++
++
++
+++
MEANS OF CONFIRMATION OR DIAGNOSIS
++
Radiographs
Bone scans
CT scans
MRI
Doppler ultrasound
++
+++
FINDINGS AND INTERPRETATION
++
Emergency surgery to prevent permanent damage with pressure measurements of 30 mm Hg or higher
Radiographs, bone scans, CT scans, or MRI can be used to rule out fractures and/or muscle tears
Doppler ultrasound used to evaluated arterial flow and rule out Deep vein thrombosis (DVT)
++
++
Acute compartment syndrome, immediate open fasciotomy to relieve pressure, and avoid permanent damage
Subcutaneous fasciotomy
Hyperbaric oxygen therapy
++
REFERRALS/ADMITTANCE
For imaging: x-ray, CT, or MRI
For surgery if fasciotomy is required
++
Weakness
Numbness and tingling
Severe pain
++
++
Avoid external pressure
If cast or bandage is causing the problem it should be loosened or removed
Avoid splints, tight would dressing
Rest
Address swelling
Address pain
Wound care
Laser therapy
Decrease pain
Decrease tenderness
Decrease stiffness
++
++
Determined by injury leading to the syndrome
Permanent injury can occur to nerves or muscles if diagnosis is delayed
Limb compartment syndrome with absent arterial pulses without a history of arterial trauma is associated with poor prognosis
++
++
3. +
The American Physical Therapy Association. Guide to Physical Therapist Practice. Alexandria,
VA: The American Physical Therapy Association; 2003.
http://guidetoptpractice.apta.org./ Accessed June 4, 2013.
4. +
Hile
AM, Anderson
JM, Fiala
KA
et al.. Creatine supplementation and anterior compartment pressure during exercise in the heat in dehydrated men. J Athl Train. 2006;41(1):30–35.
[PubMed: 16619092]
+++
ADDITIONAL REFERENCES
+
Botte
MJ, Gelberman
RH. Acute compartment syndrome of the forearm. Hand Clin. 1998;14(3):391–403.
[PubMed: 9742419]
+
Fraipont
MJ, Adamson
GJ. Chronic exertional compartment syndrome. J Am Acad Orthop Surg. 2003;11(4):268–276.
[PubMed: 12889865]
+
Geiderman
JM, Katz
D. General principles of orthopedic injuries. In:Marx
J Emergency Medicine: Concepts and Clinical Practice. 7th ed. Philadelphia, PA: Mosby Elsevier; 2009: Chapter 46.
+
Goodman
CC, Fuller
KS. Pathology Implications for the Physical Therapist. 3rd ed. Philadelphia, PA: Saunders Elsevier; 2009.
+
Gourgiotis
S, Villias
C, Germanos
S, Foukas
A, Ridolfini
MP. Acute limb compartment syndrome: a review. J Surg Educ. 2007;64(3):178–186.
[PubMed: 17574182]
CrossRef +
Konstantakos
EK, Dalstrom
DJ, Nelles
ME, Laughlin
RT, Prayson
MJ. Diagnosis and management of extremity compartment syndromes: an orthopaedic perspective. Am Surg. 2007;73(12):1199–1209.
[PubMed: 18186372]
+
Marshall
ST, Browner
BD. Emergency care of musculoskeletal injuries. In:Townsend
CM
Jr, Beauchamp
RD, Evers
BM, Mattox
KL Sabiston Textbook of Surgery. 19th ed. Philadelphia, PA: Saunders Elsevier; 2012: Chapter 20.
+
Naidu
SH, Heppenstall
RB. Compartment syndrome of the forearm and hand. Hand Clin. 1994;10(1):13–27.
[PubMed: 8188774]
+
O’Neil
D, Sheppard
JE. Transient compartment syndrome of the forearm resulting from venous congestion from a tourniquet. J Hand Surg Am. 1989;14(5):894–896.
[PubMed: 2794413]
CrossRef +
Otsuka
NY, Kasser
JR. Supracondylar fractures of the humerus in children. J Am Acad Orthop Surg. 1997;5(1):19–26.
[PubMed: 10797204]
+
Twaddle
BC, Amendola
A. Compartment syndrome. In:Browner
BD, Jupiter
JB, Levine
AM, Trafton
PG, Krettek
C Skeletal Trauma. 4th ed. Philadelphia, PA: Saunders Elsevier; 2008: Chapter 13.
+
Wall
CJ, Lynch
J, Harris
IA
et al.. Clinical practice guidelines for the management of acute limb compartment syndrome following trauma. ANZ J Surg. 2010;80(3):151–156.
[PubMed: 20575916]
CrossRef +
Yamaguchi
S, Viegas
SF. Causes of upper extremity compartment syndrome. Hand Clin. 1998;14(3):365–370, viii.
[PubMed: 9742416]
Stacey L. Frazee, DPT, Eric Shamus, PhD, DPT, PT, CSCS
++
+++
CONDITION/DISORDER SYNONYMS
++
Chronic compartment syndrome (CCS)
Chronic exertional compartment syndrome (CECC)
Limb compartment syndrome
Myofascial compartment syndrome
Anterior compartment syndrome of the lower leg
Lateral/peroneal compartment syndrome of the lower leg
Deep posterior compartment syndrome of the lower leg
Superficial posterior compartment syndrome of the lower leg
++
++
M62.2 Ischemic infarction of muscle (nontraumatic compartment syndrome)
M79.A2 Nontraumatic compartment syndrome of lower extremity
T79.6 Traumatic ischemia of muscle
+++
PREFERRED PRACTICE PATTERN3
++
4E: Impaired Joint Mobility, Motor Function, Muscle Performance, and Range of Motion Associated with Localized Inflammation
++
PATIENT PRESENTATION
A 29-year-old man with a recent tibial shaft fracture presents with severe unilateral lower leg pain. He indicates that his fracture was sustained during a crush injury and he is currently experiencing tingling and “tightness” in the area. Distal pulses and capillary refill are diminished. He is having weakness throughout the foot. There is increased pain with squeezing of the calf muscle.
++
Bleeding or edema leads to increased pressure within the fascial compartment and compromises circulation within that space as well as the function of tissues in that area causing ischemia
Arteriolar compression occurs and causes muscle andnerve ischemia
Acute, sensory changes develop after 30 minutes of ischemia
Acute, irreversible nerve damage in 12 to 24 hours
Acute, irreversible muscle changes (i.e., necrosis) in 3 to 8 hours
++
+++
Essentials of Diagnosis
++
Diagnosis is typically made by clinical examination and compartment pressure measurement
Acute compartment syndrome
Subacute compartment syndrome
Chronic exertional compartment syndrome
Conservative treatment first
Secondary surgery, fasciotomy
Begins after the start of exercise
Stops about 30 minutes following exercise
Symptoms can become progressively worse to constant
Severe pain that is not alleviated by elevation or pain medication
Distal pulses are diminished/absent
Strength and sensation are diminished
Edema in affected limb
+++
General Considerations
++
++
Younger age, high-energy/high-velocity trauma and systemic hypotension associated with increased risk of traumatic accident.
High risk patients include
Males <35 years old with tibial fracture.
Soft-tissue injury in males <35 years old with bleeding disorder or receiving anticoagulants.
Crush injury patients.
Patients with prolonged limb compression.
Individuals using circumferential wraps, restrictive dressings, casts, or immobilizer are at an increased risk.
++
SIGNS AND SYMPTOMS
First signs
Paresis
Decreased palpable pulses
Pallor of skin overlying compartment, paleness of skin
Severe pain that does not go away with pain medicine or raising affected area
Weakness
Severe cases foot drop is seen
Pain when the area is squeezed
Extreme pain when moving affected area
Swelling in affected area
+++
Functional Implications
++
Pain out of proportion top to that expected from the injury
Decreased strength in affected limb
Loss of sensation and 2-point discrimination deficits
Inability to weight bear or use the lower extremity
Fatigue
+++
Possible Contributing Causes
++
Traumatic compartment syndrome
Car accident
Crush injury
Surgery
Complex fractures
Chronic compartment syndrome
Vascular conditions
Soft tissue injuries
Anabolic steroids
Creatine supplementation5
++
+++
Differential Diagnosis
++
++
++
++
++
+++
MEANS OF CONFIRMATION OR DIAGNOSIS
++
++
+++
FINDINGS AND INTERPRETATION
++
Emergency surgery to prevent permanent damage with pressure measurements of 30 mm Hg or higher
Radiographs, bone scans, CT scans, or MRI can be used to rule out fractures and/or muscle tears
++
++
++
++
Acute compartment syndrome, immediate open fasciotomy to relieve pressure and avoid permanent damage
Subcutaneous fasciotomy
Hyperbaric oxygen therapy
++
REFERRALS/ADMITTANCE
For imaging: x-ray, CT, or MRI
For surgery if fasciotomy is required
++
++
Weakness
Numbness and tingling
Severe pain
++
++
++
++
Avoid external pressure
If cast or bandage is causing the problem, it should be loosened or removed
Avoid splints, tight would dressing
Rest
Address swelling
Address pain
Wound care
Laser therapy
Decrease pain
Decrease tenderness
Decrease stiffness
++
++
Determined by injury leading to the syndrome.
Permanent injury can occur to nerves or muscles if diagnosisis delayed.
Limb compartment syndrome with absent arterial pulses without a history of arterial trauma is associated with poor prognosis.
++
3. +
The American Physical Therapy Association. Guide to Physical Therapist Practice. Alexandria,
VA: The American Physical Therapy Association; 2003.
http://guidetoptpractice.apta.org./ Accessed March 4, 2013.
4. +
Wanich
T, Hodgkins
C, Columbier
JA, Muraski
E, Kennedy
JG. Cycling injuries of the lower extremity. J Am Acad Orthop Surg. 2007;15(12):748–756.
[PubMed: 18063715]
5. +
Hile
AM, ANDERSON
JM, Fiala
KA
et al.. Creatine supplementation and anterior compartment pressure during exercise in the heat in dehydrated men. J Athl Train. 2006;41(1):30–35.
[PubMed: 16619092]
+++
ADDITIONAL REFERENCES
+
Blackman
PG. A review of chronic exertional compartment syndrome in the lower leg. Med Sci Sports Exerc. 2000;32(3 Suppl):S4–S10.
[PubMed: 10730989]
+
Frink
M, Hildebrand
F, Krettek
C, Brand
J, Hankemeier
S. Compartment syndrome of the lower leg and foot. Clin Orthop Relat Res. 2010;468(4):940–950.
[PubMed: 19472025]
CrossRef +
Geiderman
JM, Katz
D. General principles of orthopedic injuries. In:Marx
J Emergency Medicine: Concepts and Clinical Practice. 7th ed. Philadelphia, PA: Mosby Elsevier; 2009: Chapter 46.
+
Goodman
CC, Fuller
KS. Pathology Implications for the Physical Therapist. 3rd ed. Philadelphia, PA: Saunders Elsevier; 2009.
+
Gourgiotis
S, Villias
C, Germanos
S, Foukas
A, Ridolfini
MP. Acute limb compartment syndrome: a review. J Surg Educ. 2007;64(3):178–186.
[PubMed: 17574182]
CrossRef +
Marshall
ST, Browner
BD. Emergency care of musculoskeletal injuries. In:Townsend
CM
Jr, Beauchamp
RD, Evers
BM, Mattox
KL Sabiston Textbook of Surgery. 19th ed. Philadelphia, PA: Saunders Elsevier; 2012:
+
Twaddle
BC, Amendola
A. Compartment syndrome. In:Browner
BD, Jupiter
JB, Levine
AM, Trafton
PG, Krettek
C Skeletal Trauma. 4th ed. Philadelphia, PA: Saunders Elsevier;2008: Chapter 13.
+
Wall
CJ, Lynch
J, Harris
IA
et al.. Clinical practice guidelines for the management of acute limb compartment syndrome following trauma. ANZ J Surg. 2010;80(3):151–156.
[PubMed: 20575916]
CrossRef
Eric Shamus, PhD, DPT, PT, CSCS
++
+++
CONDITION/DISORDER SYNONYMS
++
++
++
+++
PREFERRED PRACTICE PATTERN
++
4E: Impaired Joint Mobility, Motor Function, Muscle Performance, and ROM Associated with Localized Inflammation1
++
PATIENT PRESENTATION
A 24-year-old woman presents with increased pain and swelling in her right foot for the past 5 days. The patient is 1 week status post ankle sprain. The patient has an inability to tolerate light touch and has had trouble sleeping due to the sheets brushing against her foot at night. Upon palpation, the patient describes the pain as extreme burning around the foot and ankle. ROM of the right foot is limited with skin color changes. The patient stated she had an x-ray the day after she sprained her ankle and there were no fractures. She is worried because the pain is getting worse each day and she cannot tolerate the ankle brace that was provided to her.
++
Autonomic changes
Severe pain, swelling, skin changes, inability to tolerate light touch
International Association for the Study of Pain (IASP) classification2
Type I: No nerve damage
Type II: Nerve damage
+++
Essentials of Diagnosis
++
++
++
++
+++
General Considerations
++
Fatigue, swelling, pain, and sensory changes cancause disability
Deregulation of the autonomic system
++
++
SIGNS AND SYMPTOMS
Pain
Sweating in the area
Inability to toleratelight touch
Deregulation of the autonomic system
Skin-color changes
Swelling
Nerve pain
Cracked nails
Osteoporosis
Muscle atrophy
Flexor tendon contracture
Skin-temperature change
Sympathetic hyperactivity
Associated symptoms may include paresthesias, burning, tingling
+++
Functional Implications
++
Pain and stiffness can limit ADLs
Unable to use the extremity
Unable to wear socks
Unable to sleep due to pain from touching the sheets
+++
Possible Contributing Causes
++
Unknown etiology
Surgery
Injury
Vascular disease
Spinal cord injury
Fracture
Frostbite
Amputation
Psychological components
Stress
Anxiety
+++
Differential Diagnosis
++
+++
MEANS OF CONFIRMATION OR DIAGNOSIS
++
+++
Diagnostic Procedures
++
++
+++
FINDINGS AND INTERPRETATION
++
++
++
REFERRALS/ADMITTANCE
To dietician/nutritionist for nutritional counseling
To pain clinic for pain management, counseling
To neurologist for neurologic assessment
To cognitive-behavioral therapist and psychologist for
Counseling
Support groups
Biofeedback
Relaxation techniques
++
Sleep deprivation
Limited walking and movement secondary to pain and morning stiffness, which can last throughout the day
Difficulty standing or sitting in one position for an extended period of time
Limited aerobic capacity
++
Passive physiologic intervertebral mobility testing (PPIVM)
Disabilities of the Arm, Shoulder, and Hand (DASH) score to assess physical function
Lower-extremity screening examination
Postural examination
Muscle length testing, including the hamstrings, hip flexors, and calf muscles
Quadrant test
Straight-leg raise test
Slump test
Lower limb nerve tension test
Prone instability test
Lower-extremity neurologic screen (dermatome, myotome, reflexes)
Repeated movement testing
Fear-Avoidance Beliefs Questionnaire (FABQ)
++
Cardiovascular training
Patient education regarding their disease
Stress relief
Skin desensitization
Gentle stretching, flexibility
Ergonomic education
Heat
Massage for relaxation
Active and passive ROM
Weight-bearing activities
++
Patient will be able to
Perform 30 minutes of aerobic activity.
Perform an 8-hour light-duty job.
Tolerate light touch with a sheet on legs at night.
Manage stress in order to participate in community activities.
++
Good if treated early.
May go into remission.
May be severe with poor long-term results.
Stage 1 lasts 1 to 3 months.
Stage 2 lasts 3 to 6 months.
Stage 3 lasts >6 months, often not fully reversible.
+++
ADDITIONAL INFORMATION
++
++
1. +
The American Physical Therapy Association. Pattern 4E: Impaired joint mobility, motor function, muscle performance, and range of motion associated with localized inflammation. Interactive Guide to Physical Therapist Practice. 2003. DOI: 10.2522/ptguide.3.1_5. Accessed June 21, 2013.
2. +
Schwarzer
A, Maier
C. Chapter 33. Complex regional pain syndrome. In:Kopf
A, Patel
NB International Association for the Study of Pain Guide to Pain Management in Low-Resource Settings. Seattle, WA: IASP; 2010.
4. +
Veldman
PH, Reynen
HM, Arntz
IE, Goris
RJ. Signs and symptoms of reflex sympathetic dystrophy: prospective study of 829 patients. Lancet. 1993;342(8878):1012–1016.
[PubMed: 8105263]
CrossRef 6. +
Hooker
DN, Prentice
WE. Chapter 5. Basic principles of electricity and electrical stimulating currents. In:Prentice
WE, Quillen
WS, Underwood
F Therapeutic Modalities in Rehabilitation. 4th ed. New York, NY: McGraw-Hill; 2011.
http://www.accessphysiotherapy.com/content/8136367#8136367. Accessed June 21, 2013.
+++
ADDITIONAL REFERENCES
+
Birklein
F, Kunzel
W, Sieweke
N. Despite clinical similarities there are significant differences between acute limb trauma and complex regional pain syndrome I (CRPS-I). Pain. 2001;93:165–171.
[PubMed: 11427328]
CrossRef +
Dutton
M. Integration of Practice Patterns 4F and 5F: Impaired joint mobility, motor function, muscle performance, and range of motion or reflex integrity secondary to referred pain, spinal disorders, peripheral nerve entrapment, myofascial pain syndrome, and complex regional pain syndrome. In:Dutton
M Orthopaedic Examination, Evaluation, and Intervention. 2nd ed. New York, NY: McGraw-Hill; 2008.
http://www.accessphysiotherapy.com/content/55579236. Accessed August 17, 2014.
+
Hay
WW, Levin
MJ, Sondheimer
JM, Deterding
RR. Noninflammatory pain syndromes. In:Hay
WW, Levin
MJ, Sondheimer
JM, Deterding
RR CURRENT Diagnosis & Treatment: Pediatrics. 20th ed. New York, NY: McGraw-Hill; 2011.
http://www.accessphysiotherapy.com/content/6586584. Accessed June 21, 2013.
+
Hord
ED, Oaklander
AL. Complex regional pain syndrome: A review of evidence-supported treatment options. Curr Pain Headache Rep. 2003;7(3):188–196.
[PubMed: 12720598]
CrossRef +
Quisel
A, Gill
JM, Witherell
P. Complex regional pain syndrome underdiagnosed. J Fam Pract. 2005;54(6):524–532.
[PubMed: 15939004]
+
Watkins
LR, Maier
SF. Immune regulation of central nervous system functions: from sickness responses to pathological pain. J Intern Med. 2005;257(2):139–155.
[PubMed: 15656873]
CrossRef
Martha Henao Bloyer, DPT, PT, PCS
++
+++
CONDITION/DISORDER SYNONYMS
++
++
++
+++
PREFERRED PRACTICE PATTERN
++
++
PATIENT PRESENTATION
A 15-year-old female was referred with low back pain and a recent diagnosis of Ehlers–Danlos Syndrome: hypermobility type. She reports pain is 8/10 with activity and 6/10 when seated. During the examination and evaluation, she scores a 6 on the Breighton Scoring System and has severe hypermobility. She also complains of generalized muscular and joint pain limiting her ability to participate in activities with her peers at school and socially. Her affect appears flat and withdrawn during the therapy session. Past medical history is non-contributory. Referral has been made to decrease pain, promote joint stability, and improve overall strengthand posture.
++
Group of inherited disorders involving the connective tissue collagen2,3
Major manifestations include2
Classical: most common form
Autosomal dominant heritability
Hyperextensible skin with atrophic scars
Easy bruising
Friability of tissues, which can result in
Molluscoid pseudo tumors (calcified hematomas)
Hypermobility of joints: least severe form
Autosomal dominant heritability
Affects large and small joints
Recurrent joint subluxations and dislocations
Shoulder
Patella
Temporomandibular
Vascular: most severe form
Kyphoscoliosis
Autosomal recessive heritability
Scoliosis at birth; progressive throughout life
Generalized joint laxity
Severe muscle hypotonia at birth
Other findings
Arthrochalasia
Autosomal dominant heritability
Congenital bilateral hip dislocation
Other manifestations may include
Skin hyperextensibility with easy bruising
Tissue fragility, including atrophic scars
Muscle hypotonia
Kyphoscoliosis
Radiologically mild osteopenia
Dermatosparaxis
++
+++
Essentials of Diagnosis
++
Characterized by joint hypermobility, skin extensibility and tissue fragility2
Six major types, classified according symptom manifestations and family history2
+++
General Considerations
++
++
++
++
++
SIGNS AND SYMPTOMS
Most often joint and skin related, may include2, 5
Joints
Joint hypermobility: loose, unstable joints; prone to frequent dislocation or subluxation
Joint pain
Early onset of osteoarthritis
Skin
Soft, velvety skin
Variable skin hyperextensibility
Fragile skin that tears or bruises easily
Manifests as spontaneous ecchymosis
Characteristic brownish discoloration
Tendency toward prolonged bleeding despite normal coagulation status
Severe scarring
Slow and poor wound-healing
Development of molluscoid pseudo tumors (fleshy lesions associated with scars over pressure areas)
Chronic pain
Physically and psychosocially disabling
Variable age of onset, location, duration, quality, severity, response to therapy
Affected individuals may also be diagnosed with
Chronic fatigue syndrome
Fibromyalgia
Depression
Hypochondriasis
Other pain syndromes
Myofascial pain
Neuropathic pain
Headaches/Migraines
Hematologic
Gastrointestinal
Gastroesophageal reflux
Gastritis
Delayed gastric emptying
Irritable bowel syndrome
Cardiovascular
Autonomic dysfunction
Atypical chest pain
Palpitations
Orthostatic intolerance
Aortic Root Dilatation
Mitral valve prolapse
Oral/dental
Obstetric/Gynecologic
Psychiatric
Fragility of soft tissues
+++
Functional Implications
++
Avoid resistance and isometric exercises: can exacerbate joint instability, pain
Avoid high-impact activity: can increase risk of acute subluxation/dislocation, pain, osteoarthritis
Cautious use of crutches, canes, walkers: can increase stress on upper extremities
++
+++
Possible Contributing Causes
++
Inherited
Autosomal dominant (classical, hypermobility, vascular, arthrochalasia types)
Autosomal recessive (dermatosparaxis, kyphoscoliosis types)
X chromosome-linked
++
++
+++
Differential Diagnosis
++
+++
MEANS OF CONFIRMATION OR DIAGNOSIS
++
Mitral valve prolapse (MVP) and proximal aortic dilatation diagnosed by echocardiography,6 CT or MRI7,8
Joint pain
Dual-energy X-ray absorptiometry (DEXA)8
Holter monitoring for cardiovascular: A utonomic dysfunction
+++
Diagnostic Procedures
++
+++
FINDINGS AND INTERPRETATION
++
Joint hypermobility
Assessed using the Beighton Scale
Depends on age, gender, family, ethnic background
Score 5 out of 9 or greater defines hypermobility
Total score obtained by
Passive dorsiflexion of each fifth finger greater than90 degrees: One point for each hand
Passive apposition of each thumb to the flexor surface of the forearm: One point for each hand
Hyperextension of each elbow greater than 10 degrees: One point for each elbow
Hyperextension of each knee greater than 10 degrees: One point for each knee
Ability to place palms on the floor with the knees fully extended: One point
++
REFERRALS/ADMITTANCE
To orthopedist for joint hypermobility
To rheumatologist
To gastroenterologist
To dentist for periodontal disease and temporomandibular dysfunction
To occupational therapist for splinting and joint protection
To hospital for imaging
++
Joint hypermobility
Impaired mobility
Pain
Psychosocial
++
++
Management includes genetic counseling to understand the disorder’s impact on family and future children
Treat manifestations
Assistive devices for joint stability
Braces, and splints
Soft neck collars
Mobility devices for decreasing stress-load on lower extremities
Sleeping-surface assistive devices
Pain management
Medications (individualized)
Acetaminophen
NSAIDs
Cox-2 inhibitors
Topical lidocaine
Skeletal muscle relaxants
Tricyclic antidepressants
Serotonin/Norepinephrine receptor inhibitors (SNRIs)
Opioids
Glucosamine and chondroitin
Supplemental magnesium
Psychological and pain-oriented counseling
Modalities that reduce spasms
Management of gastrointestinal symptoms: gastritis, reflux, irritable bowel syndrome
Prevention of primary manifestations
Prevention of secondary complications
++
Patient will
Report decreased level of joint (specify location) pain after10 minutes of low impact physical activity.
Independent in donning and doffing (specific joint) splints.
Demonstrate ability to go up and down one flight of stairs using handrail, step-to pattern, energy conservation techniques.
Be independent and safe using powered wheelchair mobility, indoor and outdoor.
++
First-degree relatives are at 50% risk of having autosomal dominant types.
Prognosis depends on type.
Symptoms vary in severity.
++
1. +
The American Physical Therapy Association. Pattern 5F: Impaired peripheral nerve integrity and muscle performance associated with peripheral nerve injury. Interactive Guide to Physical Therapist Practice. 2003. DOI: 10.2522/ptguide.3.2_6. Accessed May 24, 2013.
4. +
Miyamoto
SD, Sondheimer
HM, Fagan
TE, Collins
KK. Chapter 19. Cardiovascular diseases. In:Hay
W, Levin
MJ, Sondheimer
JM, Detering
RR CURRENT Diagnosis & Treatment: Pediatrics. New York, NY: McGraw-Hill; 2011.
http://www.accessphysiotherapy.com/abstract/6583154#6583208. Accessed May 24, 2013.
+++
ADDITIONAL REFERENCES
+
Pagon
RA, Bird
TD, Dolan
CR, Stephens
K Source GeneReviews [Internet]. Seattle (WA): University of Washington, Seattle; 1993-2004 Oct 22 [updated 2010 Dec 14].
Eric Shamus, PhD, DPT, PT, CSCS, Mae L. Yahara, MS, PT, ATC
++
+++
CONDITION/DISORDER SYNONYMS
++
Erb–Duchenne palsy
Erb paralysis
Brachial plexus injury
++
++
G54.0 Brachial plexus disorders
P14.0 Erb paralysis due to birth injury
S14.3XXA Injury of brachial plexus, initial encounter
+++
PREFERRED PRACTICE PATTERNS
++
4F: Impaired Joint Mobility, Motor Function, Muscle Performance, Range of Motion, and Reflex Integrity Associated with Spinal Disorders1
5F: Impaired Peripheral Nerve Integrity and Muscle Performance Associated with Peripheral Nerve Injury2,3
++
++
++
PATIENT PRESENTATION
Patient is a 3-month-old infant. His mother reports a difficult birth. Review of the medical record reveals shoulder dystocia and forceps delivery. The mother is concerned about the right arm. Child exhibits poor tone in the right shoulder and upper arm, forearm extended and in pronation. No movement of the right arm on Moro reflex. No flexion of the arm with painful stimulus.
++
Paralysis of the arm
Weakness in the arm
Diminished reflexes C5–C6 vertebrae
Arm hangs by side, internally rotated
Motor or sensory changes in the nerve distribution due to pressure from
+++
Essentials of Diagnosis
++
Electromyography
Pain
Numbness
Sensory changes in multiple peripheral nerves of the upper extremity from C5 and C6 nerve roots
Hand clumsiness, weakness
Seddon classification
Neuropraxia (Class 1), First degree
Axonotmesis (Class 2), Second degree
Neurotmesis (Class 3)
Third degree, nerve fiber interruption
Fourth degree, epineurium intact
Fifth degree, complete transection of the nerve
+++
General Considerations
++
Involved nerves: Suprascapular nerve, musculocutaneous nerve, axillary nerve
Must differentiate from more proximal and distal nerve compression, thoracic outlet syndrome (TOS), ulnar tunnel, cervical radiculopathy
Lower motor-neuron syndrome
Nerve compression syndrome in the upper extremity
Wallerian degeneration occurs below the site of injury
++
++
SIGNS AND SYMPTOMS
Acute or chronic paresthesia
Sensory changes: Hyposensitivity of hand
Hand clumsiness
Feeling of arm heaviness
Hand weakness, loss of grip-power and dexterity
Intrinsic muscle atrophy
Waiter’s tip sign
Caused by excessive lateral neck flexion
Loss of lateral-rotator, arm-flexor, and wrist-extensor musculature
+++
Functional Implications
++
Feeling of arm being dead
Difficulty with hand function, hand clumsiness, and possible loss of strength during ADLs/IADLs
+++
Possible Contributing Causes
++
During forceps delivery, infant has head traction
Traction to the cervical spine
Trauma pulling arm into abduction
Ganglion or space-occupying lesion
In the womb, sustained pressure over thoracic outlet
Clavicle fracture
Glenohumeral dislocation
+++
Differential Diagnosis
++
TOS
Cervical radiculopathy
Other potential entrapment sites include
Medial humeral groove
Arcade of Struthers
Medial intermuscular septum
Flexor digitorum profundus
Flexor carpi ulnaris
Just proximal to or within Guyon canal
Sensory and motor involvement between the abductor digiti minimi and flexor digiti minimi
Near hook of hamate: Involves motor function only
Distal end of Guyon canal: Involves sensory function only
Radial neuropathy
Median neuropathy
Carpal tunnel syndrome
Proximal ulnar nerve entrapment
Distal ulnar nerve entrapment cubital tunnel (Guyon Canal)4
Klumpke paralysis
Traction of an abducted arm
Lower brachial plexus injury
Damage to C8 and T1 vertebrae
Loss of intrinsic muscles of the hand, wrist, finger flexors
Wartenberg sign4
Froment sign; ulnar nerve palsy5
Bishop deformity
+++
MEANS OF CONFIRMATION OR DIAGNOSIS
++
+++
Diagnostic Procedures
++
++
+++
FINDINGS AND INTERPRETATION
++
Muscle weakness of deltoid, biceps, brachialis muscles
Inability to flex elbow or supinate the arm
Sensory changes in mixed ulnar, median, and radial nerve distribution
++
++
++
REFERRALS/ADMITTANCE
For oral anti-inflammatory, steroidal injections
For diagnostic tests if warranted and depending on PT’s area of practice
++
Inability to perform overhead activities, such as in swimming, baseball, or tennis
Inability to perform jobs involving repetitive overhead reaching or lifting
++
++
++
Patient will
Resume full use of affected upper extremity (arm movement) during ADLs and IADLs.
Return to normal ADLs without signs or symptoms.
Be able to type for 1 hour at work.
++
Patients with mild electrodiagnostic findings, intermittent symptoms, no atrophy may respond well to conservative management.
Paralysis may resolve on its own; may need therapy or surgery.
Prognosis depends on duration of symptoms and motor involvement.
Potential for full motor recovery; may take 6 months to 1 year for nerve regeneration.
++
1. +
The American Physical Therapy Association. Pattern 4F: impaired joint mobility, motor function, muscle performance, range of motion, and reflex integrity associated with spinal disorders. Interactive Guide to Physical Therapist Practice. 2003. doi: 10.2522/ptguide.3.1_6.
http://guidetoptpractice.apta.org/content/1/SEC13.extract. Accessed June 1, 2014.
3. +
Dutton
M. Integration of practice patterns 4f and 5f: impaired joint mobility, motor function, muscle performance, and range of motion, or reflex integrity secondary to spinal disorders, peripheral nerve entrapments, compartment syndrome, and myofascial pain dysfunction (Chapter). In:Dutton
M Orthopaedic Examination, Evaluation, and Intervention. 2nd ed.
http://www.accessphysiotherapy.com/content/55576493. Accessed January 21, 2013.
+++
ADDITIONAL REFERENCES
+
Preston
D, Shapiro
B. Electromyography and neuromuscular disorders. In: Clinical Electrophysiologic Correlations. Boston, MA: Butterworth-Heinemann; 1998.
David Boesler, DO, MS, Eric Shamus, PhD, DPT, PT, CSCS, Marangela Obispo, MSPT, GCS
++
+++
CONDITION/DISORDER SYNONYMS
++
++
++
+++
PREFERRED PRACTICE PATTERNS
++
4E: Impaired Joint Mobility, Motor Function, Muscle Performance, and ROM Associated with Localized Inflammation1
5F: Impaired Peripheral Nerve Integrity and Muscle Performance Associated with Peripheral Nerve Injury2
++
PATIENT PRESENTATION
A 44-year-old female began complaining of pain in multiple areas including upper back, mid back, low back, and knees for the last 3 months. X-rays and MRI were negative. Laboratory tests including CBC, C-reactive protein, rheumatoid factor, and thyroid profile were also negative. Recently, patient had to stop working as a social worker due to the severity of pain and stiffness, fatigue, difficulty concentrating, and sleep disturbances. She reported difficulty with daily activities mainly due to pain and fatigue. Patient revealed an unremarkable PMH, except for a recent flu virus with no major symptoms. Upon examination, patient was found with multiple tender points with pain radiating to vicinity areas only with palpation. Patient presented with limited ROM in the cervical spine, lumbar spine, and bilateral knee extension. Patient presented with a normal gait pattern, and her 6MWT was abnormal for her age.
++
Widespread musculoskeletal pain and fatigue for at least 3 months
Commonly involves mood disturbances
Preliminary new criteria from American College of Rheumatology in 2010 include Widespread Pain Index and Symptom Severity Score instead of tender points
Current criteria: Tender points in at least 11 of 18 areas
Arms, chest, buttocks, knees, low back, neck, rib cage, thighs, shoulders
++
++
++
+++
Essentials of Diagnosis
++
Diagnosis based primarily on symptoms of widespread pain
Fatigue, typically begins on rising from sleep
Morning stiffness, typically lasting all day, does not diminish with activity
Controversy over diagnosing as psychosomatic disorder
Tenderness with palpation in at least 11 of 18 areas throughout the body
+++
General Considerations
++
++
75% to 90% of cases in females
Female-to-male ratio 9:1
Affects 2% to 4% of general population
Most people develop symptoms between ages 20 and 55 years
++
SIGNS AND SYMPTOMS
Widespread pain and fatigue
Headaches
Tenderness in multiple specific anatomic locations
Mood disturbances, depression, anxiety
Muscle pain
Cognitive dysfunction
Irritable bowel
Morning stiffness
Sleep disturbances with constant interruptions of sleep
Muscle spasm
Nerve pain
Sympathetic hyperactivity
Associated symptoms may include paresthesias, burning, tingling
+++
Functional Implications
++
+++
Possible Contributing Causes
++
+++
Differential Diagnosis
++
++
++
+++
MEANS OF CONFIRMATION OR DIAGNOSIS
++
CBC
ESR
C-reactive protein
Rheumatoid factor
Thyroid profile
++
+++
Diagnostic Procedures
++
+++
FINDINGS AND INTERPRETATION
++
X-ray: Negative4
MRI: Negative5
Negative laboratory tests, such as CBC, ESR, C-reactive protein, rheumatoid factor, thyroid profile
++
Analgesics (Tylenol, Ultram)
Low-dose anti-depressants (tricyclics, SSRI’s, SNRI’s)
Lyrica, Cymbalta, Savella3
++
REFERRALS/ADMITTANCE
To other therapist for gentle osteopathic manipulative treatment
To dietician for nutritional counseling
To pain clinic for pain management
To psychologist for cognitive-behavioral therapy, psychological support
Counseling
Support groups
Biofeedback
Relaxation techniques
++
Limited walking and movement secondary to pain and morning stiffness, can last throughout the day
Difficulty standing or sitting in one position for extended period of time
Limited aerobic capacity
++
Vascular examination (particularly blood flow to feet)
Heart rate
Sensory testing
Reflex testing
Manual muscle test
Active and passive ROM testing, muscle length testing
Functional assessment (assist, device, environment)
Bed mobility
Transitions
Sitting balance
Standing balance
Transfers
Gait
Stairs
Pain assessment
Postural assessment
Cardiovascular endurance
++
Patient education
Stress relief
Therapy
Acupuncture
Yoga
Tai chi
Aerobic exercise6
Heated aquatic therapy
Gentle stretching
++
Patient will be able to
Perform 30 minutes of aerobic activity.
Perform an 8-hour/day light-duty job.
Manage stress so as to participate in community activities.
++
Chronic, but not progressive.
Usually little change in long-term symptoms, but patients can learn to function and manage pain more effectively with treatment.
++
1. +
The American Physical Therapy Association. Pattern 4E: impaired joint mobility, motor function, muscle performance, and range of motion associated with localized inflammation. Interactive Guide to Physical Therapist Practice. 2003. doi: 10.2522/ptguide. 978-1-931369-64-0. Accessed April 21, 2013.
2. +
The American Physical Therapy Association. Pattern 5F: impaired peripheral nerve integrity and muscle performance associated with peripheral nerve injury. Interactive Guide to Physical Therapist Practice. 2003. doi: 10.2522/ptguide.3.2_6. Accessed April 21, 2013.
+++
ADDITIONAL REFERENCES
+
Hay
WW, Levin
MJ, Sondheimer
JM, Deterding
RR. Noninflammatory pain syndromes. In:Hay
WW, Levin
MJ, Sondheimer
JM, Deterding
RR CURRENT Diagnosis & Treatment: Pediatrics. 20th ed. New York, NY: McGraw-Hill; 2011.
http://www.accessphysiotherapy.com/content/6586584. Accessed April 30, 2013.
Matthew L. Daugherty, DPT, OTR/L, MOT, MTC, OCS, FAAOMPT, Eric Shamus, PhD, DPT, PT, CSCS
++
+++
CONDITION/DISORDER SYNONYMS
++
Ape-hand deformity
Median nerve palsy
++
++
G56.10 Other lesions of median nerve, unspecified upper limb
S44.10XA Injury of median nerve at upper arm level, unspecified arm, initial encounter
S54.10XA Injury of median nerve at forearm level, unspecified arm, initial encounter
S64.10XA Injury of median nerve at wrist and hand level of unspecified arm, initial encounter
+++
PREFERRED PRACTICE PATTERNS
++
4E: Impaired Joint Mobility, Motor Function, Muscle Performance, and Range of Motion Associated with Localized Inflammation1
5F: Impaired Peripheral Nerve Integrity and Muscle Performance Associated with Peripheral Nerve Injury2
++
PATIENT PRESENTATION
Patient is a 44-year-old male who works in a new home construction. He spends the majority of his day using power tools, such as a drill and nail gun, in various positions of the elbow and forearm. After a long period of part time work he has returned to work 60+ hours/week and spent the interim lifting weights. Over the past 2 weeks, he has begun to notice a burning/achy pain at his volar/medial forearm. This pain is exacerbated while at work and seems to get worse throughout the day, especially with usage of hand power tools. He also reports a painful tingling that radiates all the way to his thumb and first two fingers when he is really symptomatic. Functionally, he reports that he feels as if his hand fatigues quickly at work.
Clinically, he is a mesomorphic male with hyperalgesia reported across median nerve distribution of hand (thenar eminence, volar surface and tips of digits I, II, and radial side of III. No weakness of pronator teres but overall grip strength is decreased 20 lb on the affected side. Forearm pain is aggravated by sustained forearm pronation, especially with elbow extension. Palpable tenderness deep in the pronator teres with positive pronator compression test and median nerve neurodynamic testing.
++
Entrapment neuropathy of the median nerve other than within the carpal tunnel of the wrist3,4
Common entrapment sites include; ligament of Struthers, bicipital aponeurosis, and pronator teres (all generically called pronator syndrome—PN), fibrous arch of flexor digitorum superficialis (anterior interosseous syndrome—AINS)
Signs and symptoms typical of neuropathy, includes:
Symptoms are seen in the distribution of the median nerve in the hand3, distal upper arm, and volar forearm
+++
Essentials of Diagnosis
++
Pain, paresthesias, and sensory loss perceived on radial side of the palm and the palmar side of thumb, index, middle, and radial side of the ring fingers (no sensory loss if AINS)
Pain may radiate up to the elbow, shoulder, neck
In advanced cases, motor dysfunction in thenar muscles may occur, characterized by weakness, atrophy, loss of coordination
+++
General Considerations
++
In entrapment neuropathy, nerve becomes compressed, causing ischemic damage to the nerve
Often associated with repetitive motions or sustained position of the elbow
Unrelieved compression of the nerve results in neurapraxia with segmental demyelination;6 further ischemic damage results in axonotmesis and wallerian degeneration5,6
++
Four times more common in women (PS)7
AINS is rare, accounting for less than 1% of upper- extremity neuropathies7
Most common among people in their fifth decade of life7
++
SIGNS AND SYMPTOMS
Ape-hand deformity
First symptom is usually pain or paresthesias;3 most commonly with gradual onset
Pain at proximal volar forearm exacerbated by repetitive forearm rotation or elbow motion
Pain complaints include numbness (most common), tingling, burning
Pain is experienced in distribution of the median nerve in the hand, particularly the palm of hand over the thenar eminence, though may radiate up to elbow, shoulder, or neck
Tenderness to percussion or deep pressure over the pronator teres, proximal FDS, or distal volar arm above the elbow
Sensory loss may follow early symptom of pain
Motor involvement (weakness, loss of coordination, atrophy) may follow in more advanced cases
++
++
+++
Functional Implications
++
Pain with wrist movements
Difficulty with grasping and manipulation activities
Dropping items from the hand
Impaired sensation
Loss of strength in advanced cases
+++
Possible Contributing Causes
++
Most often idiopathic
Genetic structural factors
Tumors
Displaced fracture or fracture callus, especially of distal radius
Elbow dislocation
Structural abnormalities of humerus
Occupations that require repetitive motion, repetitive stress, sustained positions of elbow and forearm
Direct trauma to forearm, elbow or arm
Impaired circulation to peripheral nerves, as seen in diabetes, predisposes individuals to nerve compression symptoms
++
++
+++
Differential Diagnosis
++
+++
MEANS OF CONFIRMATION OR DIAGNOSIS
++
++
+++
FINDINGS AND INTERPRETATION
++
++
++
++
++
Upper limb tension test
Cervical spine compression test
Pain provocation test
Shoulder pain and disability index
Resisted motion testing at elbow (forearm pronation with elbow extension, elbow flexion, proximal interphalangeal flexion at the middle finger)7
Pronator compression test7
Tinel sign at proximal forearm
Sensory loss may include diminished two-point discrimination, decreased vibration sense, increased threshold in Semmes- Weinstein monofilament test5
Flick sign
Thenar muscle strength test (lateral pinch dynamometry)
FDP (index finger) and FPL manual muscle testing if AINS
Positive pinch grip test (AINS)
Weakness of pronator teres during manual muscle testing if entrapment at ligament of Struthers or bicipital aponeurosis
++
++
Early conservative intervention
Second-stage conservative intervention
Postsurgical intervention
++
Patient will have
Improved ability to perform physical tasks, self-care, home management, leisure and occupational activities.
Increased tolerance of positions and activities using elbow, forearm, and wrist.
Reduced ergonomic risk.
++
++
Prognosis dependent on duration of symptoms and motor involvement.
Patients with mild electrodiagnostic findings, intermittent symptoms, and no atrophy may respond well to conservative management.
Surgical intervention indicated for patients with symptoms lasting more than 1 year, or those for whom conservative treatment over 3 months has failed.
++
1. +
The American Physical Therapy Association. Pattern 4E: Impaired joint mobility, motor function, muscle performance, and range of motion associated with localized inflammation. Interactive Guide to Physical Therapist Practice. 2003. doi: 10.2522/ptguide.3.1_5. Accessed July 6, 2013.
2. +
The American Physical Therapy Association. Pattern 5F: impaired peripheral nerve integrity and muscle performance associated with peripheral nerve injury. Interactive Guide to Physical Therapist Practice. 2003. doi: 10.2522/ptguide.3.2_6. Accessed July 6, 2013.
5. +
Goodman
CC, Fuller
KS. Pathology: Implications for the Physical Therapist. 3rd ed. St. Louis: Saunders/Elsevier; 2009.
7. +
Skirven
TM, Osterman
AL, Fedorczyk
JM
et al. Rehabilitation Of The Hand and Upper Extremity. 6th ed. St. Louis, MO: Mosby Inc; 2011.
8. +
Halle
J, Greathouse
D. Principles of electrophysiologic evaluation and testing. In:Prentice
WE, Quillen
WS, Underwood
F Therapeutic Modalities in Rehabilitation. 4th ed. New York, NY: McGraw-Hill; 2011:Chapter 8.
http://www.accessphysiotherapy.com/abstract/8137649#8137649. Accessed July 6, 2013.
9. +
AcSkirven
TM, Osterman
AL, Fedorczyk
JM
et al. Rehabilitation Of The Hand and Upper Extremity. 6th ed. St. Louis, MO: Mosby Inc; 2011.
12. +
Muller
M, Tsui
D, Schnurr
R, Biddulph-Deisroth
L, Hard
J, MacDermid
J. Effectiveness of hand therapy interventions in primary management of carpal tunnel syndrome: a systematic review. J Hand Ther. 2004;17(2):210–228.
[PubMed: 15162107]
CrossRef
+++
ADDITIONAL REFERENCES
+
Lozano-Calderón
S, Anthony
S, Ring
D. The quality and strength of evidence for etiology: example of carpal tunnel syndrome. J Hand Surg Am. 2008;33(4):525–538.
[PubMed: 18406957]
CrossRef
Christina L. Pettie, MHA, PT, Eric Shamus, PhD, DPT, PT, CSCS
++
+++
CONDITION/DISORDER SYNONYMS
++
Intermetatarsal disorder
Morton metatarsalgia
Plantar nerve lesion
++
++
+++
PREFERRED PRACTICE PATTERN
++
++
PATIENT PRESENTATION
A 42-year-old female presents with a severe pain in the ball of her right foot that radiates into her second and third toes. She states the pain started about 1 week ago. She describes the pain as being sharp and burning in nature. She does not recall a specific injury but does state that she started barefoot running 6 weeks ago and eliminated her heel strike. She also goes to dance classes for the past 4 weeks. She feels better with a hard soled shoe on but cannot wear her dress shoes, especially heels. Upon palpation there is a thickening of the tissue between toes 2 and 3 right. Tenderness is present in the same region. There is hypomobility of the MTP toes 2 and 3 right and a positive pinch test. The patient’s radiograph, which was ordered by the referring physician, is negative for any fractures.
++
Painful condition that affects the ball of the foot
Growth of scar tissue from chronic irritation of compression
Most common area is between the third and fourth toes, but also can be in between the second and third toes
Involves a thickening of the tissues (neuroma) around one of the intermetatarsal plantar nerves
Branches from the medial and lateral plantar nerves
May alter mechanics during the push-off phase of gait
+++
Essentials of Diagnosis
++
Can be an independent diagnosis and not associated with a disease process
Characterized by numbness, burning, and pain
Sometimes relieved by removing shoes
No visible deformity
Higher risk for individuals with bunions and flat feet
++
+++
General Considerations
++
Feeling like you are stepping on something like a pebble
A burning pain in the ball of the foot that radiates to the toes
Tingling or numbness in the toes
Titled a neuroma, but is not a tumor formation as “oma”
++
++
SIGNS AND SYMPTOMS
Burning pain in the ball of the foot
Numbness and tingling in the toes, especially between the third and fourth toes
Difficulty wearing/finding shoes, especially pointed ones
Limited motion of the MTP joint
+++
Functional Implications
++
Pain with standing
Pain with ambulation at the toe
Inability to wear regular shoes
Need to wear larger shoes with a larger toe box
Alteration of gait pattern and mechanical issues of the forefoot
++
+++
Possible Contributing Causes
++
Poor footwear: Improper fit
Certain sports
Repetitive trauma from high-impact activities, such as jogging or running
Those requiring tight shoes, such as snow skiing or rock climbing
Foot deformities: Bunions, hammer toes, flat feet, excessive flexibility
+++
Differential Diagnoses
++
+++
MEANS OF CONFIRMATION OR DIAGNOSIS
++
X-ray
Diagnostic ultrasound
MRI
+++
Diagnostic Procedures
++
+++
FINDINGS AND INTERPRETATION
++
++
Anti-inflammatories
Corticosteroid injection
++
Cryogenic neuroablation
Decompression surgery
Removal of the nerve
++
++
Antalgic gait secondary to pain at the toe with push-off
Hypomobility of the MTP joint toe
Inability to ambulate distances of 1 mile, secondary to pain
++
++
Rest with weight off feet reduces inflammation
Metatarsal pad to increase space between the metatarsal (MT) heads: Taping, padding, or orthotics
Address swelling
Address pain
Ice
Massage
Joint mobilization
Electric stimulation
Iontophoresis
Infrared light (IR)
Acupuncture
Address weakness, joint instability
Address lack of flexibility
Address joint mobilization
MTP dorsal/plantar and medial/lateral glides and rotation
Posterior talus glides
Subtalar joint (STJ) inversion/eversion
Navicular/Cuboid/Cuneiforms
Address soft tissue mobilization
Patient education in footwear
++
Patient will be able to
Recognize and maintain a subtalar neutral position for >2 minutes.
Ambulate pain free for >45 minutes.
Achieve 15 degrees of talocrural dorsiflexion during stance phase of gait.
Achieve pain-free toe extension during push-off phase of gait.
Unilaterally stand in subtalar neutral for 1 minute with eyes open.
++
++
1. +
Mulder
JD. The causative mechanism in Morton’s metatarsalgia. J Bone Joint Surg Br. 1951;33-B(1):94–95.
[PubMed: 14814167]
+++
ADDITIONAL REFERENCES
+
Bencardino
J, Rosenberg
ZS, Beltran
J, Liu
X, Marty-Delfaut
E. Morton’s Neuroma, Is it Always Symptomatic. AJR Am J Roentgenol. 2000;175(3):649–653.
[PubMed: 10954445]
CrossRef +
Hamilton
N, Weimar
W, Luttgens
K. Kinesiology of fitness and exercise. In:Hamilton
N, Weimar
W, Luttgens
K Kinesiology: Scientific Basis of Human Motion. New York, NY: McGraw-Hill; 2008:Chapter 16.
http://www.accessphysiotherapy.com/content/6151836. Accessed July 5, 2013.
+
Hooker
DN, Prentice
WE. Basic principles of electricity and electrical stimulating currents. In:Prentice
WE, Quillen
WS, Underwood
F Therapeutic Modalities in Rehabilitation. 4th ed. New York, NY: McGraw-Hill; 2011:Chapter 5.
http://www.accessphysiotherapy.com/content/8136027. Accessed July 5, 2013.
+
Prentice
WE. Cryotherapy and thermotherapy. In:Prentice
WE, Quillen
WS, Underwood
F Therapeutic Modalities in Rehabilitation. 4th ed. New York, NY: McGraw-Hill; 2011:Chapter 9.
http://www.accessphysiotherapy.com/content/8137872. Accessed July 5, 2013.
Matthew L. Daugherty, DPT, OTR/L, MOT, MTC, OCS, FAAOMPT, Eric Shamus, PhD, DPT, PT, CSCS
++
+++
CONDITION/DISORDER SYNONYM
++
++
++
G56.31 Lesion of radial nerve, right upper limb
G56.32 Lesion of radial nerve, left upper limb
+++
PREFERRED PRACTICE PATTERNS
++
4E: Impaired Joint Mobility, Motor Function, Muscle Performance, and Range of Motion Associated with Localized Inflammation1
5F: Impaired Peripheral Nerve Integrity and Muscle Performance Associated with Peripheral Nerve Injury2
++
PATIENT PRESENTATION
Patient is a 25-year-old female administrative assistant. She spends a significant amount of time utilizing the computer keyboard. She is reporting a burning pain in her dorsal forearm throughout the day depending on how much typing she has done. The pain is exacerbated by flexing her wrist down, typing, and lifting file folders in pronation. She denies any numbness/tingling into her distal extremity and only reports the local forearm pain. Functionally, she has to take frequent rest breaks throughout the day and when she becomes symptomatic her typing rate decreases as well. She is woken at night approximately 5 days per week especially when her hand drops off the edge of the bed into wrist flexion.
Clinically, she does not present with any sensory deficits. She does have a 10 lb grip strength decrease and reports pain with testing. Palpable tenderness in extensor mass 5 cm distal to lateral epicondyle. Increased symptoms with passive wrist flexion/ulnar deviation/elbow extension combination as well as resisted long finger extension and forearm supination. Positive neurodynamic testing with radial nerve bias.
++
Entrapment neuropathy of the radial nerve, particularly the posterior interosseous nerve (PIN) or dorsal radial sensory nerve (DRSN) in the elbow and wrist
Common entrapment sites include3:
Thickened fascial tissue superficial to radiocapitellar joint
Fibrous origin of extensor carpi radialis brevis (ECRB)
Radial recurrent vessels-leash of Henry
Proximal border of supinator-arcade of Frohse
Distal edge of supinator
Between tendons of brachioradialis and extensor carpi radialis longus (DRSN)
Subcutaneous tissue in distal forearm (DRSN)
Signs and symptoms typical of neuropathy, includes:
Symptoms are seen in the distribution of the radial nerve in the hand3, dorsal distal upper arm and dorsal forearm 4 to 5 cm distal to the lateral epicondyle
+++
Essentials of Diagnosis
++
Burning or aching pain, paresthesias, and sensory loss perceived on dorsum of the forearm, thumb, and digits I–III dorsally; sensory changes only if DRSN syndrome
Rest pain and night pain are common3,4
+++
General Considerations
++
In entrapment neuropathy, nerve becomes compressed, causing ischemic damage to the nerve.
Often associated with repetitive motions or sustained position of the elbow.
Unrelieved compression of the nerve results in neurapraxia with segmental demyelination5; further ischemic damage results in axonotmesis and wallerian degeneration.6,5
++
Coexists with lateral epicondylitis in 5% of patients.3
AINS is rare, accounting for less than 1% of upper-extremity neuropathies.7
Most common among people in their fifth decade of life.7
++
SIGNS AND SYMPTOMS
Burning/Aching pain in dorsal forearm exacerbated by repetitive activity in forearm pronation with wrist flexion including:
Pain reported over anatomical snuff box and dorsal thumb
Grip strength weakness due to pain
++
++