SECTION J: NERVE/ENTRAPMENT DISORDERS

CONDITION/DISORDER SYNONYMS

• Facial palsy

• Peripheral facial paralysis

ICD-9-CM CODE

• 351.0 Bell’s palsy

ICD-1-CM CODE

• G51.0 Bell’s palsy, facial palsy

PREFERRED PRACTICE PATTERN

• 5D: Impaired Motor Function and Sensory Integrity Associated with Nonprogressive Disorders of the Central Nervous System-–acquired in adolescence or adulthood

KEY FEATURES

• 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

CLINICAL FINDINGS

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:

  • Nerve conduction test for facial nerve

  • Electromyography (EMG) for facial nerve

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

IMPAIRMENTS

• Impaired facial expression due to paralysis

• Problems eating (food stuck in month or falling out), difficulty swallowing

• Hearing impairment

• Pain

TESTS AND MEASURES

• History

• Physical examination

• Neurological examination to check facial nerve function

INTERVENTION

• Rest and steroids treatment

• Facial exercises

• Electric stimulation⁴

• Eye care

  • Use finger to close and open eyelid often throughout the day

  • Use eye drops (artificial tears) or ointment; use drops during the day and ointment at night while sleeping

  • Wear eye patch while sleeping, wear glasses or goggles the rest of the time

• Mouth care

  • Brush and floss teeth often and well to help prevent gum disease or tooth decay caused by residual food in the month

  • Eat slowly and chew well to prevent swallowing problems

  • Eating soft, smooth foods, such as yogurt

FUNCTIONAL GOALS

• Patient will be able to:

  • Drink without drooling, dripping.

  • Eat and chew independently.

PROGNOSIS

• 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

• For additional information, please see Case 8 in the Orthopedic Case Series on AccessPhysiotherapy.com.⁵

REFERENCES

ADDITIONAL REFERENCES

CONDITION/DISORDER SYNONYMS

• Brachial plexus lesions

• Injury to brachial plexus

ICD-9-CM CODES

• 353.0 Brachial plexus lesions

• 767.6 Injury to brachial plexus due to birth trauma

• 953.4 Injury to brachial plexus

ICD-10-CM CODES

• 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

KEY FEATURES

Description

• 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

Demographics

• 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

CLINICAL FINDINGS

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

Imaging

• Allows for dynamic imaging during arm movement

• Enlargement of brachial plexus nerves at entrapment site

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/sec^5,6

FINDINGS AND INTERPRETATION

• Muscle weakness of

  • Flexor carpi ulnaris (FCU)

  • Ulnar side of flexor digitorum profundus (FDP)

  • Abductor digiti minimi

  • Palmar and dorsal interossei

  • Intrinsic—interossei and lumbricals⁷

• Sensory changes in mixed ulnar, median, and radialnerve distribution

TREATMENT

Medication

• Lyrica

IMPAIRMENTS

• Inability to perform overhead activities, such as swimming, baseball, or tennis

• Inability to perform jobs involving repetitive overhead reachingor lifting

TESTS AND MEASURES

• 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

INTERVENTION

• 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

FUNCTIONAL GOALS

• 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

• 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.

REFERENCES

ADDITIONAL REFERENCES

CONDITION/SYNONYM

• Carpal tunnel syndrome (CTS)

ICD-9-CM CODE

• 354.0 Carpal tunnel syndrome

ICD-10-CM CODES

• 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

KEY FEATURES

Description

• Entrapment neuropathy of the median nerve within the carpal tunnel of the wrist^3,4

• Signs and symptoms typical of neuropathy, including

  • Pain

  • Paresthesias

  • Loss of sensation

  • Later loss of muscle function

• 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 degeneration^5,6

Demographics

• 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 individuals^5,7

• Most common among people aged 30 to 60 years⁵

• Nearly one-half of cases will experience bilateral symptoms⁵

CLINICAL FINDINGS

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

  • This point is debated in the literature: Association is seen, but a causal relationship is not clear; genetic structural causes appear more likely.

• Direct trauma to wrist

• Impaired circulation to peripheral nerves, as seen in diabetes, predisposes individuals to nerve compression symptoms

Differential Diagnosis

• Acromegaly

• Cervical radiculopathy

• Hypothyroidism

• Pronator teres syndrome

• Rheumatoid or other arthritis

• Scleroderma

• Thoracic outlet syndrome

• Traumatic nerve lesion

MEANS OF CONFIRMATION OR DIAGNOSIS

Laboratory Tests

• Laboratory studies for suspected rheumatoid disorders

Imaging

• MRI⁴

• Diagnostic ultrasound (ultrasonography)⁴

Diagnostic Procedure

• Nerve conduction

FINDINGS AND INTERPRETATION

• Nerve conduction velocity testing of median nerve across the carpal tunnel is considered gold standard for diagnosis.^5,8

TREATMENT

Medication

• NSAIDs⁴

• Corticosteroid injection

IMPAIRMENTS

• Hand weakness with grasping, squeezing, pinching

TESTS AND MEASURES

• 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

INTERVENTION

• Early conservative intervention

  • Ergonomic analysis and activity modification to reduce repetitive motion or positioning stress

• Second-stage conservative intervention

  • Immobilization of wrist with splint; holding wrist in neutral position to reduce compression pressures²

  • Ultrasound^10,11

  • Median nerve gliding⁴

  • Tendon gliding exercises¹¹

  • Manual therapy¹¹

    • Carpal bone mobilization plus flexor retinaculum stretch

    • Myofascial release¹²

  • Magnetic therapy¹¹

  • Cold low-level laser therapy^10,11

  • Yoga^4,11

  • Address swelling

    • Ice¹³

    • Elevation

    • Iontophoresis

• Post-surgical intervention

  • Median nerve gliding⁴

  • Tendon gliding techniques to reduce adhesions

  • Strengthening

FUNCTIONAL GOALS

• 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.

PROGNOSIS

• 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.

REFERENCES

ADDITIONAL REFERENCES

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)

ICD-9-CM CODES¹

• 729.71 Nontraumatic compartment syndrome of upper extremity

• 958.91 Traumatic compartment syndrome of upper extremity

ICD-10-CM CODES²

• 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

KEY FEATURES

Description

• 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

  • Medical emergency

  • Immediate surgery, fasciotomy

• Subacute compartment syndrome

  • Less of an emergency, usually surgery, fasciotomy

• 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

  • Pain increases with passive/active range of motion and compression

• Distal pulses are diminished/absent

• Strength and sensation are diminished

• Edema in affected limb

General Considerations

• Require emergency surgery to prevent permanent damage with pressure measurements of 30 mm Hg or higher

• Forearm has two compartments

  • Volar

  • Dorsal

• Classic P’s

  • Pain

  • Pallor

  • Pulselessness

  • Paresthesias

  • Paralysis

• Complications

  • Infection

  • Contractures

  • Deformity

  • Amputation

  • Acidosis

  • Hyperkalemia

  • Myoglobinuria

  • Acute renal failure and shock

Demographics

• 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

CLINICAL FINDINGS

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

  • Repetitive activities

  • Poor upper-extremity biomechanics

• Vascular conditions

  • Arterial or venous injuries with hemorrhage

  • Deep vein thrombosis

  • Tourniquets

  • Bleeding disorders (i.e., hemophilia)

• Soft-tissue injuries

  • Burns

  • Crush injury

  • Contusion

  • Snakebite

  • Prolonged limb compression

• Anabolic steroids

• Creatine supplementation⁴

Differential Diagnosis

• Rhabdomyolysis

• Carpal Tunnel syndrome

• Fracture

• Periostitis

• Deep vein thrombosis

• Tumor

• Nerve entrapment

• Muscle tear

• Necrotizing fasciitis

• Cellulitis

• Cnidaria Envenomation

• Gas Gangrene

• Peripheral vascular injuries

MEANS OF CONFIRMATION OR DIAGNOSIS

Imaging

• Radiographs

• Bone scans

• CT scans

• MRI

• Doppler ultrasound

Diagnostic Procedure

• Compartmental pressure measurements

• Pulse oximetry to identify limb hypoperfusion

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)

TREATMENT

Medication

• Anti-inflammatory, NSAID

MEDICAL PROCEDURES

• Acute compartment syndrome, immediate open fasciotomy to relieve pressure, and avoid permanent damage

• Subcutaneous fasciotomy

• Hyperbaric oxygen therapy

IMPAIRMENTS

• Weakness

• Numbness and tingling

• Severe pain

TESTS AND MEASURES

• Pain, visual analog scale (VAS)

  • 24-hour pain

  • Worst average pain

  • Best average pain

  • Tenderness on palpation

• Functional independence measure

• Cardiovascular integrity

  • Blood pressure at rest and after activity

  • Palpation of distal pulses

  • Capillary refill

• Skin integrity

  • Associated skin assessment

    • Edema (linear girth measurements, palpation)

    • Color

    • Temperature

• Neurologic examination

  • Sensation

    • Light touch

    • Pin prick

    • Limb sensation

    • 2-point discrimination

  • Upper-extremity deep tendon reflexes

  • Proprioception

  • Kinesthetic awareness

  • Coordination

• Limb strength

  • Manual muscle test (MMT)

INTERVENTION

• 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

FUNCTIONAL GOALS

• The patient will be able to

  • Use upper-extremity with mild symptoms for 30 minutes

  • Return to activities such as computer use, writing, and driving

PROGNOSIS

• 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

REFERENCES

ADDITIONAL REFERENCES

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

ICD-9-CM CODES¹

• 729.72 Nontraumatic compartment syndrome of lower extremity

• 958.92 Traumatic compartment syndrome of lower extremity

ICD-10-CM CODES²

• 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

KEY FEATURES

Description

• 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

  • Medical emergency

  • Immediate surgery, fasciotomy

• Subacute compartment syndrome

  • Less of an emergency, usually surgery, fasciotomy

• 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

  • Pain increases with passive/active range of motion and compression

• Distal pulses are diminished/absent

• Strength and sensation are diminished

• Edema in affected limb

General Considerations

• Require emergency surgery to prevent permanent damage with pressure measurements of 30 mm Hg or higher

• Lower leg has four compartments

  • Anterior

  • Lateral

  • Deep posterior

  • Superficial posterior

• Classic P’s

  • Pain

  • Pallor

  • Pulselessness

  • Paresthesias

  • Paralysis

• Complications

  • Infection

  • Contractures

  • Deformity

  • Amputation

  • Acidosis

  • Hyperkalemia

  • Myoglobinuria

  • Acute renal failure and shock

Demographics

• 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.

CLINICAL FINDINGS

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

    • Tibial shaft fracture has the highest risk of lower-extremity compartment syndrome

• Chronic compartment syndrome

  • Repetitive activities such as running and cycling⁴

  • Poor lower extremity biomechanics

• Vascular conditions

  • Arterial or venous injuries with hemorrhage

  • Deep vein thrombosis

  • Tourniquets

  • Bleeding disorders (i.e., hemophilia)

• Soft tissue injuries

  • Burns

  • Crush injury

  • Contusion

  • Snakebite

  • Prolonged limb compression

  • Gastrocnemius rupture

• Anabolic steroids

• Creatine supplementation⁵

Differential Diagnosis

• Rhabdomyolysis

• Shin splints

• Fracture

• Periostitis

• Deep vein thrombosis

• Tumor

• Nerve entrapment

• Muscle tear

• Necrotizing fasciitis

• Cellulitis

• Cnidaria Envenomation

• Gas gangrene

• Peripheral vascular injuries

MEANS OF CONFIRMATION OR DIAGNOSIS

Imaging

• Radiographs

• Bone scans

• CT scans

• MRI

• Doppler ultrasound used to evaluated arterial flow and rule out DVT

Diagnostic Procedure

• Compartmental pressure measurements

• Pulse oximetry to identify limb hypoperfusion

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

TREATMENT

Medication

• Anti-inflammatory, NSAID

MEDICAL PROCEDURES

• Acute compartment syndrome, immediate open fasciotomy to relieve pressure and avoid permanent damage

• Subcutaneous fasciotomy

• Hyperbaric oxygen therapy

IMPAIRMENTS

• Weakness

• Numbness and tingling

• Severe pain

TESTS AND MEASURES

• Homans sign

• Pain, visual analog scale (VAS)

  • 24-hour pain

  • Worst average pain

  • Best average pain

  • Tenderness on palpation

• Functional independence measure

  • Locomotion

• Cardiovascular integrity

  • Blood pressure at rest and after activity

  • Palpation of distal pulses

  • Capillary refill

• Skin integrity

  • Associated skin assessment

    • Edema (linear girth measurements, palpation)

    • Color

    • Temperature

• Neurologic examination

  • Sensation

    • Light touch

    • Pin prick limb sensation

    • 2-point discrimination

  • Lower-extremity deep tendon reflexes

  • Proprioception

  • Kinesthetic awareness

  • Coordination

• Limb strength

  • Manual muscle test (MMT)

    • Anterior tibialis

    • Posterior tibialis

    • Foot intrinsics

INTERVENTION

• 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

FUNCTIONAL GOALS

• The patient will be able to

  • Ambulate pain-free for >30 minutes.

  • Return to high-impact activities such as running, hiking, and dancing.

  • Demonstrate and maintain neutral calcaneal alignment with heel strike through toe-off phases of gait.

  • Stand and walk without limitation due to pain after sitting for >1 hour.

PROGNOSIS

• 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.

REFERENCES

ADDITIONAL REFERENCES

CONDITION/DISORDER SYNONYMS

• Reflex sympathetic dystrophy (RSD)

• Sudeck atrophy

• Reflex neurovascular dystrophy (RND)

• Algoneurodystrophy

• Causalgia

ICD-9-CM CODES

• 337.21 Reflex sympathetic dystrophy of the upper limb

• 337.22 Reflex sympathetic dystrophy of the lower limb

ICD-10-CM CODES

• G90.519 Complex regional pain syndrome I of unspecifiedupper limb

• G90.529 Complex regional pain syndrome I of unspecifiedlower limb

PREFERRED PRACTICE PATTERN

• 4E: Impaired Joint Mobility, Motor Function, Muscle Performance, and ROM Associated with Localized Inflammation¹

KEY FEATURES

Description

• 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

• Unknown cause

• Electromyography (EMG)

• Usually occurs near the site of injury

• Three stages³

  • Stage 1 (inflammatory phase): Severe burning, spasm, stiffness, skin changes, nonfocal pain, decreased ROM

  • Stage 2 (vasomotor phase): Symptoms of stage 1, plus muscle atrophy, osteoporosis, thickening of the dermis, cool skin temperature

  • Stage 3 (end stage): Symptoms of stages 1 and 2, plus irreversible changes in skin and bones, flexor tendon contracture, atrophic stage

General Considerations

• Fatigue, swelling, pain, and sensory changes cancause disability

• Deregulation of the autonomic system

Demographics

• Usually following injury or surgery

• Three times more likely in females thanin males⁴

CLINICAL FINDINGS

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

• Erythromelalgia

• Myasthenia gravis

• Chronic fatigue syndrome

• Hypothyroidism

• Lyme disease

• Fibromyalgia

• Peripheral nerve injury

• Systemic lupus erythematosus

• Rheumatoid arthritis

• Polymyalgia rheumatica

• Depression

• Chronic neck and back pain

MEANS OF CONFIRMATION OR DIAGNOSIS

Imaging

• X-ray⁵

• Thermography

• MRI⁵

Diagnostic Procedures

• Electromyography (EMG)

• Widespread Pain Index (WPI)

• Symptom severity score

• Sympathetic block

• Skin blood-flow test

FINDINGS AND INTERPRETATION

• X-ray and MRI negative⁵

• Laboratory tests negative

TREATMENT

Medication

• Sympathetic block

• Cortisone

IMPAIRMENTS

• 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

TESTS AND MEASURES

• 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)

INTERVENTION

• 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

FUNCTIONAL GOALS

• 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.

PROGNOSIS

• 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

• For additional information, please see case 5-5 in Chapter 5 of Therapeutic Modalities in Rehabilitation, 4e, at www.AccessPhysiotherapy.com.⁶

REFERENCES

ADDITIONAL REFERENCES

CONDITION/DISORDER SYNONYMS

• EDS

• Cutis hyperelastica

ICD-9-CM CODE

• 756.83 Ehlers–Danlos syndrome

ICD-10-CM CODE

• Q79.6 Ehlers–Danlos syndrome

PREFERRED PRACTICE PATTERN

• 5F: Impaired Peripheral Nerve Integrity and Muscle Performance Associated with Peripheral Nerve Injury¹

KEY FEATURES

Description

• Group of inherited disorders involving the connective tissue collagen^2,3

• Major manifestations include²

  • Classical: most common form

    • Autosomal dominant heritability

    • Hyperextensible skin with atrophic scars

    • Easy bruising

    • Friability of tissues, which can result in

      • Hiatal hernia

      • Anal prolapse

      • Bleeding and poor wound-healing,

    • 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

    • Autosomal dominant heritability

    • Can lead to organ or arterial rupture

    • Thin, translucent skin

    • Facial characteristics

      • Large eyes

      • Thin nose

      • Lobe-less ears

      • Short stature

      • Thin scalp hair

  • Kyphoscoliosis

    • Autosomal recessive heritability

    • Scoliosis at birth; progressive throughout life

    • Generalized joint laxity

    • Severe muscle hypotonia at birth

    • Other findings

      • Marfan-like features

      • Microcornea

      • Radiologically considerable osteopenia

  • 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

    • Autosomal recessive heritability

    • Severe skin fragility

    • Sagging, redundant skin

    • Substantial bruising

    • Wound healing not impaired

    • Scars not atrophic

Essentials of Diagnosis

• Characterized by joint hypermobility, skin extensibility and tissue fragility²

• Six major types, classified according symptom manifestations and family history²

  • Clinical evaluation and family history to identify

    • Hypermobile type

    • Joint hypermobility confirmed by a score of five or higher on the nine-point Beighton Scale

  • Skin biopsy to identify the following types

    • Vascular

    • Arthrochalasia

    • Dermatosparaxis

  • Urine test to identify

    • Kyphoscoliosis type

General Considerations

• Hypermobile type is least severe, leads primarily to musculoskeletal complications

Demographics

• Females seek more medical care related to pain and joint complications than males

• Easy bruising may be the primary presenting symptom in early childhood

CLINICAL FINDINGS

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

• Bruising

  • Child abuse should be considered

• Joint laxity is a non-specific manifestation of other diseases and syndromes

• Other diseases and syndromes with characteristic features or involvement of systems other than the joints and skin include

  • Marfan syndrome

  • Loeys–Dietz syndrome

  • Stickler syndrome

  • Williams syndrome

  • Fragile X syndrome (FXS)

  • Achondroplasia and hypochondroplasia

  • Osteogenesis imperfecta (OI)

  • Aneuploidies, such as Down, Turner, Klinefelter syndromes

MEANS OF CONFIRMATION OR DIAGNOSIS

Imaging

• Mitral valve prolapse (MVP) and proximal aortic dilatation diagnosed by echocardiography,⁶ CT or MRI^7,8

• Joint pain

  • Skeletal radiographs may be normal

• Dual-energy X-ray absorptiometry (DEXA)⁸

  • Every two years if bone loss confirmed

• Holter monitoring for cardiovascular: A utonomic dysfunction

Diagnostic Procedures

• Thorough history and physical examination

  • Musculoskeletal

  • Cardiovascular

  • Integumentary

  • Gastrointestinal

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

IMPAIRMENTS

• Joint hypermobility

• Impaired mobility

• Pain

• Psychosocial

TESTS AND MEASURES

• Skin hyperextensibility

  • Test at neutral site, such as volar surface of forearm

  • Measured by pulling up the skin until resistance felt

  • Difficult to assess in young children because abundance of subcutaneous fat

• Joint hypermobility assessed using the Beighton Scale

INTERVENTION

• 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

    • Wheelchairs, scooters

  • Sleeping-surface assistive devices

    • Specialized mattress

  • 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

  • Low-resistance exercise to increase muscle tone and joint stability

    • Walking, bicycling, swimming, range of motion

    • Progress by increasing repetitions, frequency, duration(not resistance)

  • Assistive devices for hand or finger strain

    • Writing and feeding utensils

• Prevention of secondary complications

  • Maximize bone density

    • Calcium

    • Vitamin D

    • Low impact weight-bearing exercises

FUNCTIONAL GOALS

• 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.

PROGNOSIS

• First-degree relatives are at 50% risk of having autosomal dominant types.

• Prognosis depends on type.

• Symptoms vary in severity.

REFERENCES