CTS

C5 to T1 spinal nerve roots and exits the brachial plexus through the lower trunk. Usually diagnosed as
carpal tunnel syndrome (CTS) = most common entrapment neuropathies

Motor = Thenar contraction with opposition

Sensory = Index finger sensation

List 3 physical findings of carpal tunnel syndrome. What are 6 risk factors?

Motor dysfunction = median intrinsic involvement = Test the LOAF muscles: “lumbricals ( flexion of the
metacarpophalangeal joints) and subserve thumb opposition, abduction, and flexion, known as the LOAF
muscles.”

*The most sensitive finding is abnormal sensation of the distal palmar tip of the index finger* Physical
exam (classically taught but not satisfactory sensitive or specific):

1. Tinel’s sign (percussion of the median nerve at the wrist)

2. Phalen’s sign (maximal palmar extension at the wrist) have been classically taught as provocative tests
to reproduce the sensory symptoms of CTS

3. Dropping of objects is indicative of severe CTS!!!

4. The best way to examine patients for sensory findings = touch the distal palmar tips very lightly, asking
the patient whether the sensation feels “abnormal.”

Conditions associated with Carpal Tunnel Syndrome:

• Acromegaly

• Amyloid

• Diabetes mellitus

• Hypothyroidism

• Obesity

• Pregnancy

• Renal failure

• Rheumatoid arthritis

What are the findings of a common peroneal mononeuropathy?

Anatomy = continuation of one trunk of the sciatic nerve. Most vulnerable at the fibular neck

anatomical diagram of the Sciatic and Common Peroneal nerves and their major branches

Motor: Ankle Dorsiflexion, foot eversion

Sensory: (superficial peroneal = lateral dorsal foot, deep peroneal = Dorsal 1st webspace)

O/E

❏ Foot drop

❏ Weak foot eversion

❏ BUT INVERSION SHOULD BE INTACT, if not, think about sciatic mononeuropathy

List 3 causes of a mononeuropathy multiplex

Mononeuropathy multiplex etiologies:

• Vasculitis o Systemic vasculitis § Polyarteritis nodosa § Rheumatoid arthritis § Systemic lupus

erythematosus § Sjörgen’s syndrome (keratoconjunctivitis sicca) o Nonsystemic vasculitis
• Diabetes mellitus

• Neoplastic o Paraneoplastic o Direct infiltration

• Infectious o Lyme disease o HIV infection

• Sarcoid

• Toxic (lead)

• Transiet (polycythemia vera)

• Cryoglobulinemia (hepatitis C)

Common Peroneal Compression

 New Meditators or New to Yoga

 “lotus position”

 Natural Childbirth

 Time spent squatting

 Holding knees (wrist can compress at fibular head)

 Idiopathic

Common Peroneal Compression

 Third most common compression neuropathy

 Etiology :

 Leg hooked over rail (bedridden, comatose, post operative

 Strawberry Pickers palsy

 Time spent in squatting position

 Ankle Sprains (always check fibular head)

Anterior Tarsal Tunnel Syndrome

 You further localize the compression and the nerve by dorsiflexing the foot and then asking her to
dorsiflex her big toe. Attempting to do so exacerbates the pain.

 Her history is positive for pain at night, which has been waking her from sleep more frequently
recently.

The Problem: Compression of the nerve at the inferior flexor retinaculum

-injury
-talonavicular dysfunction

-prolonged plantar flexion

-compression from shoes shoe straps shoes tied too tight

Treatment

 Remove compressive forces

 Myofascial release of inferior flexor retinaculum

 Release talonavicular joint – Traction tug

 Hiss whip for navicular, cuneiforms, 1st – 2nd metatarsal

Tarsal Tunnel Syndrome (NOT anterior tarsal syndrome)

 Difficult Diagnosis

 Pain on plantar surface of the foot

 Not very specific

 Does not affect large foot muscles

 Difficult to test toe intrinsics…

 Extrinsics compensate very well

 May be described as burning, itching, tightness, numbness.

 Gait seldom affected

Etiology

 Trauma to medial malleolus – MVA

 Congenital

 Autoimmune

 RA, Ankylosing spondylitis

 Diabetes

 Tumors

 Lifestyle (long periods of standing…)

Treatment

 Tibial ligaments/fascia

 May be posterior to normal position

 Talo-calcaneus tx

 Stretch the ligaments

 Roof of the „tunnel‟

 Talonavicular