EXERCISE 1

History:
Mary-Jane, 45 year old nurse, presents with intermittent tingling and pain the thumb,
index and middle finger of her right hand for the last 2 days that started while at work.
The pain is described as 4/10 ‘pins and needles’. The pain is made worse with
computer work and is relieved by shaking her hands. She has been awaken by ‘8/10
pain, tingling and numbness’ in the middle of the night for the last 2 nights and
hanging her hand over the side of the bed or getting up to shake her hands helps to
alleviate it enough to get back to sleep. She has been taking 500g paracetomol with
no symptom relief. She denies any trauma or recent fall.
No fever, fatigue, weight gain/loss, fever, chills or sweating
No headaches, dizziness, nausea, visual changes, hearing loss
No recent illnesses
Unremarkable family history
Unremarkable systems - no GI/ GU/ CardioRespiratory complaints
No rash or other integumentary changes
No history of allergies
Social history good
Exam:
Good posture, no gait abnormality, adequate nutritional state, adequate emotional
state, good communication, no acute distress
Neck – no masses, no lymphadenopathy, thyroid good, no visual deformity, mild
restriction on right active and passive rotation; orthopaedic exam normal; UE DTRs
2+ and muscle strength normal, 5+
Shoulder exam – unremarkable
UE – Positive Tinnel’s sign over the volar wrist, positive Phalen’s test; minor muscle
atrophy at the base of the thumb; muscle strength normal. No swelling or tenderness
to joints

Based on the above history:

• Identify the components of LODCTRAPPA

*Location –sensory distribution thumb and index and middle finger = median nerve
distribution

*Onset -last 2 days

*Duration- middle of the night , for last 2 nights ,

*Course-last 2 nights 8/10 pain at night 4/10 pins and needles at work

*Type of pain – pins and needles (neuropathy/pins and needles)

*Radiation of pain –thumb and forefinger and middle finger

*Relieving factors? – shaking the hand

*Aggravating factors ? – work occupation , sleep posture ?

*Previous episodes? –No

 *Previous treatment ?- No

*Associated signs & symptoms ? just the pins and needles neuropathay associated
with carpal tunnel syndrome

• Identify the components of GORPOMNICS

*Gait –no gait abnormaily

*observation-unremarkable
*ROM-unremarkable
*Palpation- +ve Tinnels sign, Phalens Test
*orthopaedic tests ?- Phalens Test
*motor tests ?- muscle strength normal
*Neurological Tests ? – 2 point discrimination test ?
*investigations?- LODCTRRAPPA
*Chiro tests ?- +ve Tinnels sign, Phalens Test
*Systematic testing ? +ve Tinnels sign, Phalens Test

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

possible the 2 point discrimation test

Orthopedic Conditions Vizinial pg174

EXERCISE 2

Short Case Histories:

39 year old male presents with a burning sensation at the bottom of his right foot. This has been
present for two weeks since he has started jogging to get fit again. He doesn’t feel like he’s
overdoing the training and can’t figure out why his foot hurts. Nothing makes it better or worse. He
has no history of system disorders or illness. He is generally well. Past history is only significant for
fracture of the proximal tibia when he was 25 yo. On examination on the right, the foot is normal
colour. Pulses are strong. There is decreased sensation at the posterior lateral ankle and on the
plantar aspect of his foot. He is unable to flex his toes. Ankle jerk is normal. Eversion is normal,
inversion is 3+. Examination of the left foot is normal

LODCTRRAPPA
Location-burning sensation on bottom of foot
Onset- present for 2 weeks upon starting jogging /previous fracture of Proximal Tibia
Duration-present for 2 weeks
Course-2 weeks , inversion +3 Eversion normal
Type of pain –burning neurological
Radiation of pain ?-cutaneous on bottom of right foot
Relieving factors ?-

What is your most likely diagnosis?

Likely diagnosis:
a fracture of the proximal tibia may have created a slight over-supernation(inversion) of the ankle
joint which could lead yo compression factors on the lateral and medial plantar Nerve .
which travels medially across the tibeo-tarsal joint and the tarso-calcaneous joint /articulations .
having a proximal fracture of the tibia bone may lead to the inversion problem.
Conclusion:
Medial/lateral Plantar nerve syndrome (Joggers foot)
Unable to flex toes is indicative of Tibia nerve (motor nerve to fex-digitorum long /halluces long)
also reinforces this diagnosis as Tibial nerve is the parent Nerve of the lateral and medial plantar
Nerve and the peripheral cutaneous nerve pattern of bottom of foot
GH

29 year old female; 28 weeks pregnant, presents to your office with a burning type pain over her
lateral upper leg of 4 weeks duration, 5-7/10 on NRS (numeric rating). She cannot identify a specific
onset, it came on gradually. She has aching in her low back and SI joint but that comes and goes. No
pain in her leg except the area mentioned. The pain is worse when she’s walking and sitting down
helps to relieve the pain. She is unable to take medications at this time. She has seen another
Chiropractor who adjusted her lower back and SI joint a few times but this did not help. On
examination, gait is normal, lumbar spine and hip ROM is normal. Significant discomfort is elicited on
palpation below the greater trochanter. Orthopaedic testing is generally unrewarding however when
you tap or press firmly over the inguinal region she winces. LE neurologic evaluation is normal. She is
otherwise fit and healthy.
LODCTRRAPPA
Location –burning pain over upper lateral leg (patient pregnant)
Onsett-4 weeks ago
Duration- gradual, uncertain exactly when
Course-4 weeks 5-7/10 NRS pain level, Gradual onsett
Type of pain- burning , localized
Radiating ?- no burning & localised
Relieving factors ?- sitting down
Aggravating factors ?- walking
Previous episodes ?- no
previous treatment ?- chiro did ajustments SIJ and lower back no relief
Associated signs & symptoms? –burning pain over lateral upper leg 4 weeks duration

What is your most likely diagnosis?

My diagnosis:
* the peripheral nerve cutaneous distribution is = lateral femoral cutaneous nerve
*Detmatomes = L2 nerve roots but no radiating neuropathy more localised
*fits the profile of Meralgia Paraesthesia this may be caused by pregnancy and the extra
compression forces of carrying the baby causes over the inguinal ligament area thus compressing
the genitofemoral Nerve that travels under the inguinal ligament indicating the predisposing factors
for Meralgia paresthetica
GH

EXERCISE 3

Develop a table that includes the common entrapment syndromes of the UE and similar table that
includes the common entrapments of the LE (lower extremity). Include the following components.

Name of the entrapment

Nerve or branch entrapped

Common and any outstanding symptoms

Test used for that entrapment

foot note from Graham is the below table simply extracts from the lecture notes or is there a text
reference with this compiled as all I tried to do was take notes off lecture notes .GH

Entrapment Nerve or branch Common and outstanding Tests used

symptoms
*Supracondylar Median Nerve(C6- *Aching pain in proximal *Pinch Test (OK sign)
syndrome T1) forearm weakness of hand *Pronator quadratus
*numbness /parenthesis muscle test
*1)Pronator Teres follow median nerve
Syndrome distribution

*2)anterior *night pain NOT COMMON

Interosseous N *sensory similar to carpal
Syndrome tunnel
*causes” Ape hand”
*3)Carpal tunnel Muscle manual
Viziniak pg 404

*Posterior Radial Nerve(C5-8) *chronic compression causes

Interosseous Nerve forearm extensor
(PIN) compartment atrophy
*finger metacarpal
*Triangular Interval extension weakness
(poorly adjusted *resisted supination
crutches, arm over increased > pain
back of chair, leads to Wrist drop
Saturday night palsy) Muscle manual
Viziniak pg 402
*Radial Groove

*elbow/Forarm

Cubital Tunnel Ulnar Nerve (C7-t1) *ulnar nerve obstructed Froments (card test)
along the path of cubital + if patient can grip
*Elbow (cubital tunnel card without thumb
tunnel) *common impingement in adduction
the elbow area
8compression of nerve leads
*Wrist to tingling sensations of 4th
(Guyson)medial to and 5th fingers
carpal tunnel *sleeping on arm
repeated impact *pressing elbows on chairs
from riding bicycle *truckers elbow
without gloves Leads to Claw hand
deformity or bishops /popes
hand deformity
Muscle manual
Viziniak pg 405

Lower limb
*ilioinguinal (L1-2 nerve roots) *chronic lower adominal pain *release fascial
neuralgia 8burning shooting pain restrictions
*tenderness near *Injections of
ASIS anaesthetics
*Atrophy of muscles supplied
Oburatator (L2-l4) anterior *uncommon cause of medial *Aggravated by
neuropathy divisions within the thigh pain extension and
Psoas to lower *occurs after trauma abduction
medial boarder . *no significant motor
deficits
*treat by stretching
pectineus
muscle(useful to
dignosing)
plus treat similar to
other entrapment
syndromes
*Genitofemoral Genito femoral N *Neuropathic groin pain *avoid wearing tight
Nerve Entrapment Anterior aspect of thigh jeans etc
*may be scrotal or labial pain *mobilisation of
*Meralingia *Increased by thigh tissue in the
Paresthetica extension entrapment area
*decreased perception of may relieve
pin-prick & touch symptoms
Tibial N entrapment L4-S3 8sensory changes to bottom
of foot
*loss of plantar flexion
*loss of toe flexion
*weak inverters
Common peroneal Peroneal N External: Tinels signh
(fibular entrapment) *contusion
*tight plaster casts *cross
legs
*double crush (L5 ?)
* functional change
Internal :
*bony exostosis
*osteophytes
*ganglions
*synovial cysts
*diabetes
Pain in the compressed
region >radiate to
thigh>sensory abnormalities
>Dorsiflexion >weakness foot
eversion >increased pain
plantar flex .pressure over
tunnel will increase pain
Superficial Peroneal * Pain with > inversion
Nerve Superficial peroneal *sensory loss at lateral lower
nerve ½ of Calf
*Sensation from *motor loss
lower third of calf
Deep peroneal Nerve *trauma
Tight Shoelaces
*ganglion
*pes cavus
Sural Nerve • The sural nerve is a
Entrapment cutaneous nerve
formed by union of
the medial sural
cutaneous nerve and
the peroneal
communicating
brance of the lateral
sural cutaneous
nerve at the
midposterior calf. It
then travels just
lateral to the Achilles
tendon and then
behind the lateral
malleolus supplying
sensation via
branches to the
posterolateral aspect
of the lower third of
the leg and lateral
border of the foot.
The nerve continues
along the lateral side
of the foot extending
to the 5th toe as the
lateral dorsal
cutaneous nerve.
• Rare
• Cases have been
reported due to tight
boots which come to
midcalf level such as
in ice-hockey and
some combat boots.
Cases have also been
reported in athletes
where the
entrapment occurs in
the superficial sural
aponeurosis.
• Conservative
management and
surgical management
options are offered
depending on the
cause of the
condition.

Saphenous nerve • Saphenous neuralgia

 is an uncommon
cause of medial calf
pain.
• Often medial pseudo
claudication-type
pain that may
confuse and lead the
clinician to suspect
lumbar spinal
stenosis.
• Pain that radiates
into the medial calf
to the medial
malleolus.
• May be paraesthetic
or burning in
character. The
intensity is moderate
to severe.
• There is no motor
deficit with pure
saphenous nerve
impingement.
• Patients may
complain of a
sunburned feeling
over the distribution
of the nerve.
Treatment is similar to other
tunnel syndromes with an
emphasis on neurodynamic
mobilisation
Tarsal tunnel • Tenosynovitis,
syndrome usually of the tibialis
posterior tendon is a
common cause of
entrapment. This
may be precipitated
by trauma, overuse,
or activities which
repeatedly load in
dorsiflexion, e.g.
climbing ladders. It is
also associated with
rheumatoid arthritis.
Clinical features:
• burning, throbbing
pain on the sole of
the foot
• aggravated by
prolonged
 standing/activity
• pain may radiate up
the leg
• tenderness over the
tarsal tunnel
(posterior to the
distal tip of the
medial malleolus)
• pain reproduced by
overpressure
• positive Tinel’s sign
• sensory changes on
the sole of the foot
• Diagnosis is
established by nerve
conduction studies.
May be mistaken for
plantar fasciitis. This
may be an
overlooked cause of
chronic,
nonresponsive
plantar fascia pain.

Medial plantar nerve Clinical

syndrome • Pain (burning,
(Joggers foot) shooting, sharp)
and/or dysaesthesia,
paraesthesia along
medial arch of the
foot sometimes to
plantar toes in
distribution of medial
plantar nerve
• Occurs during
running – exercise
induced
• Onset of pain often
occurs with use of
new arch support or
new shoes without
changes in exercise
regime
• Pain will often
worsen with high
arch supports –
especially rigid
orthoses
Examination findings:
• Tenderness along
medial plantar aspect
 of medial arch in the
region of the
navicular tuberosity
• Positive Tinel’s sign
just behind the
navicular tuberosity
± paraesthesia
• Neurodynamic signs
–
dorsiflexion/eversion
/SLR (structural
differentiation)
• There may be pain
with resisted great
toe abduction
• Neither flexion of the
toes against
resistance nor
passive toe
hyperextension
should increase the
pain – differentiate
from flexor
tenosynovitis and
plantar fascitis.
• No weakness
detected easily as
long flexors of foot
and toes are
preserved