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 (deep tendon reflexes) 2+ and

muscle strength normal, 5+

Shoulder exam – unremarkable
UE (upper extremity) – 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 LODCTRRAPPA

- Location: pain the thumb, index and middle finger of her right hand
- Onsite: for the last 2 days that started while at work
- Duration: for the last 2 days
- Course: made worse with computer work
- Type: intermittent tingling
- Radiation: NA
- Relieving: is relieved by shaking her hands and getting up to shake her hands helps to alleviate it enough
to get back to sleep
 - Aggravating: The pain is made worse with computer work; 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
- Previous episodes: She denies any trauma or recent fall
- Previous treatment: She has been taking 500g paracetomol with no symptom relief

• Identify the components of GORPOMNICS

- Gait: Normal

- Observation: Good posture, adequate nutritional state, adequate emotional state, good
communication, no acute distress,
- Range of Motion (Active/Passive/Resisted): mild restriction on right active and passive rotation

- Palpation (static and motion): Neck – no masses, no lymphadenopathy, thyroid good, no visual

deformity

- Orthopaedic testing: orthopaedic exam normal,

- Muscle testing: muscle strength normal, 5+, minor muscle atrophy at the base of the thumb; muscle
strength normal. No swelling or tenderness to joints
- Neurological testing: NA

- Investigation/imaging: NA

- Chiropractic testing: Positive Tinnel’s sign over the volar wrist, positive Phalen’s test

- S- System assessment: Normal

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

- As a note, a patient with true carpal tunnel syndrome (entrapment of the median nerve within the
carpal tunnel) will NOT have any sensory loss over the thenar eminence.

- If there is no any sensory loss, then it will be chance of Carpal tunnel syndrome
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

What is your most likely diagnosis?

- Tarsal tunnel syndrome and Tibial nerve entrapment (loss of toe flexion, loss of plantar flexion)
- Tarsal tunnel syndrome is a condition in which the tibial nerve is being compressed. This is the
nerve in the ankle that allows feeling and movement to parts of the foot.
- It can lead to numbness, tingling, weakness, or muscle damage mainly in the bottom of the foot.

Causes

- Tarsal tunnel syndrome is an unusual form of peripheral neuropathy. It occurs when there is damage to
the tibial nerve. As the patient had history of fracture of the proximal tibia when he was 25 yo.

- The area in the foot where the nerve enters the back of the ankle is called the tarsal tunnel. This tunnel
is normally narrow. When the tibial nerve is compressed, it results in the symptoms of tarsal tunnel
syndrome.
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 Scale). 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.

What is your most likely diagnosis?

Meralgia paresthetica (pregnancy, decrease pain on sitting, increased pain on hip extension and prolonged walking
or standing)

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.

The Common entrapment syndromes of the Upper Extremity

Name of the Nerve or branch Common and any outstanding Test used for that entrapment
entrapment entrapped symptoms

Supracondylar Median nerve (C6- weakness of the pronator teres Pressure in the ligament of
process syndrome C8,T1) muscle and of those muscles Struthers area leads to motor
affected by the pronator loss
syndrome and sensory loss of the
median nerve. Initially, the
patient complains of pain and
paresthesia in the elbow and
forearm; abnormality of
motor function is secondary
Pronator (Teres) The median nerve Aching pain in the proximal This can be tested for by
syndrome may be entrapped forearm with weakness/ palpating over the area of
between the two clumsiness 軟弱/笨拙 of the hand entrapment and by resisted
heads of the testing of the pronator teres
pronator teres Often begins insidiously. 经常不知 muscle to see if pain and
muscle (originating 不觉地开始 paraesthesia are reproduced.
ulnar coronoid and
Numbness/ paraesthesias
medial epicondyle To test the pronator teres,
follow the median nerve
of humerus) causing have the patient flex the
distribution
Pronator teres elbow to 60° with the forearm
syndrome. pronated then the examiner
Night pain is NOT common
apply a force against the distal
forearm into supination
As sensory findings are similar to
which the patient resists.
carpal tunnel syndrome, the two
conditions may be confused.

Anterior Median nerve Because there are no sensory Ask the patient to place the
Interosseous Nerve branch fibres in the nerve, the patient tips of the index finger and
(AIN) Syndrom has no sensory complaints and thumb together. If there is a
experiences only motor problem with the anterior
weakness interosseous nerve then there
is a loss of distal flexion of the
dull, aching pain in the volar thumb and index finger giving
aspect 掌側 of the proximal a characteristic ‘pinch sign’.
forearm.
The pronator quadratus is
tested with the patient’s
elbow fully flexed and the
forearm pronated.

The examiner then applies a

force against the lower
forearm into supination which
the patient resists.
 With an anterior interosseous
nerve lesion there will be
decreased resistance.
Posterior Radial nerve branch Progressive paralysis of the Inspection chronic
Interosseous Nerve The most common posterior interosseous nerve compression may cause
Syndrome entrapment forearm extensor
neuropathy of the Sensory loss to the region of compartment muscle atrophy
radial nerve or its superficial radial nerve supply is
branches involves seen along with wrist drop Finger metacarpal extension
the posterior weakness
interosseous nerve Symptoms insidious onset, may
as it passes between go undiagnosed Wrist extension weakness
the two heads of the inability to extend wrist in
supinator muscle Pain in the forearm and wrist – neutral or ulnar deviation
under a thick location depends on site of PIN
ligamentous band compression. The wrist will extend with
known as the arcade radial deviation due to intact
of Frohse (also Pain just distal to the lateral ECRL (the extensor carpi
called the supinator epicondyle of the elbow may be radialis longus) (radial n.) and
arch), caused by compression at the absent ECU (The extensor
arcade of Frohse carpi ulnaris) (PIN).

Weakness with finger, wrist and resisted supination will

thumb movements increase pain symptoms

Radial tunnel for compression of pain in the dorsal aspect of the A positive "middle finger
syndrome the posterior upper forearm test", where resisted middle
interosseous nerve finger extension produces
at the lateral Any weakness described is pain
intermuscular secondary to the pain.
septum of arm,
while "supinator Tenderness to palpation occurs
syndrome or PIN over the area of the radial neck
Syndrome" is used
 for compression at
the arcade of Frohse

Cubital tunnel Ulnar nerve to a tingling sensation along the Tinnel’s sign at the cubital
syndrome 4th and 5th fingers of the hand. tunnel (Sensitivity: 0.70,
Specificity: 0.98)

Elbow flexion test (Sensitivity:

0.75, Specificity: 0.99)

Pressure provocative test

(Sensitivity: 0.89, Specificity:
0.98)

Card test - Froment’s sign.

Carpal Tunnel Median nerve intermittent numbness of the A combination of described

Syndrome thumb, index, long and radial symptoms, clinical findings,
half of the ring finger. and electrophysiological
testing is used by a majority of
specialists
Guyon’s Canal Ulnar nerve Muscular atrophy direct pressure over the
syndrome canal may reproduce or
caused by direct Muscle sparing of the thenar exacerbate the symptoms
pressure on a group (Guyon canal compression test
handlebar (ie. Bicyle )
handlebar, weight Sensory loss and pain
lifting, construction
equipment) and
therefore, is
sometimes referred
to as “handle bar
palsy”.
 The Common entrapment syndromes of the Lower Extremity

Name of the Nerve or branch Common and any outstanding Test used for that entrapment
entrapment entrapped symptoms

Piriformis syndrome Sciatic nerve Deep aching pain in sacral or the piriformis muscle is
entrapment gluteal region remains the most tender, and hip abduction and
common symptom with lateral rotation are weak.
posterior thigh pain Bonne’s Test

Pain increases with sitting and

walking, decreases on lying
supine

Pain and paraesthesia can

radiate along tibial and/or
peroneal nerve distributions

Possible trophic changes in

territory of affected nerve

Ilioinguinal Ilioinguianl nerve Chronic lower abdominal pain Tenderness may be localised
neruralgia (L1-L2 nerve root) near the ASIS where the nerve
(Sensory Only) Burning or shooting pain in the pierces the fascia.
base of the penis, scrotum (or
labium major) and part of the Atrophy of muscles supplied
medial thigh. (internal oblique &
transversus abdominus)
Light touch sensation in the
inguinal area may be altered and
pain may be exacerbated by
hyperextension of the hip
Obturator Anterior divisions of Altered sensation in the medial Stretching the pectineus
Neuropathy L2-L4 within the thigh that may be paraesthetic muscle can be useful in
psoas to emerge at or burning diagnosing obturator nerve
the lower medial entrapment.
border of the psoas May include moderate to severe
at the pelvic brim pain that begins insidiously at
and passes inferior the adductor origin on the pubic
through the bone and worsens with exercise
obturator foramen (medial thigh or groin pain)

Pain may extend to the

knee.(NOT pass the knee)

Aggravated by extension and

lateral leg movements
(abduction)

Genitofemoral Genitofemoral nerve Chronic neuropathic groin pain Inspection chronic

nerve entrapment entrapment
Pain and/or numbness in an
elliptical area on the anterior
aspect of the thigh immediately
below the middle of the inguinal
ligament.
compression may cause
forearm extensor
compartment muscle atrophy
Finger metacarpal extension
weakness
 May present as scrotal pain or
labial pain
Increased by thigh extension
Decreased perception of
pinprick and touch.
Meralgia Entrapment of the Middle aged males
Paresthetica lateral femoral
cutaneous nerve Unpleasant paraesthesia
(L2,L3) (or lateral (burning, tingling, stinging) in
cutaneous nerve of the nerve distribution
thigh) by the
inguinal ligament Hypersensitivity to touch (e.g.
close to where it clothing)
attaches to the ASIS.
Decreased pain on sitting
increased pain on hip extension
and prolonged walking or
standing
Tibial nerve The tibial nerve is a Sensory changes in the bottom
entrapment terminal branch of of the foot and toes - burning
the sciatic nerve sensation, numbness, tingling, or
formed by branches other abnormal sensation, or
from L4-S3. pain.
Wrist extension weakness
inability to extend wrist in
neutral or ulnar deviation
The wrist will extend with
radial deviation due to intact
ECRL (the extensor carpi
radialis longus) (radial n.) and
absent ECU (The extensor
carpi ulnaris) (PIN).
resisted supination will
increase pain symptoms
Reproduced with Tinel’s sign
at site of entrapment (1 cm
medial and inferior to the
ASIS helps confirm the
diagnosis)
Loss of plantar flexion
Loss of toe flexion
Weak inverters (tibialis
anterior can still invert some)
Common peroneal Common peroneal Pain usually appears initially in Tinel’s sign or overpressure at
(figular) nerve nerve compression the compressed region before the fibula head may increase
entrapment spreading distally into the paraesthesia, aiding diagnosis
common peronal nerve’s
One of the most cutaneous distributions
Dorsiflexion paresis and foot
commonly
drop (in severe cases, look for
encountered lower Possible radiation of pain into
atrophy of anterior tibial
extremity mono- the thigh (if pain is seen in
muscles)
neuropathies. buttock or posterior thigh, think
of a more proximal cause) Weakness of foot eversion

Sensory abnormalities along the Increased pain with plantar

anterolateral leg below the knee flexion and inversion of foot
and along the top of the foot if
both superfical and deep Pressure over tunnel will
increase pain
branches involved

Superficial peroneal Superficial peroneal Pain increased with inversion passive inversion and plantar
nerve nerve flexion while applying
pressure over the point where
 Sensory loss at lateral lower half the nerve pierces the deep
of the calf and dorsum of the fascia reproduces the
foot symptoms

Motor loss, with higher lesions

only, giving weakness of foot
eversion and ankle stability

Deep Peroneal Causes of injury to pain is often aggravated by motor loss is variable
Nerve the nerve include plantar flexion depending on level of the
anterior sensory loss at the web of the lesion.
compartment great toe
syndrome and May include weak toe
passage under the extensors, weak tibialis
extensor anterior and peroneus tertius
retinaculum in a more proximal lesion
(anterior tarsal (may have foot drop)
tunnel syndrome).
atrophy of the belly of the
extensor digitorum brevis
occurs early and is a useful
sign.

Note – in 72% of people EDB

(The extensor digitorum brevis
muscle) is supplied by the
deep peroneal nerve, 28% by
the superficial peroneal nerve
Sural nerve Sural nerve is a Shooting pain To perform this test, the
entrapment sensory branch of and paresthesia in its sensory patient's leg is grasped by the
the tibial nerve distribution are diagnostic therapist's hands so that the
supplying the skin signs. leg is supported and the foot
on the is held in dorsiflexion and
posterolateral inversion. The leg is then
aspect of the lower passively raised into hip
one third of the leg flexion. This is usually felt in
and the lateral the posterolateral calf and/or
aspect of the foot posterolateral ankle.
Saphenous Saphenous nerve Sunburned feeling over the
neuralgia distribution of the nerve
Pain that radiates into the
medial calf to the medial
malleolus.
May be paraesthetic or burning
in character
Tarsal tunnel entrapment of the Pain or sensory disturbance on
syndrome tibial nerve the plantar aspect of the foot
Patients typically present with
intractable heel pain.
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 in the distribution of the
saphenous nerve, normal
motor function, and
tenderness to palpation over
the entrapment site.
Entrapment site tenderness is
a key feature of saphenous
nerve neuropathy.
Tinel's test, which involves
gently tapping the tibial nerve.
If you experience a tingling
sensation or pain as a result of
that pressure, this indicates
tarsal tunnel syndrome
Positive Tinel’s sign
sensory changes on the
dorsum of the foot
Medial plantar Occurs in the region Pain (burning, shooting, sharp) Tenderness along medial
nerve syndrome of the navicular and/or dysaesthesia, plantar aspect of medial arch
(Jogger’s foot) tuberosity when the paraesthesia along medial arch in the region of the navicular
nerve passes of the foot sometimes to plantar tuberosity
through a tunnel toes in distribution of medial
formed by the plantar nerve Positive Tinel’s sign just
abductor hallicus behind the navicular
muscle and Occurs during running – exercise tuberosity ± paraesthesia
navicular bone induced Neurodynamic signs –
dorsiflexion/eversion/SLR
Onset of pain often occurs with (structural differentiation)
use of new arch support or new
shoes without changes in There may be pain with
exercise regime resisted great toe abduction

Pain will often worsen with high
arch supports – especially rigid
orthoses
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
Morton’s neuroma: Syndrome of Usually, it is the digital If a Morton’s
Interdigital forefoot pain nerve between the third and neuroma is suspected,
Perineural Fibrosis originating from fourth toes pressure palpation should be
entrapment of applied on the plantar aspect
nerves in the Pain, numbness, paraesthesia in avoiding counter pressure
metatarsal tunnels the lateral side of one toe and on the dorsal aspect
medial side of the next
Injury to one of
the digital nerves Pain is usually described as
piercing or like an electric shock

May be aggravated by specific

activities, e.g. skiing after a
predictable length of time

Pain (‘cutting’, ‘electrical’,

‘sharp’) and/or dysaesthesia
over metatarsal heads

Increased pain with walking,

crouching, wearing high heals
(any other activity that causes
toe extension)