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 LODCTRRAPPA
A:

L: R side thumb, index and middle finger pain

O: while at work, acute onset
D: 2/7 ago
C: intermittent
T: Pain described as “pins and needles” VAS 4/10. Wakes at night with 8/10 pain and
paresthesia.
R: nil
R: hanging hands of side of bed or shaking them helps the night pain.
A: at night and with computer work
P: nil
P: nil
A: 500g paracetamol, no relief.

• Identify the components of GORPOMNICS

A:
Physical exam:
G: nad
O: good posture
R: +ve R cervical rot and (AROM and PROM).
P: nad
O: Tinel’s sign over volar wrist = +ive. Phalen’s test = +ve, minor muscle atrophy at base of
thumb.
M: nad
SMR: nad
Imaging: ?
C: n/a
S: nil

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

A:

Further investigation is required with orthopaedic tests to guarantee an accurate diagnosis

(i.e. rule out differentials/potential conditions) of CTS. No imaging, medical tests or systems
checks are required at this point, as all red and yellow flags have been ruled out.
EXERCISE 2
Short Case Histories:

39 year old male presents with a burning sensa:on at the bo;om 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 be;er 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 :bia when he was 25 yo. On examina:on on the right, the foot is normal colour.
Pulses are strong. There is decreased sensa:on 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+. Examina:on of the leP foot is normal
What is your most likely diagnosis?

A: Medial plantar nerve 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 dura:on, 5-7/10 on NRS (numeric ra:ng). She cannot iden:fy 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 men:oned. The pain is worse when she’s walking and si`ng down
helps to relieve the pain. She is unable to take medica:ons at this :me. She has seen another
Chiropractor who adjusted her lower back and SI joint a few :mes but this did not help. On
examina:on, gait is normal, lumbar spine and hip ROM is normal. Significant discomfort is elicited on
palpa:on below the greater trochanter. Orthopaedic tes:ng is generally unrewarding however when
you tap or press firmly over the inguinal region she winces. LE neurologic evalua:on is normal. She is
otherwise fit and healthy.

What is your most likely diagnosis?

A: Meuralgia Paraesthetica

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.

A:

Name of entrapment Nerve/branch Symtoms Tests used to ID

involved entrapment
Pronator teres Median nerve Aching pain in proximal Muscle testing of
syndrome forearm, weakness and pronator teres
clumsiness of hand, no
night pain.
Name of entrapment Nerve/branch Symtoms Tests used to ID
involved entrapment
PIN syndrome Radial nerve (C7-8) Sensory loss of region, Extensor muscles
wrist drop, progressive present with atrophy,
paralysis. Supination resisted supination
aggravates. increases pain
Cubital tunnel Ulna nerve Tingling sensation along Elbow ROM limited,
syndrome 4-5th fingers. Tinel’s sign, Elbow
flexion test and
Froment’s sign
Carpal tunnel Median nerve Intermittent numbness of Tinel’s sign, Roo’s test.
syndrome thumb, index and radial Thenar muscle
half of fingers, night pain weakness/atrophy
common. observed.
Sciatic nerve Sciatic nerve Constant local symptoms Bonnet’s test,
entrapment w/radicular pain and/or Bowstring test, SLR test
sensory changes down and variations.
thigh, even as far down as
peroneal/tibial n.
pathway.
Tarsal tunnel Tibial nerve Tinnitus- type pain and/or Tinel’s sign in region of
syndrome sensory disturbance along tarsal tunnel.
plantar aspect of foot.
Intractable heel pain may
also present.
Common fibular Common fibular Pain initially in Tinel’s sign, inability to
nerve entrapment nerve compressed region before dorsiflex foot is
spreading distally to foot. observed.
Foot drop and paraesthsia
also present.
Medial plantar nerve Medial plantar nerve Aching, shooting burning Tinel’s sign.
syndrome pain in medial aspect of
arch, typically during
running.