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 (eliminating cranial nerve
problems)
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 – to rule out median n. neuropathy in the upper extremity.
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= Thumb, index and middle finger of right hand
Onset= Sudden -acute
Duration= 2 days
Course= Getting worse (constant)
Type of pain= 4/10 pins and needles and pain tingling and numbness at night time
Radiation= No radiation
Relieving factors= Shaking her hands
Aggravating factors= Computer work and hanging her hand over the side of her bed. Worse at
night 8/10 pain
Previous episode= n/a
Previous treatment= 500g paracetamol with no symptom relief
Associated signs and symptoms= Positive Tinnel’s sign over the volar wrist, positive Phalen’s test;
minor muscle atrophy at the base of the thumb

Based on the above history:

• Identify the components of LODCTRAPPA
• Gait= Good posture, no gait abnormality
• Observation= No masses, no lymphadenopathy, thyroid good, no visual deformity,
• Range of motion (active/passive)= Mild restriction on right active and passive rotation
• Palpation (static/ motion)= Minor muscle atrophy at the base of the thumb
• Orthopedic testing= Normal
• Muscle testing= Normal
• Neurological testing= Positive Tinnel’s sign over the volar wrist, positive Phalen’s test
• Investigation/ Imaging= n/a
• Chiropractic testing= n/a
• Systems investigation (cardiovascular, respiration etc)= Unremarkable family history and
unremarkable systems

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

• No further investigation warranted

• No trauma
• Not falls
• No radiation of pain
• Not chronic
• If no response to therapy – maybe MRI to see what’s happening in the carpal tunnel
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

Look at it as a peripheral nerve when no history of LBP.

Because he has started running, likely to be tarsal tunnel because it’s the most common tibial
nerve entrapment

What is your most likely diagnosis?

Tarsal Tunnel – tibial n. entrapment

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.
{INDICATES: it likely coming from the lower back} 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
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.

Upper Limb

Name of the Nerve or branch Common and any outstanding Test used for that entrapment
entrapment entrapped symptoms
Carpal tunnel Median n. Intermittent numbness of the A comb. Of described symptoms,
Syndrome thumb, index, long and radial clinical findings and
half of the ring finger that is electrophysiological testing is used:
so intense it wakes one from  Positive Tinel’s sign
sleep.  Abnormal sensory testing such as
Thenar muscle weakness/ two-point discrimination
atrophy  A predominance of pain rather
than numbness is unlikely to be
CTS
Cubital tunnel Ulnar n. Tingling sensation along the Tinnel’s sign
syndrome 4th and 5th fingers of the hand Elbow flexion test
Pressure provocation test
Card test-Froment’s sign (indicates
paralysis of adductor pollicis)

Pronator (teres) Median n. Aching pain prox. Forearm Palpate over the entrapment area an
Syndrome with weakness/clumsiness of resisted pronator teres m testing to
the hand that follow median see if pain and paraesthesia are
nerve distribution reproduced.
Supinator Posterior Pain in the forearm and wrist Resisted supination increases pain
Syndrome (PIN) interosseous n. and just distal to the lateral symptoms
epicondyle
Weakness with finger, wrist
and thumb movement
(mostly ulnar deviation and
neutral extension)
Sensory loss to the region
sup. To radial n. supply seen
along with wrist drop

Lower Limb
Name of the Nerve or branch Common and any Test used for that entrapment
entrapment entrapped outstanding symptoms
Piriformis Sciatic nerve Deep aching in sacral or Bonnet’s test
Syndrome (L4-S3) gluteal region with posterior
 thigh pain.
(No significant
LBP unless overall Pain increase with sitting and
functional walking, decreases on lying
complaint) supine

Pain and paraesthesia can

radiate along tibial and/or
peroneal nerve distributions

Possible trophic changes in

territory of affected nerve

Pain exacerbated by passive

flexion with adduction and
international rotation or
resisted external rotation.
Ilioinguinal Ilioinguinal Painful sensation in the lower Diagnosis of the Ilioinguinal neuralgia
neuralgia nerve abdomen and groin radiating requires a careful history, physical
to the upper inner leg and to examination, electrophysiological
(L1-L2) the genitals . studies and ultra sound examination.
(sensory only)
Patients complain of pain,
paraesthesia and abnormal
sensation in the area
supplied by the nerve.
Obturator Obturator nerve Altered medial thigh Aggravated by extension and lateral
Neuropathy (L2-L4) sensation – paraesthetic or leg movements (abduction)
burning in character Stretching the pectineus muscle can
(no sig. motor be useful in diagnosing obturator
deficits Insidious moderate – severe nerve entrapment.
associated with pain beginning at adductor
this condition) origin on pubic bone and
worsens with exercise

Pain may extent to the knee

Genitofemoral Genitofemoral Chronic neuropathic groin Pain may be provoked by increased
Nerve n. pain thigh extension.
entrapment Pain and/or numbness in an
elliptical area on the anterior Decrease perception of pinprick and
aspect of the thigh touch.
immediately below the
middle of the inguinal lig.
Scrotal or labial pain

Meralgia Lateral femoral Unpleasant paraesthesia Decreased plain on sitting

Paresthetica cutaneous (burning, tingling, stinging) in Increased pain on hip extension and
nerve the nerve distribution (similar prolonged walking or standing
to the area covered by a Positive Tinel’s sign at site of
 hand placed in the pocket of entrapment (1cm medial and inferior
a pair of trousers). to the ASIS)
Hypersensitivity to touch
Tibial nerve Tibial nerve Sensory changes in the Passive straight leg raise with foot
entrapment bottom of the foot and toes – everted till symptoms are reproduced
(terminal sciatic burning sensation,
n. branch numbness, tingling, or other
formed from L4- abnormal sensation or pain.
S3) Loss of plantar flexion
Loss of toes flexion
Weak inverters (tibialis ant.
Can still invert some)
Common Common 1. Pain usually appears Tinel’s sign or overpressure at the
peroneal (fibular) peroneal initially in compressed fibular head may increase
nerve) (fibular) nerve) region before paraesthesia, adding diagnosis.
entrapment spreading distally into Dorsiflexion paresis and foot drop (in
the common peroneal severe case, look for atrophy of
nerve’s cutaneous anterior tibial muscles)
distributions Weakness of foot eversion
2. Possible radiation of Increased pain with plantar flexion
pain into the thigh and inversion of foot
3. Sensory abnormalities Pressure over tunnel will increase
along the pain
anterolateral leg
below the knee and
along the top of the
foot if both sup and
deep branches
involved
Superficial Superficial Pain increased with inversion To test the nerve – passive inversion
Peroneal nerve peroneal nerve Sensory loss of lateral lower and plantar flexion while applying
entrapment half of the calf and dorsum of pressure over the point where the
the foot nerve pierces the deep fascia
Motor loss, with higher reproduces the symptoms.
lesions only, giving weakness
of foot eversion and ankle
stability
Deep Peroneal Deep Peroneal Pain is often aggravated by SMR for afflicted areas
Nerve N. plantar flexion.
Entrapment Sensory loss at the web of
the great toe
Motor loss is variable
depending on level of the
lesion. May include weak toe
extensors, weak tibialis
anterior and peroneus tertius
in a more proximal lesion
(may have foot drop)
Atrophy of the belly of the
 extensor digitorum brevis
occurs early and is a useful
sign.
Sural N. Sural n. Pain in the calf as well as the
entrapment (cutaneous) lateral ankle and foot
Saphenous N. Saphenous n. Medial pseudo claudication-
entrapment (cutaneous) type pain
Pain that radiates into the
medial calf to the medial
malleolus.
May be paraesthetic or
burning in character.
Sunburnt feeling over or
burning in character.
Tarsal Tunnel Tibial N. Burning, throbbing pain on
Syndrome 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
Jogger’s foot Medial plantar Pain (burning, shooting,
nerve sharp) and/or dysaethesia,
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
Based on clinical sensory examination.
Pain can be reproduced by activities
such as kneeling: stair climbing or
even normal gait since those activities
additionally compresses the nerve. A
sharp pain at the level of the Hunter
canal which can be provoked by
pressure (Hoffmann Tinel sign)
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.
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 sings –
dorsiflex/ever/SLR (structural
differentiation)
There may be pain with resisted great
toe abduction
 or new shoes without Neither flexion of the toes against
changes in exercise regime resistance or passive toe hyper-
Worse with high arm support extension should increase the pain –
differentiate from flexor tenosynovitis
and plantar fasciitis
No weakness detected easily as long
flexors of foot and toes and
preserved.
Morton’s Nerves of Pain, numbness, paraesthesia Palpable click (Mulder’s click) in
neuroma metatarsal in the lateral side of one toe interspace with compression should
tunnel and medial side of the next. recreate the patients symptoms
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 dysaethesia
over metatarsal heads
Increased pain with walking,
crouching, wearing high heels
(any other activity that
causes toe extension)