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

L: intermittent tingling and pain the thumb, index and middle finger of her right hand
O: started while at work
D: last 2 days
C: intermittent
T: intermittent tingling and pain, 4/10 ‘pins and needles’
R: none listed
R: relieved by shaking her hands, 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
A: pain is made worse with computer work, awaken by ‘8/10 pain, tingling and numbness’ in
the middle of the night for the last 2 nights
P: not listed
P: taking 500g paracetomol with no symptom relief
A: none

• Identify the components of GORPOMNICS

G: no gait abnormality
O: minor muscle atrophy at the base of the thumb. No swelling or tenderness to joints
R: mild restriction on right active and passive rotation
 P: no masses, no lymphadenopathy, thyroid good, no visual deformity, minor muscle atrophy
at base of thumb
O: Positive Tinnel’s sign over the volar wrist, positive Phalen’s test
M: muscle strength normal in cervical spine and upper extremities
N: UE DTRs 2+
I: -
C: -
S: -

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

Not necessary because there was no trauma, fall, nor red flags to justify x-rays or other
investigations. Her presenting signs and symptoms (pain and tingling of thumb, index and middle
finger; positive Tinnel’s sign over the volar wrist, positive Phalen’s test; minor muscle atrophy at the
base of the thumb) all indicate 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 ; entrapment of the tibial nerve

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.

What is your most likely diagnosis?

 Meralgia Paresthetica; Entrapment of the lateral femoral cutaneous nerve (or lateral
cutaneous nerve of thigh) by the inguinal ligament close to where it attaches to the
ASIS.

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

 Upper Extremity Entrapments
Entrapment Name Nerve or Branch Common and any Test used
Entrapped outstanding
symptoms
Supracondylar Median nerve (C6- Pain, gradual hand Tinel’s sign
Process Syndrome T1) & brachial artery weakness and Patient may not be
sensory loss over able to make the Ok
the median nerve sign with thumb
distribution Other pathologies
ruled out.
Pronator Teres Median nerve (C6- Aching pain in the Palpate over area of
Syndrome T1) proximal forearm entrapment and
with weakness / resisted muscle
clumsiness of the testing of the
hand. Numbness pronator teres (flex
and paraesthesia of elbow 60˚
the median nerve pronated), resist
distribution. supination to
Sensory similar to reproduce pain and
carpal tunel. Night paraesthesia.
pain NOT common.

Anterior Ant. Interosseous Motor function loss Loss of the pinch

Interosseous Nerve Nerve - A branch of of Pronator sign between the
Syndrome the median nerve quadratus, index finger and the
(C6-T1) flexor digitorum thumb.
AIN profundus of middle Resisted muscle
finger, and flexor testing of pronator
pollicis longus. quadratus (elbow
Dull aching pain in fully flexed,
the volar aspect of pronated) resist into
the proximal supination
forearm. (decreased).
Posterior Radial nerve or Pain in the forearm Direct pressure over
Interosseous Nerve branches (C7- and wrist. the supinator
Syndrome C8) Pain just distal to muscle while
the lateral resisting supination
PIN epicondyle. may elicit weakness
Weakness in the of supination and
finger, thumb, and tenderness.
wrist movements.
Radial Tunnel Radial nerve Tennis elbow like Clinical tests to
Syndrome symptoms: confirm the
Pain that worsens diagnosis include
when rotating the exacerbation of the
 wrist. pain with resisted
Outer elbow supination with the
tenderness. other being
Decreased ability to increased pain in the
grip. proximal radial
Loss of strength in forearm and over
the forearm, wrist, the radial
and hand. tunnel when the
Difficulty extending wrist is
wrist. hyperextended
against resistance.
Cubital Tunnel Deep branch of the Tingling sensation in Direst pressure over
Syndrome Ulna nerve the 4th and 5th the tunnel may
(C7-T1) fingers of the hand. reproduce or
Hand pain. exacerbate
Weak grip and symptoms. Tinel’s
clumsiness due to sign at the cubital
muscle weakness in tunnel.
the affected arm Elbow flexion test.
and hand. Pressure
Aching pain on the provocation test.
inside of the elbow. Froment’s card test

Saturday / Radial nerve Symptoms vary on Awareness of clinical

Honeymoon night the severity and features of this
palsy (caused by location of the disorder and
compression from trauma. functions of the
direct pressure on a Wrist drop. radial nerve may
firm object) Inability to help clinicians
voluntarily differentiate
straighten the between radial
fingers or extend the neuropathy and
thumb other possible
Numbness in the diseases.
back of the hand
and wrist

Crutch paralysis Radial nerve Presents with a wrist To differentiate

drop on physical between a
(caused by crutches examination. peripheral radial
that are not Loss of extension of neuropathy from a
adjusted to the the forearm, hand, central pathology,
correct height) and fingers. test the
There will also be a brachioradialis
sensory loss in the muscle. It is always
posterior aspect of weak in a peripheral
the forearm radial nerve injury,
 radiating to the and less affected
radial aspect of the with a CNS disorder.
dorsal hand and
digits. 

Carpal tunnel Median nerve The main symptom A positive Phalen’s

Syndrome is Intermittent test
numbness of the
thumb, index and
(no sensory loss over long finger and
the thenar radial half of the
eminence) ring finger.
Pain in carpal tunnel
syndrome is
primarily numbness
that is so intense
that it wakes one
from sleep with the
hypothesis that the
wrists are held
flexed during sleep.

Guyon’s canal Ulnar nerve Atrophy of the ROM of the wrist

syndrome hypothenar muscles and digits 
and interossei. MMT of ulnar nerve
(Overuse injury) Weakened finger muscles innervated
abduction and distal to Guyon’s
(Dorsum of medial adduction Canal 
aspect of the fourth (interossei) Sensory exam of the
finger and the Weakened thumb ulnar nerve
dorsum of the fifth adductor (adductor cutaneous
finger don’t have pollicis) distribution distal to
sensory loss) Sensory loss and Guyon’s Canal
pain of the palmar
surface of the fifth
digit and medial
aspect of the fourth
digit.
Ulna Claw may
present (sign of
Benediction)

Wartenberg’s Superficial branch of Symptoms include Provocation tests;

syndrome the radial nerve. ill-defined pain over Tinel's sign over the
dorsoradial superficial sensory
(no motor hand (does not like radial nerve (most
 weakness) to wear watch), common exam
Paraesthesia over finding)
dorsoradial hand,
Numbness,
Symptom
aggravation by
motions
involving repetitive
wrist flexion and
ulnar deviation,
no motor weakness

Lower Extremity Entrapments

Entrapment Name Nerve or Branch Common and any Test used
Entrapped outstanding
symptoms
Sciatic nerve Sciatic nerve Deep aching pain Bonnet’s Test
entrapment (L4-S3) in sacral or gluteal
region remains the
(No significant LBP most common
unless part of the symptom with
overall functional posterior thigh
complaint) pain
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 Ilioinguinal nerve Painful sensation in Diagnosis of the
neuralgia the lower ilioinguinal neuralgia
(L1-L2) abdomen requires a careful history,
(sensory only) and groin, radiating physical examination,
to the upper inner electrophysiologic
upper leg and to studies, and ultrasound
the genitals. examination.
 Patients complain
of pain,
parasthaesia and
abnormal
sensation in the
area supplied by
the nerve.

Obturator Obturator nerve Most common Stretching the pectineus

Neuropathy symptom is altered muscle can be useful in
(Anterior divisions sensation in the diagnosing obturator
(No significant of L2-L4) medial thigh that nerve entrapment.
motor deficit may be
associated with paraesthetic or Aggravated by extension
this condition) burning in and lateral leg
character movements (abduction)

Moderate to
severe pain that
begins insidiously
at the adductor
origin on the pubic
bone and worsens
with exercise

Genitofemoral Genitofemoral Chronic Knowledge of the

nerve entrapment nerve neuropathic groin presentation of GFN
pain entrapment will prevent
Pain and/or misdiagnosis,
numbness in an unnecessary surgery, and
elliptical area on delayed treatment.
the anterior aspect Pain may be provoked by
of the thigh Increased by thigh
immediately below extension
the middle of the Decreased perception of
inguinal ligament. pinprick and touch.
May present as
scrotal pain or
labial pain

Meralgia Lateral femoral Middle aged males Reproduced with Tinel’s

Paresthetica cutaneous nerve unpleasant sign at site of
paraesthesia entrapment (1 cm medial
(burning, tingling, and inferior to the ASIS
stinging) in the helps confirm the
nerve distribution. diagnosis).
 Hypersensitivity to Mobilisation of the
touch (e.g. tissues in the entrapment
clothing). area may relieve the
Decreased pain on symptoms
sitting, increased
pain on hip
extension and
prolonged walking
or standing

Tibial n Tibial nerve Sensory changes in Passive straight leg raise

Entrapment the bottom of the with foot everted till
foot and toes - symptoms are
(a terminal branch burning sensation, reproduced
of the sciatic nerve numbness, tingling,
formed by or other abnormal
branches from L4- sensation, or pain.
S3) Loss of plantar
flexion.
Loss of toe flexion.
Weak inverters
(tibialis anterior
can still invert
some)

Common peroneal Common Peroneal Pain usually Tinel’s sign or

(fibular) nerve nerve appears initially in overpressure at the
entrapment the compressed fibula head may increase
region before paraesthesia, aiding
spreading distally diagnosis.
into the common Dorsiflexion paresis and
peroneal nerve’s foot drop (in severe
cutaneous cases, look for atrophy of
distributions. anterior tibial muscles).
Possible radiation Weakness of foot
of pain into the eversion.
thigh (if pain is Increased pain with
seen in buttock or plantar flexion and
posterior thigh, inversion of foot.
think of a more Pressure over tunnel will
proximal cause). increase pain.
Sensory
abnormalities
along the
anterolateral leg
below the knee
and along the top
 of the foot if both
superficial and
deep branches
involved

Superficial Superficial Pain increased with To test the nerve –

peroneal nerve peroneal nerve inversion passive inversion and
Sensory loss at plantar flexion while
lateral lower half applying pressure over
of the calf and the point where the
dorsum of the foot. nerve pierces the deep
Motor loss, with fascia reproduces the
higher lesions only, symptoms.
giving weakness of
foot eversion and
ankle stability

Deep peroneal Deep peroneal Pain is often SMR tests for afflicted
nerve nerve aggravated by areas
plantar flexion.
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 nerve Sural nerve Pain in the calf as The tests used to

entrapment (cutaneous) well as the lateral diagnose of sural
ankle and foot. entrapment neuropathy
is based on a clinical
sensory examination. 

Saphenous nerve Saphenous nerve Affected patients Pain can be reproduced

 complain of by activities such as
(purely sensory) neuropathic kneeling; stair climbing
(burning or or even normal gait since
electrifying) pain in those activities
the area of the additionally compresses
saphenous nerve the nerve. A sharp pain
which is the medial at the level of the Hunter
aspect of the thigh canal which can be
provoked by pressure
(Hofmann Tinel sign)

Tarsal tunnel Tibial nerve Pain or sensory Pain reproduced by

syndrome disturbance on the overpressure
plantar aspect of
the foot. Positive Tinel’s sign
Patients typically
present with Diagnosis is established
intractable heel by nerve conduction
pain. studies. May be
mistaken for plantar
fasciitis. This may be an
overlooked cause of
chronic, nonresponsive
plantar fascia pain.

Medial plantar Medial plantar Pain (burning, Tenderness along medial

nerve syndrome nerve shooting, sharp) plantar aspect of medial
(jogger’s foot) and/or arch in the region of the
dysaesthesia, navicular tuberosity.
paraesthesia along Positive Tinel’s sign just
medial arch of the behind the navicular
foot sometimes to tuberosity ±
plantar toes in paraesthesia.
distribution of Neurodynamic signs –
medial plantar dorsiflexion/eversion/SLR
nerve. Onset (structural
of pain often differentiation).
occurs with use of There may be pain with
new arch support resisted great toe
or new shoes abduction.
without changes in
exercise regime.
Pain will often
worsen with high
arch supports –
especially rigid
 orthoses
Morton’s Nerves in the Pain, numbness, A palpable click (Mulder's
neuroma: metatarsal tunnels paraesthesia in the click) in interspace with
Interdigital lateral side of one compression should
Perineural Fibrosis toe and medial recreate the patients
side of the next. symptoms
Pain is usually
described as
piercing or like an
electric shock.
Increased pain
with walking,
crouching, wearing
high heels (any
other activity that
causes toe
extension)