Muscle Denervation and Nerve Entrapment

Syndromes
Howard R. Galloway, B.M., B.S., F.R.A.N.Z.C.R.1

ABSTRACT

Nerve entrapment and muscle denervation syndromes are often hard to diagnose,
presenting as pain or unusual weakness. In addition many of the clinically named
syndromes are poorly defined and understood. An understanding of the clinical signs,
the normal and variant anatomy, and the often variable relationship between the imaging
findings and the clinical findings is essential in the accurate diagnosis and management of

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these disorders. MRI has proved sensitive to the presence of muscle denervation and can
provide high resolution imaging along the course of the major nerves allowing demon-
stration of mass lesions or normal anatomical variations. The diagnosis of nerve entrapment
and muscle denervation syndromes can be a substantial clinical challenge. Imaging,
particularly MRI, can prove very useful in confirming a nerve lesion by demonstrating
changes of muscle denervation. Identification of the muscles involved combined with
knowledge of the normal patterns of innervation and their variations can allow localization
of the site of the nerve lesion.

KEYWORDS: Muscle denervation, nerve entrapment, MRI

CLINICAL PRESENTATION AND
DIAGNOSTIC ISSUES
Nerve entrapment and muscle denervation syndromes
are often hard to diagnose, presenting as pain or unusual
weakness. In addition, many of the clinically named
syndromes are poorly defined and understood. An
understanding of the clinical signs, the normal and
variant anatomy, and the often variable relationship
between the imaging findings and the clinical findings
is essential in the accurate diagnosis and management of
these disorders.
Although the cause and site of nerve compression
syndromes can be directly imaged, in several clinical
syndromes imaging shows signs of muscle denervation
in the distribution of the affected nerve without dem-
onstrating a mass or other focal cause. In some circum-
stances this may be due to the etiology of the nerve lesion
being traction rather than compression, especially
around the shoulder in athletes.
Direct Imaging of Nerve Compression
Although at first sight an attractive proposition, in
practice direct imaging of nerve compression has proved
to be quite difficult. It is well recognized that compres-
sion of a nerve acutely causes swelling that is thought to
be due to the blockage of axonal transport. Ischemia may
also play a role, and histological studies in cadavers have
shown epineural and perineural fibrosis.1,2 In some
common situations such as carpal tunnel syndrome,
imaging of the nerve itself at the site of compression is
quite feasible. As well as unusual causes of compression

1
Department of Human Movement, University of Queensland,
Richmond Surrey, United Kingdom.
Address for correspondence and reprint requests: Howard
Galloway, B.M., B.S., Department of Human Movement, Univer-
sity of Queensland, 1/27 Petersham Road, Richmond Surrey
TW106UH UK (e-mail: galloway.howard@gmail.com).
Imaging of Muscle; Guest Editor, David A. Connell,
F.R.A.C.R., F.F.S.E.M.(UK).
Semin Musculoskelet Radiol 2010;14:227–235. Copyright #
2010 Thieme Medical Publishers, Inc., 333 Seventh Avenue, New
York, NY 10001, USA. Tel: + 1(212) 584-4662.
DOI: http://dx.doi.org/10.1055/s-0030-1253162.
ISSN 1089-7860.
227
228 SEMINARS IN MUSCULOSKELETAL RADIOLOGY/VOLUME 14, NUMBER 2
Figure 1 Short tau inversion recovery images of the ulna
nerve demonstrating high signal and swelling in a case of
ulna neuritis in the cubital tunnel. (Images courtesy of Dr. K.
Stevens, Stanford University, CA.)
by mass lesions in the canal or abnormalities of the nerve,
changes in cross sectional area of the nerve have been
described on ultrasound and appear to correlate well with
the clinical presentation. Just how much the imaging
adds to the diagnosis of the routine cases is still a matter
for evaluation.3
Sometimes the effect of compression on the nerve
itself can be demonstrated by a change in signal intensity
on magnetic resonance imaging (MRI), and this has
been described in the sciatic nerve in piriformis
syndrome4 (Fig. 1).
Often mass lesions or anatomical variations are be
diagnosed and thought to be the cause of the patient’s
symptoms, but these may be more commonly seen in
asymptomatic individuals (e.g., supraspinous notch gan-
glia, variations in the sciatic nerve, and piriformis).
IMAGING FINDINGS AND HISTOLOGICAL
CORRELATES OF DENERVATION
MRI can consistently and sensitively demonstrate signs
of muscle denervation, which has been apparent since
the changes were first described by Polak et al.5
In rats with sciatic nerve lesions, Bendszus et al6
demonstrated an increased signal on short tau inversion
recovery (STIR) images at 24 hours and on T2-weighted
2010
images at 48 hours that further increased up to 2 months.
Fatty atrophy was evident as early as 7 days. Wessig et al7
from the same group showed similar findings with an
increase in T2 after 48 hours that peaked at 3 weeks and
was associated with increased capillary dilation. They
found that the T2 signal normalized at 10 weeks, at which
time it was associated with regression of capillary dilation.
Gadolinium uptake of denervated muscle has
been described at 48 hours after denervation, presumably
on the basis of increased capillary permeability.8
Chronic denervation leads to fatty atrophy with
fiber atrophy, increased fat between muscle fascicles and
decrease in muscle size and increased signal on T1
images.
Although most studies, both experimental and
clinical, have used MRI, changes of denervation are also
visible on ultrasound.
Küllmer et al9 studied MRI ultrasound and his-
tological changes in rabbits after section of the supra-
scapular nerve. Sonography, MRI, and histopathology
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all showed early changes at 2 to 3 weeks with subtle
histological changes, a minor decrease in fascicle diam-
eter, and an increase in echogenicity on ultrasound and
increase in T2 signal intensity on MRI (STIR was not
used). At 28 to 35 days, definite changes were visible on
all modalities, and this continued through to day 65.
This was consistent with another study by Gunreben and
Bogdahn,10 which showed sonographic changes from
day 10 in a patient with acute brachial plexus palsy.
In clinical settings, MRI appears to be the most
sensitive with early changes on STIR images easy to
appreciate and appearing earlier. An appreciation of the
ultrasound findings is necessary, however, because ultra-
sound is often used in the investigation of clinical
symptoms such as pain that may be associated with
denervation.
When compared with other tests such as electro-
myography (EMG), a further study from Bendszus
et al11 demonstrated the comparable accuracy of MRI
in the diagnosis of foot drop. Imaging has a further
advantage in areas of complex anatomy where the nerves
might not be easily or specifically accessible for EMG.
In clinical settings, MRI appears to be the most
sensitive with changes on STIR images easy to appre-
ciate in the acute phase.
In the most common clinical settings, however,
nerve compression or traction injury is subacute, and so
findings of edema and/or atrophy are usually present on
MRI and ultrasound, although they may be more diffi-
cult to appreciate on ultrasound without comparison
with normal muscle.
The recognition of the imaging patterns of de-
nervation is useful not only in diagnosing the presence of
denervation but in determining the nerve involved and
the level of the lesion on the basis of the distribution of
the muscles involved.
 MUSCLE DENERVATION AND NERVE ENTRAPMENT SYNDROMES/GALLOWAY
CLINICAL SYNDROMES
Quadrilateral Space Syndrome
Quadrilateral space syndrome was first described by
Cahill and Palmer12 as a syndrome caused by compres-
sion of the posterior circumflex artery and axillary nerve
by fibrous bands in the quadrilateral space with the arm
in abduction and external rotation presenting with local
tenderness in the quadrilateral space, typically in younger
patients, often overhead athletes. The diagnosis was
initially made by arteriography.
Surgical exploration of the four patients in McA-
dams and Dillingham’s series13 showed fibrous bands
entrapping the nerve in three and venous dilation in the
fourth.
A cadaver dissection study by McCelland and
Paxinos14 showed that fibrous bands are a common
finding in the quadrilateral space, present in 14 of 16
shoulders. The most common site for a fibrous band was
between the teres major and the long head of the triceps.
Where the bands were present, both internal and exter-
nal rotation of the shoulder caused a reduction in the
cross-sectional area of the quadrilateral space.
Imaging apart from angiography in classic cases
appears to have little positive predictive value apart from
demonstrating rare cases of a mass such as a ganglion in
the quadrilateral space.15
Isolated Teres Minor Atrophy
True quadrilateral space syndrome is uncommon, but a
much more common imaging finding is isolated teres
minor atrophy (Fig. 2).
This came to light with the widespread use of
MRI for shoulder imaging and has been shown in up to
3% of consecutive shoulder MRIs.16 Initially this was
thought to be a manifestation of quadrilateral space
Figure 2 Fatty infiltration and atrophy of teres minor as an
incidental finding in an overhead athlete.
229
syndrome, but it is more common, often asymptomatic,
and occurs in an older age group. The presence of other
shoulder pathology in the older age group has led to a
hypothesis that this is related to humeral decentering
and represents a traction injury of the nerve.17
The presence of isolated teres atrophy in a
younger patient, particularly an overhead athlete, may
be significant, however, because teres minor has been
shown in EMG studies to be an important stabilizer of
the glenohumeral joint in overhead activities.18
Supraspinous Notch Syndrome
The suprascapular nerve arises from the upper trunk of
the brachial plexus and carries fibers from C5 and C6. It
provides the motor innervations to the supraspinatus and
infraspinatus muscles.
After leaving the brachial plexus, the nerve runs
dorsally through the suprascapular notch running under
the transverse scapular ligament into the suprascapular
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fossa where it supplies the supraspinatus. The nerve then
travels through the spinoglenoid notch under the spino-
glenoid ligament, exiting the fibro-osseous tunnel and
ending by innervating the infraspinatus.
The site of compromise of the nerve will deter-
mine the pattern of muscle involvement. A lesion in the
supraspinous notch will affect both supra and infra-
spinatus, whereas a lesion in the spinoglenoid notch
will only affect the infraspinatus.
The role of entrapment of the suprascapular nerve
as a cause of chronic shoulder pain was first described by
Thompson and Kopell in 1959.1 Since then the syn-
drome has been reported many times, and multiple
causes have been identified including acute trauma and
nontraumatic causes such as ganglion cysts, inflamma-
tory conditions, overhead athletic activities, and varia-
tions in the anatomy of the supraspinous notch and
ligament.
An anatomical study by Ticker et al19 demon-
strated considerable variation in the shape of the supra-
scapular notch and the superior transverse scapular
ligament. Partial and complete ossification of the liga-
ment and multiple band were described, all of which may
potentially compromise the nerve in the supraspinous or
spinoglenoid notch. A ganglion in the supraspinatus
fossa was seen in one case.
Supraspinous notch ganglions are common and
usually arise from a tear of the superior glenoid labrum.
The presence of signs of denervation associated with a
ganglion suggest the ganglion as the cause, but EMG is
required for confirmation because the nerve lesion may
be due to traction or ligament compression rather than
compression by the ganglion.
Although nerves may be injured as a result of
acute traction (e.g., acute dislocation) (Fig. 3), signs of
denervation may be common and apparently incidental
230 SEMINARS IN MUSCULOSKELETAL RADIOLOGY/VOLUME 14, NUMBER 2
Figure 3 Edema in the supraspinatus and infraspinatus as
a result of an acute traction injury that also resulted in an
acute tear of the supraspinatus tendon and an interstitial tear
of the inferior glenohumeral ligament.
in overhead athletes although associated with definite
functional abnormalities20 In this study of volleyball
players, isolated infraspinatus lesions were common.
Studies have also shown that there may be substantial
elongation of the nerve with overhead motion.21
In imaging the shoulder, radiologists need to be
aware that isolated denervation of the teres minor may be
an incidental finding, particularly in older patients with
other pathology. In overhead athletes there are often
multiple lesions, and the presence of denervation,
although not symptomatic in the usual sense, may be
associated with functional deficits.
Piriformis Syndrome
Piriformis syndrome, which proposes compression or
entrapment of the sciatic nerve by the piriformis as it
exits the pelvis, is a controversial entity that predates the
recognition of the role of the intervertebral disc in
producing symptoms. The diagnostic criteria and indeed
the very existence of the syndrome remain the subject of
discussion.22
There are no high-quality systematic studies link-
ing imaging findings to the clinical syndrome. In this
brief review we touch on the anatomical variants and the
imaging findings that various authors have believed to
play a potential role in the syndrome.
Anatomy and Variations
The sciatic nerve is formed by roots from the lumbo-
sacral plexus (L4, L5, S1, S2, and S3) and consists of
20% nerve fibers and 80% loose fibrofatty tissue. After a
short course on the piriformis muscle, it exits the pelvis
below the muscle. There are several reports in the
literature citing variations in the exit of the sciatic nerve
relative to the piriformis.22,23 The piriformis muscle
2010
itself originates from the anterior surface of the sacrum
by way of fleshy digitations from the second, third, and
fourth sacral vertebrae. After crossing the anterior sur-
face of the sacroiliac joint, it exits the pelvis through the
sciatic notch to insert into the upper border of the greater
trochanter by way of a round tendon that is often a
conjoint piriformis and obturator internus or gemelli
conjoint tendon.
Pecina24 demonstrated an intrapelvic division of
the sciatic nerve into peroneal and tibial components
within the pelvis in 26% and postforaminal division in
4.6%, division at the inferior border of the gluteus
maximus in 11.5%, and division in the proximal thigh
in the remainder. In 18% the peroneal division splits the
piriformis into two bellies with the nerve passing be-
tween them.
Proposed etiologies have included direct com-
pression of the nerve, entrapment of the nerve by
adhesions either posttraumatic or primary, and stretch-
ing of the nerve due to piriformis hypertrophy.
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MRI is capable of demonstrating the anatomical
variations and also increased signal within the sciatic
nerve itself. There are, however, only a few MRI studies
of piriformis syndrome and even fewer with surgical and
outcome correlation.4,22
Hypertrophy of the piriformis has been shown in
symptomatic patients but also in asymptomatic patients
and in the asymptomatic side of symptomatic patients.
Anatomical variants of the nerve are common and
inconsistently associated with symptoms. In the largest
series,4 there were variable findings with enlargement or
atrophy of the ipsilateral piriformis, enlargement of the
gemelli and atrophy of more distal muscles including
hamstrings and peronei.
Lewis et al4 also reported increased signal in the
sciatic nerve on STIR images at the level of the sciatic
notch or, in one patient, the ischial tuberosity. In this
and other series, patients responding to surgery have had
normal imaging.
Adhesions between the nerve and adjacent struc-
tures have been reported in an operative series23 but have
not been visualized with MRI.
The largest imaging series with surgical confirma-
tion24 affirmed the ability of MRI to demonstrate the
anatomical variations, but the relationship to symptoms
remains unclear because there was no asymptomatic
control, and three patients with no anatomical abnormal-
ity had resolution of their symptoms following tenotomy
of the piriformis and neurolysis (Figs. 4A and B).
Role of Imaging
Patients who have been assessed for sciatica that remains
unexplained after assessment of the lumbar spine may
have their pelvis imaged for extraspinal causes of sciatica.
Although the relationship to symptoms is problematic, it
 MUSCLE DENERVATION AND NERVE ENTRAPMENT SYNDROMES/GALLOWAY 231

Figure 4 Piriformis syndrome. (A) Asymmetry of the piriformis with the left muscle larger than the right (arrow). (B) Under
computed tomography guidance, needle seen in the belly of the piriformis; the muscle may be injected to relieve symptoms
and, presumably, muscle spasm. (Images courtesy Dr. D.A. Connell, The Royal National Orthopaedic Hospital, Middlesex, UK.)

is useful to be able to identify normal variants of the mass such as a ganglion arising from the proximal
piriformis and be aware of the possible significance of tibiofibula joint. In addition, an unusual site of com-
increased signal in the sciatic nerve and the perineural pression has been described due to a variation of the

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structures.
Common Peroneal Nerve
The common peroneal nerve courses anterolaterally
along the biceps femoris muscle, around the fibular
neck deep to the peroneus longus tendon, and enters
the peroneal tunnel. As it enters the tunnel, the nerve
divides into the superficial and deep peroneal nerves.
Nerve compression within this area (peroneal tunnel)
results in pain along the dermatome of the common
peroneal nerve. The common peroneal nerve is prone to
injury as it passes superficially around the neck of the
fibula. The nerve may be subject to local trauma through
impact or external compression, traction injury from an
ankle sprain or compression, or stretching from a local
distal biceps femoris tendon.25
MR imaging can depict the peroneal tunnel and
the common peroneal nerve and its branches. The most
clinically relevant use of MRI is in demonstrating
denervated muscles and space-occupying lesions, rather
than examining the nerve itself (Figs. 5A and B).
Obturator Nerve Entrapment
The obturator nerve contains fibers from L2, 3, and 4
and arises from the anterior division of the lumbar plexus
and then descends through the psoas running downward
over the sacral ala into lesser pelvis entering the upper
part of the obturator foramen and then divides into
anterior and posterior branches. The anterior branch
runs in front of obturator externus and adductor brevis

Figure 5 Large lobulated ganglion of the (A) proximal tibiofibular joint with (B) early changes of denervation in the peroneals as
a result of stretching of the nerve over the mass. The patient complained of pain and had minor objective weakness.
232 SEMINARS IN MUSCULOSKELETAL RADIOLOGY/VOLUME 14, NUMBER 2
Figure 6 (A) Image demonstrating the anatomy of the heel showing the lateral plantar nerve (arrow). Images demonstrate
atrophy and edema of the abductor digiti minimi on (B) coronal and (C) short tau inversion recovery. (Images courtesy of Dr. K.
Stevens, Stanford University, CA.) AbD, abductor digiti; AbH, abductor hallucis; FDB, flexor digitorum brevis; QP, quadralus planti.
behind the pectineus and adductor longus muscles giving
an articular branch that enters the hip joint through the
acetabular notch, supplying branches to the hip adduc-
tors, and dividing into cutaneous, vascular, and commu-
nicating branches.
Obturator neuropathy is a difficult clinical prob-
lem to evaluate. The most prominent symptom of
obturator neuropathy is pain radiating from the groin
into the medial upper aspect of the thigh. Dysesthesia
and weakness of the muscles supplied by the obturator
nerve can occur if the neuropathy is severe.
The most common cause of pain, particularly in
athletes, is due to fascial entrapment of the nerve.26,27
Surgery in patients with fascial entrapment has demon-
strated entrapment of the obturator nerve by a thick
fascia overlying the short adductor muscle.
Classically obturator neuropathy can be caused by
a pelvic fracture, hip arthroplasty, abdominal or pelvic
surgery, forceps delivery, lithotomy position, pelvic tu-
mor, obturator hernia, and, rarely, acetabular cyst.
Once again the major role of MRI is in identifying
signs of denervation in the adductor brevis and longus
muscles. In more unusual causes the primary lesion (e.g.,
acetabular labral ganglion28) may be demonstrated.
Baxter’s Neuropathy (Lateral Plantar Nerve)
Entrapment of the first branch of the lateral plantar
nerve (inferior calcaneal nerve), or Baxter’s neuropathy,
produces medial heel pain that may be indistinguishable
2010
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from heel pain due to plantar fasciitis. Baxter’s neuro-
pathy may account for 20% of cases of heel pain but is
frequently overlooked as a potential cause of pain.
Chundru et al29 found an incidence of atrophy of
the abductor digiti minimi muscle atrophy (ADMA) of
5.6%, and there were significant differences between
patients with ADMA and controls in advancing age,
calcaneal spur, and plantar fasciitis.
Entrapment of the inferior calcaneal nerve may
result from altered biomechanics, reflected by posterior
tibial tendon dysfunction or Achilles tendinosis, or it
may result from direct mechanical compression of the
nerve due to plantar fasciitis and/or plantar calcaneal
enthesophytes.
On MRI, the presence of ADMA reflects chronic
compression of the inferior calcaneal nerve and suggests
the clinical diagnosis of Baxter’s neuropathy in an
appropriate clinical setting30 (Figs. 6A–C).
For patients in whom heel pain persists despite
conservative therapy, MRI evaluation is indicated prior
to any surgical intervention.
When ADMA is demonstrated prior to fasciot-
omy, the surgical approach may be modified to address
the nerve compression as well as the fascial pathology.
ENTRAPMENT NEUROPATHIES IN THE
FOREARM
There are several entrapment neuropathies in the fore-
arm that may be difficult to diagnose clinically, often
 MUSCLE DENERVATION AND NERVE ENTRAPMENT SYNDROMES/GALLOWAY
presenting with pain and/or sensory disturbance. Imag-
ing can confirm the presence of a nerve lesion by
demonstrating changes of denervation.
Imaging is often not able to determine the cause
of the entrapment but is helpful in determining the
presence of denervation changes, and the pattern of
changes can localize the nerve involved and the site of
the lesion. In atypical cases imaging may also provide a
means of following the course of the condition.
Posterior Interosseous Nerve Syndrome
The radial nerve arises from the posterior cord of the
brachial plexus and runs with the brachial artery around
the humerus in the spiral groove. Above the elbow it
crosses onto the volar aspect of the elbow through the
lateral intermuscular septum. Anterior to the epicondyle
the nerve divides into deep motor and superficial sensory
branches. The deep branch passes through the supinator
and comes to lie on the dorsal aspect of the interosseous
membrane. The nerve then gives off multiple motor
branches mostly to the extensor muscles of the forearm
and hand.
There are multiple possible sites of compres-
sion.31,32 When the lesion occurs more distally, there is
weakness in the forearm with identification of the
specific muscle involved allowing localization of the
lesion.
The clinical radial tunnel syndrome that presents
as a purely sensory disturbance with lateral elbow pain is
a controversial clinical entity.21 The existence of the
radial tunnel and possible sites of compression remain
in dispute. The clinical picture is very similar to lateral
epicondylitis and imaging, and other tests cannot con-
firm the diagnosis. The role of imaging in this situation
Figure 7 Anterior interosseous nerve syndrome. Patient with a proximal lesion of the nerve demonstrating edema in the flexor
pollicis longus, (A) flexor digitorum profundus and (B) pronator. (Images courtesy of Dr. K. Stevens, Stanford University, CA.)
233
is in the first instance to assess the lateral epicondyle and
also to seek evidence of denervation in the more distal
muscles.
Pronator Syndrome
Pronator syndrome presents as chronic forearm pain as a
result of entrapment of the median nerve at the level of
the pronator teres. Compression is thought to result
from anatomical variants of the deep and superficial
origins of the pronator or of the bicipital aponeurosis
or the fibrous arch origin of the flexor digitalis super-
ficialis. The clinical presentation is dominated by pain
and numbness in the volar aspect of the forearm, often
bought on by an episode of excessive pronation and
supination.
MRI usually does not demonstrate the site of the
compression but demonstrates changes of denervation
(usually edema) in the pronator teres33 (Fig. 6B).
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Anterior Interosseous Nerve
The anterior interosseous nerve is a motor branch of the
median nerve lying in the anterior compartment of the
forearm. The nerve arises 2 to 8 cm distal to the medial
epicondyle lying deep in the forearm on the volar surface
of the interosseous membrane. The nerve usually gives
branches to the flexor pollicis longus (FPL), pronator
quadratus, and the flexor digitorum profundus (FDP) of
the index and middle fingers. Most cases are thought to
be neuritis and arise and resolve spontaneously.
Patients typically present with pain in the volar
aspect of the forearm with associated muscle weakness of
the thumb, index, and middle fingers as determined by
the innervation (Fig. 7A and B).
234 SEMINARS IN MUSCULOSKELETAL RADIOLOGY/VOLUME 14, NUMBER 2
The site and cause of the nerve lesion is usually
not demonstrated by MRI, but signs of denervation,
usually edema, are seen in the FPL, FDP, and the
pronator quadratus. As in other syndromes MRI may
also be useful in following the course of the condition if
it fails to resolve as expected.33 MRI can provide high-
resolution imaging along the course of the major nerves,
allowing demonstration of mass lesions or normal ana-
tomical variations.
CONCLUSION
The diagnosis of nerve entrapment and muscle denerva-
tion syndromes can be a substantial clinical challenge.
Imaging, particularly MRI, can prove very useful in
confirming a nerve lesion by demonstrating changes of
muscle denervation. Identification of the muscles in-
volved combined with knowledge of the normal patterns
of innervation and their variations can allow localization
of the site of the nerve lesion.
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