Differentiating UE

Mononeuropathies
Sun Jan 31
A 35 year old female presents to physical therapy with a referral for R arm
numbness and weakness. She reports that 3 weeks ago began having pain on the
outside of her elbow and numbness on the outside of her forearm and hand. Last
week after a hard tennis match her symptoms worsened and now she reports
difficulty opening jars and does not feel that she can grip her tennis racket well.
She reports that she has had neck pain on and off over the past few years and
that her neck has been hurting since this began. Manual muscle testing reveals
3+/5 strength in R wrist extension, 5/5 strength in R thumb extension, and 5/5
strength in wrist and finger flexion.

What is the most likely diagnosis for this patient based on the information given?

a. Lateral epicondylalgia
b. Radial tunnel syndrome
c. C6 radiculopathy
d. Posterior interosseous syndrome
A 35 year old female presents to physical therapy with a referral for R arm
numbness and weakness. She reports that 3 weeks ago began having pain on the
outside of her elbow and numbness on the outside of her forearm and hand. Last
week after a hard tennis match her symptoms worsened and now she reports
difficulty opening jars and does not feel that she can grip her tennis racket well.
She reports that she has had neck pain on and off over the past few years and
that her neck has been hurting since this began. Manual muscle testing reveals
3+/5 strength in R wrist extension, 5/5 strength in R thumb extension, and 5/5
strength in wrist and finger flexion.

What is the most likely diagnosis for this patient based on the information given?

a. Lateral epicondylalgia
b. Radial tunnel syndrome
c. C6 radiculopathy
d. Posterior interosseous syndrome
Moore, 2010
Median nerve entrapments

● Pronator Teres Syndrome

● Anterior Interosseous syndrome
● Carpal Tunnel Syndrome
Pronator Teres Syndrome
● Between two heads of the pronator teres
● Sensory AND motor
○ Weakness: Technically any median n. distribution distal to PT, but most
common weakness is FPL, AbdPB, FDP (dig 2-3), OP,
○ Numbness/paresthesia: Dig 1-3 and half of 4th, lateral palm INCLUDING
thenar eminence
● Pain over pronator teres/anterior forearm
● Symptoms increase with activity, not typically nocturnal
● Test: Palpation, Pronator teres stress test, could be unable to make “OK” sign
Anterior Interosseous
● Entrapment typically as it exits the PT, tendinous edge of deep head
● Runs between FDP and FPL
● MOTOR ONLY
○ Weakness: FPL, FDL (dig 2-3), and PQ
○ Numbness/paresthesia: NONE
● Pain/tenderness anterior forearm at/distal to pronator teres
● Test: Unable to make “OK” Sign
Carpal Tunnel Syndrome
● Most common median neuropathy
● Motor AND sensory
○ Weakness: FPB, AbdPB, OP, Lumbricals 1-2
○ Numbness/paresthesia: Dig 1-3 and radial half of 4
● Hallmarks: nocturnal symptoms, shaking hands for relief
● Test: Phalen’s, Carpal compression, Tinel
● Cluster--3 or more of:
○ >45 yo
○ Shaking hands provides relief
○ Wrist ratio >.67
○ CTQ-SSS >1.9
○ Decreased light touch median nerve distribution
Ulnar Nerve Entrapments
● Cubital Tunnel Syndrome

● Guyon’s canal
Cubital Tunnel Syndrome
● Ulnar nerve as it passes posterior to medial epicondyle, or as it dives between
heads of flexor carpi radialis
● Motor AND sensory
○ Weakness (only if severe): FCU, FDP (dig 4-5), adductor policis, interossei, Hypothenar mm
(AbdDM, FDM, ODM), lumbricals 3-4
○ Numbness/paresthesia: 5th and ulnar half of 4th dig
● May have medial elbow/forearm pain, but not sensory changes
● Test: Tinel’s, Elbow flexion test
● If severe:
○ Froment’s Sign
○ Wartenburg’s sign
Guyon’s Canal Syndrome
● Ulnar N. between hook of hamate and pisiform
● Can be Motor and sensory, pure motor, or pure sensory depending on
location
○ Weakness: adductor policis, interossei, Hypothenar mm (AbdDM, FDM, ODM), lumbricals 3-4
○ Numbness/paresthesia: 5th and ulnar half of 4th dig
● Prolonged compression, wrist extension and ulnar deviation (ie. cyclist),
trauma, ganglion cyst, fracture
● Froment’s sign
● Wartenburg’s sign - abduction of 5th digit
Radial Nerve Entrapments

● Proximal radial nerve injuries: Crutch palsy, saturday night, humeral shaft
fracture, lateral intermuscular septum
● Radial Tunnel Syndrome
○ Primarily pain, rare, can have radial distribution weakness, can have radial HAND sensory
deficits
○ Often confused with Lateral Epicondylalgia, but symptoms more distal
● Posterior interosseous syndrome
○ Most common at arcade of Frohse, pain posterior forearm, MOTOR only - some weakness in
extension (ECRL/B spared), weakness in ECU
○ Pain with resisted supination, passive wrist flexion and elbow extension
● Wartenburg’s syndrome (not to be confused with Wartenburg’s sign)
○ “Handcuff palsy”
○ Superficial branch of radial nerve at distal radius
○ Sensory loss only - radial dorsum of hand, posterior aspect of thumb
Radiculopathy: dermatomes
Radiculopathy: myotomes
C5: Shoulder abduction

C6: elbow flexion, wrist extension

C7: Elbow extension, wrist flexion

C8: Thumb extension, finger flexion

T1: Finger abduction/adduction

A 52 year old male presents to an outpatient physical therapy clinic with a 3 month
history of waking in the night with numbness and tingling in his hand. He reports
that initially he could change position and make it go away, but now it lasts longer
and is accompanied by pain in his elbow. He also reports feeling clumsy with his
hand and having more difficulty gripping objects.

Thoughts?
A 52 year old male presents to an outpatient physical therapy clinic with a 3 month
history of waking in the night with numbness and tingling in his hand. He reports
that initially he could change position and make it go away, but now it lasts longer
and is accompanied by pain in his elbow. He also reports feeling clumsy with his
hand and having more difficulty gripping objects.

What would the most appropriate intervention be for this patient?

a. Recommend wrist night splint

b. Refer for steroid injection in carpal tunnel
c. Recommend splinting elbow at 40 deg at night
d. Initiate cervical traction
A 52 year old male presents to an outpatient physical therapy clinic with a 3 month
history of waking in the night with numbness and tingling in his hand. He reports
that initially he could change position and make it go away, but now it lasts longer
and is accompanied by pain in his elbow. He also reports feeling clumsy with his
hand and having more difficulty gripping objects.

What would the most appropriate intervention be for this patient?

a. Recommend wrist night splint

b. Refer for steroid injection in carpal tunnel
c. Recommend splinting elbow at 40 deg at night
d. Initiate cervical traction
A 52 year old male presents to an outpatient physical therapy clinic with a 3 month
history of waking in the night with numbness and tingling in his R hand. He reports
that when he wakes he shakes his hand and that decreases symptoms, but now it
lasts longer and is disrupting his sleep. He also reports feeling clumsy with his
hand and having more difficulty gripping objects.
A 52 year old male presents to an outpatient physical therapy clinic with a 3 month
history of waking in the night with numbness and tingling in his R hand. He reports
that when he wakes he shakes his hand and that decreases symptoms, but now it
lasts longer and is disrupting his sleep. He also reports now feeling clumsy with
his hand and having more difficulty gripping objects.

a. Recommend wrist night splint

b. Refer for steroid injection in carpal tunnel
c. Recommend splinting elbow at 40 deg at night
d. Recommend wrist and forearm stretches 3x/day
A 52 year old male presents to an outpatient physical therapy clinic with a 3 month
history of waking in the night with numbness and tingling in his thumb, index, and
middle fingers. He reports that when he wakes he shakes his hand and that
decreases symptoms, but now it lasts longer and is disrupting his sleep. He also
reports feeling clumsy with his hand and having more difficulty gripping objects.

a. Recommend wrist night splint

b. Refer for steroid injection in carpal tunnel
c. Recommend splinting elbow at 40 deg at night
d. Recommend wrist and forearm stretches 3x/day
A 40 year old male presents to an outpatient physical therapy clinic with a 3 month
history of L arm and hand problems. He reports increasing difficulty using his L
arm and hand for woodworking projects, especially using screwdriver which
causes him significant pain on the inside of his forearm. He scores a 50% on the
DASH. Objective exam reveals 3+/5 strength and pain with pronation and 3+/5
strength with DIP flexion at the index finger.

What is the most likely diagnosis based on this information?

a. Pronator teres syndrome

b. C8 radiculopathy
c. Anterior interosseous syndrome
d. Medial epicondylalgia
A 40 year old male presents to an outpatient physical therapy clinic with a 3 month
history of L arm and hand problems. He reports increasing difficulty using his L
arm and hand for woodworking projects, especially using screwdriver which
causes him significant pain on the inside of his forearm. He scores a 50% on the
DASH. Objective exam reveals 3+/5 strength and pain with pronation and 3+/5
strength with DIP flexion at the index finger.

What is the most likely diagnosis based on this information?

a. Pronator teres syndrome

b. C8 radiculopathy
c. Anterior interosseous syndrome
d. Medial epicondylalgia
A 40 year old male presents to an outpatient physical therapy clinic with a 3 month
history of L arm and hand problems. He reports increasing difficulty using his L
arm and hand for woodworking projects, especially using screwdriver which
causes him significant pain on the inside of his forearm and numbness in the
lateral fingers of his hand. He scores a 50% on the DASH. Objective exam reveals
3+/5 strength and pain with pronation, 3+/5 strength with DIP flexion at the index
finger, and atrophy at the thenar eminence.
What is the most likely diagnosis based on this information?
a. Pronator teres syndrome
b. C8 radiculopathy
c. Anterior interosseous syndrome
d. Medial epicondylalgia
A 40 year old male presents to an outpatient physical therapy clinic with a 3 month
history of L arm and hand problems. He reports increasing difficulty using his L
arm and hand for woodworking projects, especially using screwdriver which
causes him significant pain on the inside of his forearm and numbness in the
lateral fingers of his hand. He scores a 50% on the DASH. Objective exam reveals
3+/5 strength and pain with pronation, 3+/5 strength with DIP flexion at the index
finger, and atrophy at the thenar eminence.
What is the most likely diagnosis based on this information?
a. Pronator teres syndrome
b. C8 radiculopathy
c. Anterior interosseous syndrome
d. Medial epicondylalgia
A 40 year old male presents to an outpatient physical therapy clinic with a 3 month
history of L arm and hand problems. He reports increasing difficulty using his L
arm and hand for woodworking projects, especially using screwdriver which
causes him significant pain on the inside of his forearm. He scores a 50% on the
DASH. Objective exam reveals 3+/5 strength and pain with pronation and 3+/5
strength with DIP flexion at the index finger.
Part 2: You treat this patient with education on activity modification, forearm
stretches and soft tissue mobilization for 2 weeks. At this point you reassess his
DASH, which is now 65%
a. Progress the patient to forearm strengthening within symptom tolerance due
to improvement
b. Discharge the patient to HEP as he has improved significantly
c. Reassess the patient for S/S of other potential diagnoses due symptom
worsening
d. Continue this program for 2 more weeks and reassess symptoms before
changing treatment
A 40 year old male presents to an outpatient physical therapy clinic with a 3 month
history of L arm and hand problems. He reports increasing difficulty using his L
arm and hand for woodworking projects, especially using screwdriver which
causes him significant pain on the inside of his forearm. He scores a 50% on the
DASH. Objective exam reveals 3+/5 strength and pain with pronation and 3+/5
strength with DIP flexion at the index finger.
Part 2: You treat this patient with education on activity modification, forearm
stretches and soft tissue mobilization for 2 weeks. At this point you reassess his
DASH, which is now 65%
a. Progress the patient to forearm strengthening within symptom tolerance due
to improvement
b. Discharge the patient to HEP as he has improved significantly
c. Reassess the patient for S/S of other potential diagnoses due to symptom
worsening
d. Continue this program for 2 more weeks and reassess symptoms before
changing treatment
Proximal Mononeuropathies
● Suprascapular neuropathy
● Long thoracic nerve injury
● Axillary nerve injury