Common Entrapment Neuropathies.12

Review Article
Common Entrapment
Address correspondence to
Dr Lisa D. Hobson-Webb,
Department of Neurology,
Duke University Medical
Neuropathies Center, DUMC 3403, Room

1255 EMG Laboratory,
Durham, NC 27710,
lisa.hobsonwebb@duke.edu.
Lisa D. Hobson-Webb, MD; Vern C. Juel, MD, FAAN
Relationship Disclosure:
Dr Hobson-Webb has served
on the editorial board of
ABSTRACT Clinical Neurophysiology
Downloaded from http://journals.lww.com/continuum by BhDMf5ePHKav1zEoum1tQfN4a+kJLhEZgbsIHo4XMi0hCywCX1AWnYQp/IlQrHD3i3D0OdRyi7TvSFl4Cf3VC4/OAVpDDa8K2+Ya6H515kE= on 04/26/2022
and as an associate editor

Purpose of Review: This article addresses relevant peripheral neuroanatomy, for Muscle & Nerve.
clinical presentations, and diagnostic findings in common entrapment neuropathies Dr Hobson-Webb
involving the median, ulnar, radial, and fibular (peroneal) nerves. receives research/grant
support from CSL Behring,
Recent Findings: Entrapment neuropathies are a common issue in general neurology the National Institute on
practice. Early diagnosis and effective management of entrapment mononeuropathies Aging/Duke University
are essential in preserving limb function and maintaining patient quality of life. Median Claude D. Pepper Older
Americans Independence
neuropathy at the wrist (carpal tunnel syndrome), ulnar neuropathy at the elbow, radial Center, and Sanofi Genzyme.
neuropathy at the spiral groove, and fibular neuropathy at the fibular head are among Dr Juel receives research/
the most frequently encountered entrapment mononeuropathies. Electrodiagnostic grant support as site
investigator for studies for
studies and peripheral nerve ultrasound are employed to help confirm the clinical Alexion Pharmaceuticals,
diagnosis of nerve compression or entrapment and to provide precise localization for Inc and the National Institute
nerve injury. Peripheral nerve ultrasound demonstrates nerve enlargement at or near of Allergy and Infectious
Diseases, Division of
sites of compression. Microbiology and
Summary: Entrapment neuropathies are commonly encountered in clinical practice. Infectious Diseases.
Accurate diagnosis and effective management require knowledge of peripheral Unlabeled Use of
Products/Investigational
neuroanatomy and recognition of key clinical symptoms and findings. Clinical Use Disclosure:
diagnoses may be confirmed by diagnostic testing with electrodiagnostic studies Drs Hobson-Webb and Juel
and peripheral nerve ultrasound. report no disclosures.
* 2017 American Academy
of Neurology.
Continuum (Minneap Minn) 2017;23(2):487–511.
INTRODUCTION median nerve. Carpal tunnel syn-

This article focuses on peripheral drome may be present in up to 42%
mononeuropathies, indicating dis- of workers in certain occupations
ease or dysfunction in a single periph- (eg, poultry processing) and has an
eral nerve. Mononeuropathies may be annual incidence of 193 per 100,000 in
caused by focal compression, inflam- all women.1,2 Its prevalence in the
mation, nerve tumors, trauma, or United States is estimated at 50 per
other etiologies. Compression (or 1000, with a cost of $30,000 per
entrapment) is the most common affected individual.3 Morton neuroma,
cause. While mononeuropathies may ulnar neuropathy, meralgia paresthetica,
also be superimposed upon a back- and radial neuropathy represent
ground of polyneuropathy, a survey the other most common peripheral
of polyneuropathies is beyond the mononeuropathies.2
scope of this article. Knowing peripheral nerve anatomy
Entrapment mononeuropathies and function allows clinical localiza-
represent a common reason for visits tion that can be further refined and
to primary care and outpatient neu- confirmed with electrodiagnostic stud-
rology practices. The most common of ies and peripheral nerve imaging. In
these, carpal tunnel syndrome, is patients with mononeuropathy, the
related to chronic compression of the etiology, severity, odds of spontaneous
Continuum (Minneap Minn) 2017;23(2):487–511 ContinuumJournal.com 487
Copyright © American Academy of Neurology. Unauthorized reproduction of this article is prohibited.
Entrapment Neuropathies
KEY POINT
h Early diagnosis and recovery, and patient preferences MEDIAN NERVE
effective management are important factors that guide Median neuropathy at the wrist, spe-
of mononeuropathies treatment. Early diagnosis and ef- cifically carpal tunnel syndrome, is the
are essential in improving fective management of mononeuro- most common mononeuropathy of
patient quality of life and pathies are essential in improving adults. A thorough understanding of
reducing costs of care. patient quality of life and reducing the anatomy of the median nerve and
costs of care. adjacent structures and of associated
This article presents the most com- diagnostic techniques is therefore in-
monly encountered entrapment mono- valuable in outpatient neurology.
neuropathies, with a focus on relevant
anatomy, clinical symptoms, methods Basic Anatomy
of diagnosis, and recommended The median nerve forms from the
treatment. The pathophysiologic pro- terminal divisions of the medial and
cesses related to peripheral nerve lateral cords of the brachial plexus,
trauma and compression are not receiving contributions from the C5 to
covered in this discussion because T1 nerve roots (Figure 7-1). It courses
of space limitations but are compre- medial to the brachial artery throughout
hensively reviewed by Stewart.4 the upper arm. In the distal arm, the
FIGURE 7-1 Median nerve. The nerve is labeled in bold,

and sensory branches are labeled in italics.
B 2016 Vern C. Juel.
488 ContinuumJournal.com April 2017

KEY POINT
nerve may pass beneath the ligament In the distal carpal tunnel, the h Patients with carpal
of Struthers, which is present in some median nerve divides into the motor tunnel syndrome
individuals (1% to 13%) and represents (thenar) branch and sensory branches classically present
a rare cause of median nerve entrap- to the digits and palm. The motor with numbness,
ment.5,6 The nerve then passes under branch innervates the abductor tingling, and other
the bicipital aponeurosis at the elbow. pollicis brevis, opponens pollicis, and paresthesia affecting
Moving distally, the median nerve superficial head of flexor pollicis the first through third
then travels between the two heads of brevis.10 An accessory thenar branch digits and the lateral
the pronator teres, deep to the hu- may innervate the flexor pollicis brevis aspect of the fourth
meral head and superficial to the ul- in nearly half of patients.10 digit. It is not unusual
for patients to report
nar head. The nerve then continues Median nerve anatomic variants.
sensory symptoms
distally between the flexor digitorum Martin-Gruber anastomoses are the
affecting the entire
superficialis and flexor digitorum most common anatomic variants af- hand or radiation from
profundus muscles. Approximately fecting the median nerve, with an the hand to the proximal
4 cm distal to the medial epicondyle, estimated prevalence ranging from upper extremity.
the anterior interosseus nerve branches 20% to 40%.11,12 Martin-Gruber anas-
from the main trunk of the median tomoses typically leave the main me-
nerve.5 The anterior interosseus nerve dian nerve or anterior interosseus
innervates the flexor pollicis longus, nerve trunk near the elbow and cross
flexor digitorum profundus to the over to join the ulnar nerve. There are
second and third digits, and prona- four to six types of Martin-Gruber
tor quadratus. anastomoses based on the exact anat-
Just proximal to the distal wrist omy.12 The main significance of a
crease, the palmar cutaneous branch of Martin-Gruber anastomosis is the
the median nerve leaves the main nerve confounding effect that it may cause
trunk.5 It travels between the palmaris in interpretation of electrodiagnostic
longus and flexor carpi radialis tendons studies, as discussed later in this
and proceeds outside the carpal tunnel article. Other rare anatomic variants
to provide sensation for the thenar of the median nerve include the
eminence and proximal lateral palm.7,8 Riche-Cannieu anastomosis (‘‘the all-
The median nerve lies superficially ulnar hand’’), Berrettini anastomosis,
at the volar distal wrist crease, an and Marinacci anastomosis (the reverse
external landmark that roughly ap- Martin-Gruber anastomosis).11
proximates the carpal tunnel inlet.
The flexor retinaculum forms the roof Clinical Presentation
of the carpal tunnel. Deep to and The most common median mono-
surrounding the nerve are the tendons neuropathy results from median nerve
of the flexor pollicis longus, flexor compression at the wrist, causing
digitorum superficialis, and flexor carpal tunnel syndrome. Patients with
digitorum profundus.9 The hook of carpal tunnel syndrome classically
the hamate, pyramidal, and pisiform present with numbness, tingling, and
bones form the medial (ulnar) border other paresthesia affecting the first
of the carpal tunnel, while the scaph- through third fingers and the lateral
oid bone, trapezoid bone, and tendon aspect of the fourth finger. It is not
of the flexor carpi radialis muscle unusual for patients to report sensory
comprise the lateral (radial) aspect. symptoms affecting the entire hand or
The floor or inferior margin of the radiation from the hand to the proxi-
carpal tunnel formed by the carpal mal upper extremity. These sen-
bones is known as the carpal sulcus. sory symptoms may be exacerbated
by activities that require wrist flexion, weakened grip and difficulty per-
including driving a car, and often wake forming fine motor tasks, and they
the patient from sleep at night. Shaking may drop items easily. It is often
or flicking the affected hand may allevi- unclear how much of the disability is
ate the sensation, which can be quite related to loss of muscle strength as
painful. Case 7-1 illustrates a classic opposed to loss of sensation. On
case of early carpal tunnel syndrome. physical examination, careful observa-
Weakness may occur in more ad- tion may reveal mild flattening of the
vanced carpal tunnel syndrome. Pa- thenar eminence or frank atrophy. A
tients describe a generalized sense of Tinel sign consists of paresthesia in
Case 7-1
A 24-year-old right-handed woman presented with numbness and tingling in her right hand that had
begun about 3 months previously. Initially, the symptoms only occurred while carrying her infant son.
She then began to wake at night with a sensation of painful numbness in the entire hand that
radiated to her elbow. She tried wearing a neutral position wrist brace at night, but it provided only a
minor degree of improvement. She had no history of wrist or upper limb injury.
On examination, she had mild weakness of thumb abduction and loss of sensation over the entire
palmar surface of the right first through third fingers and the lateral half of the fourth finger.
Percussion over the midvolar wrist sent shooting electrical pains into her hand.
Nerve conduction studies were performed and showed slowing of the median mixed and sensory
nerve action potentials across the wrist with normal motor responses. Nerve ultrasound demonstrated
enlargement of the median nerve at the carpal tunnel inlet (Figure 7-2). She was diagnosed with
carpal tunnel syndrome and underwent a local corticosteroid injection performed by an orthopedic
surgeon, resulting in relief of symptoms.
FIGURE 7-2 Ultrasonography showing the median nerve at the carpal tunnel inlet at the level of the distal wrist crease. A,
Ultrasonography of the patient in Case 7-1 showing enlarged cross-sectional area (19 mm2) of the median
nerve (arrow) associated with loss of nerve signal. B, Ultrasonography of a healthy control showing normal
median nerve (arrow) measuring 8 mm2 at the distal wrist crease with normal signal.
Comment. This case is a classic presentation of carpal tunnel syndrome, confirmed by nerve
conduction studies and nerve ultrasound. Although the median nerve sensory territory does not
extend proximal to the wrist, patients often describe radiation of paresthesia into the arm,
particularly upon waking. As an initial treatment option, nocturnal wrist splinting may relieve
symptoms, although the response may be incomplete in more severe cases of carpal tunnel syndrome.
In patients without axonal loss or weakness, corticosteroid injections of the carpal tunnel are a
reasonable treatment option that may alleviate symptoms short of surgical decompression.

KEY POINTS
the distal distribution of a sensory wrist and positive Phalen testing. h A negative Phalen test
nerve when it is percussed. In carpal Depending upon the exact level of the is a strong predictor
tunnel syndrome, a Tinel sign may be proximal median nerve lesion, weak- of normal nerve
present at the distal wrist crease, but ness in the flexor pollicis longus, flexor conduction studies.
the sensitivity may be as low as 30% digitorum profundus to the second h Most neurologists
to 43% with specificity up to 65%.13,14 and third digits, flexor digitorum consider electrodiagnostic
The Phalen test is performed by superficialis, and pronator teres mus- testing to be the gold
having the patient flex the wrists cles may be present. Isolated lesions standard in diagnosing
and press the dorsum of both hands of the anterior interosseus nerve may carpal tunnel syndrome.
together for 30 to 60 seconds. A false- lead to weakness in the flexor pollicis Considerable debate
positive result may occur when longus, flexor digitorum profundus exists regarding the
interpreting musculoskeletal wrist to the second and third digits, and the optimal set of tests for
pain as a positive result, and spe- pronator quadratus. Unlike carpal making a diagnosis.
cificity is only 15% to 17% range. tunnel syndrome, anterior interosseus
Sensitivity of Phalen testing is better, neuropathies are generally due to
but only around 50% to 67%.14Y16 noncompressive causes such as idio-
Patients with positive Tinel and pathic brachial neuritis/neuralgic
Phalen testing have lower nerve con- amyotrophy.19
duction velocities than those with
negative testing.17 A negative Phalen Electrodiagnostic Testing in
test is a strong predictor of normal Carpal Tunnel Syndrome
nerve conduction studies.18 Most neurologists consider electro-
Strength testing for suspected car- diagnostic testing to be the gold
pal tunnel syndrome should include standard in diagnosing carpal tunnel
upper limb and especially forearm and syndrome. Considerable debate exists
intrinsic hand muscles with special regarding the optimal set of tests for
focus on the abductor pollicis brevis, making a diagnosis. The American
opponens pollicis, and flexor pollicis Association of Electrodiagnostic Med-
longus muscles. The finding of weak- icine, now known as the American
ness in the abductor pollicis brevis Association of Neuromuscular and
and opponens pollicis with normal Electrodiagnostic Medicine (AANEM),
strength in the flexor pollicis longus has published basic guidelines for
helps localize the pathology to the recommended electrodiagnostic test-
carpal tunnel. More proximal lesions ing in patients with suspected carpal
of the median nerve would involve the tunnel syndrome. The recommenda-
flexor pollicis longus. Detailed sensory tions include performing an initial
examination will reveal loss of sensa- median sensory nerve conduction
tion in the palmar first through third study across the wrist at a distance
digits and lateral fourth digit. Sensa- of 13 cm or 14 cm. If normal, a
tion of the proximal lateral palm may shorter segment study (7 cm to
be spared in carpal tunnel syndrome 8 cm) of the median mixed nerve is
because of its innervation by the recommended. These studies should
palmar cutaneous branch of the be performed with a radial or ulnar
median nerve. sensory or mixed response across the
More proximal lesions of the median same distance in the same limb for
nerve have the same distribution of comparison of interlatency differ-
sensory loss as seen in carpal tunnel ences. A median motor response
syndrome with the addition of the recording over the abductor pollicis
palm, but lack a Tinel sign at the brevis is also recommended, along
KEY POINTS
h When performing with measurement of another motor evidence exists to support its use.22
nerve conduction response in the same limb. Optional In neuromuscular ultrasonography,
studies, clinicians testing includes needle EMG of C5 to high-frequency ultrasound probes
should be aware T1 muscles (to exclude cervical radi- provide detailed peripheral nerve
of the changes caused culopathy as a contributing factor) anatomic information. Nerves are
by a Martin-Gruber and supplementary nerve conduc- consistently enlarged at sites of com-
anastomosis. tion studies.20 pression. In carpal tunnel syndrome,
h Peripheral nerve Electrodiagnostic testing in Martin- the median nerve typically has a
ultrasound is a useful Gruber anastomosis. When performing maximal point of enlargement at or
tool in diagnosing median nerve conduction studies, cli- near the carpal tunnel inlet corre-
entrapment neuropathies, nicians should be aware of the changes sponding to the surface anatomic
with nerves consistently caused by a Martin-Gruber anastomo- marker of the distal wrist crease
enlarged at or near sites sis. A Martin-Gruber anastomosis may (Figure 7-2). Reference values are
of compression. result in low distal amplitude of the varied, but a cross-sectional area of
median nerve compound muscle ac- the median nerve of greater than 12 mm2
tion potential (CMAP) when recording is generally considered abnormal. A
over the abductor pollicis brevis and 2014 study found a cross-sectional
stimulating at the wrist. With proximal area of greater than 10 mm2 to have
nerve stimulation, the median CMAP 89% sensitivity and 90% specificity for
amplitude will be higher. This can diagnosing carpal tunnel syndrome,
create confusion and concern for as compared to a validated clinical
overstimulation of the median nerve diagnostic tool.23
at the elbow, with costimulation of the Peripheral nerve ultrasound is a
ulnar nerve. The presence of a Martin- useful tool in diagnosing entrapment
Gruber anastomosis can be confirmed neuropathies, with nerves consistently
by stimulating the median nerve at the enlarged at or near sites of compres-
elbow and recording a CMAP in an sion. Substantial literature supports
ulnar-innervated hand muscle, typically the use of ultrasound in diagnosing
the first dorsal interosseus or abductor carpal tunnel syndrome.22,23 Neuro-
digiti minimi.21 Identifying a Martin- muscular ultrasonography also pro-
Gruber anastomosis by recording vides added value in understanding
over ulnar-innervated thenar mus- the pathogenesis of carpal tunnel
cles is discouraged, as the abductor syndrome. Routine ultrasound studies
pollicis brevis CMAP may confound may reveal contributing factors or
interpretation. A drop in amplitude issues that confound the diagnosis of
between distal and proximal stimula- carpal tunnel syndrome. These may
tion of the ulnar nerve may also be range from anatomic variants and
present in a Martin-Gruber anasto- intraneural tumors to the relatively
mosis and be mistaken for conduc- common bifid median nerve and the
tion block.21 persistent median artery. The persis-
tent median artery is an accessory
Ultrasonographic Testing in artery that arises from the ulnar ar-
Carpal Tunnel Syndrome tery in the proximal forearm as an
Neuromuscular ultrasonography has embryologic remnant. When present,
recently emerged as a novel diagnostic it courses with the median nerve
tool for carpal tunnel syndrome. The through the forearm and carpal tun-
exact role for neuromuscular ultra- nel. Other non-nerve findings may
sonography in patient care is still include coexistent tenosynovitis or
under investigation, but substantial accessory musculature.22

KEY POINT
Electrodiagnostic and treatment.26 These recommendations h The American Academy
Ultrasonographic Testing in largely mirror those of the AAOS. of Orthopaedic
Other Median Neuropathies The authors individualize treat- Surgeons states that
Testing for proximal median neuropa- ment for carpal tunnel syndrome nonsurgical treatments
thies involves the same techniques based on the severity of nerve com- (splinting and local
used for the assessment of carpal pression as determined by the elec- corticosteroid injections)
tunnel syndrome, with less need for fo- trodiagnostic findings. For patients are a reasonable
cused testing across the carpal tunnel with mild carpal tunnel syndrome in- treatment option for
and increased need for needle EMG to volving abnormal findings isolated to carpal tunnel syndrome
the median mixed or sensory re- for those early in the
help determine the level and severity of
course of symptoms
involvement. Neuromuscular ultraso- sponses, the authors begin a trial of
without evidence
nography can be helpful in identifying neutral position wrist splinting and
of median nerve
peripheral nerve trauma or other ab- nonsteroidal anti-inflammatory medica- denervation. A trial
normalities of the nerve, including focal tions where appropriate. Patients who period of 2 to 7 weeks
enlargement of proximal segments. do not experience satisfactory symp- is recommended to
tom relief may subsequently be re- observe for improvement.
Treatment of Carpal Tunnel ferred for a trial of local corticosteroid
Syndrome injections. Decompressive surgery to
Clinical practice guidelines are avail- transect the transverse carpal ligament
able for the treatment of carpal tunnel may subsequently be considered in pa-
syndrome, although adherence to tients with significant residual symp-
these published standards varies widely toms. For patients with severe carpal
in practice.24 The American Academy of tunnel syndrome with prolonged, low-
Orthopaedic Surgeons (AAOS) states amplitude CMAPs and denervated
that nonsurgical treatments (splinting median-innervated thenar muscles by
of the wrist to a neutral position and needle EMG, the authors may employ
local corticosteroid injections) are a the same treatments acutely but also
reasonable option for those early in the refer patients for expeditious surgical
course of symptoms without evidence consultation with a hand surgery spe-
of median nerve denervation. A trial cialist in an effort to salvage the
period of 2 to 7 weeks is recommended maximum degree of sensorimotor
to observe for improvement. Carpal function in the hand.
tunnel release is strongly recommended
(Grade A, Level I evidence) either as a ULNAR NERVE
first option for treatment or for those Ulnar neuropathy, often occurring at
for whom nonsurgical therapies have or near the elbow, is the second most
failed. The AAOS made no recommen- common mononeuropathy seen in
dations for patients with carpal tunnel outpatient neurology settings.
syndrome and coexistent diabetes
mellitus, cervical radiculopathy, or Basic Anatomy
polyneuropathy or for carpal tunnel The ulnar nerve arises from the C8 to
syndrome in the workplace.25 Heat T1 (and occasionally from C7 to T1)
therapy, electrical stimulation, ionto- nerve roots and the medial cord of the
phoresis, and laser therapies were brachial plexus and descends through
among the treatments with no evi- the posteromedial arm, anterior to the
dence to support their use.25 The medial head of the triceps brachii
American Congress of Rehabilitative (Figure 7-3). The first branch off the
Medicine (ACRM) also has published ulnar nerve is typically a sensory
guidelines on carpal tunnel syndrome branch to the elbow, followed by a
KEY POINT
h The medial collateral
ligament of the elbow
defines the floor of the
cubital tunnel, while the
roof consists of the
thickened fascia known
as the Osborne (arcuate)
ligament. This ligament
lies between the medial
and ulnar heads of the
flexor carpi ulnaris.
FIGURE 7-3 Ulnar nerve. The nerve is labeled in bold, and

sensory branches are labeled in italics. In the
hand, the muscle labels abductor, opponens, and
flexor apply to the abductor digiti minimi, opponens digiti
minimi, and flexor digiti minimi.
motor branch to the flexor carpi cubital tunnel is located just distal to
ulnaris.27 Compression in the arm is the elbow. The medial collateral liga-
rare but may occur at the arcade of ment of the elbow defines the floor of
Struthers, a fibrous band running from the cubital tunnel, while the roof
the medial head of the triceps to the consists of the thickened fascia
medial intermuscular septum. Consid- known as the Osborne (arcuate)
erable debate exists over the preva- ligament. This ligament lies between
lence of this anatomic variant and its the medial and ulnar heads of the
clinical significance.28 flexor carpi ulnaris.
The ulnar nerve then passes through Within the proximal forearm, the
the epicondylar (ulnar) groove, lo- ulnar nerve is located medial and
cated between the medial epicondyle superior to the flexor digitorum pro-
and the olecranon. An anomalous fundus and deep to the flexor carpi
anconeus epitrochlearis muscle over- ulnaris and gives branches to inner-
lying the ulnar nerve and extending vate these muscles along its course.
between the olecranon and medial The ulnar nerve lies lateral to the
epicondyle may be a source of com- flexor carpi ulnaris and medial to the
pression in some individuals.27 The ulnar artery in the distal forearm.

KEY POINT
Compression of the ulnar nerve in the clinical assessment should not reveal h The Guyon canal, or
forearm is rare. an objective sensory deficit in the ulnar tunnel, is a site of
The Guyon canal, or ulnar tunnel, is medial forearm. Patients may have potential ulnar nerve
a site of potential ulnar nerve entrap- pain and tenderness near the epi- entrapment at the wrist.
ment at the wrist. The canal extends condylar groove in cases of ulnar neu- The canal extends from
from the proximal end of the pisiform ropathy at the elbow, although this the proximal end of the
to the hook of the hamate. The flexor is not always present. pisiform to the hook of
retinaculum and hypothenar muscles Ulnar motor dysfunction may be the hamate.
define the floor, while the roof con- perceived as clumsiness with mild or
sists of the volar carpal ligament. The early ulnar neuropathy at the elbow.
lateral (radial) border is defined by the Patients may note difficulty with fine
hook of the hamate, while the pisi- motor tasks or drop things easily.
form, pisohamate ligament, and abduc- Frequently, patients experience weak-
tor digiti minimi muscle belly compose ness of the fifth digit and may struggle
the medial (ulnar) border. The ulnar to place it into a jacket or pants pocket
nerve passes through the Guyon canal with the rest of the hand. Grip weak-
with the ulnar artery.29 ness is also a frequent symptom with
The Guyon canal can be further more advanced motor involvement.
subdivided into zones. Zone 1 extends Observant patients may notice atrophy
from the proximal volar carpal liga- of the intrinsic hand muscles, particu-
ment to the bifurcation of the ulnar larly the first dorsal interosseous.
nerve. Pathology in this region affects On clinical examination, the Froment
both the motor and sensory functions sign may be present. To test for the
of the nerve. Zone 2 extends laterally Froment sign, the patient is asked to
beneath the palmaris brevis to the hold a thin object (eg, a sheet of paper)
fibrous arch of the hypothenar mus- between the thumb and index finger
cles and contains only motor fibers and an examiner attempts to remove it.
of the ulnar nerve. Zone 3 extends In patients with weakness of the ulnar-
medially from the ulnar nerve bifur- innervated adductor pollicis, the object
cation and contains both motor and may be easily removed or the patient
sensory fibers. The motor fibers form a may attempt to compensate for the
superficial branch supplying the weakness by activating the median-
palmaris brevis muscle, so zone 3 innervated flexor pollicis longus and
pathology is generally considered to pinching with the distal phalanx of the
affect only sensory function.30 thumb. Motor testing of the ulnar-
innervated flexor digitorum profundus
Clinical Presentation and to the fourth and fifth digits along with
Examination Findings the flexor carpi ulnaris should be
The ulnar nerve provides sensory performed as part of the standard
innervation to the fourth and fifth examination.
fingers, the medial palm, and the A Tinel sign may be present over
dorsomedial hand. Patients with ulnar the ulnar nerve at sites of entrapment.
neuropathy can present with pares- Gentle palpation of the epicondylar
thesia that may range from a feeling of groove during elbow flexion and ex-
deadness to shooting electriclike pains tension can be helpful in diagnosing
that are most prominent in the fourth ulnar nerve subluxation, which is also
and fifth digits. It is not unusual for present in a proportion of asymp-
patients to note pain radiation be- tomatic individuals.31 Although its
tween the elbow and hand, although presence is not diagnostic of ulnar
KEY POINT
h Needle EMG is essential neuropathy and it is not an established minimum of 10 cm should be present
in assessing ulnar risk factor, identifying subluxation may between the above-elbow and below-
neuropathy at be helpful in selecting the appropriate elbow sites of stimulation. The diag-
the elbow. surgical intervention in patients with nosis of ulnar neuropathy at the elbow
ulnar neuropathy at the elbow. Sublux- can be made when the conduction
ation can be detected by palpation of velocity across the elbow is greater than
the ulnar nerve moving over the or equal to 10 m/s slower than the wrist
medial epicondyle with flexion or ex- to below-elbow segment. Other sup-
tension at the elbow. portive findings include a drop in CMAP
Although rarely used by neurolo- amplitude of greater than 20% across
gists, the surgical literature makes the elbow.33
frequent use of the McGowan grading Criticism of the initial AANEM guide-
system in the assessment of ulnar lines center on their lack of sensi-
neuropathy at the elbow. It is helpful tivity for precise localization in some
to know this system when reviewing patients with ulnar neuropathy at the
the literature on the topic and com- elbow. Sensitivity has ranged from
municating with surgical colleagues. 37% to 86%, while specificity has been
Grade 1 consists of paresthesia in the greater than 95%.34 Techniques for
fourth and fifth digits and a feeling of improving sensitivity reduce specific-
hand clumsiness. Grade 2 includes ity, and this should be considered
weakness and impaired sensation, when performing additional testing.
sometimes with mild atrophy of the Inching is a popular technique often
intrinsic hand muscles. In McGowan used to identify sites of pathology in
grade 3, the sensory and motor defi- ulnar neuropathy at the elbow. The
cits are severe and marked muscle 10-cm segment between the above-
atrophy is present.32 elbow and below-elbow sites is di-
vided into 2-cm segments. Stimulation
Electrodiagnostic Testing is applied at each point, with attention
Electrodiagnostic testing is considered to the latency differences and CMAP
the gold standard for the diagnosis of waveforms. Using this approach, the
ulnar neuropathy, but the recom- sensitivity of nerve conduction studies
mended testing and definition of is improved, detecting up to 90% of
abnormality is debated. The majority patients with clinical evidence of ulnar
of work published has centered on neuropathy at the elbow.35 Although
ulnar neuropathy at the elbow, the this technique offers improved sensi-
most common variant of ulnar neu- tivity and more precise localization, it
ropathy. AANEM guidelines are fre- requires attention to technical detail
quently cited in most studies of ulnar for accurate results.
neuropathy at the elbow. 33 The Needle EMG is essential in as-
AANEM guidelines for the diagnosis sessing ulnar neuropathy at the elbow,
of ulnar neuropathy at the elbow as outlined in Case 7-2. Examination
recommend performing ulnar sensory of ulnar-innervated muscles is helpful
nerve conduction studies and motor for both localization and assessment
nerve conduction studies to the ab- of severity. Other muscles with C7 and
ductor digiti minimi. Elbow position C8 innervation should also be sampled
during testing (with flexion between to assess for the presence of coexis-
70 degrees and 90 degrees recom- tent cervical radiculopathy or bra-
mended) should be recorded and chial plexopathy. Electromyographers
adequate warming maintained. A should be aware that little evidence

KEY POINT
Case 7-2 h As with carpal tunnel

syndrome, neuromuscular
A 52-year-old left-handed man noted progressive numbness and tingling
ultrasonography has
of his right fourth and fifth fingers. His hand was clumsy at times, and he
emerged as an
began having difficulty buttoning his shirts. He reported a ‘‘funny bone’’
alternative means of
sensation that radiated into his right hand, particularly after talking on the
assessing ulnar
phone for extended periods of time. Examination demonstrated mild
neuropathy at the elbow.
atrophy of the right first dorsal interosseus muscle. A Tinel sign was
The normal ulnar nerve
present over the right epicondylar (ulnar) groove. He had moderate
cross-sectional area is
weakness of right finger abduction and deep finger flexion of the fourth
8 mm2 to 11 mm2
and fifth digits with minimal weakness of thenar and finger extensor
at the elbow, with
muscles. He also had sensory loss over the right medial palm, the medial
larger values suggesting
aspect of the fourth finger and the entire fifth finger, and the dorsal
focal compression.
medial hand. Ulnar neuropathy at the elbow was suspected and classified
as a McGowan grade 2 based upon the clinical assessment.
The patient’s physician chose not to perform electrodiagnostic testing at
that time. An evaluating surgeon recommended ulnar nerve transposition, as
weakness and atrophy were already present. Following surgery, the patient
continued to have progressive symptoms and was then referred for
electrodiagnostic studies. Testing performed 6 months after surgery revealed
mild slowing of the ulnar motor conduction velocity at the elbow with
normal sensory responses. Ultrasonography of the ulnar nerve was normal.
Detailed needle EMG found evidence of denervation and reinnervation in
the right extensor indicis proprius, first dorsal interosseus, abductor pollicis
brevis, and C8 to T1 paraspinals. Along with a mild right ulnar neuropathy at
the elbow, a coexistent right C8 radiculopathy was diagnosed and confirmed
by imaging of the cervical spine.
Comment. Although the patient had symptoms compatible with ulnar
neuropathy at the elbow, mild weakness of thenar (median) and finger
extensor (radial) muscles was overlooked, and he was referred for surgical
intervention before the localizations for the deficits were confirmed.
When he failed to improve, electrodiagnostic studies subsequently
performed showed that a C8 radiculopathy was also present. This is an
example of double crush syndrome, in which two separate peripheral
nerve lesions occur along the course of the same nerve with both lesions
contributing to the clinical findings. This case illustrates the importance of
careful clinical examination and electrodiagnostic testing to establish accurate
localization prior to surgery.
exists regarding the utility of needle ultrasonography is not believed to be

EMG in determining prognosis.36 a superior means of diagnosing ulnar
neuropathy at the elbow for all pa-
Ultrasonographic Testing tients, although limited evidence in-
As with carpal tunnel syndrome, neu- dicates that it may be more sensitive
romuscular ultrasonography has than nerve conduction studies early in
emerged as an alternative means of the disease.38,39 Neuromuscular ultra-
assessing ulnar neuropathy at the sonography is best used as an adjunct
elbow. The normal ulnar nerve cross- to clinical and electrodiagnostic data
sectional area is 8 mm2 to 11 mm2 at to aid in localization. 40 It is helpful
the elbow, with larger values suggesting in pinpointing the area of pathology
focal compression.37 Neuromuscular and may identify alternative etiologies

KEY POINTS
h Testing of the dorsal for ulnar neuropathy at the elbow. outcomes with anterior ulnar nerve
ulnar cutaneous sensory These include anatomic variants (eg, transposition.43 Other studies have
nerve response can be anomalous anconeus epitrochlearis favored simple decompression over
added to EMG and muscle), ganglion cysts, and other transposition, unless difficulties with
ultrasonography when mass lesions. painful ulnar nerve luxation over the
assessing lesions distal The evaluation of ulnar neuropathy medial epicondyle are present.43
to the elbow, assisting outside the elbow region follows No consensus exists on when ulnar
in localization of an many of the previously mentioned neuropathy at the elbow becomes
ulnar neuropathy at or principles. Whether evaluating proxi- severe enough to warrant surgery.
proximal to the wrist. mal or distal lesions, ulnar motor and Some have suggested that surgical
h Three months of sensory nerve conduction studies are treatment is warranted in patients with
conservative treatment essential. Ultrasonography and needle mild (McGowan grade 1) ulnar neu-
with the use of elbow EMG also provide helpful additive in- ropathy at the elbow. Excellent out-
pads and avoidance of formation. Testing of the dorsal ulnar comes have been reported in this
prolonged elbow flexion
cutaneous sensory nerve response can population using simple decompres-
is recommended as
be added when assessing lesions distal sion and medial epicondylectomy.44
first-line treatment in
those patients with
to the elbow, assisting in localization Further supporting the case for early
ulnar neuropathy at the of ulnar nerve lesions at or proximal to intervention are data demonstrating
elbow with mild the wrist. The dorsal ulnar cutaneous that patients with McGowan grade 3
symptoms and less sensory nerve response will be normal ulnar neuropathy at the elbow are
severe electrodiagnostic with the lesions at the wrist, but more likely to have fair or poor
findings. Up to 50% of abnormal with lesions in the region postsurgical outcomes.45
patients will have of the proximal forearm or elbow. Few alternative approaches to the
resolution of symptoms treatment of ulnar neuropathy at the
with this approach. Treatment of Ulnar Neuropathy elbow are available. Unlike in carpal
h Unlike in carpal at the Elbow tunnel syndrome, corticosteroid injec-
tunnel syndrome, The best approach to treating ulnar tions have not shown efficacy in ulnar
corticosteroid injections neuropathy at the elbow remains con- neuropathy at the elbow.46,47 Ultra-
have not shown efficacy troversial. Three months of conserva- sound and low-level laser therapy have
in ulnar neuropathy at tive treatment with the use of elbow shown some promise but are neither
the elbow.
pads and avoidance of prolonged elbow widely accepted nor available.48 Addi-
flexion is recommended as first-line tional research is needed to under-
treatment in those with mild symptoms stand how clinical, electrodiagnostic,
and less severe electrodiagnostic find- and sonographic data might be com-
ings. Up to 50% of patients will have bined to predict and optimize pa-
resolution of symptoms with this ap- tient outcomes in ulnar neuropathy
proach.41 For patients for whom con- at the elbow.
servative measures fail or who have
evidence of significant axonal loss on RADIAL NERVE
initial electrodiagnostic examination, The radial nerve is less likely to be
surgical management is indicated. affected by chronic compression than
Three general approaches are used: the median or ulnar nerves but re-
simple decompression through exci- mains a frequent mononeuropathy
sion of the arcuate ligament, medial because of acute compressive lesions.
epicondylectomy, and ulnar nerve
transposition.42 An early analysis of Basic Anatomy
published data demonstrated that The radial nerve is the terminal branch
patients with more severe disease of the posterior cord of the brachial
(McGowan grade 3) have the best plexus (Figure 7-4). In the axilla, the

FIGURE 7-4 Radial nerve. The nerve is labeled in bold, and
sensory branches are labeled in italics.
radial nerve yields three branches, the lateral epicondyle, with branches
including the posterior brachial cuta- to the brachioradialis and the exten-
neous nerve and branches innervating sor carpi radialis longus and brevis.
the long and medial heads of the The nerve then bifurcates into two
triceps brachii. It then travels with terminal branches, a superficial sen-
the deep brachial artery between sory branch and a deep branch called
the long head of the triceps and the the posterior interosseous nerve.
humerus and courses through the The posterior interosseous nerve
spiral groove between the lateral passes through the arcade of FrPhse,
and medial heads of the triceps. Two formed by a fibrous arch arising from
sensory branches are present in this the superficial head of the supina-
region, including the lower lateral tor muscle at its attachment to the
brachial cutaneous nerve, the poste- lateral epicondyle. The posterior inte-
rior antebrachial cutaneous nerve, and rosseous nerve travels between and
motor branches to the lateral and innervates the superficial and deep
medial heads of the triceps. After heads of the supinator muscle to
passing through the lateral inter- supply the wrist and finger extensor
muscular septa, the radial nerve muscles.49 The superficial sensory
travels between the brachialis and bra- branch supplies sensation to the dor-
chioradialis muscles just anterior to solateral hand. It lies beneath the
KEY POINTS
h Slowly progressive radial brachioradialis muscle at the elbow Posterior interosseous syndrome is
neuropathy may occur and in the proximal forearm as it a pure motor syndrome without asso-
with humeral fracture travels with the radial artery. In the ciated sensory loss. It is much less
healing due to callus distal third of the forearm, the nerve common than radial compression
formation creating separates from the artery and travels at the spiral groove and results from
nerve entrapment. superficially beneath the brachio- posterior interosseous nerve com-
h Posterior interosseous radialis tendon. The nerve then pression within the arcade of Fröhse
syndrome is a pure travels between the brachioradialis related to repetitive supination, space-
motor syndrome and extensor carpi radialis longus occupying lesions, and trauma. It pre-
without associated tendons. Distally, the nerve pierces sents with marked weakness of finger
sensory loss. the overlying forearm fascia and di- extension and a lesser degree of wrist
h Electrodiagnostic vides into lateral and medial divi- extension weakness. Wrist extension
testing of the radial sions and ultimately into dorsal digital may be relatively spared due to exten-
nerve requires nerve nerves.50 sor carpi radialis longus innervation
conduction studies and occurring proximal to the division of
needle EMG. Clinical Presentation and the common radial nerve (Figure 7-4).
Examination Findings As the posterior interosseous nerve is a
The most common presentation of purely motor nerve, patients experi-
radial neuropathy is that of acute ence no sensory symptoms. Patients
compression at the level of the spiral sometimes report vague discomfort
groove, commonly known as Saturday over the dorsal forearm, worsened by
night palsy. In this syndrome, pa- activity involving supination of the arm.
tients compress the medial arm Pain with resisted supination of the
against a firm surface (eg, arm draped forearm can be used as a provocative
over a chair back) during prolonged test, but its specificity and sensitivity
sleep, deep sedation, or intoxica- are poorly defined.
tion. They may awaken unable to Isolated lesions of the superficial
extend the fingers or wrist. Numbness radial sensory nerve may also occur.
or paresthesia is present over the These may result from focal com-
dorsolateral hand. Pain at the spiral pression or trauma, as in cheiralgia
groove is relatively uncommon. The paresthetica (compression of the su-
symptoms typically resolve over 2 to perficial radial nerve at the wrist), or
3 months. as a rare type of diabetic mono-
Because of the close association neuropathy.56Y58 Patients experience
between the radial nerve and the sensory loss, sometimes associated
humerus, fractures of the humeral with uncomfortable paresthesia over
shaft are also a common cause of the dorsolateral hand. Sensory test-
proximal radial neuropathies. 51,52 ing of the affected region and the
Examination findings are dependent absence of associated weakness are
upon the level of the fracture. Acute essential in making the clinical diagnosis.
presentations are readily identified in
most cases, but delayed involvement Electrodiagnostic Testing
may be overlooked. Slowly progres- Electrodiagnostic testing of the radial
sive radial neuropathy may occur nerve requires nerve conduction stud-
with fracture healing due to callus ies and needle EMG. Typically, the
formation creating nerve entrap- radial motor response is recorded
ment53 or may be related to the over the extensor indicis proprius
surgical hardware used to repair the following stimulation at the forearm,
fracture itself.54,55 lateral elbow, and spiral groove. This

KEY POINTS
permits assessment of potential areas gation is needed to determine how h Needle EMG can assist
of entrapment, and special attention finding these secondary lesions might in localization and
to CMAP amplitudes and dispersion is impact prognosis and treatment. Al- prognosis of radial nerve
necessary. Stimulation at Erb point is though peripheral nerve trauma is not entrapment. The triceps
helpful in localizing proximal humeral covered in this article, neuromuscular brachii, brachioradialis,
lesions, although costimulation of the ultrasonography can be used to deter- and long head of
brachial plexus may contaminate the mine nerve continuity within hours or extensor carpi radialis
recordings.59 A superficial radial sen- days of peripheral nerve trauma, expe- are spared with isolated
sory response is valuable for differen- diting treatment decisions. posterior interosseous
tiating between common radial and nerve pathology.
posterior interosseous nerve pathol- Treatment of Radial h The most common of
ogy. As with any mononeuropathy, Neuropathies the radial neuropathies,
nerve conduction studies of other The most common of the radial neu- acute compression at
upper extremity nerves may be needed ropathies, acute compression at the the spiral groove
(Saturday night palsy),
to confirm isolated involvement of the spiral groove (Saturday night palsy),
typically resolves
radial nerve. typically resolves without additional
without additional
Needle EMG can assist in localization intervention. These acute compres- intervention. These
and prognosis. The triceps brachii, sions cause focal demyelination that acute compressions
brachioradialis, and long head of ex- will resolve within 2 to 3 months. cause focal demyelination
tensor carpi radialis are spared with Avoidance of further compression is that will resolve within
isolated posterior interosseous nerve recommended during this time. If 2 to 3 months.
pathology. Distally, the extensor secondary axonal damage has oc-
digitorum communis and extensor curred, recovery may take longer and
indicis proprius muscles are sampled. be incomplete.
Additional examination of nonradial Aside from repair of traumatic
muscles is helpful and often neces- nerve injuries and compression
sary in excluding brachial plexopathy due to mass lesions, surgical inter-
or cervical radiculopathy as a cause ventions for radial neuropathy are
of symptoms. uncommon, and no standard pro-
cedures exist for routine release of
Ultrasonographic Testing the radial nerve.
Neuromuscular ultrasonography may In patients with posterior interos-
also be used in the diagnosis of radial seous syndrome, anti-inflammatory
neuropathies. Focal enlargement has medications, rest, and corticosteroid
been documented at sites of compres- injections are common first-line treat-
sion and can be helpful in localization. ment recommendations.63 Surgical re-
Radial nerve cross-sectional area is lease of the superficial head of the
typically less than 10 mm2 in the supinator muscle may be performed
upper arm and antecubital fossa, with in patients for whom conservative
the superficial radial sensory nerve management has failed, but this is
measuring only 1 mm2 to 3 mm2.60,61 rarely performed at the authors’ insti-
The posterior interosseous nerve tution. Although the surgical literature
cross-sectional area measures ap- reports good response to treatment
proximately 2 mm2.62 Interestingly, in most cases,65,66 patients involved
distal enlargement of the posterior in workers’ compensation claims are
interosseous nerve has been docu- known to have less favorable out-
mented in cases of proximal radial comes.67 Given the lack of large
nerve lesions, suggesting a double prospective trials and potential for
crush syndrome.63,64 Additional investi- surgical complications,68 posterior
KEY POINT
h The common fibular interosseous nerve release surgery is the short head of the biceps femoris
(peroneal) nerve is the not routinely advised. muscle before separating from the
lateral division of the sciatic nerve in the popliteal fossa.
sciatic nerve and FIBULAR (PERONEAL) NERVE The nerve branches within the fossa
formed by the L4 to Fibular neuropathy is the most fre- to make a small contribution to the
S1 spinal roots. quent entrapment neuropathy of the sural nerve, although considerable var-
lower extremity. An organized diag- iability exists. The fibular tunnel, a
nostic approach is necessary in the potential site of nerve entrapment, is
evaluation of affected patients. composed of the arch made by the
peroneus longus, the soleus tendon,
Basic Anatomy and the proximal fibula.69
The common fibular (peroneal) nerve is At the level of the fibular head, the
the lateral division of the sciatic nerve common fibular nerve divides into deep
and formed by the L4 to S1 spinal roots. and superficial divisions (Figure 7-5
It branches from the sciatic nerve in the and Figure 7-6). The deep branch of
distal thigh and wraps around the the fibular nerve provides innervation
biceps femoris tendon and fibular head to the muscles of the anterior com-
on its course to the anterolateral leg.69 partment (tibialis anterior, extensor
The fibular nerve gives off a branch to digitorum longus, extensor hallucis
FIGURE 7-5 Common and deep fibular (peroneal) nerves.

The nerves are labeled in bold, and sensory
branches are labeled in italics.

KEY POINT
h Compression of the
common fibular nerve at
the level of the fibular
head is the most
common lower extremity
mononeuropathy.
Common causes include
weight loss, prolonged
immobility, and frequent
crossing of the legs.
FIGURE 7-6 Common and superficial fibular (peroneal)

nerves. The nerves are labeled in bold, and
sensory branches are labeled in italics.
longus, peroneus tertius, extensor lar neck exostosis, and acute compres-
digitorum brevis) and sensation to the sion after wearing tight-fitting pants
dorsal web space between the first and (ie, skinny jeans).72Y74 Patients with
second toes. The superficial fibular common fibular neuropathy typically
nerve innervates the lateral compart- present with difficulty walking. While
ment muscles (peroneus longus and some patients describe overt footdrop,
peroneus brevis) and supplies sensa- many will report a ‘‘toe dragging,’’
tion to the distal lateral leg and dor- ‘‘foot slapping,’’ or frequent tripping.
sal foot.70 Paresthesia is sometimes noted in the
lower lateral leg and dorsal foot but is
Clinical Presentation and often overlooked in the setting of
Examination Findings significant weakness. Pain may also be
Compression of the common fibular present at the site of compression.
nerve at the level of the fibular head is Detailed physical examination may
the most common lower extremity reveal a Tinel sign over the fibular nerve
mononeuropathy.71 Common causes near the knee. Observation may dem-
include weight loss, prolonged immo- onstrate frank footdrop when walking
bility, and frequent crossing of the legs. or steppage gait. In milder cases, the
Other etiologies include prolonged gait may appear unaffected, with weak-
squatting, knee dislocation, ankle ness noted only when the patient is
sprains, intraneural ganglion cysts, fibu- asked to walk on his or her heels. Motor

KEY POINTS
h Any weakness of ankle testing will reveal weakness in the ankle Other L4 to L5 and sciatic muscles
inversion, toe flexion, or dorsiflexor, evertor, and toe extensor should be sampled to differentiate
hip abduction suggests muscles. Sensory loss can be variable isolated fibular mononeuropathy from
an L5 radiculopathy as but typically spares the dorsal fifth toe. sciatic neuropathy, lumbosacral plexo-
opposed to an isolated Any weakness of ankle inversion, toe pathy, and lumbar radiculopathy. For
fibular neuropathy. flexion, or hip abduction suggests an example, abnormalities on needle
h Superficial fibular L5 radiculopathy as opposed to an EMG of the tibialis posterior can assist
neuropathies spare isolated fibular neuropathy. in differentiating L5 radiculopathy
sensation in the first Cases of isolated deep fibular neuro- from fibular neuropathy.
dorsal web space, pathy are less common. Etiologies
as the deep fibular include trauma, compression, and Ultrasonographic Testing
nerve innervates this ganglion cysts.75 Involvement spares On neuromuscular ultrasonography,
sensory field. the ankle evertors and sensation of increased cross-sectional area is pres-
the lateral leg and foot. Sensory loss ent at sites of compression; early
of the web space between the first and studies suggest that larger nerve
second toes is present. Superficial cross-sectional area is associated with
fibular neuropathy is also relatively axonal loss.76 The nerve is usually
rare. Depending upon the level of smaller than 12 mm2 at the level of
involvement, it can present with sen- the fibular head.60 Neuromuscular
sorimotor or isolated sensory symp- ultrasonography in fibular neuropathy
toms. Weakness of ankle eversion is at the fibular head may reveal ana-
detected in more proximal disease, tomic causes, particularly in patients
while loss of sensation over the lateral without risk factors for nerve com-
leg and dorsolateral foot can occur pression. In one study, neuromuscular
with either proximal or distal lesions. ultrasonography demonstrated com-
The web space between the first and pressive intraneural ganglion cysts at
second toes will be spared any loss of the fibular head in 18% of patients.72
sensation, as the deep fibular nerve A 2015 analysis found abnormal bi-
supplies this area. ceps femoris anatomy, ganglion cysts,
and lipomas in a series of only 21
Electrodiagnostic Testing patients with footdrop due to com-
Motor nerve conduction studies of mon fibular neuropathy.77 This type of
the fibular nerve are performed with information cannot be obtained from
the recording electrode placed over the electrodiagnostic testing alone and is
extensor digitorum brevis with stimu- essential in guiding appropriate treat-
lation at the anterior ankle, fibular ment. Case 7-3 describes how electro-
head, and popliteal fossa. If the motor diagnostic studies and neuromuscular
response is absent, the recording ultrasonography can be used together
electrode can be placed over the in clarifying complicated cases of
tibialis anterior with stimulation at fibular nerve entrapment.
the fibular head and popliteal fossa.
The superficial fibular sensory re- Fibular Neuropathy Treatment
sponse can also be performed to assist Treatment of fibular neuropathy is
in localization. guided by etiology. Surgical repair is
Needle EMG is necessary to assess often necessary after traumatic injury.
severity and assist in prognosis. A Compressive intraneural ganglion
minimum examination consists of the cysts must be excised to prevent re-
tibialis anterior, peroneus longus, and currence and further nerve injury. For
short head of the biceps femoris. unremarkable cases of compression

Case 7-3
A 79-year-old man with lung cancer noted left foot weakness after
entering a rehabilitation program following a 2-month hospital stay. He
was persistently tripping over his left foot, and his wife stated that his
walking was ‘‘too loud.’’ He denied any trauma to the leg and had not
noticed any pain but did describe an intermittent tingling sensation over
his dorsal left foot. He had no low back pain.
Examination was remarkable for cachexia and mild diffuse weakness of the
bilateral upper and lower extremities. He also had superimposed weakness
with only movement against gravity for left ankle dorsiflexion, ankle eversion,
and extension of all toes. Bilateral lower extremity reflexes were absent, and
he had reduced sensation in a stocking-glove distribution bilaterally.
Electrodiagnostic testing demonstrated evidence of a widespread
sensorimotor axonal polyneuropathy. No fibular motor response was
present with recording over the extensor digitorum brevis on either side.
Bilateral superficial fibular sensory responses were absent bilaterally, as
were sural sensory responses. Needle EMG exhibited denervation and
reinnervation in the bilateral tibialis anterior and medial gastrocnemius,
but the changes were most prominent in the left tibialis anterior. A fibular
motor response recording over the left tibialis anterior demonstrated a
drop in amplitude and slowing across the fibular head. Ultrasound of the
left fibular nerve at this site showed marked focal enlargement of the nerve.
The patient was diagnosed with left fibular neuropathy at the fibular head
superimposed on a background of sensorimotor polyneuropathy.
Comment. The patient in this case had a preexisting polyneuropathy
complicating assessment of superimposed mononeuropathies. Fibular
neuropathy at the fibular head was strongly suspected given the patient’s
presentation and risk factors of immobilization and apparent weight loss.
The use of needle EMG, alternate recording sites for fibular motor
responses, and ultrasonography permitted an accurate diagnosis.
at the fibular head with no or minor OTHER LOWER EXTREMITY

changes on electrodiagnostic testing, ENTRAPMENT NEUROPATHIES
time and avoidance or correction of Any peripheral nerve can be affected
risk factors may suffice. For more by entrapment. A few of the lesser
severe cases involving axonal loss, sur- known peripheral nerve entrapment
gery is indicated. This is compli- syndromes are reviewed here.
cated by lack of a standard approach
and the existence of differing sites of Tarsal Tunnel Syndrome
potential entrapment. Most patients The tibial nerve derives from the sciatic
have improvement in function and nerve and receives contributions from
pain following intervention, but the the L4 to S1 nerve roots. The tibial
published studies are small and nerve branches from the sciatic nerve at
lack standardization.78Y80 Microsurgical the level of the popliteal fossa and
decompression, with dissection of only travels distally beneath the arch of the
the fibrous band between the superfi- soleus. Its branches provide innervation
cial head of the peroneus longus and to muscles of ankle plantar flexion and
the soleus, may be an equally effective to the sural nerve. At the level of the
approach as compared to a more ankle, it passes through the tarsal
invasive surgical decompression.81 tunnel before dividing into its terminal

KEY POINTS
h The tarsal tunnel branches, the medial and lateral plan- diagnosis.89 Neuromuscular ultraso-
represents the space tar nerves. The tarsal tunnel repre- nography may aid in assessment of
between the flexor sents the space between the flexor structural causes of tarsal tunnel syn-
retinaculum and medial retinaculum and medial malleolus, drome symptoms, and some reports90
malleolus, containing containing the tibial nerve, posterior establish cross-sectional area cutoff
the tibial nerve, tibial artery, posterior tibial vein, flexor values to be used in the diagnosis of
posterior tibial artery, hallucis longus, tibialis posterior, and idiopathic tarsal tunnel syndrome.
posterior tibial vein, flexor digitorum longus.82 The medial In the absence of a structural cause
flexor hallucis longus, and lateral plantar nerves supply of compression, the exact value of
tibialis posterior, and cutaneous sensation over the plantar surgical decompression is unknown.
flexor digitorum longus.
surface of the foot, along with inner- A 2015 review of 31 patients undergo-
h Idiopathic tarsal tunnel vation of intrinsic foot muscles. The ing surgery for tarsal tunnel syndrome
syndrome is rare. tarsal tunnel is a potential site of tibial demonstrated good outcomes in 71%
Potential etiologies of nerve entrapment. but found that only 6 of 11 patients
tibial neuropathy at the
Tarsal tunnel syndrome, also known with idiopathic tarsal tunnel syndrome
ankle include trauma,
as tibial neuropathy at the ankle, is a improved. The best surgical outcomes
masses, accessory
muscles, bony
controversial topic in neurology. In occurred in those with a determined
malformations, vascular most cases, the diagnosis is established cause of tarsal tunnel syndrome, in-
anomalies, and by clinical presentation, although diag- cluding trauma and masses.91 This
iatrogenic causes. nostic criteria are ill defined. Symp- should be considered when designing
h The most common toms consist of numbness and painful a treatment plan.
location for Morton paresthesia involving the heel, medial
neuroma is the ankle, and the sole of the foot, al- Morton Neuroma
third or fourth though some definitions include ankle Although a separate entity from tarsal
interdigital nerves. pain with weight bearing.82 A Tinel tunnel syndrome, Morton neuroma is
sign may be present over the tibial a distal tibial mononeuropathy pre-
nerve at the ankle. In the authors’ expe- senting with shooting pains into the
rience, idiopathic tarsal tunnel syn- toes and other associated paresthesia
drome is rare. Potential etiologies of of the forefoot provoked by weight
tibial neuropathy at the ankle include bearing. It results from chronic repet-
trauma, masses, 83 accessory mus- itive mechanical trauma of a plantar
cles,84,85 bony malformations,86 vascu- digital nerve and is considered to
lar anomalies,87 and iatrogenic causes.88 represent a degenerative perineural
Electrodiagnostic testing can be fibrous enlargement of the nerve, as
helpful in excluding other causes of opposed to a true neuroma. The most
tarsal tunnel syndrome symptoms, but common location is the third or fourth
its exact utility in diagnosis is un- interdigital nerves. Diagnosis is through
known.89 No single set of characteristic clinical examination and, more recently,
electrodiagnostic findings exists, as it is ultrasound imaging.92Y94
often stated that plantar nerve re-
sponses are frequently unobtainable Meralgia Paresthetica
in individuals who are asymptomatic, Meralgia paresthetica is the commonly
particularly with advanced age. A sys- used term describing pathology of the
tematic review of the literature from lateral femoral cutaneous nerve, also
1965 to 2002 yielded only four studies known as the lateral cutaneous nerve
meeting review criteria, and these of the thigh. The lateral femoral
met only Class III level of evidence. cutaneous nerve arises from the L1
The review concluded that nerve con- to L3 nerve roots and lumbar plexus
duction studies might be helpful in and is a pure sensory nerve. Its path

KEY POINT
over the iliacus and under the ingui- gies and require special investigation. h Treatment of meralgia
nal ligament make it prone to injury Entrapment neuropathies may present paresthetica is most
and compression.95 The lateral fem- in the context of other peripheral often conservative,
oral cutaneous nerve may have a neuropathic processes and be super- including behavioral
variable course between individuals, imposed on a background of poly- modifications (eg,
with five distinct patterns identified, neuropathy or occur in parallel with wearing looser clothing),
making diagnostic testing and treat- other mononeuropathies or radicu- symptomatic relief of
ment challenging.96 lopathies. Clinical assessment and local- painful paresthesia
Meralgia paresthetica is associated ization may be confirmed and refined with nonsteroidal
with obesity, diabetes mellitus, and with electrodiagnostic studies and neu- anti-inflammatory drugs,
and nerve blocks.
wearing tight clothing.95 Other causes romuscular ultrasonography. Electro-
include trauma and surgical injury. Typ- diagnostic studies provide physiologic
ical symptoms of meralgia paresthetica information regarding peripheral nerve
include lateral or anterolateral thigh and muscle function, and neuromus-
paresthesia and sensory loss. Pain can cular ultrasonography provides com-
be severe and described as stabbing, plementary anatomic information.
shooting, or burning. Physical exami- Early diagnosis and expeditious treat-
nation should reveal sensory loss in ment seek to minimize morbidity and
the distribution of the lateral femoral maximize function to achieve optimal
cutaneous nerve without associated patient outcomes.
findings suggestive of lumbar radicu-
lopathy or lumbosacral plexopathy.
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doi:10.1016/j.apergo.2014.03.005.
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2. Latinovic R, Gulliford MC, Hughes RA.
ing the lateral femoral cutaneous nerve Incidence of common compressive
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Review Article

Neuropathies Center, DUMC 3403, Room

and as an associate editor

INTRODUCTION median nerve. Carpal tunnel syn-

FIGURE 7-1 Median nerve. The nerve is labeled in bold,

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490 ContinuumJournal.com April 2017

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FIGURE 7-3 Ulnar nerve. The nerve is labeled in bold, and

B 2016 Vern C. Juel.

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Copyright © American Academy of Neurology. Unauthorized reproduction of this article is prohibited.

Case 7-2 h As with carpal tunnel

exists regarding the utility of needle ultrasonography is not believed to be

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FIGURE 7-5 Common and deep fibular (peroneal) nerves.

B 2016 Vern C. Juel.

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FIGURE 7-6 Common and superficial fibular (peroneal)

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at the fibular head with no or minor OTHER LOWER EXTREMITY

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Continuum (Minneap Minn) 2017;23(2):487–511 ContinuumJournal.com 507

8. Tagliafico A, Pugliese F, Bianchi S, et al. 20. American Association of Electrodiagnostic

508 ContinuumJournal.com April 2017

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Continuum (Minneap Minn) 2017;23(2):487–511 ContinuumJournal.com 509

54. Kinaci A, Kloen P, Videler A, Kreulen M. 2014;38(10):2129Y2135. doi:10.1007/

510 ContinuumJournal.com April 2017

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