ADVERSE NEURAL

TISSUE TENSION
The Manual Therapy Institute
Anatomy & Physiology
Going back to Anatomy…
Connective Tissue Covering
1) Endoneurium - encompasses the
axon or nerve fiber; important role
in protecting against transmission
of substances across the membrane
(the blood-nerve barrier)
2) Perineurium - surrounds each
fascicle; provides a perineural
diffusion barrier capable of
controlling flow of substances bi-
directionally.
3) Epineurium - outermost
connective tissue; highly vascular
and provides no diffusion barrier
function
Nerve Nutrition
 Bi-directional Nutritional Flow (Axoplasmic Flow):
 Antegrade Flow:
 Fast 400mm day, carries substances used in the transmission of
impulses (neurotransmitters and transmitter vesicles)
 Slow 1-6 mm/day, carries substances needed for the
maintenance of the structure of the axon
 Retrograde Flow: 200 mm/day, responsible for carrying
extracellular materials from the nerve terminal and trophic
messages about the status of the nerve and the target tissues
 Nutritional Requirements – 20% of O 2 consumption
while only composing 2% of total body weight
Continuity of Central & Peripheral Nerves

The system is considered continuous in three ways:

1) the connective tissues are continuous
2) the neurons are interconnected electrically
3) the system is continuous chemically.

Any stresses that are imposed on the peripheral

nervous system are conveyed to the central nervous
system, and the reverse holds true.
Nerve Innervation
 The connective tissues of the peripheral nerves,
nerve roots and autonomic nervous system have a
source of intrinsic innervation = nervi nervorum
 Free nerve endings have been found in the:
1. Perineurium
2. Epineurium
3. Endoneurium
MOI’s & Examination of the Peripheral Nerve
 Dysfunctions of Peripheral Nerves
• Motor Problems – motor neuron (body, axon, motor end
plate, muscle fiber).
• Signs:
• distal weakness
• decreased DTR’s
• myotomal patterns
• Sensory Problems – sensory neuron (cell body in ganglion,
axon, sensory receptor).
• Reports: tingling, burning, dysesthesias, paresthesias;
dermatome pattern.
• Mixed Nerves – both
• ANS – sweating and/or vascular control; skin changes
Overview of MOI’s for Peripheral Nerves

• Entrapment/Compression - small amount of pressure

chronically endured over time (ie posture, repeated compression
or dysfunctional movement); CTS, Cubital Tunnel, TOS
• Trauma – laceration, severing, blunt, crushing
• Heredity – Charcot-Marie-Tooth
• Nutritional/Metabolic - diabetics, alcohol
• Infections – Guillain-Barre, post-Polio, Herpes Zoster, Bell’s
Palsy or Trigeminal
• Exposure to Toxins – lead, organophosphates
• Motor End Plate Disorders - Myasthenia Gravis, Botulism

Both MOI’s will lead to classic nerve s/s…

Systemic Risk Factors

Create an “at risk” environment for the neural tissue.

Be mindful of theses conditions, and whether they are

under control…
Systemic Risk Factors
 Microvascular diseases  Pregnancy
 Diabetes  Obesity
 Thyroid issues  Age
 Renal Disease  Smoking
 Inflammatory arthritis  Occupational
 Gender exposure/activities
Nerve Compression Injuries
Goals:
1. know the major peripheral nerves
2. understand the individual motor and sensory function
of each peripheral nerve
3. be able to establish a treatment plan based upon clinical
presentation…

Realize that Compression leads to:

 decreased vascular flow
 interrupts axonal transport and conduction
 leads to myelin thinning
 epineural thickening
Diagnostic Considerations with Peripheral Nerve
Compression….

 Mimics some tendonosis/tendonitis and can occur

concurrently with such
 Concurrent with many other orthopedic injuries:
 Lateral ankle sprains (sural or peroneal)
 Proximal Humeral fractures (radial)
 Knee scope (saphenous)
 Spine hypermobility
 Occur frequently after fractures
Examination Considerations
 Pt. Hx, physical exam and laboratory data assist in
diagnosis and locating lesion.
 However, no one test is 100% specific or sensitive
(so look at multiple pieces of the puzzle…)
Nerve Compression Diagnostic Procedures

 Pt. History
 Motor Exam – myotomal as well as specific to suspected
peripheral nerve
 Sensory Exam – dermatomal as well as specific peripheral
nerve
 NTPT (neural tissue provocation testing)
 Provocative Testing (ie Tinel’s, Phalen’s, Roo’s)
 Physical findings - atrophy, clawing, etc.
 Body diagrams
 EMG/NCV studies
Dermatomal Key Points
Sensory Regions
Examination Note:
 Always consider proximal points of
compression….
 Be mindful that initial changes may be transient,
but if situation persists or worsen, the changes can
become permanent with fibrosis.
 Localization and correct diagnosis allow for
appropriate intervention planning.
 Based on peripheral nerve anatomical organization,
which is affected first - motor or sensory?
Sidenote on EMG/NCV
 Sometimes the only objective measure
 Can localize lesion by “inching”
 Not always positive in early stages
 Operator dependent
 Assists in diagnosis and allows measurement of
progression/resolution
 Adverse Neural Tissue Tension

Never-ending Acronyms:
ANTT = Adverse Neural Tissue Tension
ULTT = Upper Limb Tension Testing
NTPT = Neural Tissue Provocation Testing
 Important Concepts

 Initially may not suspect ANTT with straight

forward orthopedic conditions
 tend to develop gradually as a secondary result
from injury
 The nerve as a source of pain
 Concept of AIG = abnormal impulse generating
site
 AIG’s

 Coined by David Butler

 When a peripheral nerve is injured, it can develop
the ability to repeatedly & spontaneously generate
its own impulse
 Main Characteristics of AIG’s

 Mechano-sensitivity: stimulated by mechanical

stimuli (movement, touch, etc)
 Spontaneous Activity

Susceptible Sites = area of myelin damage or

regenerating axon sprouts
 When to suspect ANTT?
 When not responding as should within the
expected time frame
 Describes in terms consistent with ANTT -
“burning”, “crawling”, “electrical”, “ants on
me”, “pulling”, bizarre sounding things like
“warm water”
 Worsening despite objective improvement of
ROM, strength, etc
 Symptoms of ANTT
1. Development of pain & paresthesia is gradual
(neural zone)
2. Symptoms radiate (either proximally or
distally)
3. Pain along the nerve pathway or spot pain
(hyperalgesic response to palpation)
4. Aggravated by positions or movements that
“stretch” the nerve
5. Nocturnal s/s not uncommon
 Signs of ANTT

 Sensory nerve?
 Motor nerve?
 Positive neural tissue provocation testing (NTPT)
 TTP along the nerve
 What makes a NTPT positive?

 Reproduction of s/s (know it is relevant)

 Response is altered by a distant component (either a
distal or proximal component)
 Difference in response from side to side, or what is
normal

 May have to differentiate of a positive test is

relevant or not….
 Susceptible Sites

1) sites of nerve branching

2) unyielding interfaces
3) sites of nerve attachment
4) soft tissue and fibro-osseous tunnels
5) sites at which a nerve is cutaneous
 Common MOI’s

 External forces – ie casts, belts, walking boots, ill-

fitting shoes

 Internal forces – ie swelling, bone spur

 Chronic repeated microtrauma – ie posture

 Double crush – ie ask about old injuries proximal &

distal to site
Double Crush
 Proteins and cell bodies travel distally while waste
products travel proximally thru axonal transport
systems.
 Disruption causes decreased threshold for s/s or
AIG’s elsewhere along the nerve.
 Either site may be asymptomatic without the
second insult.

What does this tell you must be done on evaluation?

 ANTT Differential Diagnosis
Lumbar Radiculopathies:
Pain with cough, sneeze, Valsalva?
Well delineated area of sensory change?
Partial weakness, decreased reflexes?
Electrodiagnostic testing?
What is the key to differential diagnosis of ANTT and
lumbar root?
 The Key…


 Identify a different peripheral nerve with the
major contribution from the same root level as
the suspected nerve
 Or test a more proximal branch originating from
the same peripheral nerve
 Then compare motor and sensory function

Common LE Entrapments
 Femoral Nerve
MOI: pelvic fracture, scarring after abdominal surgery, tumors,
inguinal hernias
S/S: most pronounced at the knee, knee buckling may occur
 Local tenderness in the groin, pain and paresthesiae over the

anteromedial surface of the thigh and the medial surface of the leg.
 Decreased sensation over anteromedial thigh, weakness of

quadriceps (compensated for by hyper extending the leg in standing

and walking) and sartorius, decreased patellar tendon reflex.
 Increased pain at endrange hip flexion and hip extension. Positive

neural tension signs.

Radiculopathy? What level? Will present with anterior tib and
adductor weakness.
R/O: hip arthritis and psoas strain
Femoral & Saphenous Nerve
Lateral Femoral Cutaneous Nerve
 Originates from L2 and L3, runs through the pelvis and angles downward at the ASIS.
 MOI: weight distribution changes, such as a pendulous abdomen, scarring following
surgery and to direct external pressure (corset or belt)
 Sites of entrapment:
 fascia lata
 inguinal ligament (naturally kinked as it passes through the ligament)
 C/O: pain, numbness and paresthesiae over anterior and lateral surfaces of the thigh.
 Aggravating Factors: worsened by erect posture, prolonged standing, hip extension
and adduction.
 There are no motor signs.
 Differential diagnosis (Differentiate from L2, L3 nerve root radiculopathy and
femoral nerve neuropathy):
 peripheral entrapment may cause complete anesthesia with well delineated borders, while
with lumbar nerve root problems the loss of sensation is usually partial due to overlap of
the dermatomes)
 Pain over the inguinal ligament is not common with lumbar radiculopathy, but happens
frequently with peripheral nerve entrapment of the lateral femoral cutaneous nerve.
 Obturator Nerve
 Originates: L2 and particularly L3, 4; formed in the psoas, runs through the pelvis to the
obturator canal, leaves the pelvis and enters the medial thigh.
 Site of entrapment = obturator canal.
 MOIs: pelvic fracture, hip surgery and inflammation of the pubic bone following surgery.
 Clinical findings:
 Pain in the groin, radiating from the inner thigh to the knee.
 Decreased sensation over the medial thigh and knee, and local pain with pressure over the
inguinal ligament.
 Pain on endrange hip flexion, hip extension and abduction.
 Weakness in the adductor musculature leads to gait pattern disturbances: circumduction during
swing phase. Duchenne during stance phase.
 Differential diagnosis (Radiculopathy from L2-4 and femoral nerve neuropathy)
 L2, 3 dermatomes include portions of the medial thigh, which could confuse the diagnosis of
peripheral entrapment, but generally cover more lateral portion of the thigh. L4 is distinctively
different from the sensory distribution of the obturator nerve.
 Direct pressure in the groin should not cause pain in a lumbar radiculopathy, but highly typical
with obturator entrapment.
 Rule out hip arthritis and psoas strain.
Obturator Nerve
 Saphenous

MOI: knee arthroscopy, medial meniscal repair,

trauma
Saphenous Medial Knee
 Sciatic

MOI: sacral dysfunction with piriformis spasm, thick

wallets, scarring from hip surgery, injections, gluteal
or pelvic tumors
Key: glutei help differential from radiculopathy

Caution: Neurodynamic testing will give the same

result as for radiculopathy
Sciatic Nerve and Major Branches
 LE Nerves Commonly Involved

Tibial:

MOI: plantar fascitis, eversion sprains, “joggers” foot

 Tarsal Tunnel Syndrome

Entrapment of posterior
Causes:
tibial nerve within canal:
◦ Tibial Nerve divides into:
Not clear concensus
 Medial and lateral plantar
regarding causitive
nerves factors but suspect:
 Medial calcaneal branch ◦ Excessive
Pronation
Symptoms: ◦ Assessory FDL

◦ Pain/parathesia plantar ◦ Tight flexor

aspect of foot retinaculum
◦ Ganglion cysts
◦ Soft tissue tumors
Tarsal Tunnel Syndrome
Anterior Tarsal Tunnel Syndrome

Deep Peroneal Nerve entrapment:

◦ Beneath inferior extensor retinaculum
◦ Over talonavicular joint
◦ Over tarsometatarsal joints
Signs and Symptoms:
◦ Pain/parathesia over dorsum to 1st web space
◦ Weakness of EDB
Deep Peroneal Nerve
Plantar Nerves
 LE Nerves Commonly Involved

Peroneal:
MOI: ankle sprains, casts, walking boots, shoe wear
S/S: pain & paresthesia lateral leg & dorsum of foot;
deep peroneal - loss of sensation first web space;
loss of strength in the lateral & anterior
compartments
Differential: anterior compartment syndrome
(extreme pain, pallor, loss of dorsalis pedis pulse,
foot drop)
Lateral Nerves at the Foot
Medial Nerves of the Foot
 Adverse Neural Tissue Tensioning

Provocative Testing
Positive:
1. Different from uninvolved LE
2. Reproduction of s/s
3. Changes with “remote” component
Caution!
Assessment of irritability is key, as well as severity.
Irritability guides the nerve glide prescription
related to intensity…
 Principles of Management of ANTT

 Intensity directly related to the level of irritability present –

greater the irritability the less intense the glide (ie NOT
into s/s)
 Neurological s/s (ie tingling, numbness) should NOT
persist after gliding technique or should be improved
 Choose one component motion of the testing position to
utilize as the “gliding force”
 Either “floss” or “glide” – either one works
 Ask regarding s/s after each treatment and document
changes across the course of treatment
 Any worsening at all need to be immediately reported to
the PT – pt. education…
 Guidelines for Prescription
 Educate pt on condition and goals of treatment
 Emphasize NOT to push treatment – MUST be gentle

 ALWAYS start with assisting to ensure perfect form and

determine response; when pt masters, give nerve glides as

HEP.
1. Intensity & Duration:
 Initially: Perform 20-30 glides just out of s/s
 Progress to: glides with minimum s/s at the end of the “glide”
only
2. Frequency:
 Initially: 1x day, determine response
 Progress to: Gradually build up to 3x-5x day if appropriate