module 1 readings (capsular patter, nerve roots, nerve injury, peripheral nerve disorders, spinal pathways and pediatric conditions)

Temporomandibular (TMJ) Capsular Pattern

Limitation of mouth opening.

Cervical Spine Capsular Pattern

Side flexion and rotation equally limited, then extension.

Glenohumeral (Shoulder) Capsular Pattern (think "the whip" lol)

Lateral rotation (ER) > Abduction > Medial rotation (IR).

Sternoclavicular Joint Capsular Pattern

Pain at end range, especially horizontal adduction and full elevation.

Acromioclavicular Joint Capsular Pattern

Pain at end range, especially horizontal adduction and full elevation.

Ulnohumeral (Elbow) Capsular Pattern

Flexion > Extension.

Radiohumeral Joint Capsular Pattern

Flexion > Extension > Pronation > Supination.

Proximal Radioulnar Joint Capsular Pattern (think turning doorknob)

Supination and pronation equally limited.

Distal Radioulnar Joint Capsular Pattern

Full ROM with pain at extremes of pronation and supination.

Radiocarpal (Wrist) Capsular Pattern

Flexion and extension equally limited.

Carpometacarpal (Thumb) Capsular Pattern

Abduction > Extension.

Thoracic Spine Capsular Pattern

Side flexion and rotation equally limited, then extension.

Lumbar Spine Capsular Pattern

Side flexion and rotation equally limited, then extension.

Hip Capsular Pattern (think karate kick)

Flexion > Abduction > Medial rotation (IR).

Knee Capsular Pattern

Flexion > Extension.

Talocrural (Ankle) Capsular Pattern

Plantarflexion > Dorsiflexion.

Talocalcaneal (Subtalar) Capsular Pattern

Limitation of range of motion.

Axillary Nerve — Roots & Innervation

Roots: C5-C6

Motor: Deltoid, Teres Minor

Sensory: Regimental badge area (lateral shoulder)lower half of deltoid and upper part of long head of triceps

what are the causes of axillary nerve damage and its effects

Axillary nerve can be injured due to:

- Dislocation of shoulder

- Fracture of surgical neck of humerus

► Effects:

- "Square shoulder" from deltoid muscle atrophy

- Sensory loss over lower half of deltoid

Musculocutaneous Nerve — Roots & Innervation

Roots: C5-C7

Motor: Biceps Brachii, Brachialis, Coracobrachialis

Sensory: Lateral forearm

Radial Nerve — Roots & Innervation

Roots: C5-C8,T1

Motor: Triceps, Anconeus, Brachioradialis, Extensor Carpi Radialis Longus/Brevis, Supinator, Extensor Digitorum, Extensor Indicis, Extensor Digiti Minimi, Extensor Carpi Ulnaris, Abductor Pollicis Longus, Extensor Pollicis Longus/Brevis

Sensory: Posterior arm, posterior forearm, dorsal web space between thumb and index finger

Radial Nerve — Clinical Presentation / Sign

Deformity: Wrist Drop (inability to extend wrist and digits)

Common Injury Site: Radial groove of humerus (mid-shaft humeral fracture), compression at Axilla ("Saturday night palsy")

Median Nerve — Roots & Innervation

Roots: C5-8, T1

Motor: Pronator Teres, Flexor Carpi Radialis, Palmaris Longus, Flexor Digitorum Superficialis, Flexor Digitorum Profundus (lateral 1/2), Flexor Pollicis Longus, Pronator Quadratus, LOAF muscles (Lumbricals 1 & 2, Opponens Pollicis, Abductor Pollicis Brevis, Flexor Pollicis Brevis)

Sensory: Palmar surface of thumb, index, middle, and radial half of ring finger

Median Nerve — Clinical Presentation / Sign

Deformity: Ape Hand (at rest; loss of thumb opposition) and Hand of Benediction (when attempting to make a fist)

Common Injury/Entrapment Sites: Carpal Tunnel, Pronator Teres

Anterior Interosseous Nerve (Branch of Median) — Motor & Clinical Sign

Motor: Flexor Pollicis Longus, Pronator Quadratus, FDP (lateral half)

Clinical Sign: Loss of "OK" sign (pincer grasp fails due to lack of DIP/IP flexion in index finger and thumb)

Sensory: NONE (pure motor)

Ulnar Nerve — Roots & Innervation

Roots: C8-T1

Motor: Flexor Carpi Unaris, Flexor Digitorum Profundus (medial 1/2), Hypothenar muscles, Lumbricals 3 & 4, Adductor Pollicis, Dorsal Interossei (DAB), Palmar Interossei (PAD)

Sensory: Ulnar 1.5 digits (ulnar half of ring finger, small finger) palmar and dorsal aspects

Ulnar Nerve — Clinical Presentation / Sign

Cubital Tunnel Syndrome

- Compression at cubital tunnel at elbow

- Paralysis of flexor carpi ulnaris, flexor digitorum profundus (ulnar half), hypothenar

eminence, interossei, and the third and fourth lumbrical muscles

- All sensations affected

- Inability to grip paper

► Guyon's Canal Syndrome

- Sensory changes and progressive weakness of muscles innervated distal to the site

Ulnar Claw hand

- Hyperextension at 4th,5th MCP, Flexion at 4th, 5th IP due to weakness of lumbricals and interossei

Long Thoracic Nerve — Roots, Innervation & Sign

Roots: C5-C7

Motor: Serratus Anterior

Clinical Sign: Scapular Winging (medial border of scapula lifts off thorax, especially with forward arm elevation/pushing)

Suprascapular Nerve — Roots & Innervation

Roots: C5-C6

Motor: Supraspinatus, Infraspinatus

Common Entrapment Site: Suprascapular notch or spinoglenoid notch

subscapular nerve-roots and innervation

roots:C5-C6

Motor supply

► Teres Major (Lower Subscapular Nerve)

► Subscapularis

lateral pectoral nerve

C5-C7

motor supply: pec major and clavicular fibers

medial pectoral nerve

C8, T1

motor supply: pec minor

Thoracodorsal Nerve — Roots & Innervation

Roots: C6-C8

Motor: Latissimus Dorsi

dorsal scapular nerve

C5

motor supply: rhomboid major, minor and levator scapulae

nerve to subclavius

C5-C6

motor supply:

subclavius

spinal accessory nerve motor supply

traps, and SCM

Femoral Nerve — Roots & Innervation

Roots: L2-L4

Motor: Iliopsoas, Pectineus, Sartorius, Quadriceps Femoris (Rectus Femoris, Vastus Lateralis/Intermedius/Medialis)

Sensory: Anterior thigh, medial lower leg and ankle via Saphenous Nerve

Femoral Nerve — Clinical Presentation

Functional Deficit: Weakness in hip flexion and knee extension

Gait Deviation: Knee buckling during stance phase or excessive forward trunk lean/hand-on-thigh compensation

Obturator Nerve — Roots, Innervation & Deficit

Roots: L2-L4

Motor: Adductor Longus, Adductor Brevis, Adductor Magnus (anterior part), Gracilis, Obturator Externus

Sensory: Medial thigh

Deficit: Difficulty with leg adduction and scissoring gait compensations

Superior Gluteal Nerve — Roots, Innervation & Sign

Roots: L4-S1

Motor: Gluteus Medius, Gluteus Minimus, Tensor Fasciae Latae (TFL)

Clinical Sign: Trendelenburg Sign / Gait (contralateral pelvis drops during single-leg stance on affected side)

Inferior Gluteal Nerve — Roots, Innervation & Deficit

Roots: L5-S2

Motor: Gluteus Maximus

Deficit/Gait: Gluteus Maximus Lurch (posterior trunk lean at heel strike/initial contact to keep center of mass posterior to hip)

nerve to piriformis

L5-S2

motor supply: piriformis

nerve to quadratus femoris

Nerve Roots: L4-S1

Motor supply

► Gemellus inferior

► Quadratus Femoris

nerve to obturator internus

Nerve Roots: L5-S2

Motor supply

► Gemellus superior

► Obturator Internus

Sciatic Nerve — Roots & Innervation

Roots: L4-S3

Motor: Hamstrings (Semitendinosus, Semimembranosus, Biceps Femoris), Adductor Magnus (posterior part)

Branches: Splits into Tibial and Common Peroneal (Fibular) nerves at the popliteal fossa

Tibial Nerve — Roots & Innervation

Roots: L4-S3

Motor: Gastrocnemius, Soleus, Plantaris, Popliteus, Tibialis Posterior, Flexor Digitorum Longus, Flexor Hallucis Longus

Sensory: Sole of the foot via Medial and Lateral Plantar nerves

Tibial Nerve — Clinical Presentation

Deficit: Loss of plantarflexion and toe flexion, loss of sensation on plantar foot

Gait: Lack of push-off / terminal stance phase

Entrapment Site: Tarsal Tunnel (behind medial malleolus)

Common Peroneal (Fibular) Nerve — Roots & Divisions

Roots: L4-S2

Divisions: Deep Peroneal Nerve, Superficial Peroneal Nerve

Common Injury Site: Fibular head / neck (e.g., from tight casting, lateral leg trauma)

Deep Peroneal (Fibular) Nerve — Innervation & Presentation

Motor: Tibialis Anterior, Extensor Digitorum Longus, Extensor Hallucis Longus, Peroneus (Fibularis) Tertius, Extensor Digitorum Brevis

Sensory: Web space between 1st and 2nd toes

Deformity/Gait: Foot Drop, High Steppage Gait, Slap Foot

Superficial Peroneal (Fibular) Nerve — Innervation & Presentation

Motor: Peroneus (Fibularis) Longus, Peroneus (Fibularis) Brevis

Sensory: Anterolateral lower leg and dorsum of foot (except 1st web space)

Deficit: Loss of foot eversion; varus deformity risk

Lateral Femoral Cutaneous Nerve — Roots & Presentation

Roots: L2-L3

Motor: NONE (purely sensory)

Sensory: Anterolateral thigh

Condition: Meralgia Paresthetica (compression under inguinal ligament due to tight clothing, pregnancy, obesity)

Sural Nerve — Roots, Type & Innervation

Roots: S1-S2

Type: Purely sensory (formed by branches from Tibial and Common Peroneal nerves)

Sensory: Posterolateral calf, lateral foot, lateral ankle

Scapular Elevation — Muscles

Upper trapezius, levator scapulae, rhomboids

Scapular Protraction — Muscles

Serratus anterior, pectoralis minor and major

Scapular Depression — Muscles

Serratus anterior, pectoralis minor and major, lower trapezius, latissimus dorsi

Scapular Retraction — Muscles

Trapezius, rhomboids

Scapular Downward Rotation — Muscles

Levator scapula, rhomboids, pectoralis minor

Scapular Upward Rotation — Muscles

Serratus anterior, trapezius (upper and lower fibers)

Neuropraxia (Sunderland 1°) — Pathology & Causes

Segmental demyelination from mild ischemia due to nerve compression or traction; action potential is blocked locally.

Neuropraxia (Sunderland 1°) — Signs & Recovery

Pain, minimal muscle wasting, numbness, and weakness. Recovery occurs within minutes to days.

Axonotmesis (Sunderland 2° & 3°) — Pathology & Causes

Loss of axonal continuity with intact connective tissue; Wallerian degeneration occurs distal to lesion.

Axonotmesis (Sunderland 2° & 3°) — Signs & Recovery

Muscle wasting, complete loss of function, sensation returns before motor. Regenerates 1 mm/day over months.

Neurotmesis (Sunderland 3°, 4°, & 5°) — Pathology & Causes

Complete severance of nerve fiber and connective tissue coverings; caused by severe trauma or avulsion.

Neurotmesis (Sunderland 3°, 4°, & 5°) — Signs & Recovery

Anesthesia (no pain), muscle wasting, complete functional loss. Recovery takes months and requires surgery.

What are the three classifications of peripheral nerve injuries?

Neuropraxia → Axonotmesis → Neurotmesis (least severe to most severe).

Which peripheral nerve injury has the best prognosis?

Neuropraxia.

Which peripheral nerve injury requires surgery?

Neurotmesis.

What structures are damaged in neuropraxia?

None—the nerve remains intact; there is no nerve degeneration.

What causes neuropraxia?

Compression causing ischemia.

Which nerve injury is commonly seen in carpal tunnel syndrome?

Neuropraxia.

What is the prognosis for neuropraxia?

Excellent if compression is removed; recovery occurs within weeks to months.

What structures are damaged in axonotmesis?

Axon, myelin, and varying amounts of connective tissue (endoneurium, perineurium, epineurium).

What commonly causes axonotmesis?

Crush injuries or traction injuries.

What determines prognosis after axonotmesis?

The amount of connective tissue damage.

What is the rate of axonal regeneration?

1-3 mm/day (≈1 inch/month).

What structures are damaged in neurotmesis?

Complete severing of the axon, myelin, and all connective tissue.

What are the clinical findings with neurotmesis?

Complete loss of function requiring surgical repair.

After axonal regeneration, do regenerated axons remyelinate back to preinjury levels?

No.

Why is incomplete remyelination clinically important?

It decreases nerve conduction velocity and impairs movement speed and coordination.

What is collateral sprouting?

Intact axons reinnervate denervated muscle fibers.

What muscle fiber change commonly occurs with collateral sprouting?

Type I fibers often convert to Type II fibers.

Mononeuropathy involves what?

One peripheral nerve.

What is an example of a mononeuropathy?

Carpal tunnel syndrome.

What is mononeuropathy multiplex?

Two or more individual nerves affected without a polyneuropathy pattern.

What common diseases are associated with mononeuropathy multiplex?

Diabetes, renal disease, chronic alcoholism.

What is radiculopathy?

Involvement of nerve root(s).

What is plexopathy?

Involvement of the brachial or lumbosacral plexus.

What are the three biggest NPTE risk factors for polyneuropathy?

Diabetes, renal failure, alcohol abuse.

Name autoimmune diseases associated with polyneuropathy.

Guillain-Barré syndrome, Sjögren syndrome, lupus.

What hereditary disorder commonly causes polyneuropathy?

Charcot-Marie-Tooth disease.

Approximately what percentage of polyneuropathies are idiopathic?

25%.

Segmental demyelination primarily damages what?

Myelin.

Which condition is a classic example of segmental demyelination?

Guillain-Barré syndrome.

Can remyelination occur after segmental demyelination?

Yes, if treated.

Axonal degeneration progresses in what direction?

Distal → proximal.

Which disease commonly causes axonal degeneration?

Alcoholic neuropathy.

Which polyneuropathy affects both myelin and axons?

Diabetic polyneuropathy.

What sensory distribution is typical in polyneuropathy?

Stocking-and-glove pattern (distal → proximal).

Which sensory fibers should always be tested in polyneuropathy?

Small fibers (pain, temperature) and large fibers (proprioception, kinesthesia).

What autonomic signs should be screened for in polyneuropathy?

Dry skin, warmth, edema, orthostatic hypotension, vasodilation/loss of vasomotor tone.