Nerve injuries and compression

brachial plexus

Randy Travis Drinks Cold Beverages- Roots, Trunks, Divisions, Cords, Nerves

Roots

C5, C6, C7, C8, T1

trunks

upper, middle, and lower

divisions

anterior and posterior

cords

lateral, posterior and medial

branches (nerves)

axillary, musculocutaneous, ulnar, median, and radial

median nerve compression

can be compressed at various points along the forearm

proximal forearm compression

pronator syndrome and anterior interosseous nerve syndrome

wrist/hand nerve compression

carpal tunnel syndrome

pronator syndrome

compression between heads of the pronator teres

pronator syndrome symptoms

pain tenderness proximal volar forearm, perceived weakness, and decreased sensation radial 3.5 digits and palmar cutaneous branch

anterior interesseus nerve syndrome

compression of AIN branch deep to pronator teres

anterior interosseus syndrome symptoms

proximal forearm pain, no sensory problems, and weakness/paralysis of FDP, FPL, and pronator quadratus

distal compression definition

compression of the median nerve beneath the transverse carpal ligament

distal compression symptoms

decreased sensation in radial 3.5 digits, thenar clumsiness, and weakness in lumbricals of index and middle fingers

distal compression diagnostic tests

Phalen’s test, berger test, and lumbrical incursion test

Phalen’s test

sustained wrist flexion reproduces symptoms

Berger’s test

volar forearm swelling

lumbrical incursion test

hand in fist (1 min), paresthesias suggest lumrbcial compression

causes of median nerve compression

mechanical/overuse: repetitive motion, vibratory tool use, forceful grip

systemic conditions: inflammatory arthritis, kidney disease, pregnancy, obesity

trauma: factures, dislocations, space-occupying lesions

early compression

blood flow to the nerve is reduced, no major structural changes, symptoms: tingling/numbness, and conservative treatments are best

moderate compression

blood flow impacted more, edema is present along with possible internal scarring, symptoms: decreased vibratory sensation, positive findings for proactive tests, c/o abnormal sensation

severe compression

increased edema and scarring, denervation, symptoms: poor 2-point discrimination, thenar muscle atrophy

nonoperative therapy: proximal compression

long arm orthosis for 3-4 weeks then night wear, cryotherapy, allow elbow/wrist AROM, tendon and nerve gliding exercises

nonoperative therapy: distal compression

wrist orthosis for 3-4 weeks then night wear, severe compression (sensory precautions, carpometacarpal joint orthosis)

nonoperative therapy: distal compression

exercises: intrinsic stretches, nerve gliding techniques, tendon gliding techniques, and strengthening and ROM exercises

nonoperative therapy: distal compression

ergonomics, modalities, and PT education

post rehab: proximal compression

immobilization, scar management, ergonomics, strengthening and nerve and tendon gliding

post rehab: distal compression

immobilization, AROM as tolerated, nerve and tendon gliding, edema management, overhead extrinsic hand exercises, sensory evaluation, strengthening

ulnar nerve compression syndromes vulnerable sites

elbow cubital tunnel syndrome and wrist Guyon’s canal syndrome

cubital tunnel syndrome

compression of the ulnar nerve at the elbow as it passes through the cubital tunnel

Guyon’s canal syndrome

compression of the ulnar nerve at the wrist as it passes through guyon’s canal

cubital syndrome symptoms

pain, deformity, decreased grip/pinch strength, fine motor coordination issues; severe: claw hand due to intrinsic loss

cubital syndrome causes

compression, traction, friction, nerve elongation, recurrent subluxation, trauma, rheumatoid arthritis, bony spurs

Guyon’s canal syndrome distinguishing feature

absence of dorsal sensory branch symptoms (differentiates from cubital tunnel)

Guyon’s canal anatomic zones

zone I: proximal to canal (motor and sensory deficits)

zone II: exit of canal (deep motor branch only)

zone III: exit of canal (sensory branch only)

Guyon’s canal causes

blunt trauma, tumorous conditions, hamate/metacarpal fractures

cubital tunnel syndrome mild stage

intermittent paresthesias, increased vibration sensitivity, clumsiness/loss of coordination

cubital tunnel syndrome moderate stage

intermittent paresthesias, decreased vibratory perception, measurable grip/pinch weakness, more consistent symptoms, conservative therapy still viable but may require longer

cubital tunnel syndrome severe stage

persistent paresthesias, decreased vibratory perception, abnormal 2-point discrimination, measurable grip/pinch weakness, muscle atrophy, claw deformity, significant functional deficits, often requires surgery, challenging for full recovery

nonoperative therapy: cubital tunnel syndrome

orthosis: night splint preventing elbow flexion beyond 45 degrees, avoid pressure on medial elbow, nerve gliding performed cautiously to improve soft tissue mobility, modalities: anti-inflammatory modalities

nonoperative therapy: guyot’s canal

rest and avoid pressure: advise resting the hand and avoiding pressure at the hypothenar eminence, wrist immobilization orthosis, anti inflammatory modalities for pain relief, ROM exercises, strengthening, sensory reeducation, scar management: trauma/lesion removal

postoperative rehab: cubital tunnel syndrome

general principles: pain relief, scar management, orthosis, sensory assessment, postural/positional education, ROM of uninvolved joints

postoperative rehab: cubital tunnel syndrome decompression

oWeek 1: Soft dressing, AROM as tolerated, sensory assessment, wound care, edema control, nerve mobilization.

oWeek 2: Gentle strengthening.

postoperative rehab: cubital tunnel syndrome subcutaneous transposition

oWeek 1: Orthosis (60-90° elbow flexion), gentle AROM all joints, sensory, wound/edema, nerve mobilization.

oWeek 3: Discontinue orthosis, progress AROM.

oWeek 4: PROM, initiate strengthening.

postoperative rehab: Guyon’s canal release

·Prerequisite: Therapy begins only after cause of compression is fully addressed (e.g., healed fractures, removed masses).

·Interventions:

oPain relief (modalities).

oScar management.

oWrist orthosis (for rest) and/or anti-claw orthosis (to prevent deformity/increase function), as needed.

oSensory education and desensitization.

oStrengthening: May start at 4-6 weeks for fracture (if healed), or after ulnar-innervated muscles have AROM.

radial nerve compression

radial nerve palsy, posterior interosseous nerve, radial tunnel syndrome, wartenberg syndrome

radial nerve palsy

compression of the radial nerve in the spiral groove, often due to external pressure

radial nerve palsy symptoms

sensory: hypesthesia to the dorm of the forearm and hand; motor: weakness/absence of wrist extensors, digital extensors, and thumb extension

radial nerve palsy: nonoperative OT management

joint suppleness and contracture prevention: frequent passive PROM to pronators, wrist flexors, and extrinsic finger flexors

radial nerve palsy: progressive therapy

restore balance, early strengthening, support, and progression

posterior interosseous nerve syndrome

weakness of supination, wrist extension, digital extension, and thumb extension, insidious onset, key feature: primarily a motor deficit; no sensory complaints

radial tunnel syndrome

tenderness over the radial nerve at the proximal or distal edge of the supinator; symptoms: deep, achy pain, often increased by passive pronation or active supination

RTS and PIN causes

mass, humeroradial joint degeneration, radiocapitellar synovitis, radial head fractures

wartenberg syndrome

compression of the sensory branch of the radial nerve at the wrist, symptoms: pain and/or paresthesia on the dorsal radial forearm, radiating to the thumb and index finger

wartenberg syndrome compression sites

where the nerve exits deep tissues between BR and ECRL

peripheral nerve repair

activate muscles for movement and transmit sensory stimuli, enabling hand function

peripheral nerve impact of injury

nerve loss disrupts this balance, leading to permanent hand deformities and functional impairments

peripheral nerve surgical repair techniques

epidermal repair and group fascicular repair

British System (MRC Scale) - Sensory Recovery:

–S0: Absence of sensibility.

–S1: Recovery of deep cutaneous pain.

–S2: Return of superficial pain and tactile sensibility.

–S3: Return of superficial pain and tactile sensibility with good localization.

–S4: Complete recovery (e.g., ≤6 mm 2-point discrimination).

British System (MRC Scale) - Motor Recovery:

–M0: No contraction.

–M1: Perceptible contraction in proximal muscles.

–M2: Perceptible contraction in proximal and distal muscles.

–M3: All muscles act against resistance.

–M4: Synergistic and isolated movements possible.

–M5: Complete recovery.

tinel’s sign

a tingling sensation elicited by percussion over a regenerating nerve, indicating the advancing front of nerve regeneration. OTs track its advancement

nerve injury response and brain plasticity

central nervous system changes after nerve injury, cause immediate changes in sensation, sensory feedback, and hand’s representation in the somatosensory cortex

nerve injury response and brain plasticity core concepts

sensory reeducation, desensitization, hypersensitivity, tactile gnosis, dysesthesia, and allodynia

nerve injury response and brain plasticity core concepts treatment purpose

•Facilitate the brain’s capacity to maintain the cortical hand map.

•Help the brain interpret altered sensory stimuli as accurately as possible.

•Desensitization builds tolerance to stimulation, allowing for later sensory reeducation.

nerve injury response and brain plasticity core concepts treatment goals

•Achieve the highest sensory potential provided by nerve repair/injury through early-phase and late-phase sensory relearning.

•Attain independence in activities of daily living (ADLs) and vocational pursuits through early and late sensory/motor rehabilitation.

desensitization precautions/contraindications

–Active infection, diffused/organic pain, increased pain with desensitization, open wounds, psychological pain aspects.

desensitization program development

–Assess patient's tolerance to stimulation (texture, immersion particles, vibration).

–Organize stimuli from least to most irritating.

–Begin with slightly irritating but tolerable stimulus; advance when comfortable.

–Encourage maintained contact with texture (avoid cyclic stimulation).

–Use mirror imagery if direct contact is intolerable.

–Incorporate bilateral hands and functional activities.

desensitization techniques

texture, immersion particles, vibration, maintained pressure, physical agents, therapeutic activities, avoid: cold exposure, emotional stress, local irritants innerly desensitization

second phase sensory reeducation

goal: reeducate specific perceptions and improve localization

late phase sensory reeducation

goal: guide recovery of tactile gnosis (object recognition)

complex regional pain syndrome

post-traumatic neuropathic syndrome characterized by pain and vasomotor/sudomotor changes in the involved limb

IASP criteria type I

Develops after a noxious event; pain disproportionate, not limited to single nerve; evidence of edema, skin blood flow, or sudomotor abnormality.

IASP criteria type II

Develops after a nerve injury; similar symptoms, not necessarily limited to injured nerve territory.v

CRPS characteristics

pain, vasomotor changes (temperature, color), sudomotor changes (sweating, edema), and motor/trophic changes

CRPS treatment purpose

•Address severe functional limitations caused by CRPS symptoms.

•Enable participation in ADLs, leisure, and vocational activities.

•Implement an aggressive multidisciplinary team approach (physical, emotional, psychosocial aspects).

•Provide extensive patient education, activity modification, and symptom management.

CRPS treatment goals

•Decrease or eliminate pain, edema, and other symptoms.

•Restore maximum mobility (ROM).

•Restore maximum function.

CRPS indications for immediate treatment

pain, edema, stiffness/contracture, discoloration, abnormal temperature, trophic changes

CRPS precautions for therapy

–Overly aggressive ROM or modalities causing increased symptoms.

–Overly aggressive manipulation/PROM on stiff joints, especially under pain-altering treatments.

CRPS pain management

TENS, moist heat, paraffin, cooling modalities

edema management

elevation, compression, retrograde massage

graded motor imagery

tricks the brain into correcting its distorted image of the body, pain results from mismatch in the way the brain perceives the body and actual condition, this is a way to trick the brain into believing the limb is better than the brain thinks it is

graded motor imagery

laterality reconstruction, visual and motor imagery, and mirro

laterality

non-painful movement, helps restore disruption of normal interaction between intention to move the limb in absence of appropriate sensory feedback

imagery

fires area of the brain that are related to functions of planning and control of movements. think-preparation and carrying out a movement imaging or watching an activity

mirror therapy

tricks brain into correcting distorted image of body, affected limb is in mirror box or behind mirror, brain thinks affected limb is better than it actually is, movement of uninvolved limb must not cause pain in involved limb

mirror therapy

patient looks at un-injured limb in the mirror and its reflection looks like affected limb → progress to movement: affected limb first imagines the motion and then replicates the motion in the box while patient watches reflection of un-injured limb in mirror → always starts with involved limb in box or hidden from view → take off jewelry

ULTT1

median nerve, anterior interosseous nerve

ULTT2

median nere, musculocutaneous nerve, axillary nerve

ULTT3

radial nerve

ULTT4

ulnar nerve