Clinical Syndromes of Neural Origin LQ- PDF

CLINICAL SYNDROMES OF NEURAL ORIGIN LOWER QUADRANT Musculoskeletal Physiotherapy II San Pablo-CEU University Elena Cabezas Yagüe  INDEX INTRODUCTION NERVE ENTRAPMENT SYNDROMES IN THE LOWER EXTREMITY: – C...

CLINICAL SYNDROMES OF NEURAL ORIGIN LOWER QUADRANT Musculoskeletal Physiotherapy II San Pablo-CEU University Elena Cabezas Yagüe  INDEX INTRODUCTION NERVE ENTRAPMENT SYNDROMES IN THE LOWER EXTREMITY: – Clinical Presentation 2  INTRODUCTION Possible entrapment by muscular, bony, or ligamentous structures. Mechanical Interface Which are the higher risk areas? 3  INTRODUCTION Bone tunnels, osteofibrous tunnels, etc. Areas where the NS is more fixed. Places of division of the SN. Areas where the SN is close to rigid structures. Stress Points. 4  NERVE ENTRAPMENT SYNDROMES IN THE LOWER EXTREMITY: LUMBAR RADICULOPATHY 5  NERVE ENTRAPMENT SYNDROMES IN THE LOWER EXTREMITY: DEEP GLUTEAL SPACE SYNDROME (AKA PIRIFORMIS SYNDROME ) 6 NERVE ENTRAPMENT SYNDROMES IN THE LOWER EXTREMITY: LATERAL FEMOROCUTANEOUS NERVE (AKA MAERALGIA PARESTHESICA) 7  LATERAL FEMOROCUTANEOUS NERVE L2-L3 (sensitivity) Relation with psoas & iliacus Iliopubic tract and Inguinal ligament At the thigh, it descends superficially to the sartorius muscle Compression Zones: – Retroperineal – Tractoiliopubic (cycling) – Subcutaneous tissue (tight clothing, belts) 8  SUBJECTIVE EXPLORATION (C/O) BODY CHART – Neuropathic pain – Associated symptoms (paresthesias) 9  SUBJECTIVE EXPLORATION (C/O) HISTORY 24-HOUR BEHAVIOR 30-40 years old Pain when prolongued walking and Gradual onsest Risk factors: standing, improves with sitting. Abdominal surgery It may also hurt in hip flexion (prolonged Obesity sitting) Pregnancy There may be an antalgic march Diabetes Alcoholism 10 MAERALGIA PARESTHESICA: OBJECTIVE EXPLORATION (P/E) PALPATION Inguinal ligament Pelvic compression test Lateral femorocutaneous test Neurological examination 11  MAERALGIA PARESTHESICA: DIFFERENTIAL DIAGNOSIS/ SPECIAL QUESTIONS L3 12  NERVE ENTRAPMENT SYNDROMES IN THE LOWER EXTREMITY: FEMORAL NEURALGIA 13  FEMORAL NERVE CHARACTERISTICS L2 to L4 Pierces the psoas Relation with psoas and iliacus Inferior to the inguinal ligament Innervates the psoas, iliacus, quadriceps Compression areas: – Iliopsoas compartment – Inguinal ligament 14 FEMORAL NERVE 15 FEMORAL NEUROPATHY: SUBJECTIVE EXPLORATION(C/O) BODY CHART Neuropathic pain Other symptoms: – Paresthesias – Numbness Muscle weakness/atrophy: Quadriceps 16 FEMORAL NEUROPATHY: SUBJECTIVE EXPLORATION (C/O) 24-HOUR BEHAVIOR Functional alterations (in advanced cases): – Lack of stability in the knee – Trouble walking, going up / downstairs HISTORY Gradual onset Possible relationship with sports activity => elongation. Previous hip/abdominal surgery 17 FEMORAL NEURALGIA: OBJECTIVE EXPLORATION(P/E) Palpation=> Groin Neurodynamic test for femoral nerve Neurological examination In advanced stages, assess Quadriceps and its reflex 18 OBTURATOR NERVE 19  OBTURATOR NERVE L2 a L4 SIJ Passes through the obturator canal Anterior branch & posterior branch Compression Zones: – Obturator channel – Between obturator externus, pectineus and adductor muscles 20 OBTURATOR NERVE 21  SUBJECTIVE EXPLORATION(C/O) BODY MAP – Neuropathic pain – Other symptoms: Paresthesias Numbness Muscle weakness/atrophy=> Adductor 22  SUBJECTIVE EXPLORATION(C/O) 24-HOUR BEHAVIOR – Pain in monopodal support and hip adduction – Pain can also be associated with sports – Functional alterations (in advanced cases): Abduction and pendulum gait HISTORY Gradual onset Previous hip arthroplasty or inguinal surgery Childbirth In sports that include twists or kicks 23  OBJECTIVE EXPLORATION(P/E) PALPATION – Obturator channel NEURODYNAMIC TEST FOR OBTURATOR NERVE TENSION AND PAIN IN EXTERNAL ROTATION AND ABDUCTION NEUROLOGICAL EXAMINATION 24  DIFFERENTIAL DIAGNOSIS Appendicitis (obturator sign + on the right side and other signs) Obturator hernia (Howship-Romberg+ sign and signs of bowel obstruction) 25 NERVE ENTRAPMENT SYNDROMES IN THE LOWER QUADRANT: PERONEAL NERVES 26  PERONEAL NERVES L4-S3 Upper angle of the popliteal fossa Superficial peroneal nerve: – Between fibula and peroneal muscles – Superficial at the back of the ankle Deep peroneal nerve: – Interosseuos membrane, under the extensor retinaculum 27 PERONEAL NERVES 28  PERONEAL NERVES AREAS OF INJURY: – Common peroneal nerve: Fibula’s head (long lateral peroneus origin) – Superficial peroneus nerve: Foot dorsum (after ankle inversion injury or prolonged plantar flexion) – Deep peroneal nerve: Anterior tarsal tunnel (maintained plantar flexión) Foot dorsum (tight shoes, bruises/contusions) 29  SUBJECTIVE EXPLORATION(C/O) BODY MAP – Neuropathic pain in the area – Associated symptoms (paresthesias, etc.) – Possible pain at the areas of entrapment – In severe cases, walk with foot drop 30  SUBJECTIVE EXPLORATION(C/O) 24-HOUR BEHAVIOR: – Pain on contraction in eversion – Pain when stretching in inversion HISTORY: - History of lateral ankle sprain (superficial peroneal nerve) - Maintained plantar flexion (use of heels in deep peroneus) - Sports practice (deep peroneal ball striking vs superficial peroneal dance) 31  OBJECTIVE EXAMINATION (P/E) PALPATION STRAIGHT LEG RAISE TEST – Superficial and deep peroneal variants NEUROLOGICAL EXAMINATION 32  DIFFERENTIAL DIAGNOSIS Lumbar radiculopathy L5 Muscle pathology Consider possible Affectation after traumatic ankle injuries 33 NERVE ENTRAPMENT SYNDROMES IN THE LOWER QUADRANT: TIBIAL NERVE 34  TIBIAL NERVE L4 to S4 Descends throw the deep posterior leg compartiment Branches: – Lateral plantar nerve – Medial plantar nerve – Medial calcaneal nerve 35 TIBIAL NERVE 36 TIBIAL NERVE 37 TIBIAL NERVE 38  TIBIAL NERVE AREAS OF INJURY: – Tibial nerve: Arch of the soleus Posterior tarsal tunnel (PTT syndrome) 39  TIBIAL NERVE AREAS OF INJURY: – Medial plantar nerve: Medial plantar tunnel (abductor muscles of the first toe and quadratus plantae) – Lateral plantar nerve*: Between the abductor of the fifth finger and the quadratus plantae 40  SUBJECTIVE EXPLORATION (C/O) BODY CHART – Soleus arch sindrome: Pain in the popliteal fossa and back of the calf – Posterior tarsal tunnel sindrome: Pain and paresthesias in the medial ankle area Can extend to the heel, sole of the foot 41  SUBJECTIVE EXPLORATION(C/O) BODY CHART – Medial plantar nerve: Plantar and heel pain – Lateral plantar nerve: Heel pain, which can radiate to the inner arch 42  SUBJECTIVE EXPLORATION (C/O) 24-HOUR BEHAVIOR AND HISTORY – Soleus arch síndrome Inability to load Weakness when finger flexion Symptoms worsen when walking 43  SUBJECTIVE EXPLORATION(C/O) 24-HOUR BEHAVIOR AND HISTORY – Posterior tarsal tunnel syndrome: Symptoms worsen when walking and are relieved at rest Possible nighttime pain In severe cases, involvement of the intrinsic muscles Possible flatfoot/pronated (increased pressure in the tarsal tunnel) – Assess other clinical alterations/syndromes associated with flatfoot/pronated foot Consider space-occupying injuries 44  SUBJECTIVE EXPLORATION (C/O) 24-HOUR BEHAVIOR AND HISTORY Lateral plantar nerve: – Elderly – Associated with being overweight and standing for long periods of time – Consider systemic pathologies (diabetes) – Also featured in runners Hyperpronation of the foot, atrophy of plantar fat 45  OBJECTIVE EXAMINATION (P/E) PALPATION STRAIGHT LEG RAISE TEST Tibial nerve variant NEUROLOGICAL EXAMINATION 46  OBJECTIVE EXAMINATION (P/E) Posterior tarsal tunnel syndrome: Triple compression test Dorsiflexion/eversion test 47  DIFFERENTIAL DIAGNOSIS Lumbar radiculopathy (L5-S1) Posterior compartment syndrome Achilles tendinopathy Plantar fasciitis Retrocalcaneous bursitis Inflammation of plantar ligaments/fascia 48  NERVE ENTRAPMENT SYNDROMES IN THE LOWER QUADRANT: SURAL NERVE 49  SURAL NERVE Cutaneous branch of the tibial nerve Descend between the gastrocnemius and passes through a fibrous arch in the myotendinous transition zone Receives collateral branch of peroneal nerve Continues behind the external malleolus Forms the lateral calcaneal nerve Possible compression in the fibrous arch 50  SUBJECTIVE EXPLORATION (C/O) BODY MAP – Pain and paresthesia in the posterolateral aspect of the leg, ankle and foot (up to 5th toe) 24-HOUR BEHAVIOR Symptoms increase with standing and exercise (running) Possible nighttime pain Pain is reproduced in active eversion and passive inversion HISTORY Possible previous trauma to the area, surgery to the area Ankle squeezes, 5th MTT fractures, Achilles tendinopathy (make differential diagnosis), bandages 51  OBJECTIVE EXAMINATION (P/E) PALPATION STRAIGHT LEG RAISE TEST – Sural nerve variant NEUROLOGICAL EXAMINATION 52 NERVE ENTRAPMENT SYNDROMES IN THE LOWER QUADRANT: INTERDIGITAL NERVES (MORTON'S NEUROMA) 53  INTERDIGITAL NERVES Plantar nerve branches Medial Plantar – 1st and 2nd Interdigital Nerves Lateral Plantar Nerve: 4th Interdigital Nerve Medial and lateral plantar nerve: 3rd interdigital nerve Mechanical stress injury and neural fibrosis/edema. Associated with compression ischemia and bursitis 54  SUBJECTIVE EXPLORATION (C/O) BODY CHART – Pain/paresthesia in the intermetatarsal region – Usually unilateral 24-HOUR BEHAVIOUR Worsens in load, heel wear Improves when taking off shoes 55  SUBJECTIVE EXPLORATION (C/O) HISTORY – Women – 30-50 y.o. – Possible pes cavus – High heels – Dance (on pointe) DIFFERENTIAL DIAGNOSIS Metatarsalgia Synovitis of the metatarsal heads 56  OBJECTIVE EXAMINATION (P/E) PALPATION PAINFUL PASSIVE FINGER EXTENSION MULDER'S SIGN 57