Clinical Syndromes of Neural Origin (Lower Extremity) PDF

INDEX CLINICAL SYNDROMES OF NEURAL ORIGIN LOWER EXTREMITY • INTRODUCTION • NERVE ENTRAPMENT SYNDROMES IN THE LOWER EXTREMITY • Clinical Presentation Fisioterapia Musculoesquelética II Universidad San Pablo-CEU 2 1 INTRODUCTION INTRODUCTION • Possible entrapment by muscular, bony, or ligament...

INDEX CLINICAL SYNDROMES OF NEURAL ORIGIN LOWER EXTREMITY • INTRODUCTION • NERVE ENTRAPMENT SYNDROMES IN THE LOWER EXTREMITY • Clinical Presentation Fisioterapia Musculoesquelética II Universidad San Pablo-CEU 2 1 INTRODUCTION INTRODUCTION • Possible entrapment by muscular, bony, or ligamentous structures. • Bone tunnels, osteofibrous tunnels, etc. • Mechanical Interface • Places of division of the SN. • What are the areas • Areas where the SN is close • higher risk? • to rigid structures. • Areas where the NS is more fixed. • Stress Points. 3 4 2 LUMBAR RADICULOPATHY SUBJECTIVE EXPLORATION(C/O) • Lumbar plexus • BODY MAP • Lumbosacral plexus • Neuropathic pain in the dermatome • Causes: • Associated Symptoms • Hernia lumbar • (paresthesias) • Foramen stenosis • Motor Symptoms in Cases • conjunction • Serious • More common in L5 and S1 • Consider the level of injury 7 8 4 SUBJECTIVE EXPLORATION(C/O) OBJECTIVE EXPLORATION(P/E) 24-HOUR BEHAVIOR • STRAIGHT LEG RAISE TEST Unilateral pain • PRONE KNEE BEND TEST Pain increases when sitting, coughing, sneezing • NEUROLOGICAL EXAMINATION It will depend on the level affected HISTORY Between 5% and 10% with low back pain have radiculopathy Consider Previous Episodes Consider Peripheralization of Symptoms 9 10 5 OBJECTIVE EXPLORATION(P/E) SUBJECTIVE EXPLORATION • RED FLAGS: • Bladder/bowel dysfunction • Saddle anesthesia • Ataxic gait • Weight loss and other symptoms • Chest pain 11 12 6 DIFFERENTIAL DIAGNOSIS • Degenerative pathology • Espondilolistesis • Lumbar stenosis • Traumatic pathology PYRAMIDAL SYNDROME (DEEP GLUTEAL SPACE SYNDROME) • Fractures with displacement: traumatic history • Tumour pathology • Infectious pathology 13 14 7 PYRAMIDAL SYNDROME SUBJECTIVE EXPLORATION(C/O) • Sciatic nerve • BODY CHART • Compression Zones: • Neuropathic pain (buttocks, hips, • The fibular branch is more common • posterior aspect of the thigh) • Compression in the pyramidal space/muscle • Associated symptoms (paresthesias, • motor symptoms in severe cases) • It can also refer to the territory • Sciatic nerve 15 16 8 SUBJECTIVE EXPLORATION(C/O) OBJECTIVE EXPLORATION(P/E) 24-HOUR BEHAVIOR • PALPATION Symptoms worsen with hip movements • At the level of the piriformis muscle Pain when getting out of bed • STRAIGHT LEG RAISE TEST Difficulty sitting still • ORTHOPEDIC TESTING HISTORY • NEUROLOGICAL EXAMINATION Possible friction of the nerve during physical activity Previous fall or car accident Periods of prolonged sitting (work) In advanced cases, possible motor impairment 17 18 9 OBJECTIVE EXPLORATION (P/E) OBJECTIVE EXPLORATION(P/E) TEST FAIR TEST PACE TEST FREIBERG 19 TEST BEATY 20 10 DIFFERENTIAL DIAGNOSIS • Low back pain (discogenic, facet) • Sacroiliac joint • Root Compression (L5) • Lumbar stenosis LATERAL FEMOROCUTANEOUS NERVE (MAERALGIA PARESTÉSICA) • Hamstring injury 21 22 11 LATERAL FEMOROCUTANEOUS NERVE SUBJECTIVE EXPLORATION(C/O) • L2-L3 (sensation) • BODY CHART • Relación con psoas e iliaco • Neuropathic pain • Iliopubic tract and ligament • Associated symptoms (paresthesias) • Inguinal • At the thigh, it descends superficially • To the tailor • Compression Zones: • Retroperineal • Tractoyliopubic (cycling) • Subcutaneous tissue (tight clothing, belts) 23 24 12 EXPLORACIÓN SUBJETIVA (C/O) OBJECTIVE EXPLORATION(P/E) 24-HOUR BEHAVIOR • PALPATION Pain when walking and standing • Inguinal ligament It may also hurt in hip flexion (prolonged sitting) • PELVIC COMPRESSION TEST There may be an antalgic march • LATERAL FEMOROCUTANEOUS TEST HISTORY • NEUROLOGICAL EXAMINATION Patient 30-40 years old Gradual start Risk factors: abdominal surgery, obesity, pregnancy, diabetes, alcoholism 25 26 13 DIFFERENTIAL DIAGNOSIS FEMORAL NERVE • L3 27 28 14 FEMORAL NERVE FEMORAL NERVE • L2 a L4 • Pierce the psoas • Relación con psoas e iliaco • Inferior to the inguinal ligament • Innervates the psoas, iliacus, quadriceps • Compression Zones: • Iliopsoas compartment • Inguinal ligament 29 30 15 SUBJECTIVE EXPLORATION(C/O) SUBJECTIVE EXPLORATION (C/O) BODY CHART • 24-HOUR BEHAVIOR Neuropathic pain • Functional alterations (in advanced cases): Other symptoms: • Lack of stability in the knee Paresthesias • Trouble walking, going up/down stairs Numbness • HISTORY Muscle weakness/atrophy • Gradual start Quadriceps • Possible relationship with sports activity that causes elongation. • Previous hip/abdominal surgery 31 32 16 OBJECTIVE EXPLORATION(P/E) • PALPATION • Ingle • NEURODYNAMIC TEST FOR FEMORAL NERVE • NEUROLOGICAL EXAMINATION OBTURATOR NERVE • IN ADVANCED STAGES, ASSESS: • Quadriceps reflex and quadriceps 33 34 17 OBTURATOR NERVE OBTURATOR NERVE L2 a L4 ABOUT Passes through the obturator canal Forebouquet and hind bouquet Compression Zones: Shutter channel Between the obturator muscles external, pectineus and adductors 35 36 18 SUBJECTIVE EXPLORATION(C/O) SUBJECTIVE EXPLORATION(C/O) • BODY MAP 24-HOUR BEHAVIOR • Neuropathic pain Pain in monopodal support and hip adduction • Other symptoms: Pain can also be associated with sports • Paresthesias Functional alterations (in advanced cases): • Numbness Abduction and pendulum gait • Muscle weakness/atrophy HISTORY • Adductor Gradual start Previous hip arthroplasty or inguinal surgery Childbirth In sports that include twists or kicks 37 38 19 OBJECTIVE EXPLORATION(P/E) DIFFERENTIAL DIAGNOSIS PALPATION Shutter channel NEURODYNAMIC TEST FOR OBTURATOR NERVE TENSION AND PAIN IN EXTERNAL ROTATION AND ABDUCTION NEUROLOGICAL EXAMINATION • Appendicitis (obturator sign + on the right side and other signs) • Obturator hernia (Howship-Romberg+ sign and signs of bowel obstruction) 39 40 20