EXERCISE 1

History:
Mary-Jane, 45 year old nurse, presents with intermittent tingling and pain the thumb,
index and middle finger of her right hand for the last 2 days that started while at work.
The pain is described as 4/10 ‘pins and needles’. The pain is made worse with
computer work and is relieved by shaking her hands. She has been awaken by ‘8/10
pain, tingling and numbness’ in the middle of the night for the last 2 nights and
hanging her hand over the side of the bed or getting up to shake her hands helps to
alleviate it enough to get back to sleep. She has been taking 500g paracetamol with
no symptom relief. She denies any trauma or recent fall.
No fever, fatigue, weight gain/loss, fever, chills or sweating
No headaches, dizziness, nausea, visual changes, hearing loss
No recent illnesses
Unremarkable family history
Unremarkable systems - no GI/ GU/ Cardiorespiratory complaints
No rash or other integumentary changes
No history of allergies
Social history good
Exam:
Good posture, no gait abnormality, adequate nutritional state, adequate emotional
state, good communication, no acute distress
Neck – no masses, no lymphadenopathy, thyroid good, no visual deformity, mild
restriction on right active and passive rotation; orthopaedic exam normal; UE DTRs
2+ and muscle strength normal, 5+
Shoulder exam – unremarkable
UE – Positive Tinel’s sign over the volar wrist, positive Phalen’s test; minor muscle
atrophy at the base of the thumb; muscle strength normal. No swelling or tenderness
to joints

Based on the above history:

• Identify the components of LODCTRAPPA

• L- the thumb, index and middle finger of her right hand

• O- it started in the last 2 days while at work.

• D- the last 2 days
• C- The pain is made worse by doing computer work and goes from a 4/10 to an 8/10
at night
• T- Pins and needles type pain
• R- hanging her hand over the side of the bed or getting up to shake her hands helps
to alleviate the pain
• A- The pain is made worse with computer work
• P- Nil
• P- 500g paracetamol with no symptom relief
• A- Nil

Identify the components of GORPOMNICS

• G- unremarkable
• O- minor muscle atrophy at the base of the thumb
• R- unremarkable
• P- positive Tinel’s sign over the volar wrist
• O- positive Phalen’s test
• M- muscle strength is normal
• N- DTR normal
• I- Nil
• C- Need more info
• S- unremarkable

Is any further investigation warranted? If yes, what might this be?

• Has this happened before and what treatment was sought if any, to rectify it.
• Then the information should be checked against the VINDICATE mnemonic to assist
with coming up with a differential diagnosis

• V- pins and needles can be associated with restricted blood flow

• I- unlikely
• N- possible due to the night pain, such acute onset would make it unlikely
• D- decreased tunnel size for nerves and blood vessels,
• I- possible
• C- ?
• A- ?
• T- nil
• E- ?
Due to the intermittent numbness of the thumb, index and long finger along with
the intense night pain and slight muscle wasting of the thumb and positive
Phalen’s test my DDx would be carpal tunnel syndrome.
EXERCISE 2
Short Case Histories:

39 year old male presents with a burning sensation at the bottom of his right foot. This has
been present for two weeks since he has started jogging to get fit again. He doesn’t feel like
he’s overdoing the training and can’t figure out why his foot hurts. Nothing makes it better or
worse. He has no history of system disorders or illness. He is generally well. Past history is
only significant for fracture of the proximal tibia when he was 25 yo. On examination on the
right, the foot is normal colour. Pulses are strong. There is decreased sensation at the
posterior lateral ankle and on the plantar aspect of his foot. He is unable to flex his toes.
Ankle jerk is normal. Eversion is normal, inversion is 3+. Examination of the left foot is
normal
What is your most likely diagnosis?
• L - bottom of his right foot
• O - present for two weeks since he has started jogging
• D - two weeks
• C - nothing makes it better or worse
• T - burning type pain
• R - nil
• R - none
• A - may need more info here, but patient does say the pain remains constant
• P - fracture of tibia 14 years ago
• P - need more info
• A - nil

History reveals no serious red or yellow flags

• G – unable to flex toes, (possible Steppage gait)

• O – unremarkable, foot normal colour
• R – decreased toe flexion in right foot compared to left
• P – pulse are strong
• O – decreased sensation on decreased sensation at the posterior lateral ankle and on
the plantar aspect of his foot.
• M – cannot flex toes
• N – ankle jerk normal
• I -?
 • C -?
• S-?

• V – unlikely

• I – no change in pain with the time of day

• N – Unlikely due to his age

• D – possible

• I – need more information

• C – ruled out

• A – not according to his history

• T – possibly due to the increased exercise

• E – nil

Due to the decreased sensation of the posterior lateral ankle and the plantar aspect of his foot
as well as the loss of toe flexion my DDx would be Tarsal Tunnel Syndrome. I would rule out
Medial plantar nerve syndrome due to the fact that due to the pain pattern is exercised
induced.

29 year old female; 28 weeks pregnant, presents to your office with a burning type pain over
her lateral upper leg of 4 weeks duration, 5-7/10 on NRS (numeric rating). She cannot
identify a specific onset, it came on gradually. She has aching in her low back and SI joint but
that comes and goes. No pain in her leg except the area mentioned. The pain is worse when
she’s walking and sitting down helps to relieve the pain. She is unable to take medications at
this time. She has seen another Chiropractor who adjusted her lower back and SI joint a few
times but this did not help. On examination, gait is normal, lumbar spine and hip ROM is
normal. Significant discomfort is elicited on palpation below the greater trochanter.
Orthopaedic testing is generally unrewarding however when you tap or press firmly over the
inguinal region she winces. LE neurologic evaluation is normal. She is otherwise fit and
healthy.

What is your most likely diagnosis?

• L – lateral upper leg, low back and SI joint

• O – cannot identify specific onset, came on gradually
• D – 4 weeks
• C – back and SI joint pain is intermittent , leg pain constant
• T – burning type pain 5-7/10 on NRS (numeric rating) (neuropathic?)
• R – possibly
• R – sitting down helps relieve the pain
• A – walking makes it worse
 • P – no previous episodes disclosed
• P – she has seen a chiropractor who did adjust her lower back and SI joint to no avail
• A – history depicts that she is in good health apart from the presenting condition

History reveals no serious red or yellow flags

• G – normal
• O – unremarkable
• R – hip and lumbar spine ROM normal
• P – significant discomfort is elicited on palpation below the greater trochanter
• O – unrewarding, apart from inguinal region sensitive upon tapping and compression
• M – undisclosed
• N – LE neurologic evaluation is normal
• I – No images disclosed (too hard to take images around that area while pregnant)
• C – none disclosed
• S – none disclosed

• V – unlikely (vascular pain tends to be diffuse aching and poorly localised)

• I – unlikely- pain relieves at rest, no drug usage (neuritis?)
• N – due to her age, unlikely
• D – lumbar spinal stenosis or radiculopathy
• I – unsure
• C – unlikely due to the onset
• A – systemically, patient is well
• T – none elicited from the history
• E – nil

The burning type pain would indicate a neurological type of pain pattern. The upper lateral
leg would be in the L2 dermatomal distribution network. The cutaneous distribution in the
upper lateral leg is innervated by the lateral femoral cutaneous nerve. My main working DDx
for this patient would be a possible Meralgia Paresthetica due to the painful discomfort
caused when palpating in and around the inguinal ligament and greater trochanter. My other
DDx would be Ilioinguinal neuralgia while unlikely, due to the inguinal ligamentous pain on
provocation it may need further tests to rule out.

EXERCISE 3
Develop a table that includes the common entrapment syndromes of the UE and similar table
that includes the common entrapments of the LE (lower extremity). Include the following
components.
Name of the entrapment
Nerve or branch entrapped
Common and any outstanding symptoms
Test used for that entrapment
Upper Extremity
Name of Nerve or Common Test used
the branch and any for that
entrapmen entrapped outstandin entrapmen
t g t
symptoms

Supracondylar Median nerve (C6- T1) Pain, gradual hand Tinel’s sign
Process & brachial artery weakness and sensory Patient may not be
Syndrome loss over the median able to make the Ok
nerve distribution sign with thumb

Pronator Teres Median nerve (C6-T1) Aching pain in the Patient’s symptomatic
Syndrome proximal forearm with arm is pronated and
(no night pain) weakness/ clumsiness resists the examiners
along with numbness forced supination
and paraethsia of the
median nerve
distribution

Anterior A branch of the Motor function loss of Loss of the pinch sign
Interosseous median nerve (C6- Pronator Quadratus between the index
Nerve T1) Flexor digitorum finger and the thumb.
Syndrome profundus and flexor Patient’s resistance
pollicis longus. against forced
Dull aching pain in the supination is
volar aspect of the decreased
proximal forearm

Posterior Radial nerve or Pain in the forearm Direct pressure over

Interosseous branches (C7-C8) and wrist. the supinator muscle
Nerve Pain just distal to the while resisting
Syndrome lateral epicondyle. supination may elicit
No sensory deficit* Weakness in the weakness of
finger, thumb, and supination and
wrist movements. tenderness.

Radial Tunnel Radial nerve Tennis elbow like Clinical tests to

Syndrome symptoms: confirm the diagnosis
Pain that worsens include exacerbation
when rotating the of the pain with
wrist. resisted supination
Outer elbow with the other being
tenderness. increased pain in the
Decreased ability to proximal radial
grip. forearm and over
Loss of strength in the the radial tunnel when
 forearm, wrist, and the wrist is
hand. hyperextended
Difficulty extending against resistance.
wrist.

Cubital Tunnel Deep branch of the Tingling sensation in Direst pressure over
Syndrome Ulna nerve (C7-T1) the 4th and 5th fingers the tunnel may
of the hand. reproduce or
Hand pain. exacerbate symptoms.
Weak grip and Tinel’s sign at the
clumsiness due to cubital tunnel.
muscle weakness in Elbow flexion test.
the affected arm and Pressure provocation
hand. test.
Aching pain on the Froment’s card test
inside of the elbow.

Saturday / Radial nerve Symptoms vary on the Awareness of clinical

Honeymoon severity and location features of this
night palsy (caused by of the trauma. disorder and functions
compression from Wrist drop. of the radial nerve
direct pressure on a Inability to voluntarily may help clinicians
firm object) straighten the fingers differentiate between
or extend the thumb radial neuropathy and
Numbness in the back other possible
of the hand and wrist diseases.

Crutch Radial nerve Presents with a wrist To differentiate

paralysis drop on physical between a peripheral
(caused by crutches examination. radial neuropathy
that are not adjusted Loss of extension of from a central
to the correct height) the forearm, hand, pathology, test the
and fingers. brachioradialis
There will also be a muscle. It is always
sensory loss in the weak in a peripheral
posterior aspect of the radial nerve injury,
forearm radiating to and less affected with
the radial aspect of a CNS disorder.
the dorsal hand and
digits. 

Carpal tunnel Median nerve The main symptom is A positive Phalen’s

Syndrome Intermittent test
numbness of the
thumb, index and long
(no sensory loss over finger and radial half
the thenar eminence) of the ring finger.
Pain in carpal tunnel
syndrome is primarily
numbness that is so
intense that it wakes
 one from sleep with
the hypothesis that
the wrists are held
flexed during sleep.

Guyon’s canal Ulnar nerve Atrophy of the ROM of the wrist and
syndrome hypothenar muscles digits 
and interossei. MMT of ulnar nerve
(Overuse injury) Weakened finger muscles innervated
abduction and distal to Guyon’s
(Dorsum of medial adduction (interossei) Canal 
aspect of the fourth Weakened thumb Sensory exam of the
finger and the dorsum adductor (adductor ulnar nerve cutaneous
of the fifth finger pollicis) distribution distal to
don’t have sensory Sensory loss and pain Guyon’s Canal
loss) of the palmar surface
of the fifth digit and
medial aspect of the
fourth digit.
Ulna Claw may
present (sign of
Benediction)

Wartenberg’s Superficial branch of Symptoms include ill- Provocation tests;

syndrome the radial nerve. defined pain over Tinel's sign over the
dorsoradial superficial sensory
(no motor weakness) hand (does not like to radial nerve (most
wear watch), common exam
Paraesthesia over finding)
dorsoradial hand,
Numbness,
Symptom aggravation
by motions
involving repetitive
wrist flexion and ulnar
deviation,
no motor weakness

Lower Extremity
Name of Nerve or Common Test used
the branch and any for that
entrapme entrapped outstandin entrapment
nt g
symptoms
Sciatic nerve Sciatic nerve Usually presents with Bonnet’s Test
entrapment (L4-S3) symptoms consistent
with radicular pain or
(No significant LBP radiculopathy
unless part of the Deep aching pain in
overall functional sacral or gluteal
complaint) region remains the
most common
symptom with
posterior thigh pain

Pain increases with

sitting and walking,
decreases on lying
supine

Pain and paraesthesia

can radiate along
tibial and/or peroneal
nerve distributions

Possible trophic
changes in territory
of affected nerve

Ilioinguinal Ilioinguinal nerve Painful sensation in Diagnosis of the

neuralgia the lower abdomen ilioinguinal neuralgia
(L1-L2) and groin, radiating requires a careful history,
(sensory only) to the upper inner physical examination,
upper leg and to the electrophysiologic
genitals. studies, and ultrasound
examination.
Patients complain of
pain, parasthaesia
and abnormal
sensation in the area
supplied by the
nerve.

Obturator Obturator nerve Most common Stretching the pectineus

Neuropathy symptom is altered muscle can be useful in
(Anterior divisions of sensation in the diagnosing obturator
(No significant motor L2-L4) medial thigh that may nerve entrapment.
deficit associated be paraesthetic or
with this condition) burning in character Aggravated by extension
and lateral leg
Moderate to severe movements (abduction)
pain that begins
insidiously at the
adductor origin on
 the pubic bone and
worsens with
exercise

Genitofemoral Genitofemoral nerve Chronic neuropathic Knowledge of the

nerve groin pain presentation of GFN
entrapment Pain and/or entrapment will prevent
numbness in an misdiagnosis,
elliptical area on the unnecessary surgery, and
anterior aspect of the delayed treatment.
thigh immediately Pain may be provoked by
below the middle of Increased by thigh
the inguinal ligament. extension
May present as Decreased perception of
scrotal pain or labial pinprick and touch.
pain

Meralgia Lateral femoral Middle aged males Reproduced with Tinel’s

Paresthetica cutaneous nerve unpleasant sign at site of
paraesthesia entrapment (1 cm medial
(burning, tingling, and inferior to the ASIS
stinging) in the nerve helps confirm the
distribution. diagnosis).
Hypersensitivity to Mobilisation of the
touch (e.g. clothing). tissues in the entrapment
Decreased pain on area may relieve the
sitting, increased pain symptoms
on hip extension and
prolonged walking or
standing

Tibial n Tibial nerve Sensory changes in Passive straight leg raise

Entrapment the bottom of the with foot everted till
foot and toes - symptoms are
(a terminal branch of burning sensation, reproduced
the sciatic nerve numbness, tingling,
formed by branches or other abnormal
from L4-S3) sensation, or pain.
Loss of plantar
flexion.
Loss of toe flexion.
Weak inverters
(tibialis anterior can
still invert some)

Common Common Peroneal Pain usually appears Tinel’s sign or

peroneal nerve initially in the overpressure at the
(fibular) nerve compressed region fibula head may increase
entrapment before spreading paraesthesia, aiding
distally into the diagnosis.
common peroneal Dorsiflexion paresis and
 nerve’s cutaneous foot drop (in severe
distributions. cases, look for atrophy of
Possible radiation of anterior tibial muscles).
pain into the thigh (if Weakness of foot
pain is seen in eversion.
buttock or posterior Increased pain with
thigh, think of a more plantar flexion and
proximal cause). inversion of foot.
Sensory Pressure over tunnel will
abnormalities along increase pain.
the anterolateral leg
below the knee and
along the top of the
foot if both
superficial and deep
branches involved

Superficial Superficial peroneal Pain increased with To test the nerve –

peroneal nerve nerve inversion passive inversion and
Sensory loss at lateral plantar flexion while
lower half of the calf applying pressure over
and dorsum of the the point where the
foot. nerve pierces the deep
Motor loss, with fascia reproduces the
higher lesions only, symptoms.
giving weakness of
foot eversion and
ankle stability

Deep peroneal Deep peroneal nerve Pain is often SMR tests for afflicted
nerve aggravated by plantar areas
flexion.
Sensory loss at the
web of the great toe.
Motor loss is variable
depending on level of
the lesion. May
include weak toe
extensors, weak
tibialis anterior and
peroneus tertius in a
more proximal lesion
(may have foot drop).
Atrophy of the belly
of the extensor
digitorum brevis
occurs early and is a
useful sign.

Sural nerve Sural nerve Pain in the calf as The tests used to

entrapment (cutaneous) well as the lateral diagnose of sural
 ankle and foot. entrapment neuropathy
is based on a clinical
sensory examination. 

Saphenous Saphenous nerve Affected patients Pain can be reproduced

nerve complain of by activities such as
(purely sensory) neuropathic (burning kneeling; stair climbing
or electrifying) pain in or even normal gait since
the area of the those activities
saphenous nerve additionally compresses
which is the medial the nerve. A sharp pain
aspect of the thigh at the level of the Hunter
canal which can be
provoked by pressure
(Hofmann Tinel sign)

Tarsal tunnel Tibial nerve Pain or sensory Pain reproduced by

syndrome disturbance on the overpressure
plantar aspect of the
foot. Positive Tinel’s sign
Patients typically
present with Diagnosis is established
intractable heel pain. by nerve conduction
studies. May be
mistaken for plantar
fasciitis. This may be an
overlooked cause of
chronic, nonresponsive
plantar fascia pain.

Medial plantar Medial plantar nerve Pain (burning, Tenderness along medial
nerve shooting, sharp) plantar aspect of medial
syndrome and/or dysaesthesia, arch in the region of the
(jogger’s foot) paraesthesia along navicular tuberosity.
medial arch of the Positive Tinel’s sign just
foot sometimes to behind the navicular
plantar toes in tuberosity ±
distribution of medial paraesthesia.
plantar nerve. Neurodynamic signs –
Onset of pain often dorsiflexion/eversion/SLR
occurs with use of (structural
new arch support or differentiation).
new shoes without There may be pain with
changes in exercise resisted great toe
regime. abduction.
Pain will often
worsen with high
arch supports –
especially rigid
 orthoses

Morton’s Nerves in the Pain, numbness, A palpable click (Mulder's

neuroma: metatarsal tunnels paraesthesia in the click) in interspace with
Interdigital lateral side of one toe compression should
Perineural and medial side of recreate the patients
Fibrosis the next. symptoms
Pain is usually
described as piercing
or like an electric
shock.
Increased pain with
walking, crouching,
wearing high heels
(any other activity
that causes toe
extension)