Peripheral Nerve Injury

Nora Barrett, MS, OTR/L, CHT

February 10, 2018

Objectives

• Differentiate between segmental involvement and symptoms in peripheral nerve distribution

• Contrast the pathology and presentation of compression versus laceration in nerve injury

• Evaluate historical and current concepts of sensibility retraining in nerve injury

• Describe rehabilitation phases for UE nerve palsies• Select appropriate clinical examination techniques and

therapeutic interventions for common nerve compression syndromes

Fundamentals

(Bathen & Gupta, 2011; Freedman, Dholakia, Ivill, Hilibrand & Broyer, 2011; Hammert, 2013; McClure, 2011; Topp & Boyd, 2012)

PNS Anatomy• Unit = neuron

• Connective tissue• Provides nutrition, prevents compression, allows

lengthening, and speeds conduction• Endoneurium-surrounds the axon• Perineurium-surrounds fascicles, blood-nerve barrier• Epineurium-binds fascicles into named nerve

• Arteriae nervorum• Blood supply affected with nerve compression or traction,

impairing nerve conduction

• Nervi nervorum• Sensory and autonomic fibers to peripheral nerves

(Jarosz, 2009, CC 3.0; https://en.wikipedia.org/wiki/File:Neuron_Hand-tuned.svg)

DendriteAxon terminal

Schwann cellMyelin sheath

Node of RanvierSoma

Axon

Nucleus

PNS Anatomy• Efferent (motor) fibers – anterior horn cell

• Afferent (sensory) fibers – dorsal root ganglion

• Stellate ganglion at C7

• Mixed spinal nerves divide into 2 major branches/rami• Dorsal rami

• Supply muscles close to the vertebral column and the skin of the back

• Ventral rami• C5-T1 form the

brachial plexus(Mysid, 2006, CC 3.0;

https://en.wikipedia.org/wiki/File:Spinal_nerve.svg)

Brachial Plexus

(https://en.wikipedia.org/wiki/File:Brachial_plexus_2.svg)

Nerves• Roots – Trunks –

Divisions• Segmental involvement

• Dermatomes and myotomes

• Cords – Nerves • Peripheral nerve

distribution• Sensory and motor

symptoms

Cervical Screen • Observation/Inspection

• AROM

• PROM

• Neurological screen

• Special tests• Spurling’s

• Cervical distraction

• Upper limb tension test

• Bakody’s sign / shoulder abduction test (http://www.ehealthstar.com/test/spurlings-test-sign)

Clinical Prediction Rule For Cervical Radiculopathy

•Cervical rotation toward involved side <60°

•Positive upper limb tension testing•Positive cervical distraction•Positive Spurling’s Test

Segmental Testing

SEGMENT MYOTOME REFLEX DERMATOME

C2‐C4 Shoulder shrug Supraclavicular

C5 Shoulder abduction BicepsLateral arm (mid‐deltoid)

C6Elbow flexion, wrist 

extensionBrachioradialis Thumb

C7Elbow extension, wrist flexion

Triceps MF

C8 Thumb abduction SF

T1Finger abduction, finger adduction

Medial proximal forearm

Anomalous Innervations

• Martin-Gruber anastomosis• Proximal forearm, AIN/median n. ulnar n.

• Marinacci anastomosis• Proximal forearm, ulnar n. median n.

• Riche-Cannieu anastomosis• Hand, deep/motor branch of the ulnar n. recurrent

branch of the median n.

• Berretini anastomosis• Hand, between the ulnar and median common digital

nerves(Doygan, Uysal, & Seker, 2009)

Pathophysiology of Nerve Injury

(Bathen & Gupta, 2011; Clark, Barr, & Safadi, 2003; Hammert, 2013; Jacoby, Eichenbaum, & Osterman, 2011; Mackinnon & Novak, 1984; Slutsky, 2011; Smith,

2011; Topp & Boyd, 2012; Walsh, 2012)

Classification• Seddon’s Neuropraxia / Sunderland’s I

• Local conduction block involving local demyelination

• Axon remains intact

• Conduction preserved proximal and distal to the lesion

• Good to excellent prognosis

• Recovery complete within weeks

Classification• Seddon’s Axonotmesis / Sunderland’s II

• Axon disruption with Wallerian degeneration• Conduction lost distal to lesion• Endoneurial tube intact• Prognosis is fair because supportive connective

tissue remains• Recovery time depends on the distance from the

injury to the innervated end organ• 1 mm/day

Classification• Seddon’s Neurotmesis / Sunderland’s III, IV, V

• All layers disrupted• III – Perineurium intact; may regenerate but with

intrafascicular mixing

• IV – Epineurium intact; no regeneration

• V – Complete disruption; no regeneration

• Prognosis is poor

• Surgical repair required

Light Compression Neuropraxia Axonotmesis Neurotmesis

Paradigm for Nerve Injuries

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(Clark, Barr, & Safadi, 2003; Mackinnon & Novak, 1994)

Nerve Compression• Pathophysiology

• Fluid accumulation in endoneurial compartment increased endoneurial pressure decreased blood flow to nerve and scar formation

• Double crush syndrome• Decreased axoplasmic flow in chronic compression• Distal to compressive force,

nerve is more sensitive to sub-clinical levels of entrapment

• Water hose analogy

(Mizisin & Weerasuriya, 2011)

Nerve Laceration• Motor dysfunction

• Negative effects of unopposed antagonists

• Joint contractures, overstretched denervated muscles, muscle substitution patterns

• Sensory dysfunction• Allodynia, dysesthesia• Loss of tactile discrimination• Loss of protective sensation

• Sympathetic dysfunction

• Vasomotor, sudomotor, pilomotor, and trophic changes

Nerve Repair• Rate of nerve recovery after surgical repair is 1-3

mm/day• Faster proximally

• Complicating factors• Scarring• Mismatching fibers• Delayed repair• Older age of patient• Proximal injury• More severe initial injury• Complex surgical techniques, including grafts

Evaluation

COMPRESSION LACERATION

• History of onset• Social history• Patient goals• Symptoms (pain, paresthesias,

exacerbating/ relieving factors)• Functional status• Cervical screen• Posture evaluation• Worksite analysis• Provocative tests• Sensory/motor evaluation

• History of injury• Operative notes• Social history• Patient goals• Pain scale• Functional status• Edema• Sensory/motor evaluation

Intervention

COMPRESSION LACERATION

• Patient education • Activity modification and

ergonomics• Postural exercises• Orthoses• Physical agent modalities• Manual therapy techniques• Nerve gliding• ROM• Targeted strengthening• Sensory reeducation

• Patient education• Pain management• Sensory reeducation/injury

prevention• Desensitization• Scar management• Orthoses • ROM • Motor reeducation following

tendon/nerve transfers

Addressing Sensory Dysfunction

(Bell Krotoski, 2011; Hsu et al., 2016; Lu et al., 2016; Rosen & Ludborg, 2011)

Sensory Intervention

• Based on principles of learning

• Tailored to patient’s interests and abilities

• Must be accompanied by early and repeated evaluation

Loss of sensation

Diminished sensation

Hypersensitivity

Compensatory techniques

Sensory reeducation

Desensitization

Evaluation of Sensory Return

Pain and temperature – sharp/dull

Vibration 30 cps – tuning fork

Moving touch

Constant touch – Semmes Weinstein

Vibration 256 cps – tuning fork

Touch localization

2 point discrimination

Stereognosis

Sensory Reeducation – Previous

• Early phase• Begin when 30 cps vibration and/or moving touch returns• Progress through moving touch, constant touch, and 256 cps

vibration• Include touch localization in post-stimulus recognition

• Late phase• Begin when moving and constant touch and/or 256 cps vibration

perceived at fingertips with good localization• Guide recovery of tactile gnosis• Sequence with/without vision• Grade size, shape, weight, and temperature of objects• Progress to role-specific objects (i.e. job-related)

Sensory Reeducation – Current

• Start immediately after nerve repair to preserve cortical hand representation

• Stage 1• Begins immediately after nerve repair• Lasts several months until measurable sensibility in

hand via Semmes-Weinstein monofilaments• Focus is maintaining cortical hand

representation• Sensory imagery• Cortical visuo-tactile interaction• Cortical audio-tactile interaction

Sensor glove (Mendes et al., 2013)

Sensory Reeducation – Current

• Stage 2• Begins with measurable sensibility in palm via

Semmes-Weinstein monofilament (6.65)• Once “some” protective sensibility localized correctly in

fingertips, touch discrimination and identification is initiated

• Classic Wynn-Parry and Dellon training used• Focus is re-establishing functional reinnervation of

hand via cortical reorganization

** This approach may improve sensory outcomes after wrist-level peripheral nerve repair (Walbruch, & Kalliainen, 2015)

25

Desensitization

• Progressive structured stimulation beginning at patient’s level of tolerance

• Basic modalities• Touch• Tapping • Textures • Vibration

• Often 7-8 weeks to have positive effects

• Activity involvement (https://www.ncmedical.com/item_1163.html)

Nerve Palsies

(Duff & Estilow, 2011; Hammert, 2013)

Nerve Palsy – Phase One

• Protected positioning• Protect surgical repair if post-op• Rest overused structures• Prevent nerve compression or traction• Prevent deformity/soft tissue shortening

• Mange edema

• Protect areas of altered sensibility

• AROM of uninvolved joints

• Early sensory reeducation

Nerve Palsy – Phase Two

• AROM with reinnervation• Place and holds

• Facilitate sensorimotor control• Biofeedback and/or NMES• Mirror visual feedback• Meaningful goal-directed activity

• Maintain PROM of affected and surrounding joints

• Sensory reeducation

• Maximize function with orthoses as needed for appropriate positioning

Nerve Palsy – Phase Three

• Strengthening

• Aerobic conditioning

• Advance functional activities• Work simulations • Recreational activities

• Issue adaptive equipment/orthoses as needed for residual deficits

Brachial Plexus Injuries• Obstetric or traumatic• Preganglionic vs. postganglionic

• Horner’s syndrome – avulsion of T1 nerve root

• Erb’s palsy• Upper trunk• “Waiter’s tip”—shoulder IR, elbow

extension, wrist/finger flexion• Klumpke’s palsy

• Lower trunk• May imitate ulnar nerve lesion

• Flail arm(http://erbpalsy.org/symptoms.html)

(Kang & Wolfe, 2011)

Proximal Nerve Palsies• Long thoracic nerve

• Functional loss: scapular winging

• Suprascapular nerve• Functional loss: weakness in abduction and ER

• Musculocutaneous nerve• Functional loss: biceps atrophy, weak elbow flexion in

supination, decreased sensation along radial aspects of forearm

• Axillary nerve• Functional loss: shoulder abduction/elevation/ER,

numbness of lateral upper arm

(Bednar & Wurapa, 2011)

Median Nerve PalsiesMuscle loss Functional deficit

HIGH LEVEL

PT, PQ* Forearm pronationFCR Weak wrist flexion / radial deviationFDS all digits, FDP index/long*

PIP/DIP flexion – absent index/long, weak ring/small

FPL* Loss of thumb IP flexionLOW

LEVELLumbricals index/long

MP flexion/IP extension deficit of index/long

APB, OP, superficial FPB

Loss of opposition, palmar abduction (deficits in functional prehension)

Median Nerve Palsies

Short opponens

(B. Stern)

Web spacer

(ASHT test prep book, p. 351)

Ulnar Nerve Palsies

Muscle loss Functional deficitHIGH

LEVELFCU Weak wrist flexion / UDFDP ring/small Loss of power grip

LOW LEVEL

Adductor pollicis and 1st DI Loss of key pinch

FPB deep head Impaired thumb stability during pinch

Lumbricals ring/small Clawing of ring/small

Interossei Wartenburg’s sign, flattened palmar arch

Ulnar Nerve Palsies• Hollowing

• Froment’s sign

• Jeanne’s sign

• Wartenberg’s sign

• Duchenne’s sign

• Masse’s sign

• Pollock’s sign

(Young, Fattah, & Felming, 2008)

(B. Stern)

Radial Nerve Palsies

Muscle loss Functional deficitHIGH

LEVELBrachioradialis Weak elbow flexionECRL/ ECRB* Weak wrist extension / radial deviation

LOW LEVEL

Supinator Weak supination (test in extension to eliminate biceps)

ECU Weak wrist extension / ulnar deviationEDC, EIP, EDQ Lost digital extension

EPL, EPB, APL Lost thumb extension / radial abduction

*Variable, may be innervated by PIN and may be lost in low-level

Radial Nerve Palsies

Colditz design (Staines, 2015)

Theratube design

Compression Syndromes

(Abzug, Martyak, & Culp, 2011; Amadio, 2011; Evans, 2011; Hammert, 2013; Poretto-Loehrke & Soika, 2011; Rekant, 2011; Strohl & Zelouf, 2017; Valdes &

LaStayo, 2013; Walsh, 2012; Xing & Tang, 2014)

General Rehab Principles• Conservative

• Myofascial length and mobility• Neural mobilization• Activity modification• Orthoses• Physical agents?

• Post-operative• Protected ROM• Neural mobilization• Scar management• Sensory reeducation• Activity modification

(Porretto-Loehrke & Soika, 2011)

Thoracic Outlet Syndrome

• Compression sites• Scalene interval• Costoclavicular space• Subcoracoid space

• Neurogenic• True vs. disputed• Compressive vs. entrapment

• Vascular• Venous• Arterial

(https://med.stanford.edu/ctsurgery/clinical-care/thoracic-surgery-services/thoracic-outlet-syndrome.html)

(Osterman & Lincoski, 2011; Walsh, 2011)

Thoracic Outlet Syndrome• Clinical provocation

• Wright’s test• Roos’ test• Halstead maneuver• Cyriax release

• Treatment• Patient education and behavioral

modification/avoidance overhead activity• Postural exercises/scap stab/position to

limit plexus drag• Diaphragmatic breathing• Gentle pec minor stretch

(Osterman & Lincoski, 2011; Walsh, 2011)

Reliability 1.0Sensitivity 52-84%, Specificity 30-100%

Reliability .92Specificity 77-97%

Sensitivity 70-90% Specificity 29-53%

Radial Nerve

• Sites of compression in forearm

• Fibrous bands anterior to radiocapitellar joint

• Fibrous origin of ECRB• Radial recurrent vessels

– leash of Henry• Proximal border of

supinator – arcade of Frohse

• Distal border of supinator

*Arcadeof Frohse PIN

DRSN

(http://act.downstate.edu/courseware/haonline/labs/L09/070105.htm)

Radial Tunnel Syndrome• PIN compression at radial tunnel (arcade of

Frohse)• Presentation

• Deep, burning, aching pain• 4-5 distal to lateral epicondyle• Resting and night pain are common• Symptoms increased with pronation and wrist

flexion• Sensory and motor complaints are rare

• Risk factors• Exertion greater than 1kg F > 10x/hour• Static pinching or squeezing of tools• Working with elbow extended• Maintained position of supination or pronation

Radial Tunnel

• Clinical provocation• Tenderness to palpation

4-5 cm distal to lateral epicondyle • Resisted supination• Resisted middle finger extension with elbow extension

• Intervention• Nerve gliding – “turtle scooping sand”• Stretching and postural exercises• Ergonomics • Orthoses

• Wrist extension orthosis• Relative motion orthosis (IF or MF MCP)

Differential DiagnosesLateral epicondylitis

Brachial plexus neuritisCervical radiculopathyAnconeus tendonitis

Extensor compartment syndromeRadiocapitellar pathology

(Porretto-Loehrke & Soika, 2011)

PIN Syndrome• PIN compression in forearm

• Motor deficits• (ECRB), supinator, EDC, EDM, ECU, APL,

EPL, EPB, EIP• No pain or sensory complaints

• Orthosis to support fingers and thumb (and wrist) in extension

Wartenberg’s Syndrome• Compression of DSRN as it exits deep

tissues distally between BR and ECRL

• Pain/paresthesias • Dorsal/radial surfaces of distal third of

forearm• Dorsal hand, thumb, IF, and/or MF

• Differentiate from DeQuervain’s• APL and EPB strong and painless • Finkelstein’s (Eichoff’s) maneuver in

forearm neutral vs. pronation

• Forearm-based thumb spica

Median Nerve

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• Sites of compression in forearm

• Under ligament of Struthers

• Bicipital aponeurosis• Between 2 heads of

pronator teres • FDS arch• Gantzer muscle

Pronator Syndrome

• Compression of median nerve in forearm

• Presentation• Non-localized forearm pain (volar proximal 2/3)

• No nocturnal pain• Exacerbated with repetitive forearm rotation

• Paresthesias in median nerve distribution including thenar eminence

• Note the palmar cutaneous branch• Subjective complaints of weakness• Negative Phalen’s

(http://ww

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s-books.de/book/living-textbook-hand-surgery/chapter/median-

nerve-compression-pronator-and-anterior)

Pronator Syndrome

(https://nervesurgery.wustl.edu/ap/sensation/Hand/MedianNerve/Pages/default.aspx)

(https://nervesurgery.wustl.edu/ev/upperextremity/median/Pages/PalmarCutaneousNerve.aspx)

Pronator Syndrome• Clinical Provocation

• Compression of pronator teres• Site-specific testing

• Resisted forearm pronation (PT)• Resisted elbow flexion in forearm supination (bicipital

aponeurosis)• Resisted MF PIP flexion (FDS arch)

Pronator Syndrome• Intervention

• Rest• Posterior elbow orthosis with 90° elbow flexion and

forearm neutral x 2 weeks – remove for gentle ROM• Avoid repetitive rotation and forceful grasp

• Address muscle imbalances • i.e. PT shortening

• Ergonomics• Physical agents• Nerve gliding

• “Lacertus tunnel”

clinicalgate.com

Anterior Interosseous Syndrome• Compression of AIN in forearm• Presentation

• No sensory complaints• Lost function of FPL and FDP to IF (& MF)

• Limitations in precision pinch• Weak pronation

• Test PT vs. PQ – elbow extension vs. flexion

• Intervention• Thumb orthosis to block IP hyperextension to

increase function and prevent FLP overstretching

• Patient education – avoid gripping and forearm rotation

Carpal Tunnel Syndrome

• Median nerve compression at wrist • Transverse carpal ligament

• Most common compression neuropathy

• Presentation• Nocturnal pain• Paresthesias of radial 3 1/2 digits• Thenar atrophy in advanced cases

(http://act.downstate.edu/courseware/haonline/labs/L08/070101.htm)

Carpal Tunnel Syndrome• Provocative tests

• Tinel’s- over carpal canal: Specificity 93%

• Phalen’s- passive wrist flexion 1 minute: Sensitivity 85% Specificity 89%

• Pressure Provocative Phalen’s: Sensitivity 96% with pressure in wrist flexion, 94% with pressure in wrist extension

• Durkan/Carpal compression test• Scratch collapse test: Sensitivity 69% Specificity 99%

• Berger test/Lumbrical incursion: Specificity 95% when includes wrist flexed

• Sensory testing and MMT

• Boston Carpal Tunnel Questionnaire (Symptom Severity Scale, Functional Status Scale)

Carpal Tunnel Syndrome• Intervention

• Wrist orthosis • 2° flexion, 3° degrees UD• Full-time vs night• MCP block? (Berger’s test)

• Physical agents• Nerve gliding• Tendon gliding exercises – avoid tight composite fist• Manual therapy (carpal mobs + flexor retinaculum

stretch)• Activity modification and ergonomics

(Brininger, et al., 2007; Horng et al., 2014; Nuckols et al., 2011; O’Connor et al., 2012; Page et al., 2013; Page, Massy-Westropp et al., 2012; Page, O’Connor et al., 2012)

Carpal Tunnel Syndrome• Surgical/electrodiagnostic consult

• Atrophy in opponens muscle• SW monofilament tests >3.61• Constant daytime paresthesia• No improvement in nocturnal pain• (+) provocative testing after 1 week of night orthosis

• Surgical release• Mini-open vs. endoscopic

• Post-op rehab

(Evans, 2011; Mack et al., 2017; Peters et al., 2016; Vasiliadis et al., 2014)

Ulnar Nerve

• Sites of compression at elbow

• Arcade of Struthers• Medial intermuscular

septum• Osborne’s band• Fibrous bands of FCU• Anconeus epitrochlearis(http://act.downstate.edu/courseware/haonli

ne/labs/L07/100103.htm)

Cubital Tunnel Syndrome• Ulnar nerve compression at elbow

• Presentation• Pain in medial proximal forearm• Paresthesias in ulnar nerve distribution

• Volar and dorsal• Weakness

Stage 1 Mild paresthesias Subjective weakness only

Stage 2A Moderate paresthesias Mild weakness

Stage 2B Moderate paresthesias Moderate weakness

Stage 3 Severe paresthesias Severe weakness, intrinsic atrophy

(Chiementi & Hammert in Hammert, 2013)

Cubital Tunnel Syndrome• Provocative tests

• Elbow flexion test• Tinel’s• Scratch collapse test

• MMT and sensory testing

• Activity analysis

• PRUNE

(Pixabay.com)

(Pixabay.com)

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Cubital Tunnel Syndrome

• Intervention• Rest and protect

• (Night) orthosis in 30-45° comfortable elbow flexion, wrist/forearm neutral (Hely & Weber)

• Soft elbow pad during day• Nerve gliding• Physical agents • Activity modification and ergonomics• Postural exercises/movement training/core

strengthening

(Basson et al, 2017; Caliandro et al., 2016; Shah, Calfee, Gelberman & Goldfarb, 2013)

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Cubital Tunnel Syndrome• Ulnar nerve decompression

• Fascial bridge between olecranon and medial epicondyle released

• Anterior subcutaneous transposition of ulnar nerve (with Eaton Sling)

• Ulnar nerve transferred anterior to medial epicondyle and held in place using flexor-pronator fascia

• Intramuscular transposition

• Anterior submuscular transposition of ulnar nerve• Ulnar nerve transferred anterior to medial

epicondyle and buried beneath muscle• Origin of flexor-pronator mass resected and

reattached

SMUT

Ulnar Tunnel Syndrome• Compression of ulnar nerve at

Guyon’s canal

• Presentation• Zone 1: motor and sensory• Zone 2: motor only• Zone 3: sensory only

• Causes• Space-occupying lesion• Hamate fracture• Handlebar’s palsy

(http://www.ehealthstar.com/anatomy/-)

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• Conservative management• Orthosis (neutral wrist)• Activity modification and ergonomics• Nerve gliding

• Post-operative management• Scar management• ROM• Intrinsic strengthening

Acknowledgments

• Mary Formby, OTR/L, CHT

• Lorna C. Kahn, PT, CHT

• Broca Stern, MOT, OTR/L, CHT

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Images are courtesy of Primal Pictures when indicated.