Upper Limb Neurodynamics & Tendinopathy

Upper Limb Neurodynamics & Tendinopathy Part 1 Learning Objectives 1. 2. 3. 4. 5. What subjective clues would lead you to investigate the Median Nerv...
Author: Basil Doyle
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Upper Limb Neurodynamics & Tendinopathy Part 1 Learning Objectives 1. 2. 3. 4. 5.

What subjective clues would lead you to investigate the Median Nerve? What tendinopathies could be imitated by the Median Nerve? What structures can limit the movement of the Median Nerve? What is the course of the Median Nerve? When would you perform ULNT2 testing?

Objective 1. 2. 3. 4. 5. 6.

What range is “full range” for the ULNT1? How should you manage an acute nerve irritation? Why only go to R1 or P1? How long should ice be applied for? What taping techniques can be used in the early stages? Who should you refer patients to?

Anatomy and In the clinic (see the handout for further anatomy) 1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11. 12. 13. 14.

Palpate along the course of the median nerve Locate and palpate the pronator teres, the Flexor Digitorum Superficialis and Flexor Digitorum Profundus Palpate the median nerve where it crosses the wrist Perform the ULNT1 to R1 and P1, and notice the difference between the two in objective results Change the order of movement, start with the shoulder, or start with the fingertips, and compare results Release any muscle overactivity along the median nerve Reassess the ULNT1 If the ULNT1 has not changed, why do you think this may be? Palpate along the path of the radial nerve Palpate the radial nerve at the spiral groove, over the head of the radius, and on the lateral border of the radius Perform ULNT2 testing to R1 and P1 Palpate the supinator muscle Release any overactive muscles along the Radial Nerve Reassess the ULNT2

Discussion 1. 2.

Why would objective results vary if you tell the patient you are performing a nerve test compared to a muscle test? How can sensitivity in the brain (“central sensitivity”) influence your neurodynamic testing results?

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Part 2 Learning Objectives 1. 2. 3. 4.

When would you examine the Musculocutaneous Nerve (MN)? What activities may cause entrapment of the MN? What sports involve repetitive or sustained end of range UD and RD? When would you assess the Ulnar Nerve?

Practical 1. 2. 3. 4. 5. 6. 7. 8. 9. 10.

Test the MN Palpate along the path of the MN Release any overactivity along the MN Reperform testing of the MN Perform a “slider” for the MN Palpate along the Ulnar Nerve path Perform ULNT3 Palpate the Ulnar notch and the Ulnar Nerve where it crosses the wrist Palpate for thoracic ring shifts (as taught by LJ Lee) while performing ULNT testing Correct any thoracic ring shifts while reperforming ULNT testing and assess the range

Discussion 1. 2. 3. 4. 5.

When would you use a night splint for the wrist? Why would a patient have overactivity of the muscles along the Ulnar Nerve? Why would your patient explanation make a difference to a patients treatment outcome and speed of recovery? How would you treat someone with a Radial Nerve irritation or restriction How would this treatment vary to someone with a Wrist Extensor tendinopathy?

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nerves and neuroanatomy

Why bother with nerves

• The concepts in this video include the work of David Butler

(www.noigroup.com) and Discover Physio (www.discoverphysio.ca)

• Tendinopathy is very common in the medial and lateral epicondyles of the elbow, in sports and the workplace

• Explore • Upper Limb nerves that can imitate or be involved in tendinopathy around the wrist and elbow

• Part 2 explores the role of the radial, musculocutaneous and

• If you miss nerve involvement, you will on the slow track to recovery

• If you find it, you will crack some pretty hard clinical cases, and come out looking like a champion

ulnar nerves

We are going to explore

1st up - median nerve

• Anatomy of the nerves

• One of the more well known nerves of the UL

• Testing for neural involvement

• Can be implicated in golfer’s elbow

• Find out about an UL nerve you may not even know exists

• Figure out how to treat these

Median n course

(tendinopathy of the medial epicondyle), biceps tendinopathy at the elbow, elbow joint pain, thrower’s shoulder and OH activities eg hanging out washing

ulnt 1 - (median) testing

• C5 right through to T1

• Test opposite side first

• Under the biceps tendon

• GENTLE testing - watch your patient for other signs -

• Sits on brachialis, in the bicipital furrow • Crosses the elbow medial to the biceps tendon • Dives between two heads of pronator teres, and then under the FDS and FDP

• Carpal tunnel - can be palpated at the wrist with F/E

wincing, eyes etc

• Fist on bed, hand on fingers, thumb on thumb, arm resting on thigh

• Sh Abd (110 or Resistance), Wrist E, Supin, elbow ext • Elbow last - easier to measure, for patient to protect with biceps if need to

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ulnt 1 - (median) treatment • STR or needling along median nerve • Palpate for irritated muscles • Assess supinator

Who • All suspected tendinopathies in the upper limb • All patients with meaningful or painful movements that resemble the ULNT in some way

• Release supinator

• Patients with a line of pain that follows the UL nerves

• Release with neural mobilisation

• Any dislocation of the shoulder

• Scalene release • Palpate for lateral shifts of the cervical spine, correct with nerve glides

positive tests • What makes up a positive neurodynamic test? • There is some debate, and it can consist of • R1 - (first resistance) or R2 (EOR) •

P1 - (first sign of pain) or P2 (as far as they can tolerate)

• M1 - mechanical response in the muscle • Clinically, I find R1 and P1 the most useful, and will also calm the patient - letting them know they are not going to be hurt

other factors • Some aspects not covered in this lecture are: • NR pain • Cervico-genic pain • Neuro exam - sensory, motor and reflex testing • Thoracic involvement - see this in a future lecture

• Arm pain that changes with neck movement • Any neural symptoms eg CTS

testing considerations • Studies show that if you tell patients you are testing their

nerve movement, they will get less ROM than if you keep that bit of info to yourself

• You are testing the brain’s response to input from the

periphery, not just the physical health of the nerves. Your manner, manual handling and connection with the patient may all vary your results

• Test the unaffected side first so the patient feels safe by the time you get to their affected side

radial nerve - when? • Pain with activities where elbow extended, not flexed

• Forearm/lateral epicondyle pain with IR of arm • Pain along the path of the radial nerve • Pain with biceps curls • Any lateral epicondylosis

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radial nerve path

ulnt2 (radial nerve) testing

• Palpate in the axilla

• Shoulder depression

• Wraps around humerus in the spiral groove (3 fingers width

• Elbow extension

below deltoid insertion, b/w lateral and medial heads of triceps

• Between brachialis and biceps • Over the head of the radius • Passes into supinator mm • Runs along the lateral border of the radius (can palpate 4 fingers above wrist)

ulnt2 (radial nerve) treatment • STR along the line of the Radial nerve (partic in triceps and forearm)

• STR with nerve glides eg wrist flexion • Nerve sliders (self) • eg swimmers

MC Nerve - path

• Whole arm IR • Wrist flexion • Shoulder Abd up to 40deg • Can also do Shoulder Ext • Vary amount of shoulder depression

musculocutaneous nerve when? • deQuervain’s • Tenderness lateral to biceps tendon • Patients that spend a lot of time doing Wrist UD/ RD like:

• Dragon boat rowers • Big tackle sport-fishermen

MC Nerve testing • Similar position to Radial N testing

• C5,6,7

• Shoulder depression

• Pierces coracobrachialis

• Elbow Ext

• Between brachialis and biceps

• Shoulder Ext

• Down lateral part of forearm to thumb

• Wrist UD • Tuck thumb in

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MC Nerve Treatment

Ulnar nerve - when?

• Check coracobrachialis • Release along brachioradialis • Progress to release with wrist UD/thumb tuck • Can be combined with night splint if suspect deQuervain’s • Nerve sliders/tensioners

• Arm symptoms posterior arm • Pain reaching up and brushing back of hair,

putting glasses on, carrying school bag, pushups or bench press, driving, drying back with towel

• Remove aggravating activities - UD/RD esp EOR activities. Change paddle stroke etc

ulnar nerve path • C8 and T1, sometimes C7 • Close to the Median N

ulnar n testing (ulnt 3) • Elbow on knee • Wrist ext • Forearm pron

• Through medial intermuscular septum

• Elbow F

• In ulnar groove of forearm, under UCL

• Sh LR

• Palpate b/w Pisiform and hook of Hamate

• Shoulder girdle depr • Shoulder Abd

ulnar n treatment (ulnt 3) • Scalene release • Teaching patients how to relax their scalenes • Tricep release • FCU release with wrist ext • Nerve glides

how you talk • The way you describe your nerve testing and

results can make a large impact on the patients pain experience and recovery

• Using terms like “how well the nerves slide or floss through the muscles”

• Avoid terms like “pinch” and “compressed by a disc”

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What do we do with this info • We are definitely not “stretching nerves” or anything

aggressive - this will only serve to aggravate irritated neural structures

• Don’t take neural testing to P2 - your patients will hate you, and you will stir them up a lot if the nerves are sensitised

• Develop your sensitivity to R1 - this will often correspond to the patients first feeling of stretch, and often be just prior to P1

other areas

nerve mobilisation • Sliders or Tensioners • Acutely - release tissues first • Start with sliders if irritable • Progress to tensioners • Integrate into active movement • If pain not responding, need to look elsewhere

References

• The Cervical and Thoracic spine will have a

• Butler, D (2000) The Sensitive Nervous System.

• Always assess the C/sp and T/sp with any upper

• Palastanga et al, (1994) Anatomy and Human

large effect on neural mobility of the upper limb. limb involvement

NOI Publications, Adelaide

Movement, Structure and Function 2nd Ed. Butterworth-Heinemann Ltd, Oxford

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