Differential Diagnosis and Intervention of Proximal Median Nerve Entrapment: A Resident's Case Problem.

Study Design Resident's case problem. Background Entrapment neuropathies represent a diagnostic challenge and require a comprehensive understanding of the nerve's path and the anatomical structures that may cause compression of the nerve. This resident's case problem details the evaluation and differential diagnosis process for median nerve entrapment resulting from forceful and repetitive pronation/supination motions. Diagnosis Median nerve compression syndromes include pronator syndrome, anterior interosseous nerve syndrome, and carpal tunnel syndrome. A cluster of clinical special tests were performed to determine the anatomical site of median nerve entrapment. Based on the patient's history and clinical test results, a diagnosis of pronator syndrome was determined. Provocation testing specific to pronator syndrome assisted with further localizing the site of entrapment to the pronator teres muscle, which guided effective management strategies. Discussion This resident's case problem illustrates the importance of detailed anatomical knowledge and a differential diagnostic process when evaluating a patient with signs and symptoms of an entrapment neuropathy of the median nerve. Electrodiagnostic studies are useful in ruling out carpal tunnel and anterior interosseous nerve syndromes, but are often inconclusive in cases of pronator syndrome. Therefore, a diagnosis of pronator syndrome in this case problem was based on a detailed understanding of median nerve anatomy, potential sites of compression, and unique clinical features associated with this condition. Level of Evidence Differential diagnosis, level 4. J Orthop Sports Phys Ther 2016;46(9):800-808. Epub 5 Aug 2016. doi:10.2519/jospt.2016.6723.

Immediate and long-term effects of selected physiotherapy methods in patients with carpal tunnel syndrome.

BACKGROUND: Carpal tunnel syndrome is a serious therapeutic problem and it considerably impairs the patients' quality of life. Despite many studies, the effectiveness of conservative treatment is still debatable. This study aimed to evaluate the immediate and long-term effects of conservative treatment involving ultrasound therapy combined with massage and kinesiotherapy for carpal tunnel syndrome. MATERIAL AND METHODS: A total of 61 patients with carpal tunnel syndrome were assessed with regard to such symptoms as pain, numbness, tingling sensation, morning stiffness, and self-care difficulties. We used provocation tests and investigated sensory impairments, autonomic disturbances, and Lüthy's sign. Conduction in the median nerve fibres was assessed during a nerve conduction study. We performed computer-aided measurement of the hand joint range of motion and global grip strength. The tests were conducted before and on completion of a rehabilitation programme. The hands were re-examined one year later. The treatment involved ultrasound therapy, massage, and kinesiotherapy. RESULTS: The treatment outcomes confirmed the effectiveness of the therapeutic programme. Significant improvements concerning the majority of the symptoms were observed between the first and second examination as well for the entire follow-up period. We observed significant improvement in the quality of sensation, the hand range of motion and muscle strength. CONCLUSIONS: Ultrasound therapy combined with massage and kinesiotherapy brings the expected, long-term effects in patients with carpal tunnel syndrome.

Isolated median sensory neuropathy after acupuncture.

A 47-year-old left-handed man presented with pain and numbness in his left thumb and index finger after acupuncture treatment on an acupoint in his left wrist. A technique of herbal acupuncture, involving the use of a needle coated with apricot seed extract, was used. Median nerve conduction study showed an absence of sensory nerve action potential in the left index finger, whereas the results were normal in all other fingers. The radial and ulnar nerves in the left thumb and ring finger, respectively, showed no abnormality. Infrared thermography of the left index finger showed severe hypothermia. The patient was diagnosed as having an isolated injury to the sensory nerve fibers of the median nerve innervating the index finger. This is the first case report of complications from an herbal acupuncture treatment, and it highlights the possibility of focal peripheral nerve injury caused by acupuncture.