Class 9

Question 1

What are the nerves of the upper limb?

Answer 1

• Median
• Axillary
• Radial
• Musculocutaneous
• Ulnar

Question 2

What is the brachial plexus?

Answer 2

• Brachial plexus is bundle of nerves that exit intervertebral foramen from C5 - T1.
• Travel between anterior & middle scalenes, deep to clavicle & over first rib, deep to pec minor & through axilla to become terminal branches.
• These are all potential areas for impingement.
• Braiding of nerves accounts for all sensory & motor control to entire upper limb.
•Interruption of nerve supply via muscular spasm, trauma, compression, tumours,

Question 3

What is Thoracic outlet syndrome?

Answer 3

Compression/interruption of brachial plexus, subclavian artery, & subclavian vein.

Question 4

What are symptoms of Thoracic outlet syndrome?

Answer 4

• paresthesia (ie. numbness, tingling etc) of entire upper limb
• bluish discoloration of affected arm
• arm fatigue during activity
• weak pulse or lack of pulse
• coldness of arm/hand
• swelling

Question 5

What are common causes of Thoracic outlet syndrome?

Answer 5

• Cervical ribs
• Pregnancy
• Repetitive strain (especially with overhead activity or sports)
• Postural fault
• Trauma
• Fractures (cervical, clavicular, etc)
• Heavy bags/backpacks
• Shoulder dislocations
• surgery

Question 6

(Terminal branches of brachial plexus) What is the Median nerve?

Answer 6

• Travels with brachial artery through arm
• Passes into anterior forearm through cubital fossa
• Deep to flexor retinaculum at wrist (via carpal tunnel)
• Provides motor innervation to all muscles in superficial, intermediate & deep layers of anterior forearm EXCEPT, flexor carpi ulnaris & medial half
of flexor digitorum profundus.
• In hand it gives off motor supply to thenar eminence & lateral lumbricals
• Sensory area of supply is lateral palm & lateral 3 ½ digits (thumb, index, middle finger & lateral half of ring finger

Question 7

What is Median nerve damage?

Answer 7

• Presentation is determined by level of injury
• More proximal injury, more severe impairment
• Injury above or at elbow, would be loss of pronation, & weak wrist flexion.
• May notice ulnar deviation as flexor carpi ulnaris would be unopposed
• Wasting of thenar eminence resulting in loss of opposition
• Inability to flex MCP’s or extend PIP’s & DIP’s (lumbricals)

Question 8

Typical characteristicof median nerve injury is ___________________________.

Answer 8

Hand of Benediction

Question 9

What are the structures passing through the carpal tunnel?

Answer 9

• The median nerve
• 4 tendons of FDS
• 4 tendons of FDP
• 1 tendon of FPL

Question 10

What are causes of Carpal tunnel syndrome?

Answer 10

• Trauma/swelling at wrist
• Diabetes
• Pregnancy
• Tendonitis
• Rheumatoid arthritis
• Wrist fracture
• Positional fault
• Idiopathic

Question 11

What are common signs and symptoms of Carpal tunnel syndrome?

Answer 11

• Parasthesia (feelings of tingling, numb, burning, shooting, electric etc… associated with interruption of nerve supply) into lateral 3 ½ digits
• Weakness

Question 12

What is the axillary nerve?

Answer 12

• Travels through quadrangular space of posterior shoulder
• Wraps around surgical neck of humerus
• Provides motor supply to deltoids, teres minor, & long head of triceps brachii
• Sensory innervation to “regimental badge” area, around deltoid tuberosity

Question 13

Typical causes of Axillary nerve damage includes?

Answer 13

• Inferior shoulder dislocations
• Direct trauma/fracture to proximal humerus
• Improper use of crutches
• Breech births (Erb’s palsy C5, C6 nerve roots)

Question 14

Typical presentation of axillary nerve damage may include?

Answer 14

• Loss of abduction of shoulder (between 15 - 90 degrees)
• Weakness with flexion, extension & lateral rotation
• Loss of sensation over “regimental badge”
• Flat shoulder deformity

Question 15

What is the radial nerve?

Answer 15

• Travels through triangular interval
• Spiraling around humerus in radial groove
• Motor innervation to lateral & medial heads of triceps brachii, & superficial & deep compartments of posterior forearm (including brachioradialis &
supinator)
• Sensory supply to posterolateral aspect of arm & posterior forearm as well as posterior hand & lateral 3 ½ digits

Question 16

Typical presentation of radial nerve damage may include?

Answer 16

• Loss of elbow extension
• Loss of wrist & finger extension (Finger/wrist drop)
• Weak supination
• Numbness in sensory distribution pattern
• “Saturday night palsy”

Question 17

What is the musculocutaneous nerve?

Answer 17

• Travels through axilla & pierces muscles of anterior arm
• Motor supply to biceps brachii, brachialis, & coracobrachialis
• Sensory innervation to anterolateral forearm
• It presents with frequent irregularities in its pathway

Question 18

What are muscles innervated by musculocutaneous nerve?

Answer 18

BBC = Biceps, Brachialis, Coracobrachialis

Question 19

What are motor functions of musculocutaneous nerve?

Answer 19

Flexion of arm at elbow, supination of forearm

Question 20

What are sensory function of musculocutaneous nerve?

Answer 20

Lareral surface of forearm through antebrachial cutaneous nerve

Question 21

What is Musculocutaneous nerve damage?

Answer 21

• Nerve may be compressed through hypertrophy of biceps brachii & brachialis, can be trapped between 2 muscles, especially for serious weightlifters or body builders
• Can also be compromised by stretch injuries & dislocations of GH joint, or during surgery
• Will likely observe weakness with elbow flexion & supination &/or sensory loss to anterolateral forearm

Question 22

What is the ulnar nerve?

Answer 22

• Ulnar nerve is notorious for being largest unprotected nerve in human body.
• Most superficially exposed between olecranon & medial epicondyle. Compression at this point known as “hitting your funny bone”. Because of association to word humorous & arm bone, humerus.
• Provides no motor or sensory supply to arm, as it passes through this region.
• In forearm, innervates flexor carpi ulnaris, medial half of flexor digitorum profundus & remaining muscles of hand which are not supplied by median nerve. (hypothenar eminence, dorsal & palmar interossei, medial 2 lumbricals etc)
• Provides sensory innervation to 5th digit & medial half of 4th digit.
• In forearm ulnar nerve travels between 2 heads of flexor carpi ulnaris & down medial forearm to enter hand superficial to flexor retinaculum & deep to hook of hamate (tunnel of Guyon)

Question 23

What is Ulnar nerve damage

Answer 23

• Injuries to ulnar nerve are common, d/t its superficial exposure, posterior to medial epicondyle.
• Long haul biking can cause compression at Tunnel of Guyon.
• Severe injury may result in condition called “ulnar claw”.
• Presentation is extension at MCP & flexion of PIP’s & DIP’s.
• In present day, with excessive cell phone use & video games, flexor carpi ulnaris can show high MRT in majority of population, which results in compression of ulnar nerve.

Question 24

What are nerves of the lower limb?

Answer 24

• Sciatic
• Common peroneal
• Superficial peroneal
• Deep peroneal
• Tibial
• Femoral
• Obturator

Question 25

What is The lumbar plexus?

Answer 25

• Exits intervertebral foramen from T12 - L4 • Travels through psoas to exit pelvis either deep to inguinal ligament, through greater sciatic notch or through obturator foramen • Branches of lumbar plexus supply sensory & motor innervation to entire lower limb • Injuries at spinal level can lead to severe functional impairment including paraplegia & altered gait

Question 26

What is the sciatic nerve?

Answer 26

• Largest nerve fibre in body is comprised of tibial & common peroneal nerves wrapped in one sheath. • Exits pelvis through greater sciatic notch, passing deep to piriformis down posterior thigh. • Gives motor innervation to hamstrings & posterior fibres of adductor magnus. Does’nt have any sensory supply to thigh, but it’s branches do in leg & foot. • Just above level of popliteal fossa, sciatic nerve branches into tibial & common Peroneal nerves which supply leg & foot with both motor & sensory function.

Question 27

Sensory innervation of the sciatic nerve (sural nerve)

Answer 27

Formed by branches of common fibular & tibial nerves

Question 28

Sensory innervation of the sciatic nerve (deep fibular nerve)

Answer 28

Branch of common fibular nerve

Question 29

Sensory innervation of the sciatic nerve (superficial fibular nerve)

Answer 29

Branch of common fibular nerve

Question 30

Sensory innervation of the sciatic nerve (superficial fibular nerve medial calcaneal branches)

Answer 30

Branches off tibial nerve

Question 31

What is Sciatic nerve damage/impingement/compression?

Answer 31

• Interruption to sciatic nerve can lead to severe pain & dysfunction. • Most often caused by disc herniation, spondylolisthesis, spasm in musculature (ie. piriformis pain syndrome), or stenosis (narrowing of intervertebral foramen). • Obesity & pregnancy weight gain can both be possible factors causing “sciatica” d/t additional weight compressing IVD’s & bulging them into nerve roots. • Forward flexion often increase symptoms, while extension exercises can help alleviate discomfort. • Pain often described as shooting, burning, or electric patient may have difficulty controlling affected limb. • Motor dysfunction typically presents with weightbearing on affected side.

Question 32

What is the tibial nerve?

Answer 32

• Originates just above level of popliteal fossa & travels down posterior leg, into foot through tarsal tunnel (between medial malleolus & calcaneus) • Gives motor supply to all muscles in superficial & deep posterior crural compartments of leg. • Gives motor information to layers of sole of foot as well as sensory supply.

Question 33

What is Tarsal tunnel syndrome?

Answer 33

• Compression of tibial nerve as it passes through tarsal tunnel (between medial malleolus & calcaneus). • S/S present as numbness, tingling, shooting pain etc into sole of foot. • Common causes include: RA, prolonged eversion, pes planus, direct trauma, tendonitis etc.

Question 34

What are the The common, superficial and deep peroneal nerves?

Answer 34

• Only called common peroneal nerve from area where it bifurcates above popliteal fossa, until it wraps around neck of fibula, where it is most superficially exposed. • Branches into deep peroneal nerve which innervates muscles of anterior compartment of leg, & superficial peroneal nerve which innervates muscles of lateral compartment of leg. • Deep peroneal nerve also gives sensory supply to web space between the 1st & 2nd toes on dorsum of foot. • Superficial peroneal nerve provides sensation to anterolateral leg & majority of dorsum of foot, with above noted exception.

Question 35

What is the obturator nerve?

Answer 35

• Exits pelvis through obturator foramen. • Gives motor supply to adductor muscles with exception of pectineus (femoral n) & posterior fibres of adductor magnus (sciatic n). • Provides sensation to majority of skin on medial aspect of thigh. • Most commonly injured during abdominal or pelvic surgeries. Can cause loss of sensation on medial thigh & difficulty with gait, d/t lack of adduction. May be observable abduction & external rotation with damage.

Question 36

What is the femoral nerve?

Answer 36

• Femoral nerve provides motor information to anterior thigh, including quadriceps, pectineus, sartorius, & iliacus. • Passes deep to inguinal ligament & through femoral triangle. • Sensation to anteromedial thigh & medial leg comes from branches of femoral nerve. • There is branch called lateral femoral cutaneous nerve (LFCN) that has clinical relevance in massage therapy.

Question 37

What is Meralgia Parasthetica?

Answer 37

• Compression of LFCN as it exits pelvis, deep to inguinal ligament, just medial to ASIS. • Characterized by burning, sometimes excruciating pain over anterolateral thigh. Some people report feeling of multiple bee stings. • Populations affected include, pregnant people, police officers, construction workers, former hipsters, & obese. • Often presents with anterior pelvic tilt. • Find cause - treat cause. • During massage, firm pressure often feels better than superficial techniques. • Hip extension can exacerbate symptoms.