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Nerve Entrapment Syndromes

  1. Carpal Tunnel Syndrome
    It is entrapment of median nerve at the wrist beneath the flexor retinaculum.
  2. Etiology (Associated Conditions)
  1. Idiopathic (most common)
  2. Endocrinal disorders
    1. Hypothyroidisrn
    2. Diabetes mellitus
    3. Myxedema
    4. Acromegaly
    5. Hyperparathyroidism
  3. Pregnancy
  4. Deposition disorders
    1. Rheumatoid arthritis
    2. Gout
    3. Rheumatic disorders
    4. Amyloidosis
    5. Sarcoidosis
    6. Leukemia
    7. Chronic renal failure
    8. Mucopolysaccharoidosis
  5. Injury related
    1. Synovitis of tendon- sheath & carpal joints
    2. Maluniteal fractures

Phalen test

Tinel’s sign

Durken’s test

  1. Clinical Features
    1. Eight times more common in women than men. The usual age group is 40-50 years.
    2. Burning pain, paraesthesia, tingling and numbness in the distribution of median nerve
    3. Pain is increased by activities, most troublesome in night and relieved by hanging the arm over the side of bed, or shaking the arm.
    4. Clumsiness & weakness in tasks requiring fine manipulation such as fastening buttons.
    5. Sensory symptoms can often be reproduced by percussing over the median nerve (Tinel’s sign) or by holding the wrist fully flexed for a minute or two (Phalen’s test)
    6. Most specific test is Durken’s test(Carpal compression test)
    7. In late cases weakness of thumb abduction and wasting of thenar muscles occur.
*Splints, NSAID’s corticosteroid injection & open surgical division of transverse carpal ligament ae methods of management.
Meralgia paraesthetica is entrapment (compression) syndrome of lateral cutaneous nerve of thigh as it runs the inguinal ligament just medial to anterior superior iliac spine. Mortan’s metatarsalgia is common interdigital nerve compression and tarsal tunnel syndrome is entrapment of (posterior) tibia! nerve.
Entrapment Syndrome Nerve involved
Carpal tunnel syndrome
Pronator syndrome
Median nerve (at wrist)
Median nerve (proximally compressed beneath - ligament of struthers, bicipital aponeurosis or origins of pronator teres or flexor digitorum superficialis)
Cubital tunnel syndrome
Ulnar nerve (between two heads of flexor carpi ulnaris or arcade of struthers)
Guyon’s canal syndrome Ulnar nerve (at wrist)
Thoracic outlet syndrome Lower trunk of brachial plexus, (C8 & T1) & subclavian vessels (between clavicle & first rib)
Merralgia parasthetica Lateral cutaneous nerve of thigh
Tarsal tunnel syndrome Posterior tibial nerve (behind & below medial malleolus
Morton’s metatarsalgia Interdigital nerve compression (usually of 3rd, 4th toe


Ulnar nerve entrapment
  1. Cubital tunnel (Flexor Carpi Ulnaris)
  2. Guyon canal
Median nerve entrapment Pronator syndrome

Radial nerve entrapment

Superficial radial nerve entrapment cheiralgia paresthetica
Mnemonic: FREAS
  1. Fibrous sheath
  2. Recurrent lease of Henry
  3. ECRB muscle
  4. Arcade of Froshe
  5. Supinator muscle
    1. Neuralgic pain is burning in character Commonest cause of neuralgic pain in foot is compression of communication between medial and lateral plantar nerves.
    2. Burning pain localized to plantar aspect of foot is due to tarsal tunnel syndrome with compression of posterior tibial nerve or its terminal branches medial & lateral plantar nerves.
  1. Tarsal Tunnel Syndrome
    1. It is analogus to carpal tunnel syndrome but instead of median nerve entrapment beneath the transverse carpal ligament, the tibial nerve is compresed beneath the flexor retinaculum (Laciniate ligament).
    2. It is compressive neuropathy of posterior tibial nerve as it passes behind the medial malleolus. It may arise from space occupying lesion with in the tarsal tunnel (eg. a ganglion, synovial cyst or lipoma) or distally against one of the two terminal branches: the medial or lateral plantar nerve. The most common cause is idiopathic
    3. The nerve may be compressed by bone fragments from displaced tibial, talar or calcaneal fractures; tenosynovitis, ganglion or tumor of adjacent tendon sheath; and bone and soft tissue encroachment. Causes are Idiopathic >OA > RA.
    4. A fixed valgus hindfoot (eg in talocalcaneal coalition) can also predispose to chronic traction neuropathy of posterior tibial nerve or one of its branches.
    5. Burning pain and paraesthesia over the plantar surface of foot. Pain may be precipitated by prolonged weight bearing, often worse at night & the patient may seek relief by walking around or stamping his foot.

Tarsal tunnel syndrome (Posterior tibial nerve entrapment)

  1. Percussion may elicit Tinel’s sign over the posterior tibial nerves in tarsal tunnel or distally along the division of posterior tibial nerves (the medial calcaneal nerve & medial & lateral plan tar nerves). The medial calcaneal nerve may be involved at the level of ankle or at the level of abductor digit quinti muscle. In these cases, the pain is noted along the plantar medial aspect of foot.
  2. Muscle weakness is usually not observed, but loss of sensation & two point discrimination may be detected.
  3. Nerve conduction velocities along the medial plantar nerve to the abductor hallucis muscle (latency <6.2 ms) and of the lateral plantar nerve to the abductor digiti quinti (latency <7 ms) should be within limits of each other, otherwise indicating nerve compression in the tarsal tunnel.
  4. Release of flexor retinaculum is not as effective in tarsal tunnel syndrome as release of transverse carpal ligament in carpal tunnel syndrome.
  1. Contracture of iliolibial tract
    Ober’s test demonstrates iliotibial tract contractures (as in polio).
    Tendon transfers are preferable after 4 to 5 years of age.

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