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 Peripheral Nerve Injuries – Lower QuadrantDefinitionsPeripheral Nerve Injury – Please refer to Peripheral Nerve Injury Handout for the Upper QuadrantNerve Symptoms - Please refer to Peripheral Nerve Injury Handout for the Upper QuadrantReferred Pain vs. Radicular Pain vs. RadiculopathyReferred PainPresents as general and can occur around the area of the injury tissuePerceived in regions that share the same segmental innervation as the sourceGenerally, does not cause neurological signs General Lumbar Referral PatternLumbar Facet Referral Pattern Radicular PainGenerally, stem from the spine that will cause abnormal nerve signals along or at certain parts of the nerveThe source of symptoms is the dorsal root or its ganglionDescribed as lancinating pain along the length of the lower limb in a band (dermatomal pattern) that is about 2-3 inches wideRadiculopathyWhere the conduction of the nerve is blocked along the spinal nerve or its rootsMay present with numbness, weakness, or diminished reflexesFollows along a dermatomal or myotomal pattern depending if sensory or motor fibers are blockedRadicular pain and radiculopathy can occur together or separatelyIf they are occurring together, the distribution of numbness that will determine the affected spinal segment. Not the pain distributionPeripheral Nerve Entrapment/Impingement Compression of nerve through repetitive activities or acute injury or can be trapped due to scar tissue formation or swellingLateral femoral cutaneous nerve of the thigh impingement – compression of the nerve where the inguinal ligament meets the anterior superior iliac spineGenerally, due to wearing too tight of a belt or waistband Sciatic Nerve impingement – compression of the nerve at the pelvis by the piriformis muscleFemoral nerve impingement - compression of the nerve deep to the inguinal ligamentGenerally, due to abdominal surgery or pelvic fractureCan be associated with psoas muscle or iliopsoas muscle tendinopathyCommon Peroneal/Fibular Nerve impingement – entrapment at the superior posterior fibular headTibial Nerve impingement – entrapment of the nerve at the tarsal tunnelNerve Injury Classification - Please refer to Peripheral Nerve Injury Handout for the Upper QuadrantObjective TestingSensory Testing – to assess if it has a dermatomal patternPlease refer to Peripheral Nerve Injury Handout for the Upper Quarter for sensory testingReflex TestingPatellar Tendon (L2-L4)Achilles Tendon (S1)Rating0 = absentAbnormal if present on the contralateral side or if middle aged or younger (may expect to have in geriatric population)May be a sign of peripheral nerve injury1+ = diminished, trace2+ = normal3+ = brisk, hyper-reflexive4+ = unsustained clonus (Clonus presents as muscular spasms involving repeated, rhythmic contractions)Abnormal if >3 beats that diminishes on its ownSign of central nerve lesionReferral to neurologist if not under the care of one yet5+ = sustained clonusAbnormal if >3 beats that does to diminish over time and needs manual support too stepSign of central nerve lesionReferral to neurologist if not under the care of one yetMyotomal TestingUsing manual muscle tests – looking for significant weakness compared to contralateral side or significant weakness compared to age-based normsL2 Nerve Root = Hip flexion (variable and based on whole clinical picture as to what is significant)L3 Nerve Root = Knee extension (authors clinical judgment is <5/5 not due to pain in young health patient is significant)L4 Nerve Root = Ankle dorsiflexion (authors clinical judgment is <4/5 not due to pain in young healthy patient is significant)L5 Nerve Root = Great toe extension (variable and based on whole clinical picture as to what is significant)S1 Nerve Root = Ankle plantar flexion (authors clinical judgement is <5/5 or unable to complete a single leg heel raise not due to pain in young healthy population is significant)S2 Nerve Root = Knee flexion (authors clinical judgment is <4/5 not due to pain in young healthy population is significant)Nerve Tension Testing/Neurodynamic AssessmentPositive findings are:Reproduction of the patient’s primary complaint/symptomsAsymmetry between limbs or significant deviation from the normChanges in symptoms with distant joint movements termed sensitizing maneuvers (at least 2 joints from location of symptoms) Passive Straight Leg RaiseWith the knee extended, the clinician passively flexes the hip until onset of the patient’s symptomsIf symptoms are located between the lumbar spine at knee then use sensitizing maneuver with ankle dorsiflexion (increase symptoms) or plantar flexion (reduce symptoms) to change symptoms is positive testIf symptoms are located distal to the knee then use sensitizing maneuvers of cervical flexion or hip adduction and/or external rotation (increase symptoms) or hip abduction and/or internal rotation (decrease symptoms) to change symptoms is positive testIf hip flexion is <30 degrees then positive testIf hip flexion of the contralateral leg causes their primary symptoms then positive testIf affected side is 30 degrees less than contralateral side then positive test Side-lying knee flexion testNot strong test but may help with symptoms in anterior thigh to lower backThe patient is in side-lying position with bottom leg flexed to chest and held by their arms. The patient will also maintain a fully flexed neckThe clinician then fully plantar flexes the ankle and flexes the kneeThen the clinician will passively extend the patient’s hip while maintaining the positions at the ankle and knee. If symptoms are reproduced then the clinician will hold that position and ask the patient to desensitize the symptoms by extending the neck actively or by dorsiflexing the anklePositive if symptoms are diminished with desensitizing maneuversSlump TestThe patient is seated with their hands clasped behind their backs and neck and upper trunk fully flexedThe clinician passively extends their knee until the patient feels their symptoms and then use a sensitizing maneuver to either dorsiflex the ankle (increase symptoms) or plantar flex (decrease symptoms) if symptoms are between lower back and knee or extend the neck (decrease symptoms) if symptoms are distal to the knee. Positive test is ability to change symptoms with sensitizing maneuvers.Joint Accessory Motion of the Lumbar SpineThe patient will lie in prone positionThe clinician will apply a posterior to anterior force specific to the spinous processes from L1-L5 centrally and unilaterally facets L1-S1 on right and left individuallyPositive findings are reproduction of the patient’s primary symptomsAlso, assess for joint mobility (Hypomobility, normal, hypermobility)Palpation sitesSustained compression at the piriformis muscle to elicit sciatic nerve symptomsSustained compression at the femoral nerve and lateral cutaneous nerve of the thigh approaching from superior to the inguinal ligament and pressing in a posterior and inferior direction to elicit their symptoms in the lateral thigh or along the femoral nerve distributionSustained pressure or tapping at the superior and posterior aspect of the fibular head to elicit symptoms in the anterior lower leg and footSustained pressure or tapping at the tarsal tunnel to elicit symptoms on the plantar surface of the footTreatmentHighly Irritable SymptomsUse of modalities to reduce nerve irritation and inflammationRefer to modalities handout for specifics on types and proceduresManual therapy such as massage to nerve distribution, light stretching, nerve desensitizing techniques, joint mobilizations grade I and II to sensitive segments found during accessory motion testingPatient education on positioning, posture (sitting, standing, lying down) that will reduce symptomsMay recommend back brace/supportMedicationsModerately Irritable SymptomsManual therapy such as joint mobilizations grade III and IVManual therapy to entrapment sites found during objective testing to improve neural mobilityExercises that involve core stabilization, pain free stretching, and strengthening of weak muscle groupsMovement programs for proper mechanicsNerve Slider Exercises/ Nerve mobility exercisesHere are examples of Sliders - If suspecting disc herniation, prone press ups either repeated or sustained based on toleranceFindings indicative of disc herniation:Lumbar flexion reproduces symptoms while lumbar extension may reproduce symptoms at the spine but decrease down the lower extremity or reduce symptoms at the spine and leg togetherPositive straight leg raise test <30 degrees, significant difference between sides with range of motion, or positive contralateral straight leg raiseReproduction of symptoms while coughing, sneezing, or bearing downMildly irritable symptomsComplete similar treatments as in moderately irritable symptomsProgress exercise program to involve full body movements with core stabilization and start applying load/resistancesNerve Tension Exercises/ Nerve mobility exercisesHere are examples of Nerve Tension Exercises - Drop footIf drop foot is due to significant nerve compromise and presents with signs of weakness (manual muscle test <2/5) that does not improve over the course of 4-8 weeks of rigorous exercise after nerve symptoms have resolved then recommendation of and Ankle Foot Orthosis (AFO) is warranted. This will prevent the foot from falling into plantar flexion during gait and functional activities. Recommend gait training with patient if recommending an AFOReferences:Bogduk, N. (2009). On the definitions and physiology of back pain, referred pain, and radicular pain. Pain, 147(1), pages 17-19. doi: 10.1016/j.pain.2009.08.020Physitutors. (2019, February 22). Lower Limb Neurodynamic Techniques: Sliders & Tensioners. Youtube. ................
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