QUESTIONS; ENTRAPMENT SYNDROMES

1. Describe the entrapment of the Saphenous Nerve. What are the signs and symptoms? Describe the
typical aetiology.

Entrapment of the Saphenous nerve occurs within the adductor canal (image below). The fascia between
the vastus medialis and the adductor magnus resides within the adductor canal and may be come
thickened and impact the saphenous nerve which passes through this fascia. Aetiology occurs
spontaneously and many times the entrapment is iatrogenically induced following knee surgery. Signs
and symptoms include;
 Point tenderness over the exit of the saphenous nerve through the adductor canal.
 The patient may have essentially normal sensation, hypaesthesia, or hyperaesthesia.
 Activities that involve the sartorius muscle with knee in extension tend to aggravate the patients
symptoms. This may occur by compressing the infrapatellar branch of the saphenous against the
posterior margin of the femoral condyle.

2. How would you diagnose a Saphenous Nerve Entrapment?

This disorder should be differentiated from medial meniscal lesion, medial collateral ligament disorders
and pes anserine bursitis. Aspects gained from the history and physical include;

 Pain in a sensory distribution typical of the saphenous nerve (medial aspect of the lower
extremity in the regions of the distal thigh knee or leg)
 Essentially normal motor function in the affected area.
 Tenderness upon palpation of the adductor canal region.
3. Describe the entrapment of the Common Peroneal Nerve. What are the signs and symptoms?
Describe the typical aetiology.

This condition is considered to be the most commonly encountered nerve injury of the lower extremity.

The Common Peroneal Nerve leaves the popliteal space, traverses the plantaris and lateral head of the
gastrocnemius, and curves anteroinferiorly around the fibular head. As the nerve courses about the
fibular head, it passes through fibrous tissue. This fibrous tissue, adherent to the peroneus longus, is
drawn tight during inversion of the ankle. There are several aetiological factors that can lead to Common
Peroneal Nerve entrapement;

 The common peroneal nerve is subject to compression the tension exerted by the peroneus
longus tendon as it passes through the fibrous arch between the two heads of the peroneus
longus muscle. The nerve is also subject to traction injuries.
 In ‘strawberry picker’s peroneal palsy it has been thought that prolonged squatting compresses
the nerve between the lateral head of gastrocnemius muscle and the biceps tendon.
 It has been reported that common peroneal nerve entrapment may occur due to compression of
tight lateral structures and mechanical irritation caused by hypermobility of the fibular head.
 Crossing the legs is considered the most common cause of common peroneal nerve palsy.
 Systemic diseases such as diabetes mellitus, rheumatoid arthritis, hypothyroidism, nutritional
deficiencies, gout, leprosy, Guillian Barre syndrome and some chronic illnesses make peripheral
nerves more sensitive to pressure. It has been reported that the course of recovery reflects the
type of injury sustained. If the recovery takes several weeks, it most likely indicates a metabolic
block. If the recovery takes several months, it probably indicates axonal degeneration.
 Other causes of common peroneal nerve entrapment include: Adduction injury of the knee,
fracture of the proximal end of the fibula, pressure from a case, the patient’s position on the
operating table, animal bites, and automobile accidents.

Symptoms and clinical signs of Common Peroneal Nerve entrapment include;

 There may be tenderness over the nerve at the fibular head.

 The patient may notice weakness of the peroneal muscles. The patient may also note the foot in
question dragging on the ground as he/she walks (steppage gait or foot drop).
 The patient tends to have sensory loss to the lateral side of the calf and dorsum of the foot.
  There is weakness on dorsiflexion of the ankle and weakness of the evertors of the foot.
 The patient cannot perform heel walking on the affected side.

4. How would you diagnose a Common Peroneal Nerve Entrapment?

An L5 nerve root lesion can yield a similar clinical picture. This condition should be differentiated from
anterior compartment syndrome. The latter condition is associated with pain, swelling, absence of the
dorsalis pedis, and foot drop.

5. Describe the entrapment of the Superficial Peroneal Nerve. What are the signs and symptoms?
Describe the typical aetiology.

After giving off muscular branches to the peroneal longus and brevis the superficial peroneal nerve
passes as a purely sensory nerve through the deep fascia, approximately 10 cm superior to the lateral
malleolus. It is where this nerve passes through the fascia that the superficial entrapment usually
occurs. Aetiology is not clearly understood, although compression is a common factor and
mechanical irritation and hypoxia may play a role, Other possible aetiological factors include;

➢ A force inversion and plantar flexion injury of the ankle, varus ligamentous injury of the knee, or
the wearing of tight boots may precipitate this syndrome.

 Exercise increases the turgor within the lateral compartment, and a compartment syndrome
may facilitate this entrapment neuropathy.
 Fibular neck or head fractures may produce entrapment of the superficial peroneal
nerve. However, fibular shaft fractures rarely do so. Entrapment of the superficial peroneal
nerve at the fracture site may produce tethering of the nerve by scar tissue.
 This syndrome may be aggravated by lipoma and muscle herniation, and it may be
iatrogenically induced following fasciotomy for chronic anterior compartment syndrome.

Symptoms of Superficial Peroneal Nerve entrapment include pain in the distribution of the nerve
over the lateral calf and dorsum of the foot and a possibility of a sensory dyseasthesia with pain that
may radiate up into the thigh.

6. How would you diagnose a Superficial Peroneal Nerve Entrapment?

Clinical and Diagnostic Findings of Superficial Peroneal Nerve entrapment include;

➢ Sensory hypaesthesia over the dorsum of the foot and the distal one third of the lateral calf.

➢ An exquisitely tender area approximately 10 cm above the lateral malleolus may be noted.

➢ A firm mass is often palpated about the lateral aspect of the calf, which may increase in size during
exercise. The firm mass is an extrusion through the fascial sheath of the point where the superficial
peroneal nerve exits.

Diagnostic Factors of entrapped Superficial Peroneal Nerve include three tests to advocate for the
correct diagnosis of this condition. If any of these three tests cause pain or paraesthesia, compression of
the peroneal nerve is suggested and further neurological investiatigations are indicative.

Test One: In the region where the superficial peroneal nerve emerges through the fascia, digital pressure
should be applied by the examiner while the patient dorsiflexes and everts the foot actively against
resistance.

Test Two: Apply gentle stretch to the nerve by passive plantar flexion and inversion of the ankle.

Test Three: The second procedure may be applied, with the addition of percussion to the area where
the superficial peroneal nerve exits through the fascial defect. Such percussion of the tender area may
cause shooting pain down the leg and into the dorsum of the foot.

Differential diagnosis

 An L5 radiculopathy may give the appearance of a superficial peroneal entrapment syndrome.

 What is characteristic of superficial peroneal entrapment is the preservation of the motor aspect
with abnormal findings of the sensory component. Superficial peroneal entrapment should also
be differentially diagnosed from vascular abnormalities, saphenous entrapment and sural

7. Describe the Meralgia Paraesthetica. What are the signs and symptoms? Describe the typical
aetiology.

Meralgia Paraesthetica describes a compression neuropathy of the lateral femoral cutaneous nerve
as it passes under the lateral portion of the inguinal canal. The lateral femoral cutaneous nerve arises
form the posterior branches of the anterior primary divisions of the second and third nerve
segments. It emerges at the lateral border of the psoas major and obliquely crosses the iliacus
muscle heading toward the ASIS. It then either passes under or goes through the lateral portion of
 the inguinal ligament about 1cm medial to the anterior superior iliac spine. This nerve supplies the
parietal peritoneum, supplies sensory information for most of the skin and fascia of the antero-
lateral thigh, beginning approximately 10cm below the anterior superior spine and ending just above
the knee.

Aetiology of Meralgia Paraesthetica is actually caused by neuro-biomechanical dysfunction of the

lumbo-pelvic complex. It is most commonly caused by an accumulation of factors. Multiple
potential sights for irritation traction and compression are found along the anatomical environment
of this nerve. It appears to be more common in diabetes, bilateral about 20% of the time, and
associated with sudden weight gain or loss. Increased intrabdominal pressure, a pendulous
abdomen, trauma or surgery may be related to Meralgia Paraesthetica.

Symptoms are characterized by burning dyesthesia in the distribution of the lateral femoral
cutaneous nerve and may be associated with hyperaesthesia, hypaesthesia and/or formication.
These symptoms are often exacerbated by prolonged walking, standing and/or bending forward as
well as by thigh extension or abduction.

8. How would you diagnose a patient with Meralgia Paraesthetica?

Reproduction of symptoms elicited by pressure over the inguinal ligament at the passage of the lateral
femoral cutaneous nerve is highly suggestive of Meralgia Paraesthetica (MP).

9. Describe ‘double crush syndrome’? What are the symptoms of double crush syndrome?

The pathophysiology of the double crush syndrome is thought to be due to interruption of the
axoplasmic flow neuronal impairment loss of functional integrity of the axon susceptible to distal focal
insults.Nerve fibres compressed at level become especially susceptible to damage further distally. An
example of double crush: Nerve fibres that make up the median nerve maybe affected in numerous
regions of the neck and upper extremity. Carpal tunnel syndrome is associated with cervical disc and
spondylolisthesis. The median nerve originates from C6-T1. Nerve root entrapment or compression in
the cervical region may cause fibres that make up the median nerve at the carpal tunnel may be
necessary to produce symptomatology and the double crush phenomena. A cervical spondylosis
affecting the median nerve may not be symptomatic but it may exacerbate a carpal tunnel syndrome.

Aetiology includes;

 A proximal axonal lesion may render the distal aspect of the neuron more susceptible or
vulnerable to subsequent pressure injury from frank or microtrauma incidents.
  A localized lesion in the upper extremity maybe associated with or triggered by another lesions
along the same axon.
 Common conditions such as spondylotic myelopathy, spinal radiculopathy, central canal or
neuroforaminal stenosis and the vertebral subluxation complex be considered as possible
precursors to subsequent peripheral entities (ie. Entrapment syndromes and peripheral
neuropathies).
 Upper extremity sites for nerve entrapment include carpal tunnel, thoracic outlet, humeral
epicondylar grooves, pronator teres, and Guyon’s tunnel. Frequent lower extremity sites include
the piriformis muscles, proximal fibula (due to fracture or dislocation), and tarsal tunnel. Among
the common aetiologies of nerve entrapment are masses, infection, structural malposition,
anomaly, muscle spasm/hypotonia and trauma.

The diagnosis of ‘double crush’ syndrome will likely fall into the differential diagnosis list along with
polyneuropathy, spinal radiculopathy and single nerve syndromes. Symptoms include;

 Neck or low back complaints, with secondary complaints of numbness or pain of the involved
(‘crushed’) peripheral nerve in the upper or lower limb respectively.
 The extremity symptoms are frequently more prominent at night.
 The onset of neck or low back pain may be insidious or related to a specific traumatic event.
 Questioning will often reveal repetitive insult to the upper extremity or lower extremity from
occupational or recreational activity.

10. Complete an illness script for entrapment syndromes (in general).

Refer to the PDF on the ‘Code of Conduct’ from the Chiropractic Board of Australia and answer the
following questions. Refer to ‘Providing good care’ Section 2
True or False
1. The code of conduct only relates to clinical aspects within chiropractic practice. TRUE
2. The identification of red and yellow flags is of upmost importance for a chiropractic health
professional. TRUE
3. The chiropractic professional should not support continuity of care if there are not symptoms.
FALSE
4. Patients should be not be supported to make their own decisions as they are not the experts. FALSE
5. Chiropractic practitioners need not be bothered with the patients’ symptoms. Chiropractors should
only focus on the ‘cause’ of their symptoms. FALSE
REVIEW QUESTIONS to test your general knowledge 

Any discussion concerning the biological plausibility and potential causal relationship between cervical
manipulation and vertebral artery torsion (or potential injury) should begin with a review of the relevant
anatomic relationships. The vertebral artery, the first branch from the subclavian trunk, becomes closely
related to the spine by entering the transverse foramen at the sixth cervical vertebral level. It then
passes through the transverse foramen from C6 to C1, lying directly in front of the cervical nerves and
medial to the intertransverse muscles. The vertebral artery then passes through the foramina of the
transverse processes from the sixth through to the first cervical vertebrae and enters the skull through
the foramen magnum. Due to the location of the vertebral artery, rotation of the neck during a cervical
adjustment can cause torsion on the artery as it compresses onto the boarders of the foramina.
Accompanying the artery is the vertebral plexus of veins and the vertebral nerve composed of
sympathetic fibers arising from the inferior ganglion. After leaving C2, they pass with the artery through
the transverse foramen of C1, necessitating a sharp deflection outward, a tortuous course around the
posterolateral aspect of the superior articular process of the atlas. As the artery heads posterior, it
passes by the atlanto-occipital joint capsule and through the arcuate foramen, which is formed by the
posterior atlanto-occipital membrane. As the artery travels over the atlas, it lies in a groove in the
posterior arch of the atlas, which it shares with the first cervical nerve. It then turns upward and runs
through the foramen magnum into the cranial cavity and passes to the lower border of the pons where it
joins the opposite vertebral artery to become the basilar artery (which then splits to form the circle of
Willis, which is joined anteriorly by the internal carotid arteries). Specific head and neck movements
have been proposed as the source of potential mechanical injury to the vertebral artery which provides
a potential link to cervical spine manipulative therapy. End-range neck movements are speculated to
affect the vessel wall integrity by inducing injurious compression or stretching of the arterial wall.
Rotation and Extension have been proposed to be the most risky movements in creating torsion of the
vertebral artery because of vessel stretching or compression that occurs with rotation of the atlas.
Brudzinki Test, which can if deemed positive indicate meninigeal irritation such as viral or bacterial
meningitis.

A tuff of hair present in the lower lumbar spine can indicate a spine or spinal cord indicative of a spinal
column or cord underlying condition such as spinal bifida or Tethered Cord Syndrome
TISSUE IN LESION LIKELY PAIN TYPE OF PAIN NERVE NEUROLOGICAL POSTIVE ORTHO
DISTRIBUTION (RADICULAR OR TENSION TESTS:
REFERRED) TESTS DEFICIT
(+VE OR YES/NO
SHARP/SHOOTING
-VE OR
DULL BOTH)
SYNOVITIS OF Local or REFERRED -VE NO Cervical Kemps
C4,5 (POSTERIOR referred (above
FACET the elbow) DULL
SYNDROME) Rotation Cervical
Compress
Lateral Flexion Cervical
Compression
PIRIFORMIS Sciatic Nerve RADICULAR +VE YES Bonnets
ENTRAPMENT entrapment
SHARP
Pain or loss of
sensation along SLR /WSLR
course of nerve Flip Test
from buttocks,
posterior thigh, Bowstring
leg & foot Braggards
(except medial
leg supplied by
saphenous
nerve)
QUADRATUS Deep in the REFERRED VE - NO
LUMBORUM angle where
TRIGGER POINT the crest of DULL
ilium &
paraspinal mass
meet
Inner crest of
ilium where
iliocostalis
lumborum
fibers attach
Angle where
paraspinal
 muscles & 12th
rib meet
COMMON Mild pain or RADICULAR VE + YES
PERONEAL NERVE loss of
ENTRAPMENT sensation to SHARP
anterolateral
leg & dorsum of
foot,
tenderness over
the nerve at the
fibular head

PSOAS TRIGGER Upper muscle: REFERRED VE - NO

POINT refers pain to
posterior low DULL
back & upper
medial buttock
Lower muscle:
refers pain
down anterior
thigh & Inguinal
region
MERALGIA Anterior lateral RADICULAR VE+ YES
PARAESTHETICA thigh
SHARP
COMPLETE THE FOLLOWING TABLE