Differential Upper Extremity Nerve Pathologies in Collegiate Football Players : Differential Upper Extremity Nerve Pathologies in Collegiate Football Players Danielle Constantin Athletic Training Senior Case Presentation


Overview: Overview Introduce the 3 cases Review Anatomy of Cervical Spine, Shoulder, Elbow, Forearm and Wrist General Cervical Spine Pathologies & Nerve Root Damage Case Specifics Conclusions


Anatomy: Anatomy


Cervical Spine Anatomy: Cervical Spine Anatomy The cervical spine consists of 7 vertebrae (C1-C7) The purpose of the cervical spine is to protect the spinal cord, support the head (skull) and aid in neck: Flexion Extension Lateral flexion Rotation


Cervical Spine Anatomy: Cervical Spine Anatomy C1 & C2 differ from the other five, as they function together to support the head on the spinal column Atlas: articulates with the occipital condyles of the skull and allows for flexion, extension and some lateral movement of the neck. No bony or spinous processes Axis: allows the atlas and the skull to rotate on it. Has a toothlike projection that fits into a ring on the atlas.


Muscles of the cervical spine: Muscles of the cervical spine


Ligamentous Anatomy for the Cervical Spine: Ligamentous Anatomy for the Cervical Spine Anterior and Posterior longitudinal ligaments reinforce and support spinal column from cervical spine to lumbar spine The supraspinous ligament becomes the ligamentum nuchae, which is an area for muscle attachment in the neck Interspinous ligaments are found between the spinous processes, while the ligamentum flavum connects one vertebral lamina to the next


Nerve Roots of the Cervical Spine: Nerve Roots of the Cervical Spine For the 7 vertebrae, there are 8 pairs of nerve roots The Brachial Plexus consists of nerve roots from C5-T1 segmenting into roots, trunks, divisions, cords and branches.


Slide9: Anterior Posterior Posterior Posterior Anterior Anterior UPPER MIDDLE LOWER


Shoulder Anatomy: Shoulder Anatomy Bones & processes include: Humerus Scapula Clavicle (with acromion)


Shoulder Anatomy: Shoulder Anatomy The joints and ligaments of the shoulder include: Sternoclavicular Acromioclavicular Glenohumeral


Shoulder Anatomy: Shoulder Anatomy The major muscles acting on the scapula are: Serratus Anterior Pectoralis major/minor Levator scapula Rhomboids (major and minor) Trapezius (upper, middle and lower) Latissimus Dorsi


Shoulder Anatomy: Shoulder Anatomy The major muscles acting on the humerus are: Biceps brachii Deltoid (anterior, posterior and middle) Latissimus Dorsi Pectoralis major Teres Major Rotator Cuff muscles Infraspinatus Supraspinatus Teres minor Subscapularis Triceps


The Elbow and Forearm: The Elbow and Forearm The elbow is a hinge joint that performs the motions of flexion, extension, supination and pronation The bones include the humerus, radius and ulna Ligaments include the ulnar and radial collateral for varus and valgus forces


Elbow Anatomy: Elbow Anatomy


Elbow musculature: Elbow musculature Elbow flexors and supinators include: Biceps Brachialis Brachioradialis Supinator Elbow Flexors and pronators include: Triceps Anconeus Pronator Teres Pronator Quadratus


Anatomy of the Wrist and Hand: Anatomy of the Wrist and Hand


Muscles of the Wrist and Hand: Muscles of the Wrist and Hand Wrist extensors are on the posterolateral portion of the forearm Wrist flexors are on the anteromedial portion of the forearm The palmar muscles are the intrinsic muscles of the hand


Nerve Distribution into the Elbow, Forearm and Hand : Nerve Distribution into the Elbow, Forearm and Hand


Median Nerve Distribution: Median Nerve Distribution Crosses anterior elbow with brachial artery Travels deep into forearm to flexors in anterior forearm Becomes superficial into wrist through carpal tunnel between wrist flexor tendons


Median Nerve Distribution: Median Nerve Distribution From spinal nerve roots C6, C7, C8, T1 Innervates: Pronator teres Palmaris longus Lumbricals Pronator quadratus Abductor pollicis brevis Opponens pollicis Flexor carpi radialis Flexor pollicis longus Flexor pollicis brevis Flexor digitorum profundus (latter half) Flexor digitorum superficialis


Radial Nerve Distribution: Radial Nerve Distribution Travels posterior to the humerus and laterally through the elbow between brachialis and brachioradialis then into 2 branches Superficial branch gives sensation to posterior hand/wrist Deep branch into deeper musculature


Radial Nerve Distribution: Radial Nerve Distribution From spinal nerve roots C5, C6, C7, C8, T1 Innervates: Triceps Brachialis Brachioradialis Anconeus Supinator Abductor pollicis longus Extensor carpi ulnaris Extensor digitorum communis Extensor digiti minimi Extensor carpi radialis longus & brevis Extensor pollicis brevis Extensor pollicis longus


Ulnar Nerve Distribution: Ulnar Nerve Distribution Crosses through elbow between olecranon process and medial epicondyle (cubital tunnel) Travels deep to follow ulnar artery and into wrist through pisiform and hook of the hamate (tunnel of Guyon)


Ulnar Nerve Distribution : Ulnar Nerve Distribution From spinal nerve roots C8 and T1 Innervates: Palmaris brevis Adductor pollicis Abductor digiti minimi Interossei Opponens digiti minimi Flexor pollicis longus Flexor carpi ulnaris Flexor digiti minimi Flexor digitorum profundus Lumbricales 3 & 4


Cervical Spine Pathologies: Cervical Spine Pathologies


Brachial Plexus Pathology: Brachial Plexus Pathology Acute trauma called a “burner” or “stinger” Very common in contact sports, such as Football Most often occurs in defensive players between the shoulder pad and superior medial scapula Injury mechanisms: traction or stretch of the brachial plexus Direct blow Compression or impingement of the brachial plexus Must rule out fracture/ dislocation with special tests


Brachial Plexus Injury: Brachial Plexus Injury Most common site of pain = Erb’s point Most superficial point of the brachial plexus found 2-3cm above clavicle in line with transverse process of C6 Stretch can occur due to traction on opposite side of lateral flexion from activity such as tackling (C5 and C6 most commonly involved) when shoulder is depressed Often tested through Brachial plexus traction test (reproduction of injury)


Brachial Plexus Injury: Brachial Plexus Injury Compression can occur due to the impingement of the nerve roots between the vertebrae Could be caused by spinal stenosis The narrowing of the intervertebral foramen Can be tested through Spurling’s test (compresses neural foramina, causing impingement) and/or Cervical Compression test (compresses facet joints, which would cause pain) Research has shown that spinal stenosis will also increase the risk of “stingers”


Signs and Symptoms : Signs and Symptoms Immediate pain followed by “burning” or “shocking” pain radiating through arm/shoulder Manual muscle testing leads to decreased strength (Myotomes) Sensation testing leads to “numbness” throughout specific nerve roots (Dermatomes) Symptoms may subside within minutes or last much longer due to severity of injury or repetitive injury (up to a week+)


Ulnar Nerve Trauma: Ulnar Nerve Trauma Superficial location of the ulnar nerve between the medial epicondyle and olecranon process predisposes it to direct forces (contusion) Acute trauma can occur to area causing inhibition of the nerve into the wrist and hand Inflammation causing compression Burning into medial forearm, 4th and 5th fingers Decreased strength in flexors


Dermatomes: Dermatomes Dermatomes are areas of skin that are innervated by specific single nerve roots


Myotomes: Myotomes Myotomes are areas of muscle that are innervated by nerve roots C5 supplies the shoulder muscles for shoulder abduction C6 is for elbow flexion (biceps) C7 is for elbow extension (triceps) C8 is for finger flexion


Treatment & Return to Play: Treatment & Return to Play Treatment should include strengthening of musculature, biofeedback exercises, functional exercises, ROM exercises and muscle re-education Athlete must have: Full Range of Motion Full return of sensation Normal strength Padding the area is important. E.g. neck rolls


Introduce the Cases: Introduce the Cases


Case 1: Case 1 20 yr. old male senior football defensive lineman Athlete has previous history of multiple non disclosed “stingers” Reported to Athletic Training staff on 10/11/06 after brachial plexus injury during practice Hit on R side, experienced symptoms on L Experienced s/sx of “stinger” briefly numbness subsided after a few minutes Evaluated by ATC and referred to team physician the following day after presenting shoulder weakness during MMT (disrupted myotomes C4-6)


Case 1 cont.: Case 1 cont. Athlete started treatment the following day VMS for muscle re-education No play until 10/17/06 Athlete continued with VMS or Russian e-stim treatment for 3 days, then add Hot packs Athlete evaluated daily while strength gradually increased No contact until 10/25/06 Re-evaluated on 10/25/06 by team physician Athlete restricted w/ limted reps & limited contact until 10/27/06 where evaluated by ATC for return to play per verbal with team physician for limited game time


Case 2 : Case 2 18 yr. old male freshman football offensive lineman Reported to Athletic Training staff after game on 10/16/06 with R elbow pain and numbness/burning radiating down into medial forearm and hand (4th and 5th phalanges) Normal strength Concluded: Ulnar Nerve contusion Loss of sensation for 3 days (removed from play due to illness, not injury)


Case 3: Case 3 21 yr. old junior football defensive back Repetitive history of brachial plexus injury Reported to Athletic Training staff on 10/21/06 with L side brachial plexus injury after game (stretch mech.) Normal strength Radiating numbness down radian nerve distribution Athlete referred for chiropractic care on 10/23/06 for treatment and evaluation of continued discomfort Symptoms resolved within 2 days


Applications of the Cases: Applications of the Cases Case 1 had brachial plexus compression mechanism and loss of myotomes in shoulder Case 2 had ulnar nerve contusion and loss of dermatomes in the distal extremity Case 3 had brachial plexus stretch mechanism and loss of dermatomes to distal extremity Case 1 was out of play for almost 2 wks, while case 2 & 3 only had symptoms for a few days


Conclusions: Conclusions It is extremely important to use special tests and understand dermatomes/myotomes to specify a nerve root and plan treatment accordingly Upper extremity nerve injuries can range from mild to severe and should be evaluated and monitored thoroughly as to avoid more serious injury or complications Each individual will sustain or improve s/sx in a different amount of time The result is not usually textbook and the same mechanism of injury can result in inhibition of dermatomes or myotomes in any portion of the upper extremity (isolated or in its entirety)


Thank you and Happy Halloween!!: Thank you and Happy Halloween!!


Slide43: http://depts.washington.edu/anesth/regional/brachialplexusanatomy.html http://en.wikipedia.org/wiki/Shoulder http://www.nismat.org/orthocor/exam/shoulder.html http://classes.kumc.edu/sah/resources/handkines/nerves/ulnar.htm