Anterior Interosseous Nerve Entrapment/Palsy (Full Version)

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jlharris -> Anterior Interosseous Nerve Entrapment/Palsy (May 14, 2008 2:40:27 PM)

Greetings everyone.  I have been referred a pt with the Dx of "Anterior Interosseous Nerve Entrapment".  I have not encountered this condition before in the clinic and am at a loss as to effective treatment options.  She has thenar eminence atrophy, weakness (1/5 MMT) of profundus (laterally) and inability to flex IP of her thumb.  Interestingly, she also has pain and parasthesia in her thumb and thenar eminence.

So far I am treating with US at the area of the AIN passing throught the pronator teres, neural glides, and NMES for wrist/finger flexors.

Any additional insights or resources would be much appreciated.  Thanks.



proud -> RE: Anterior Interosseous Nerve Entrapment/Palsy (May 15, 2008 9:36:01 AM)

Anyone?

I am interested as well as I just had a patient with pretty clear signs of Ulnar nerve entrapment either through Guyon canal or through the two heads of FCU. Not sure really.

What do people do other than rest/splinting for these things? Ultrasound I suppose but I'm not convinced on that.



Kaden -> RE: Anterior Interosseous Nerve Entrapment/Palsy (May 15, 2008 11:08:57 AM)

splinting is a good idea as well as mobing any hypos around the wrist and elbow to decrease stress to the healing nerve.  I have seen a similar UN entrapment following a transplantation surgery.  After all was said and done I realized that time was the biggest factor to allow for healing of the damage arean of the axon.



Hpsg -> RE: Anterior Interosseous Nerve Entrapment/Palsy (May 15, 2008 3:33:23 PM)

Instead of splinting one can use a short strip of stretchy tape over the back of the carpals. Stretch it out before applying. The tape will try to shorten, which will pull the outer layer of the hand more, relative to the inner layers. It feels good, but the best thing is it permits free and more comfortable movement, unlike a splint, and doesn't cover up the palmar surface.



jlharris -> RE: Anterior Interosseous Nerve Entrapment/Palsy (May 15, 2008 6:34:12 PM)

Will wrist splinting and taping is good for median nerve passing through the carpal tunnel, but what about the AIN which terminates proximal to the wrist?  Painful movement is not this pt's c/o but lack of strength and fine motor control in her hand.



Kaden -> RE: Anterior Interosseous Nerve Entrapment/Palsy (May 15, 2008 7:19:43 PM)

Jason,

I think you are on the right track with what you are doing.  Again, I think time is a major factor if there has been damage to the AIN.  E-stim work well for me with the patient I treated with ulnar nerve entrapment.

Once he could do AROM and then PRE I would have him fatigue with those motions and them f/u with FES to fatigue and recruit all motor units.

I also found a few sessions of ionto worked well as inflammation can often be the pain producer inhibiting muscle activation.



TexasOrtho -> RE: Anterior Interosseous Nerve Entrapment/Palsy (May 15, 2008 8:50:06 PM)

Wow...those all seem like sound recommendations.  I haven't run into this pathology before either and now have some treatment options ready to go.  Thanks for the good thread Jason.



ginger -> RE: Anterior Interosseous Nerve Entrapment/Palsy (May 16, 2008 12:03:31 AM)

Jason , suggest doing some AP mobs in supine of C6, see if this reproduces any of her symptoms , or more importantly , with five minutes of CM , does this reduce pain and altered sensations  distally. This may well provide an important clue  to the origins of this problem.



jlharris -> RE: Anterior Interosseous Nerve Entrapment/Palsy (May 16, 2008 2:10:39 PM)

ginger,

I am willing to try, and see the connection with the parasthesia, C6 CM.  However, my biggest worry in the mm atrophy all in the distribution of the AIN and not in a myotomal pattern.  It's this weakness and loss of fine motor skill that is having the biggest impact on her function.

Thanks again everyone for your input.



Hpsg -> RE: Anterior Interosseous Nerve Entrapment/Palsy (May 16, 2008 3:38:43 PM)

jharris, you might have to go more proximally and treat up near the elbow where the nerve plows deeper into the forearm. You will find a thread on this problem here: LINK



80dub -> RE: Anterior Interosseous Nerve Entrapment/Palsy (June 2, 2008 10:21:19 AM)

What about locating the nerve entrapment within the musculature and releasing the adhesion?  I practice Active Release Technique (ART), which specializes in nerve entrapments/scar tissue that forms intra/intermuscularly.  I have had great success with ART, including with interossei musculature. 
In response to effective treatment for Ulnar distribution, the Ulnar nerve can get entrapped at the hypothenar muscles, the tunnel of Guyon, at the pronator teres/fcu intersection, fcu (proximally), the medial intermuscular septum, and at the medial cord of the brachial plexus at the subscapularis.  The Median nerve (carpal tunnel symptoms) get entrapped at the thenar, carpal tunnel, flexor digitorum/pronator teres intersection, and the ligament of struthers. 
These entrapments are palpable, and using the correct tension one can break the adhesion to get the nerve 'flossing' better.



jlharris -> RE: Anterior Interosseous Nerve Entrapment/Palsy (June 2, 2008 3:23:05 PM)

Palpable?  Great.  To you, or can we all in general feel these entrapments?  Thanks for the response.



proud -> RE: Anterior Interosseous Nerve Entrapment/Palsy (June 2, 2008 8:32:23 PM)

Palpable huh? I suppose you can "palpate" the ERSL's as well huh?

Nice info on entrapment sights though.



80dub -> RE: Anterior Interosseous Nerve Entrapment/Palsy (June 3, 2008 10:31:35 AM)

All can palpate the entrapment sights, however it takes time to build these 'skills'....The nerve feels like an al dente noodle; and especially with any of those sights that I previously mentioned, you can feel where the adhesion is; and with proper tension are able to break it down ....while doing this, there should be an internal glide and not an external slide over the skin....it sort of feels like a real intense arm burn (I used to call them indian burns, but that isn't pc anymore).  once this skill is developed, one can tell if the tissue is a chronic or acute (or acute chronic) injury...I don't, however, claim to be there yet (I have been practicing ART for almost 2 years)
regarding palpating the ESRL's, I don't know if that is considered palpating, or if you are being a smartass....but I don't palpate these, I try and diagnostically see where things are 'stuck' and where the limitation in movement is....typical osteopathic stuff...if we are speaking structural terms.  For muscles that have increased tone, I would check the structure and see if there is limitation in movement, and once moving better I would use ART to release the muscle to allow proper slide.
activerelease.com has more info on this technique.



proud -> RE: Anterior Interosseous Nerve Entrapment/Palsy (June 3, 2008 11:19:02 AM)

quote:



All can palpate the entrapment sights, however it takes time to build these 'skills'


You don't read here often do you? It's time we as a profession move away from the secret, unclassifiable "skills". No reliability...certainly no validity. Unless you can show me some new evidence that I am not aware of? 80dub..are you a DPT?


....
quote:

The nerve feels like an al dente noodle; and especially with any of those sights that I previously mentioned, you can feel where the adhesion is; and with proper tension are able to break it down ....while doing this, there should be an internal glide and not an external slide over the skin


speaking of noodles....


quote:

once this skill is developed, one can tell if the tissue is a chronic or acute (or acute chronic)


Really? Show me the relaibility studies....


quote:

or if you are being a smartass


No....just smart.


quote:

activerelease.com has more info on this technique.


I bet it does. Or we could all just log on here:   

http://www.myofascialrelease.com/home.asp

Same level of evidence....



bonez -> RE: Anterior Interosseous Nerve Entrapment/Palsy (June 3, 2008 2:44:56 PM)

quote:

ORIGINAL: 80dub

All can palpate the entrapment sights, however it takes time to build these 'skills'....The nerve feels like an al dente noodle; and especially with any of those sights that I previously mentioned,


I believe that I referenced this strange ability to palpate hair thin nerves under multiple layers of tissue earlier. I suspect that we have a lurking Chiro here by the lingo.



Hpsg -> RE: Anterior Interosseous Nerve Entrapment/Palsy (June 3, 2008 7:41:22 PM)

Actually, cutaneous nerves are about the size of digital camera cables. I know because I've dissected some. They are not hard to feel. The deep one being discussed in this thread would be unpalpable by any direct means, probably.



proud -> RE: Anterior Interosseous Nerve Entrapment/Palsy (June 3, 2008 7:58:43 PM)

Yes...some cutaneous nerves are palpable. Of course. But this guy is talking about something much different. Telling where the adhesions are and determining if it's chronic or acute.

Clearly this fella has been sold down the river...or has lost his al dente noodles.....



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