SPORTS PHYSICAL
THERAPY
PERIPHERAL NERVE INJURIES
(PART “A”)
01/31/2025 PERIPHERAL NERVE INJURIES 2
PERIPHERAL NERVE INJURIES
CHAPTER OBJECTIVES
This chapter aims to introduce the structure and
function of nerves and the neurological system,
and the pathophysiology of common nerve injuries.
The chapter also reviews some common nerve
injuries, their assessment and evidence based
treatment
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THREE CONNECTIVE TISSUE LAYERS
The innermost Encompassing the The Epineurium is
Endoneurial regarded as the most
connective tissue
components, axon and resistant connective
layer is the layer to tensile forces
Schwann cells
Endoneurium, is the Perineurium, the (Sunderland 1978) as it
which is composed second layer of surrounds, protects and
of longitudinally connective tissue, cushions the nerve
fascicles (Butler 1991).
aligned collagen whose primary
fibres and responsibility is to act
as a primary barrier to
therefore, plays an
external forces
important role in (Lundborg 1988).
protecting the axon
from tensile forces
(Butler 1991).
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PERIPHERAL NERVE INJURIES
The ability of the nervous system to
withstand and adapt to the mechanical
stresses placed on it, is essential to prevent
injury (Shacklock 1995).
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PERIPHERAL NERVE INJURIES
Injury to tissues is caused by excessive physical
stress via any of the following mechanisms:
High magnitude Low magnitude Moderate stress
stress applied to stress applied for applied to a tissue
the tissue for a long duration or many times. Cubital
brief duration; repetitively; an Tunnel Syndrome at
spinal cord injury example of nerve the elbow, for
is a typical injury from this example in a javelin
outcome from this particular thrower, whereby
mechanism of mechanism of injury repetitive high load
injury. is Carpal Tunnel forces are exerted
Syndrome at the through the elbow
wrist. and consequently
the ulnar nerve, is an
example (Mueller
and Maluf 2002).
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PERIPHERAL NERVE INJURIES
Maintenance stress range
• Biological tissues, such as nerves, have an ideal physical stress
range that they can tolerate to maintain homeostasis.
Stress levels lower than the maintenance range
decreases a tissue’s tolerance to physical stress;
for example during immobilization of a limb,
muscle atrophy is a typical byproduct of being in a
cast for a prolonged period of time
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PERIPHERAL NERVE INJURIES
The extent of an injury to a nerve is dependent on
the mechanism of injury, as traumatic injuries, such
as a gun-shot wound (i.e. high magnitude stress),
will significantly damage a nerve’s integrity, whilst a
low magnitude stress, such as prolonged
intermittent compression over a long duration of
time, will have less of an impact on the nerve.
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NERVE INJURY CLASSIFICATION
Seddon's classification
In 1943, Seddon described three basic types of peripheral
nerve injury that include;
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Seddon's classification
NEUROPRAXIA
• A transient physiological block caused by
ischemia from pressure or stretch of a nerve with
no wallerian degeneration
AXONOTMESIS
• Internal architecture of the nerve is preserved, but
axons are so badly damaged that wallerian
degeneration occurs
NEUROTMESIS
• Structure of the nerve is destroyed by cutting,
severe scarring or prolonged severe compression
NERVE INJURY CLASSIFICATION
Sunderland Seddon Injury Recovery Potential
Ionic block;
I Neuropraxia possible segmental Full
demyelination
Axon severed;
II Endoneurial tube Full
intact
Axonotmesis Endoneurial tube
III Slow; incomplete
torn
Only epineurium
IV Neuroma-in-continuity
intact
V Loss of Continuity None
Neurotmesis Combination of
VI Unpredictable
above
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PERIPHERAL NERVE INJURIES
The majority of nerve injuries in sport will typically
involve Neurapraxia or Axontmesis and therefore
prognosis for recovery is generally good.
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ASSESSMENT OF NERVE INJURY
Knowledge of the myotomes and dermatomes of
the upper and lower extremities is important to
conduct a thorough assessment of the peripheral
nervous system.
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ASSESSMENT OF NERVE INJURY
Myotomes of the Upper limb
• C1 • Cervical flexion
• C2 • Cervical extension
• C3 • Cervical lateral flexion
• C4 • Shoulder elevation
• C5 • Shoulder abduction
• C6 • Elbow flexion
• C7 • Elbow extension
• C8 • Thumb extension
• T1 • Finger abduction
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ASSESSMENT OF NERVE INJURY
Myotomes of the Lower limb
• L1 • Hip flexion
• L2 • Hip adduction
• L3 • Knee extension
• L4 • Ankle dorsi-flexion
• L5 • Great toe extension
• S1 • Ankle plantar flexion
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ASSESSMENT OF NERVE INJURY
Myotomes
ASSESSMENT OF NERVE
INJURY
Dermatomes
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NEURODYNAMIC TESTING
Nerves slide and stretch during limb
movements to allow for changes in nerve
bed length (Babbage et al. 2007).
healthy nerves can tolerate strain and
compression,
injured or inflamed nerves become sensitive
to mechanical stimuli and can inflict pain on
movement (Bove et al. 2005).
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NEURODYNAMIC TESTING
Neurodynamic tests were developed to
• evaluate peripheral nerve sensitivity to
movement and
• to infer underlying pathomechanics (Topp
and Boyd 2006).
UPPER LIMB
NEURODYNAMIC TEST
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UPPER LIMB NEURODYNAMIC TEST WITH
MEDIAN NERVE BIAS
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UPPER LIMB NEURODYNAMIC TEST WITH RADIAL
NERVE BIAS
UPPER LIMB NEURODYNAMIC TEST WITH
ULNAR NERVE BIAS
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LOWER LIMB
NEURODYNAMIC TEST
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LOWER LIMB NEURODYNAMIC TEST THE
SLUMP TEST
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LOWER LIMB NEURODYNAMIC TEST THE
STRAIGHT LEG RAISE
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NEURODYNAMIC TESTS AS TREATMENT TOOLS
The purpose of utilizing neurodynamic tests
as treatment tools is
• to minimize scarring
• stretching of the nerve,
• maintain or restore normal nerve excursion
and function
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NEURODYNAMIC TESTS AS TREATMENT TOOLS
“SLIDING” TECHNIQUE
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NEURODYNAMIC TESTS AS TREATMENT TOOLS
“TENSIONING” TECHNIQUE
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Treatment plans for nerve injury
• Immediately post-injury, inflammation occurs,
thereby rendering injured tissues less capable of
tolerating stress compared to their pre-morbid level
(Mueller and Maluf 2002).
• Non-steroidal anti-inflammatory drugs (NSAIDs),
ice, rest, elimination of the aggravating activity,
physical and manual therapy into the conservative
treatment plan (McKean 2009; Shapiro and Preston
2009);
END OF LECTURE
Part A
