Management of nerve entrapment

1. PHYSIOTHERAPY MANAGEMENT
OF HIP/THIGH NERVE
ENTRAPMENT
JOS UNIVERSITY TEACHING
HOSPITAL.
PHYSIOTHERAPY DEPARTMENT.
SEMINAR PRESENTATION BY
UGWU KENNETH CHINEDU.

2. • Anatomy of the hip:
• The hip joint is a synovial joint of ball-and-
socket variety
• It is formed where the thigh bone (femur)
meets the pelvis(Dr. Andrew tng).
• It is made of the following structures:
• Bones:
• femur,
• pubis,

3. • Anatomical picture of the hip.

4. • Normally, a smooth cushion of shiny white
hyaline (or articular) cartilage about 1/4 inch
thick covers the femoral head and the
acetabulum(Dr. Andrew Chung).
• Legaments of the hip:
• Iliofemoral ligament
• Pubofemoral legament
• Synovial fluids: made in the synovial
membrane.

5. • When the cartilage is damaged, joint
movement will be limited snd
painful(Benjamin R).

6. • Like the shoulder, the hip is a ball-and-socket
joint.
• But it is much more stable than the shoulder.
• There are numerous structures that contribute
stability to the hip
:i. The ball and socket bony structure
ii. The labrumb
iii. The capsule and its associated ligaments: e.g.
iliofemoral ligament, pubofemoral ligament

7. iv. The surrounding muscles including the
abductors (gluteus medius and minimus) and
external rotators (gemelli muscles, piriformis,
the obturators).

8. • NERVE ENTRAPMENT:
• Nerve entrapment is a medical syndrome that
develops when nerves become compressed
(or entrapped) and restricted(Pirouzmand F
midha)
• This occurs due to a variety of causes, from
trauma or injury to repeated or overuse
activity.

9. • Nerve entrapment syndrome is also known
as:
• -Nerve compression syndrome
• -Entrapment neuropathy-
• Compression neuropathy-
• Trapped nerve
• Nerve entrapment negatively impacts the
nerve’s ability to do its job(Bradshaw C
mcCrorry)

10. • This can lead to:
• swelling,
• reduced blood flow and
• Pain.
• Limited ROMs
• Abnormal gait etc

11. • The most common types of nerve
entrapment are.
• -Carpall tunnel syndrome (carpal nerve
compression, at the wrist)
• -Cubitall tunnel syndrome (ulnar nerve
compression, at the elbow)
• -Herniated disc (in the spine)
• -Peroneal nerve entrapment (in the knee)
(Neurological associates of central Jessy).

12. • -Sciatic nerve entrapment(around hip and
thigh).
• Rarer types of nerve entrapment include
• -Suprascapular nerve entrapment (in the
shoulder)
• -Ulnar tunnel syndrome (in the wrist)
• -Radial nerve compression syndrome (in the
arm)
• -Meralgia paresthesia(compression of the

13. • Etiology.
• There are a variety of causes of nerve
entrapment. It can be caused by:
• trauma, such as from sprains or bone
fractures,
• Duties in jobs or sports are eamples.
• pregnancy .

14. • heredity.
• Diabetes
• Tumors or cysts
• Autoimmune disorders
• High blood pressure

15. • Cancer or cancer treatments
• Obesity
• Neurological disorders
• Pregnancy
• Birth defects
• Thyroid disorders

16. • NERVES AROUND THE HIP AND THIGH.
• Nerves carry signals from the brain to the
muscles to move the hip and thigh.
• The main nerves of the hip that supply the
muscles in the hip include the
• femoral,
• obturator, and
• sciatic nerves.

17. • The sciatic nerve:
• The sciatic nerve is the most commonly
recognized nerve around the hip/thigh.
• It is a very long nerve.
• And travels beneath the gluteus maximus
down the back of the thigh.
• Hip dislocations can cause injury to the sciatic
nerve.

20. • ENTRAPMENT AROUND THE HIP AND THIGH.
• The nerves commonly entraped at the
anterior hip/thigh are:
• Femoral nerve
• Obturator nerve and
• Lateral cutaneous nerve.
• While for posterior hip/thigh includes:
• Sciatic and
• Pudendal nerves

21. • Forms of hip/thigh nerve entrapment:
• 1. FEMORAL NERVE ENTRAPMENT:
• This occurs if the never is entraped around it's
course/branches.
• This can lead to:
• Pain
• Tenderness
• Swelling
• Etc.

22. Medication/physical therapy is indicated to
improve the symptoms.
• Especially if the patient/client has suffered
with symptoms lasting longer than two weeks.

23. • Causes of Femoral Nerve Entrapment
• The most common cause are:
• a disc prolapse at the L2/3 or L3/4 vertebra in
the spine.
• Narrowing of the vertebral foramen.

24. • Hip arthritis
• Tumors/cancerous growth.
• Muscle tightness
• Surgical operation.

25. • If the therapist or physiscian suspects a
trapped nerve,
• they might suggest an MRI scan of the spine,
or hip joint.
• This would show how badly the nerve is
compressed, and any underlying issues.
• An MRI scan takes about 20-25 mins per
region.

26. • Femoral nerve entrapment.

27. • 2. Sciatic nerve entrapment:
• Sciatic nerve, formed by the L4-S3 roots
• It is the largest nerve in the body(Chulson,
MD, pH.D).
• It exits through the greater sciatic foramen to
form distinct :
• tibial and
• peroneal divisions

28. • Points of sciatic nerve entrapments:
• Between the greater sciatic notch and the
ischial tuberosity.
• At the fibrous edge of the biceps femoris
muscle.

29. Causes of sciatic nerve entrapment:
Scars following surgery, infection, injections.
• mass e.g., bony impingement, tumor,
• Leg crossing
• Direct injuries and stretch injuries to the
sciatic nerve in the buttock could occur.

30. • Sciatic nerve entrapment/compression can
result to sciatica.
• Which radiates to the buttocks and legs.
• It’s actually made up of five nerve roots:
• Two from lumbar spine and
• three from the final section of the spine
called the sacrum

31. • The five nerve roots come together to form a
right and left sciatic nerve.
• On each side of the body, one sciatic nerve
runs through the hips, buttocks and down a
leg, ending just below the knee.
• The sciatic nerve then branches into other
nerves, which continue down the legs and into
the feet and toes.

32. • True injury to the sciatic nerve “sciatica” is
actually rare,
• but the term “sciatica” is commonly used to
describe any pain that originates in the lower
back and radiates down the leg.
• What this pain shares in common is an injury
to a nerve -- an irritation, inflammation,
pinching or compression of a nerve in the
lower back.

33. • Sciatic nerve
entrapment.

34. • 3. PUDENDAL NERVE ENTRAPMENT
• Pudendal neuralgia caused by pudendal nerve
entrapment (PNE)
• is a chronic and severely disabling
neuropathic pain syndrome(Kaur J, Singh p).
• It presents in the pudendal nerve region and
affects both males and females.
• It is mostly underdiagnosed and
inappropriately treated and causes significant
impairment of quality of life.

35. • The pudendal nerve emerges from the S2, S3,
and S4 roots' ventral rami of the sacral plexus.
• It carries sensory, motor, and autonomic
fibers;
• however, an injury to the pudendal nerve
causes sensory deficits more than motor.
• It courses between two muscles, the
piriformis and coccygeos muscles.

36. • passes medial to and under the sacrospinous
ligament at the ischial spine level to re-enter
the pelvic cavity through a lesser sciatic
foramen.

37. • The pudendal nerve entrapment syndromes
subdivide into four types based on the level of
compression.
• Type I - Entrapment below the piriformis
muscle as the pudendal nerve exits the
greater sciatic notch.
• Type II - Entrapment between sacrospinous
and sacrotuberous ligaments is the most
common cause of nerve entrapment.
• Type III - Entrapment in the Alcock canal.

38. • OBTURATOR NERVE ENTRAPMENT.
• The obturator nerve arises from the lumbar
plexus on the posterior abdominal wall.
• Root L2-L4.
• The nerve descends medial to psoas major to
the obturator canal where it divides into
anterior and posterior divisions
• Obturator nerve entrapment is when the
obturator nerve becomes trapped as it passes
through the inner thigh muscles and tissues.

39. • This occurs when the nerve becomes adhered
to the muscles and tissues of the inner thigh
• These adhesions may limit the amount that
the nerve can slide forwards and backwards
during movement of the leg
• This lack of sliding may overstretch the nerve
at the site of the adhesions,
• causing interference in the signals being
transmitted by the nerve

40. • Pain is initially felt in the groin, usually during
exercise.
• If one continues to exercise, the pain worsens
and, usually, radiates down the inner thigh.
• Other symptoms include:

41. • reduced range of movement
• ii. swelling/inflamation
• iii. stiffness
• iv. weakness
• v. numbness
• vi. spasm

42. • Entraped obturator nerve.

43. • Lateral femoral cutaneous nerve entrapment:
• Meralgia paresthetica (also known as lateral
femoral cutaneous nerve entrapment)
• is a condition characterized by tingling,
• numbness and
• burning pain in the outer thigh.
• It's caused by compression of the nerve that
provides sensation to the skin covering the
thigh.

44. • Causes include:
• Tight clothing,
• obesity or weight gain,
• and pregnancy
• However, meralgia paresthetica can also be
due to local trauma or a disease, such as
diabetes

45. • Symptoms include:
• Tingling and numbness
• Burning pain
• Decreased sensation
• Increased sensitivity and
• pain to even a light touch
• These symptoms commonly occur on one side
of your body and might intensify after walking
or standing.

46. • PHYSIOTHERAPY MANAGEMENT OF NERVE
ENTRAPMENTS.
• Physical diagnosis:
• 1. Femoral nerve tension test.
• The Femoral Nerve Tesion Test,
also known as the Femoral Nerve StretchTest
(FNST) is a test used to screen for femoral nerve
entrapment/impingments(Grossman MG
Ducey).

47. • Method:
• The patient lies prone,
• and the therapist stands on the affected side
and stabilizes the pelvis to prevent anterior
rotation with one hand.
• With the other hand, the therapist then
maximally flexes the knee to end range
• If no positive signs are noted in this position,
the therapist proceeds to extend the hip while
maintaining knee flexion.

48. • FEMORAL NERVE TENSION TEST.
• Reproduction of pain at the anterior thigh
along femoral nerve course shows positive
test.

49. • SCIATIC NERVE ENTRAPMENT TEST.
• Straight Leg Raise Test
• The straight leg raise (SLR) test determines if
there is sciatic nerve entrapment/injury.
• The test stretches the sciatic nerve and, if it’s
compressed, the symptoms will occur.

50. • Method:
• Lie flat on your back with your legs extended
• Flex the foot and lift the leg 30 to 70 degrees
upwards, keeping your leg straight.
• Repeat with the other leg.
• If you experience pain down the leg to the
foot or are unable to lift your affected leg as
much as the other, this is a positive sciatica
test result.

51. • PUDENDAL NERVE ENTRAPMENT TEST
• Patient is can be reffered for imaging.
• One might get an imaging test with an MRI
machine.
• It uses powerful magnets and radio waves to
take a picture of your body’s internal organs.

52. • The doctor may also give you a pudendal
nerve block.
• This is a shot you get in your pelvis to numb
the nerve and see if the symptoms go away.

54. • Physiotherapy treatments:
• Goals of Physical Therapy and Exercise in
Treating nerve entrapment.
• Physical therapy and exercise help strengthen
and mobilize tissues in the lower back, pelvis,
abdomen, buttocks, and thighs.
• The goals of physical therapy and exercise in
treating the signs and symptoms of nerve
entrapment are to:

55. • 1.Restore pain-free functional movement
patterns
• 2.Relieve lower back, buttock, thigh, and leg
pain
• 3.Reduce muscle spasm
• 4.Restore function of the lumbar spine and
the sacroiliac joint
• 5.Improve mobility of the lower body

56. • 6.Foster a better healing environment in the
lower back
• 7.Promote neurologic adaptations to reduce
the perception of pain
• 8.Prevent future pain flareups and reduce fear
associated with movement

57. • Means:
• A physical therapist may prescribe a
combination of various types of
• physical,
• manual,
• soft tissue mobilization,
• and/or exercise therapies in treating nerve
entrapment.

58. • 1.Extension and flexion back exercises:
• Help relieve pain by promoting movement of
the spine.
• Often, individuals with lower back pain and
sciatica feel relief with specific directional
movement of the spine.

59. • These exercises include
• backward (extension) and
• forward (flexion) bending.
• This directional movement is an important
component of the McKenzie Method,
• also known as mechanical diagnosis and
therapy (MDT).

60. • 2.The McKenzie Method (mechanical
diagnosis and therapy).
• is a technique that involves a series of active
directional movements
• to identify and treat a pain source in the
spine, muscles, and/or joints.
• The technique focusses on moving the
radiating pain closer to the center of the body
through exercise,
• for example, moving leg pain closer to the

61. • . The theory of this approach is that
• centralizing the pain indicates improvements
in symptoms.
• The goal is to reduce radiating symptoms
originating from the spine.
• A therapist who practices this technique
usually has special training in the McKenzie
Method.

62. • 3.Strengthening exercises
• include body weight and resistance exercises
to strengthen the muscles of the abdomen,
low back, hips, and legs.
• isometricc exercises involve contracting
muscles without moving the joints.
• Examples of isometric exercises include a
plank or a bridge hold.

63. • 4. Functional retraining.
• includes reintroducing movements, such as
• lifting,
• carrying, and
• bending or squatting.
• The use of proper technique and healthy
movement patterns are incorporated to
reduce pain and prevent re-injury.

64. • 5. Exercise/weight loss: Obesity is one of the
causes of nerve compression.
• Exercises channelled at weight loss can help
relieve the compressed nerve and improve
symptoms.
• This can be achieved by staying active and
exercise.
• 6. Joint mobilization is a manual therapy
technique in which the therapist applies
pressure to a joint to mobilize it and produce a

65. • 7. Cryotherapy.
• Nerve entrapment reults to acute/chronic pain
sensation.
• Cold therapy is applied to help numb the pain
and improve symptoms.
• Cryotherapy is applicable usually when the
pain is acute and inflammation is involved.

66. • 9. Gait training includes analysis of walking
technique and retraining correct gait patterns.
• This technique may include video analysis.
• 10. Patient's education.

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