Proximal Lower Motor Neuron syndrome
Age 45 to 76 years, predominantly male. Clinical upper extremities, asymmetric, with weakness of the lower motor neuron. Asymmetric distribution with shoulder and elbow focus. Bulbar muscles can be involved. Fasciculations occur. Reflexes reduced in arms, preserved in legs. Progresses to affect the legs and ventilation. Differential diagnosis from ALS slower development 2-6 years . Associated with anti-asialo-GM1 antibodies 10 to 20 Serum CK Mildly elevated Electrodiagnostic EMG with...
Muscle biopsy Tlg
Muscle biopsies obtained 24 hours after the onset of symptoms often contain staining in the region of the Z-discs due to reduced A-band staining Fig. 31 . Myosin ATPase activity is markedly reduced in affected muscle fibers. There is evidence of massive loss of myofilaments in some muscle fibers. Previously undiagnosed motor neuron disease There is no specific therapy. Any potentially causative medication should be discontinued. Variable, depending on the severity of the illness. Advanced...
Rheumatologic drugs
Intravenous lidocaine, procaine and similar drugs potentiate the effect of neuromuscular blockings agents. Myasthenic crisis after large doses of local anesthetics has been reported. Trimethaphan ganglionic blocking agent Estrogen and progesterone Thyroid hormone May develop some months after onset of treatment. Individual reports describe worsening of myasthenic symptoms. Inhibition of ACh release. Occurs only with parenteral application, almost never with oral use. Drugs containing magnesium...
Differential diagnosis Coxarthrosis
Neurinoma Pelvic neoplasm Radiculopathy L2 Wartenberg syndrome - migrant sensory neuritis Therapy Anesthetics, local infiltration, steroids Local novocain infiltration Spontaneous recovery Surgical intervention only if pain persists Prognosis Short term depending on etiology References Jablecki CK 1999 Postoperative lateral femoral cutaneous neuropathy. Muscle Nerve 22 Staal A, van Gijn J, Spaans F 1999 The lateral cutaneous nerve of the thigh. Mononeuro-pathies. WB Saunders, London, pp 97-100...
Provocative test
An oral potassium load administered in a fasting patient in the morning after exercise may induce weakness. The study should only be done if renal and cardiac function, and the serum potassium are normal. The patient is given 0.05g kg KCl in a sugar free liquid over 3 minutes. The patient's electrolytes, EKG and strength are monitored every 20 minutes. Weakness typically occurs in 1 to 2 hours. If the test is negative, a higher dose of KCl up to 0.15 g kg may be required. An exercise test may...
Interdigital tendernessClinical syndrome
Pain might be elicited by adduction of metatarsals and metatarsal compression. Pain and paresthesias of adjacent toes may be present. Forefoot pain and numbness may also occur. Mechanical irritation of the nerve may cause neuroma and neuritis. Causes Lateral pressure from adjacent metatarsal heads result in neuritis and neuroma formation. NCV SNAP reduction - difficult to assess. Diagnosis
Long thoracic nerve
Fig. 28. Long thoracic nerve palsy after thoracic surgery. A Note winging of caudal edge of the scapula. B Scar after thoracic surgery Fibers stem from the ventral rami of C5-7, and travel through the dorsal part of Anatomy the plexus. The nerve traverses the middle scalene muscle, and then passes below the brachial plexus on the thoracic wall. The nerve contains motor fibers exclusively for the serratus anterior muscle Fig. 27 . Dull ache in the shoulder, affected shoulder seems lower,...
Vasculitic neuropathy systemic
Fig. 4. Sural nerve biopsy from a patient with isolated peripheral nerve vasculitis. A Infiltration of a perineurial vessel wall by multiple inflammatory cells including lymphocytes and macrophages black arrows . There is also evidence of pink fibrin deposits consistent with the presence of fibrinoid necrosis. B Teased fiber preparations showing multiple axon balls white arrows and evidence of empty strands consistent with axonal degeneration Fig. 4. Sural nerve biopsy from a patient with...
Focal myositis
Fig. 6. Calf hypertrophy. This patient had a unilateral right calf hypertrophy in a case of focal myositis Fig. 7. Focal Myositis. A Atro-phic fibers arrows top left , inflammatory response arrows bottom left , hypertrophied fiber arrow head , increased connective tissue top right . B Lob-ulated fibers outlined by bands of collagen arrows Fig. 6. Calf hypertrophy. This patient had a unilateral right calf hypertrophy in a case of focal myositis May involve any muscle, although the quadriceps...
Emg 1
Early on, there is decreased recruitment and interference, with decreased motor unit action potential amplitudes. In 2-4 weeks, fibrillations will develop, with possible fasciculations. Over time, reinnervation will lead to polyphasic motor units. Nerve conduction velocities and sensory studies are normal. Imaging Inflammation of the anterior spinal cord may be detected with MRI. Post-polio syndrome The diagnosis of PPS is by exclusion of other conditions and demonstration of progressive...
Anatomy
Signs Weakness of lower abdominal muscles, hernia. Causes Abdominal operations with a laterally placed incision Endometriosis, leiomyoma, lipoma Herniotomy Iliac bone harvesting Pregnancy, child birth Spontaneous entrapment - inguinal neuralgia Diagnosis Studies no standard electrophysiologic techniques are available Therapy Local anesthetic infiltration Surgical exploration and resection of the nerve
Poliomyelitis
Poliomyelitis is a viral infection that causes the death of motor neurons in the Anatomy spinal cord and brainstem. During the acute phase of the infection, the virus may infect the cortex, thalamus, hypothalamus, reticular formation, brainstem motor and vestibular nuclei, cerebellar nuclei, and motor neurons of the anterior and lateral horns of the spinal cord, causing an inflammatory reaction. Death of motor neurons may result, leading to muscle atrophy. The motor neurons that survive recover...
Muscle biopsy Pfq
1 CCD. There is variation in muscle fiber size and presence of cores Fig. 21 , in muscle with reduced or absent oxidative enzyme activity. The cores run along the long axis of the muscles and sometimes the whole length of the muscle fiber. There may be an increase in the RYR 1 protein in the core. 2 MCD. Light microscopy may show normal muscle fiber architecture or slight variation in muscle fiber size. Numerous unstructured cores are observed and there is an abundance of central nuclei. 3 NM....
Emg
High yield muscles are suggested for identification of lumbosacral radiculopathy. Most lesions occur at the L4 5 or L5 S1 level. Five limb muscles have been suggested for a reasonable screening the rectus femoris or adductor longus, tibialis anterior, gastrocnemius, gluteus maximus, and tibialis posterior or peroneus longus muscles. The examination of the paraspinal muscles is useful, but must be handled with caution in patients who have had a laminectomy and in older patients. Diabetics may...
Hereditary neuropathy with liability to pressure palsies HNPP
Fig. 20. Teased fibers from a patient with hereditary neuropathy and pressure palsy HNPP showing a large sausage shaped myelin enlargment tomacula Peripheral nerves in HNPP exhibit segmental demyelination and tomacula Anatomy distribution Fig. 20 . Patients appear to have recurrent mononeuropathies that cause weakness and numbness, often following mild compression or trauma. These neuropathic episodes begin in adolescence. Men tend to present earlier than women. Some cases present in childhood,...
Episodic weakness of lumbosacral plexus Table 8
Diagnosis Laboratory exclude diabetes CT or MR angiography for suspected vascular lesions CSF when cauda equina lesion or inflammatory lesion is suspected Electrophysiology motor and sensory studies NCV, late response, needle EMG, evoked potentials Bulbocavernosus reflex Table 8. Episodic weakness of the lumbosacral plexus Episodic weakness of the lumbosacral plexus Cauda equina lesion Exacerbated walking Lumbar vertebrostenosis, Unaffected by bicycling forward, less symptoms Pain amp Sensory...
Bulbar muscular disordersDifferential diagnosis
For neuralgia amytriptyline, carbamazepine, gabapentin Therapy Kumral E, Afsar N, Kirbas D, et al 2002 Spectrum of medial medullary infarction clinical References and magnetic resonance imaging findings. J Neurol 249 85-93 Newsom-Davies J, Thomas PK, Spalding JMK 1984 Diseases of the ninth, tenth, eleventh, and twelfth cranial nerves. In Dyck PJ, Thomas PK, Bunge R eds Peripheral neuropathy. Saunders, Philadelphia, pp 1337-1350 Scheid W, Wieck H 1949 Klinische Befunde bei Diphteriel hmung im...
Differential diagnosis Borreliosis Fig 4
Multiplex neuropathy Multiple sclerosis root lesions Referred pain Syringomyelia Depending on cause surgical, conservative Thoracic disc protrusion with spinal cord compression may have a poor prognosis. Raynor EM, Kleiner-Fisman G, Nardin R 2002 Lumbosacral and thoracic radiculopathies. In Katirji B, Kaminski HJ, Preston DC, Ruff RL, Shapiro B eds Neuromuscular disorders in clinical practice. Butterworth Heinemann, Boston Oxford, pp 859-883 Stewart JD 2000 Thoracic spinal nerves. In Stewart JD...
IgM paraproteinemia with antiMAG antibodies
Half of patients with MGUS develop antibodies against MAG myelin associated glycoprotein . Patients have a moderate to severe sensory loss with distal weakness. Nerve conduction velocities are significantly slowed with temporal dispersion and conduction block. These patients do not respond to therapy, but the disorder itself is usually indolent. Large fiber sensory function is lost, and there may be tremor. The disease presents as a sensorimotor neuropathy with predilection of large- Clinical...
Diabetic mononeuritis multiplex and diabetic polyradiculopathy amyotrophy
Anatomy distribution Diabetic mononeuritis multiplex DMM and diabetic polyradiculopathy DPR are due to the loss of motor and sensory axons in one or more named nerves or nerve roots. The term mononeuritis multiplex refers to multiple mononeuro-pathies in conjunction with polyneuropathy. Symptoms Patients experience proximal and distal weakness and sensory loss in specific named peripheral nerves including cranial or truncal nerves or nerve roots. The onset is sudden and usually extremely...
Bacterial and parasitic neuropathies
Borrelia Burgdorferi Lyme disease Clinical syndrome signs The earliest stage of Lyme disease stage I is characterized by the unique skin rash and symptoms of general infection. Neuroborreliosis begins in stage II of the disease. In stage II disease, the most common occurrence is lymphocytic meningoradi-culitis. Motor and sensory symptoms may occur variably and undulate in severity over the course of months. Half of patients have focal or multifocal cranial nerve disease, including the facial,...
Median nerve
Fig. 8. Section at the distal end of the carpal tunnel. 1 Median nerve. 2 Ulnar nerve. 3 Deep ulnar nerve. 4 Flexor retinaculum. 5 Flexor tendons. 6 Flexor pollicis longus. 7 Abductor dig-iti minim muscle Fig. 9. Transsection of the median nerve and sural nerve inter-plantate in a 24 month follow up. A Orators hand prior to operation, B after 24 months the long flexors of the thumb and particularily the index finger show increased mobility Fig. 10. Acute carpal tunnel syndrome. A Local painful...
Neoplastic neuropathy
Fig. 9. Sural nerve biopsy from a patient with lymphoma. A Infiltration of the peripheral nerve by collections of B cells, with disruption of normal sural nerve architecture. B Disruption of myelin, with myelin splaying, and partial loss of axons Fig. 9. Sural nerve biopsy from a patient with lymphoma. A Infiltration of the peripheral nerve by collections of B cells, with disruption of normal sural nerve architecture. B Disruption of myelin, with myelin splaying, and partial loss of axons There...
Fascioscapulohumeral muscular dystrophy FSHMD
Fig. 16. Patient with FSHMD. A There is bilateral ptosis and facial weakness. B and C Prominent scapular winging in patients with FSH Fig. 17. FSHMD showing lobu-lated type 1 fibers white arrows that are smaller than the type 2 fibers succinic dehydro-genase FSHMD affects the face, scapula and proximal shoulder girdle and the lower extremities in a peroneal distribution. The disorder progresses slowly and is compatible with a normal life span even Time course in those who are symptomatic. FSHMD...
Postsynaptic defects
Kinetic abnormalities in AChR junction Increased response to AChR slow AChR syndrome Fast channel syndrome epsilon, alpha subunits gating abnormality delta subunit Normal numbers of AChR at the neuromuscular junction Reduced response to ACh Fast channel, low ACh affinity Reduced channel opening High conductance and fast closure of AChRs Slow AChR channel syndrome Reduced numbers of AChR at neuromuscular junction AChR mutation, usually epsilon subunit
Pupillary size and equality
Anisocoria indicates an inequality in pupil size between the right and left pupils. Light reflex direct indirect Horner's syndrome see Horner's syndrome Ciliospinal reflex see CN and Coma Pinpoint pupils May be a sign of opioid intoxication or a structural lesion of the pons pontine hemorrhage . Foodborne Cranial nerve duction appears first, then dilated fixed pupils not always present Optic nerve lesions swinging flashlight test - MS Adie tonic pupils Unilateral dilatation Raised intracranial...
Dermatomyositis DERM
Fig. 3. Patient with dermatomyositis. There is evidence of a hyperememic rash on the upper chest, face and palm Fig. 4. Dermatomyositis. A Typical perifascicular regeneration arrows . B Necrotic capillaries demonstrated by dark precipitates on alkaline phosphatase arrow heads Usually affects proximal muscles and bulbar muscles. Progressive disorder with gradual onset in most cases. Any age, bimodal frequency 5-15 years and 45-65 years. Equally common in men and woman. Symptoms include myalgias,...
Hyperkyphosis Fshmd
Introduction Tools Cranial nerves Olfactory nerve Optic nerve Oculomotor nerve Trochlear nerve Trigeminal nerve Abducens Facial nerve Acoustic Vestibular Glossopharyngeal Vagus nerve Accessory Hypoglossal nerve Cranial nerves and painful conditions - a Cranial nerve examination in Pupil Multiple and combined oculomotor nerve Plexopathies Cervical plexus and cervical spinal Brachial plexus Thoracic outlet syndromes Lumbosacral Cervical Thoracic radiculopathy Lumbar and sacral Cauda equina...
Phrenic nerve
Fig. 22. Phrenic nerve is in the vicinity of the pericardium. 1 Right. Phrenic nerve. 2 Left. Phrenic nerve. 3 Anterior portion of Diaphragm The phrenic nerve fibers are from C3, 4, and 5. The connection with C3 may be via the inferior ansa cervical is cervical plexus . The nerve travels over the anterior scalenus muscle, dorsal to the internal jugular vein, and crosses the dome of the pleura to reach the anterior mediastinum. On the right side, it is positioned next to the superior vena cava...
Intercostobrachial nerve 1
Anatomy Originates from lateral cutaneous nerve of second and third intercostal nerves to innervate the posterior part of the axilla. This nerve often anastomizes with the medial cutaneous nerve of the upper arm from the medial cord of the brachial plexus . Symptoms Pain in the axilla, chest wall, or thorax. Often occurs one or two months after mastectomy. Reduced movement of the shoulder enhances pain. Signs Sensation is impaired in the axilla, chest wall, and proximal upper arm. Differential...
InvestigationsPlain radiographs
CT and MRI do not detect fibrous bands, but are good to exclude other causes Electrophysiology to exclude CTS Characteristics low or absent sensory NCV of ulnar and medial cutaneous nerves. EMG abnormalities of muscles lower trunk Paraverterbrals are normal. 1. Conservative treatment posture correction, stretching may relieve problems. 2. Orthosis to elevate shoulder 3. Surgery resection of the first rib Due to cervical rib and vascular involvement subclavian artery compression with...
Hypoglossal nerve
Fig. 14. Hypoglossal nerve lesions. A Left hypoglossal peripheral paresis. Note deviation of the tongue to the left. B Right sided hypoglossal paresis, in a patient with meningeal carcinomatosis. Midline of the tongue shifted to the right. C Amyloid tongue in a patient with multiple myeloma. Patient's subjective impression was, that the tongue was too big Fig. 14. Hypoglossal nerve lesions. A Left hypoglossal peripheral paresis. Note deviation of the tongue to the left. B Right sided...
Radial nerve
Fig. 20. a 1 Radial nerve. b Sensory area of the posterior cutaneous and the superficial radial nerve Fig. 20. a 1 Radial nerve. b Sensory area of the posterior cutaneous and the superficial radial nerve Fig. 21. Radial nerve injury. Hand drop and wrist drop Fibers from C5-T1 spinal cord contribute to the radial nerve. Anatomy The nerve travels through the brachioaxillary angle, then along the spiral groove of the humerus, continuing in the anterior compartment of arm. At the elbow joint, it...
Musculocutaneous nerve
Fig. 3. 1 Musculocutaneous nerve. 2 Cutaneus antebrachii lateralis nerve. 3 Coracobrachial muscle. 4 Short head of biceps muscle. 5 Long head of biceps muscle. 6 Brachialis muscle Fig. 4. Biceps pathology. A Atrophy of the biceps brachii in a patient with neuralgic shoulder amyotrophy. Note the absent relief of the muscle. B Biceps tendon rupture. Typical clinical manifestation with flexion of the elbow Fig. 5. Nerve metastasis of a carcinoid tumor in the muscu-locutaneous nerve. A...
Paramyotonia congenita
Fig. 35. Myotonia of the hand in a patient with cold induced my-otonia Von Eulenburg's disease . The patient is trying to open his hand Many patients who have myotonia have only minimal or no symptoms. In more Distribution anatomy severely affected subjects myotonia may affect both proximal and distal muscles. Many subjects are asymptomatic. In those who develop symptoms the condi- Time course tion either remains stable or only slowly progresses. The disorder may present at any age, most...
Autonomic
Autonomic fibers travel with the tibial nerve. Lesion of the tibial nerve produces trophic skin changes and hyperkeratosis Fig. 46c . Hematoma in the popliteal fossa Morton's neuralgia Nerve sheath tumor Rupture of the popliteus muscle Stretch from ankle sprain Superior tibiofibular joint injury Synovial cyst Tendinous arch between soleus muscle Tarsal tunnel syndrome see below Laboratory tests Electrophysiology NCV, EMG Imaging Sciatic nerve lesion, radicular lesion. Fasciitis. Burning feet in...
Lumbar and sacral radiculopathy
Fig. 6. Lumbar anatomy. a1 1. Intervertebral foramen, 2. Dorsal root ganglion, a2 Section at L4-level, b1 1. Mediolateral prolaps, 2. Lateral prolapse, 3. Median prolapse, b2, b3 1. Mediolateral prolapse, b4 2. Lateral prolapse, 3. Median prolapse Fig. 6. Lumbar anatomy. a1 1. Intervertebral foramen, 2. Dorsal root ganglion, a2 Section at L4-level, b1 1. Mediolateral prolaps, 2. Lateral prolapse, 3. Median prolapse, b2, b3 1. Mediolateral prolapse, b4 2. Lateral prolapse, 3. Median prolapse...
Congenital myopathies
Fig. 20. Nemaline myopathy. A Large nemalin rod inclusions arrows on Trichrome stain. B Electron microscopy-nemalin rod inclusion arrows Fig. 19. Nemaline myopathy. A Distal leg atrophy in a patient with nemaline myopathy. B Atrophy of the proximal arm muscles, neck muscles, and weakness of the facial muscles. C Bilateral hand wasting Fig. 20. Nemaline myopathy. A Large nemalin rod inclusions arrows on Trichrome stain. B Electron microscopy-nemalin rod inclusion arrows Fig. 21. Central Core...
Superior
Misplaced injection, trauma, hemorrhage, arthroplasty, aneurysm. Inferior Rarely isolated, often associated with the sciatic nerve, occasionally with pudendal nerve. Colorectal carcinoma, injections, trauma. Sacral plexus lesion Hip and pelvic pathology Grisold W, Karnel F, Kumpan W, et al 1999 Iliac artery aneurysm causing isolated superior gluteal nerve lesion. Muscle Nerve 22 1717-1720 Rask MR 1980 Superior gluteal nerve entrapment syndrome. Muscle Nerve 3 304-307 Wilbourn AJ, Lesser M 1983...
Hexacarbon neuropathy
Anatomy distribution Paranodal demyelination and retraction of myelin and focal axonal accumulation of 10 nm neurofilaments. Slow onset of distal sensory pain, followed by calf pain and distal weakness. Variable degrees of atrophy, loss of ankle reflexes. CNS damage may cause delayed spasticity in 15 of cases. Hexacarbons are common in industry and domestic products, but only N-hexane and methyl-n-butyl ketone are known to cause neuropathy. Inhalation is the main route of exposure. Methyl ethyl...
Myotonia congenita
Fig. 33. Myotonia congenita. A Muscle myotonia in the hypoth-enar muscles. B Myotonic discharges in the EMG from affected muscle Fig. 34. Thomson's myotonia congenita. A Increased muscle bulk in the arms and chest in a patient with Thomson's disease. B Hypertrophy of the extensor digitorum brevis muscle Variable, may affect both limb and facial muscles. Progresses very slowly over a lifetime. Usually strength is spared. - Myotonia congenita Thomsen onset in infancy. - Myotonia congenita Becker...
Paraneoplastic neuropathy
Fig. 10. Dorsal root ganglion pathology A and B show an example of an inflammatory paraneoplastic ganglionitis. B shows an infiltrate that is immunostained for T cells. C is a rare example of neoplastic infiltration of a DRG by lymphoma cells of a Burkitt-like lymphoma. This patient had additional meningeal infiltration Fig. 10. Dorsal root ganglion pathology A and B show an example of an inflammatory paraneoplastic ganglionitis. B shows an infiltrate that is immunostained for T cells. C is a...
Ulnar nerve
Fig. 16. Medial epicondyle and cubital tunnel. 1 Right ulnar nerve. 2 Medial epicondyle. 3 Aponeurosis. 4 Flexor carpi ul-naris Fig. 16. Medial epicondyle and cubital tunnel. 1 Right ulnar nerve. 2 Medial epicondyle. 3 Aponeurosis. 4 Flexor carpi ul-naris Fig. 18. Ulnar nerve lesion. A Complete transsection at lower arm level by a glass pane. Note the typically flexed finger 4 and 5. B Distal ulnar nerve lesion with a 50 year duration. C Distal ulnar lesion, after the exit of the branch to the...
Anterior tarsal tunnel syndrome
Fig. 48. Anterior tarsal tunnel syndrome. A and B Sensory loss in a case of anterior tarsal tunnel syndrome, atrophy of extensor digitorum brevis muscle. C Atrophy of the the extensor digitorum brevis muscle. D Opposite foot with a normal muscle Terminal branch of the deep peroneal nerve. Passes under the pars cruciforme vaginae fibrosae. Pain at the dorsum of the foot. Sensory loss over the first interosseus space. Atrophy of the extensor digitorum brevis muscle Fig. 48 . Tinel's is sign...
Cephalic tetanus
May occur in lesions of the head and neck e.g., otitis . Symptoms are unilateral facial paralysis, trismus, facial stiffness, nuchal rigidity, and pharyngeal spasms. Caudal cranial nerves and oculomotor nerves may be affected. The incubation period is short, and it may progress to generalized tetanus. Diagnosis is based on clinical findings. The absence of a wound does not Diagnosis exclude tetanus, and anaerobic cultures are only positive in a third of cases. CSF is normal. EMG shows...
Differential diagnosis Spinal cord epiconus medullary lesions
Rapidly ascending polyneuropathy Sensorimotor neuropathies with autonomic involvement Guigui P, Benoist M, Benoist C, et al 1998 Motor deficit in lumbar spinal stenosis a References retrospective study of a series of 50 patients. J Spinal Disord 11 283-288 Hoffman HJ, Hendrick EB, Humphreys RB, et al 1976 The tethered spinal cord its protean manifestation, diagnosis and surgical correction. Childs Brain 2 145-155 Tyrell PNM, Davies AM, Evans N 1994 Neurological disturbances in ankylosing...
Cervical radiculopathy
Fig. 2. Left hand C8 radiculopathy with atrophy in a patient with leukemic infiltration Fig. 2. Left hand C8 radiculopathy with atrophy in a patient with leukemic infiltration Fig. 3. Meningeal carcinomatosis with neoplastic deposits in C6 and C7. Extensor deficits of fingers 3, 4, 5 mimicks partial radial paralysis With exception of the upper two, the cervical vertebrae articulate with each other by an intervertrebral disc, plus a pair of smaller joints between articular facets and pedicles....
Diabetic amyotrophy Bruns Garland syndrome
This entity has several names, including diabetic femoral neuropathy, although usually more than the femoral nerve is affected. Diabetic amyotrophy is usually a unilateral but can be bilateral proximal plexopathy affecting the hip flexors, femoral nerve, and some adjacent structures. Vasculopathies, metabolic causes, or vasculitic changes have been described. A paper by Dyck 1999 summarizes the characteristic features it typically strikes elderly diabetic individuals between 36 and 76 years...
Pseudoradicular
The term pseudoradicular is often applied in the German speaking neurologic nomenclature. It implies that the symptoms of the patients resemble a radicular distribution. However, definite radicular symptoms dermatomal and myotomal symptoms are often incomplete, and signs are absent or obscured by local pain or reduced mobility due to pain. The origin of pseudoradicular symptoms is variable and ranges from degenerative vertebral column disease, to osseous disease and pathologic conditions...
Medial plantar proper digital nerve syndrome Joplins neuroma
Differential diagnosis arthritis of big toe. References Marques WJ, Barreira AA 1996 Joplin's neuroma. Muscle Nerve 19 1361 Park TA 1996 Isolated inferior calcaneal neuropathy. Muscle Nerve 19 106-108 Staal A, van Gijn J, Spaans F 2000 The tibial nerve. In Staal A, van Gijn J, Spaans F eds Mononeuropathies examination, diagnosis and treatment. Saunders, London, pp 125-132 Medial plantar proper digital nerve Joplin's neuroma