Neurogenic symptoms in the upper extremity can fool even seasoned clinicians. Evidence-based chiropractors sometimes struggle differentiating radiculopathy vs. peripheral neuropathy vs. a double crush syndrome…or maybe even something else. To help you nail these diagnoses, ChiroUp has compiled a short video and several of our favorite practical tips.
1. When assessing sciatica, you ALWAYS perform a straight leg raise, so why wouldn’t you apply the same logic when evaluating upper extremity complaints? Check out this quick tutorial to review three simple nerve tension tests to help you differentiate upper extremity neurogenic complaints.
2.Although generalizations can be dicey since not all conditions adhere to their Merck manual description; radiculopathy in a patient under age 50 is most likely from disc lesion, while radiculopathy in a patient over 50 is more likely from degenerative stenosis. (2)
3.Radicular complaints from disc lesions and degeneration most commonly follow a C6 or C7 nerve distribution. In fact, 90% of disc lesions occur at C5/6 (C6 nerve root) or C6/7 (C7 nerve root). (3-5) However, symptoms of TOS follow an ulnar nerve distribution, i.e. C8 or T1, in 90% of cases. (6,7)
4.Having a patient hold their arm overhead, i.e., Shoulder abduction sign, can help differentiate cervical radiculopathy from TOS. Patients with cervical radiculopathy will find relief in this position while those with TOS will likely experience exacerbation of symptoms.
5.The ulnar nerve innervates all intrinsic hand muscles, except the lateral two Lumbricals, Opponens pollicis, Abductor pollicis, and Flexor pollicis brevis, which are innervated by C8 and T1 via the median nerve. (8) Clinicians can differentiate ulnar radiculopathy, i.e., cubital tunnel syndrome, from C8–T1 radiculopathy by examining these five (LOAF) hand muscles via pinch grip strength.
6.Bilateral carpal tunnel syndrome is unlikely and should suggest central cord involvement, until disproven by MRI. (1)
7.Pronator syndrome is the second most frequent cause of median nerve compression (9.2% of all cases). (9). This condition occurs from entrapment of the median nerve by the pronator teres muscle. Nocturnal exacerbations are common in carpal tunnel syndrome but notably absent in pronator syndrome. Pronator syndrome is the likely diagnosis when symptoms are reproduced within 30 seconds of applying deep sustained compression over the pronator muscle, i.e. Pronator compression test. (10)
8.Radial tunnel syndrome commonly mimics or coexists with lateral epicondylitis. In fact, up to 10% of patients diagnosed with lateral epicondylitis actually have radial tunnel syndrome. Nocturnal pain is more common in radial tunnel patients than those with lateral epicondylitis. Most notably, the peak area of tenderness for radial tunnel syndrome is four finger breaths distal to the lateral epicondyle, i.e. Radial tunnel compression test. (11)
9.The Arm Squeeze Testcan be used to differentiate between a shoulder and neck complaint. In short, compressing the affected arm will exacerbate radicular symptoms via compression of hypersensitized nerves. Compression of the arm will not exacerbate pain that originates from shoulder dysfunction, i.e. rotator cuff impingement. In a study of over 1500 patients with arm pain, the Arm Squeeze test showed very high sensitivity (97%), specificity (>91%), and inter/ intraobserver reliability. (12)
10.Sensory disturbances (i.e. sciatica) can occur from simple irritation or inflammation of a nerve; however, motor or reflex loss generally signifies a true compression or more significant pathologic process – that almost always deserves a more significant response. In many cases, the patient must perform MULTIPLE repetitions before a motor weakness is uncovered. i.e. observing a single heel raise maneuver will not catch as many S1 deficits as watching what happens on the 10th repetition.
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- Kim HJ, Tetreault LA, Massicotte EM, Arnold PM, Skelly AC, Brodt ED, Riew KD. Differential diagnosis for cervical spondylotic myelopathy: literature review. Spine. 2013 Oct 15;38(22 Suppl 1):S78-88.
- DeLisa JA, Gans BM, Walsh, NE, Physical Medicine and Rehabilitation: Principles and Practice, Volume 1. Wolters Kluwer Health
- Constantoyannis C, Konstantinou D, Kourtopoulos H, Papadakis N: Intermittent cervical traction for cervical radiculopathy caused by large-volume herniated disks. J Manipulative Physiol Ther. 2002, 25(3):188-92.
- Kramer J. Intervertebral Disk Diseases. Causes, Diagnosis, Treatment and Prophylaxis.
- George Thieme Verlag, Stuttgart Year Book, Medical Publishers Inc; 1981.
- Wheeless’ Textbook of Orthopaedics. wheelessonline.com
- Chang AK. et. al. Thoracic Outlet Syndrome in Emergency Medicine Clinical Presentation. Medscape.com Accessed 6/23/18 at https://emedicine.medscape.com/article/760477-clinical
- Stoker GE, Kim HJ, Riew KD. Differentiating C8–T1 Radiculopathy from Ulnar Neuropathy: A Survey of 24 Spine Surgeons. Global Spine Journal. 2014;4(1):1-6.
- Gessini L, Jandolo B, Pietrangeli A. Entrapment neuropathies of the median nerve at and above the elbow. Surg Neurol. 1983;19:112-116.
- Gainor BJ. The pronator compression test revisited. A forgotten physical sign. Orthop Rev. 1990;19:888-892.
- Spinner M, Spinner RJ. Management of nerve compression lesions of the upper extremity. In: Management of Peripheral Nerve Problems, 2nd ed. 1998, Philadelphia, WB Saunders, pp. 501-533.
- Gumina S, Carbone S, Albino P et al. Arm squeeze test: a new clinical test to distinguish neck from shoulder pain. European Spine Journal 2013; 22: 1558-63.
About the Author
Dr. Tim Bertelsman
DC, CCSP, DACO
Dr. Tim Bertelsman graduated with honors from Logan College of Chiropractic and has been practicing in Belleville, IL since 1992. He has lectured nationally on various clinical and business topics and has been published extensively. He has served in several leadership positions within the Illinois Chiropractic Society and currently serves as President of the executive board.