Positive Tinel's Sign Research Articles

Uncommon Anatomical Causes of Ulnar Compression: A Narrative Review.

Some patients develop ulnar nerve compression due to rare anatomical variations or malformations. The aims of this review are to provide a comprehensive overview of anatomical structures and variations that can cause ulnar nerve compression and to evaluate treatment options. Case reports and case series about rare cases of unusual ulnar nerve compression published from January 2000 until April 2022 were obtained from databases Embase, MEDLINE, and Web of Science. A total of 48 studies describing 64 patients were included in our study. The following structures have proven to cause ulnar nerve compression: anconeus epitrochlearis, accessory abductor digiti minimi, vascular anomalies, palmaris longus, fibrous bands, and flexor carpi ulnaris. All cases except one have had a surgical release of the ulnar nerve resulting in diminished symptoms or complete recovery at follow-up. In addition to considering common compression points, it is important to be aware that proximal compression symptoms, such as pain and a positive Tinel sign at the medial elbow, may be attributed to a hypertrophic AE or vascular anomaly. Distal compression symptoms encompass swelling, along with pain and a positive Tinel sign at the distal forearm. Various structures contributing to distal compression include an accessory abductor digiti minimi muscle, an accessory or anomalous palmaris longus muscle, or an accessory or hypertrophic flexor carpi ulnaris muscle. The occurrence of fibrous bands exhibits variability, manifesting in diverse locations across the arm.Level of Evidence: IV.

Anterior Tarsal Tunnel Syndrome: Entrapment of the Articular Branch of Deep Peroneal Nerve

Case: A 28-year-old male patient who injured his ankle 2 years ago presented with unilateral ankle pain, tingling, and numbness for 1 year. Clinically, tenderness and positive Tinel sign were localized on anterior aspect of ankle. On exploration, deep peroneal nerve and mainly its articular branch were encased in fibrotic tissue. Decompression of both nerves resulted in symptomatic relief after surgery. Conclusion: High index of suspicion, a thorough medical history, meticulous clinical examination, complete knowledge of nerve anatomy, proper radiological studies, and careful surgical decompression are all necessary for the diagnosis and management of such atypical cases.

Cubital Tunnel Syndrome: Does a Consensus Exist for Diagnosis?

Cubital tunnel syndrome (CuTS) is the second most common compressive neuropathy of the upper extremity. We aimed to determine a consensus among experts using the Delphi method for clinical criteria that could be validated further for the diagnosis of CuTS. The Delphi method was used for establishing a consensus among a group of expert panelists, comprising 12 hand and upper-extremity surgeons, who ranked the diagnostic clinical importance of 55 items related to CuTS on a scale from 1 (least important) to 10 (most important). The average and SDs of each item were calculated, and Cronbach α was used to assess homogeneity among the panelist-ranked items. All panelists answered the 55-item questionnaire. A Cronbach α value of 0.963 was obtained on the first iteration. The top criteria that were considered most clinically relevant to the diagnosis of CuTS among the group were determined based on the most highly ranked and correlated items among the expert panelist group. The criteria based on which there was agreement were as follows: (1) paresthesias in ulnar nerve distribution, (2) symptoms precipitated by increased elbow flexion/positive elbow flexion tests, (3) positive Tinel sign at the medial elbow, (4) atrophy/weakness/ late findings (eg, claw hand of the ring/small finger and Wartenberg or Froment sign) of ulnar nerve-innervated muscles of the hand, (5) loss of two-point discrimination in ulnar nerve distribution, and (6) similar symptoms on the involved side after successful treatment on the contralateral side. Our study demonstrated a consensus among an expert panelist group of hand and upper-extremity surgeons on potential diagnostic criteria for CuTS. This consensus on diagnostic criteria may help clinicians readily diagnose CuTS in a standardized form; however, further weighting and validation are necessary prior to the development of a formal diagnostic scale. This study is the first step in producing a consensus on how to diagnose CuTS.

Prevalence and Impact of Cell Phone Elbow among Mobile Users in Different Cities of Punjab, Pakistan

Cell phone elbow is the pinching of ulnar nerve behind the elbow resulting in tingling or numbness within the hand when using a cell phone, sleeping with your elbows bent, or holding your arms bent and by your head for long period of time. Objective: To find out the prevalence of cellphone elbow among mobile phone users and its associated impairments and functional limitations. Methods: A cross-sectional study was conducted during October 2021 to April 2022. Data were collected from different Punjab colleges and universities: NUR International University, Riphah International University, The University of Lahore, University of Faisalabad, Niazi College of Physical Therapy and Fatima Memorial Hospital and College. Participants were recruited through convenience sampling from 17-50 years of age with positive Tinel sign test. Data collection were done by using the Numeric Pain Rating Scale and Boston Carpal Tunnel Syndrome Questionnaires. Results: Out of 250 subjects 33.2% were having noticeable symptoms associated with prolong phone usage. Among them 39.6% experienced numbness and tingling. Hand pain is reported in 32.8% and 27.6% experienced pain on ulna side of elbow. Conclusions: The prevalence of cell phone elbow was 33.2%, higher than the previous studies. This research advice the cell phone users to minimize their mobile usage, avoid prolonged calls, use hands alternately to avoid strain on one hand, use hands-free and ear pods while taking calls

Tarsal tunnel syndrome – a disease ignored by doctors and totally unknown for the patients

Tarsal tunnel syndrome (TTS), or tibial nerve compression at the internal malleolus level, is a frequently missed disease among clinicians, although it can be found in diabetic pa­tients (almost half of them will develop peripheral neu­ro­pa­thy and related complications) and in non-diabetic pa­tients due to the existence of tumors and anatomical ac­ces­sory elments. The aim of this paper is to increase the le­vel of awareness regarding the TTS diagnostic tools and treat­ments among doctors. The main source of literature re­view was PubMed database and the author’s per­so­nal ex­­pe­­rience. Although it is considered a rare di­sease, for sure underdiagnosed, left without treatment, TTS will lead to foot sensitive and motor deficits with dra­ma­tic ef­fects on patients quality of life and survival. Pa­tient’s his­to­ry, cli­ni­cal examination (positive Tinel sign, ob­jec­tive test­ing of in­creased sensibility threshold) and pa­ra­cli­ni­cal exa­mi­na­tion (soft tissue ultrasonography and ner­vous conduction stu­dies) highlight the diagnostic. The con­ser­va­tive and mi­ni­mally invasive therapeutic methods are effi­cient, but limited in time, the surgical solution – tarsal tun­nel de­com­pre­sion – being still the elective procedure, even in cri­ti­cal peri­pheral neu­ro­pa­thy.

The effects of tibial nerve mobilization in patients with tarsal tunnel syndrome: A randomized controlled trial

In tarsal tunnel syndrome (TTS), the nerve mobilization, one of the conservative treatment methods, aims to relieve abnormal nerve tension with appropriate movements of the nerve tissue. The aim of this study was to investigate the effect of tibial nerve mobilization in addition to home exercise on the tibial nerve area in patients diagnosed with TTS. The study included 40 participants, including 20 cases in the intervention group (IG) and 20 cases in the control group (CG). IG received tibial nerve mobilization and a home exercise program for and foot-ankle joint. Participants in the control group had only a home exercise program for the foot-ankle joint. Primary outcome measures were tibial nerve diameter and Tinel's sign measurements. Secondary outcome measures were pain intensity, neuropathic pain status (NPQ) and foot functional index (FFI). The positive Tinel's sign incidence was lower in favour of IG (Odds ratio:0.11 95% CI: 0.03 to 0.46). Between-group comparisons revealed a significant difference in pain intensity (Mean difference: 1.45; 95% CI: 0.69 to 2.20), NPQ (Mean difference: 0.70; 95% CI: 0.36 to 1.03), pain subscale (Mean difference: 10.0; 95% CI: 4.33 to 15.66) and total score of FFI (Mean difference: 20.60; 95% CI: 0.53 to 40.66) in favour of IG. There was no reported adverse events. This study showed that the addition of tibial nerve mobilization to home exercise program might improve symptoms, especially pain and functionality in patients with TTS. Further studies with large sample sizes are need to support these results.

Pronator Quadratus: A Preferable Recipient for Targeted Muscle Reinnervation of Neuromas in the Hand.

Targeted muscle reinnervation (TMR) has emerged as a useful solution to the problem of painful neuromas and is increasingly being applied in many clinical circumstances. Relatively little has been written about TMR for painful neuromas of the hand, and what has been written describes use of the intrinsic muscles as recipients for the nerve transfer. Except in cases of amputation, intrinsic muscle sacrifice carries morbidity. Furthermore, TMR to intrinsic muscles will place the nerve coaptation in areas subject to pressure with loading of the palm. For these reasons, the pronator quadratus may be a preferable target muscle when performing TMR for painful neuromas of the hand. In this report, we describe the rationale for its use and demonstrate the surgical technique and outcomes with case examples.

Autoimmune hepatitis complicated with entrapment neuropathy & fibromyalgia: A case report

46. y-old right-handed female with history of controlled autoimmune hepatitis since 2001 with negative liver biopsy on 2017 presented with chronic generalized pain affecting neck, upper back, buttocks, knee and chest associated with paresthesia and tingling of left hand with nocturnal exacerbation. Clinical exam revealed; Neurologically Positive Tinel sign over median nerve at wrist bilaterally, Positive Phalen test bilaterally, Musculoskeletal exam revealed multiple tender points bilaterally with limited neck Rom due to pain. Electrophysiological testing of both upper extremities documented bilateral median sensory neuropathy at wrist, demyelinating pathology and bilateral ulnar nerve entrapment at wrist: Guyon canal syndrome; sensory-motor axonal demyelinating. Normal liver and kidney function tests and glycosylated hemoglobin 5.

The Tinel Sign and Myelinated Axons in the Cross-Face Nerve Graft: Predictors of Smile Reanimation Outcome for Free Gracilis Muscle Transfer?

Introduction: During a two-stage free gracilis muscle transfer (FGMT) to restore smile to patients with facial paralysis, some surgeons assess nerve regeneration through the cross-face nerve graft (CFNG) with the Tinel sign and a nerve biopsy. Objective: To test whether ultimate smile reanimation outcomes are correlated with (1) the Tinel sign or (2) myelinated axons of the biopsied CFNG at the time of FGMT. Methods: Retrospective case series was performed at a tertiary care facial nerve center. Dynamic smile outcomes were quantified with Emotrics analysis of pre- and postoperative photographs. Results: Of the 113 FGMT surgeries by CFNG performed since 2002, 92 patients had pre- and postoperative photo-documentation. Most patients (89%, N = 82) had a positive Tinel sign at the time of FGMT; however, 14 patients with positive Tinel signs were deemed failures. Interestingly, 4 patients with a negative Tinel sign went on to have successful dynamic outcomes and 16 patients lacking myelinated axons in their CFNG biopsy ultimately achieved successful smile outcomes. Conclusion: Although the majority of patients had a positive Tinel sign and myelinated axons in the CFNG at the time of FGMT, the presence or absence of either factor did not predict ultimate smile outcome in this series.

An Update on Posterior Tarsal Tunnel Syndrome.

Posterior tarsal tunnel syndrome (PTTS) is an entrapment neuropathy due to compression of the tibial nerve or one of its terminal branches within the tarsal tunnel in the medial ankle. The tarsal tunnel is formed by the flexor retinaculum, while the floor is composed of the distal tibia, talus, and calcaneal bones. The tarsal tunnel contains a number of significant structures, including the tendons of 3 muscles as well as the posterior tibial artery, vein, and nerve. Focal compressive neuropathy of PTTS can originate from anything that physically restricts the volume of the tarsal tunnel. The variety of etiologies includes distinct movements of the foot, trauma, vascular disorders, soft tissue inflammation, diabetes mellitus, compression lesions, bony lesions, masses, lower extremity edema, and postoperative injury. Generally, compression of the posterior tibial nerve results in clinical findings consisting of numbness, burning, and painful paresthesia in the heel, medial ankle, and plantar surface of the foot. Diagnosis of PTTS can be made with the presence of a positive Tinel sign in combination with the physical symptoms of pain and numbness along the plantar and medial surfaces of the foot. Initially, patients are treated conservatively unless there are signs of muscle atrophy or motor nerve involvement. Conservative treatment includes activity modification, heat, cryotherapy, non-steroidal anti-inflammatory drugs, corticosteroid injections, opioids, GABA analog medications, tricyclic antidepressants, vitamin B-complex supplements, physical therapy, and custom orthotics. If PTTS is recalcitrant to conservative treatment, standard open surgical decompression of the flexor retinaculum is indicated. In recent years, a number of alternative minimally invasive treatment options have been investigated, but these studies have small sample sizes or were conducted on cadaveric models.

Assessing carpal tunnel syndrome with magnetoneurography

ObjectiveTo measure the neuromagnetic fields of carpal tunnel syndrome patients after electrical digital nerve stimulation and evaluate median nerve function with high spatial resolution. MethodsA superconducting quantum interference device magnetometer system was used to record neuromagnetic fields at the carpal tunnel after electrical stimulation of the middle digital nerve in 10 hands of nine patients with carpal tunnel syndrome. The patients were diagnosed based on symptoms (numbness, tingling, and pain) supported by a positive Phalen or Tinel sign. A novel technique was applied to remove stimulus-induced artifacts, and current distributions were calculated using a spatial filter algorithm and superimposed on X-ray. ResultsIn 6 of the 10 hands, the amplitude of the inward current waveform attenuated to <70% or the nerve conduction velocity was <40 m/s. The results of conventional nerve conduction studies were normal for two of these six hands. All four hands that could not be diagnosed by magnetoneurography had severe carpal tunnel syndrome superimposed on peripheral neuropathy secondary to comorbidities. ConclusionsTechnical improvements enabled magnetoneurography to noninvasively visualize the electrophysiological nerve activity in carpal tunnel syndrome patients. SignificanceMagnetoneurography may have the potential to contribute to the detailed diagnosis of various peripheral nerve disorders.

Surgical Treatment Compared to Conservative Treatment in Remission of Pain and Hyposthesia in Tarsal Tunnel Syndrome – Systematic Review

Abstract Introduction Tarsal tunnel syndrome (TTS) is caused by compression of the posterior tibial nerve. Objective To evaluate the effectiveness of surgical treatments compared to conservative treatments in reducing the symptoms of the syndrome. Methods The PubMed, Lilacs, Cochrane Library, and PEDro databases were used for this review. Results Only 11 articles were selected. Conclusion The most common causes of TTS identified were presence of ganglia, bone prominence causing a talocalcaneal collision, trauma, varicose and idiopathic veins. The main symptom was pain in the medial plantar region and paresthesia that can radiate to the fingers or to the calf. Most patients have a positive Tinel sign upon physical examination. Electrodiagnostic test usually shows the presence of latency in sensory nerve conduction. There is no consensus suggesting that a longer time between diagnosis and surgical treatment leads to worse prognosis. In the group of operated patients, the ones who benefited most from the procedure were those who had a structure such as ganglion, cysts, or varicosities causing compression. The most cited surgical complications were postsurgical wound infection, wound dehiscence, and calcaneus hypoesthesia. Regarding surgical techniques, the release of the posterior tibial nerve via endoscopy had a favorable outcome in relation to the symptoms of pain and hypoesthesia, with no reports of infection of the operative site in the articles identified in this review. We observed a rate of good or excellent pain control of 68% (n = 204) for open surgery (n = 299), 100% (n = 8) for endoscopic surgery (n = 8), and 7% (n = 2) for conservative treatment (n = 28).

Nerve decompression in diabetics with chronic nerve compression: update 2022

The number of people with diabetes worldwide has reached epidemic proportions. Diabetics are well-known to have chronic nerve compressions, and the prevalence of compressions exceeds 50% in those with neuropathy. The loss of sensation in the feet of people with diabetic neuropathy is the primary cause of their ulceration and amputation, as well as pain. The aim of this article is to update the reader on the current status of lower extremity nerve decompression in patients with diabetic neuropathy. A review of the history and literature related to the current approach to the patient with chronic nerve compression plus diabetic neuropathy was undertaken. The current evidence is overwhelmingly clear, in diabetics with neuropathy and a positive Tinel sign over the tibial nerve at the tarsal tunnel, that decompression, by neurolysis of lower extremity nerves, can relieve pain, restore sensation, and prevent ulceration and amputation. Furthermore, economic cost-benefit analysis by the Markov technique demonstrates that lower extremity nerve compression is not only cost-effective compared to standard medical care, but also increases the quality of life and life expectancy. The remaining barriers to acceptance and implementation of this proven surgical approach must lie in the education of physicians in training and re-education of diabetes educators, primary care providers and endocrinologists.

Nerve conduction study findings and their predictors in clinically diagnosed patients with carpal tunnel syndrome in a Saudi population.

Despite the reports of carpal tunnel syndrome (CTS) being commonplace in Saudi Arabia, there is scarcity of cross-sectional or prospective studies detailing the profile of nerve conduction study (NCS) findings in patients with CTS. The study aimed to evaluate the neurophysiologic profile of CTS with the view to finding the determinant of abnormal findings in clinically diagnosed cases of CTS in a population of Saudis. Nerve conduction study was performed on consecutive patients with clinically diagnosed CTS. Median sensory, ulnar sensory, radial sensory median motor and ulnar motor nerves were assessed. The nerve conduction parameters measured were median and ulnar sensory peak latency, amplitude and velocity. Median conduction velocity, distal latency, and amplitude were also measured. Comparative median-ulnar and median-ulnar-digit 4 studies were done and the severity of CTS was determined. Data was analyzed using STATA software version 12. A total of 152 patients, comprising 59 males and 93 females (mean age of 42.7 years) with clinically diagnosed CTS were seen during the study period. About 72.4% patients had numbness and paresthesia in the affected fingers, 66.5% had pain in the hands, and 10.5% had weakness in the affected hands. Majority of the patients (62%) had bilateral clinical features. Carpal tunnel syndrome was confirmed with NCS in 84 (55.26%) patients. Presence of weakness in the affected hand, positive Phalen' sign, and positive Tinel's sign in patients appear to predict [6.1 (1.2-30.7), 3.9 (1.2-30.2), and 4.9 (1.4-17.0) respectively] abnormal NCS findings after adjustment for age, gender and the presence of DM. The study revealed that over half of the patients with CTS had NCS/ Electromyography (EMG) abnormalities. Presence of hand muscles weakness, positive Phalen and Tinel's signs predict abnormal findings on NCS/EMG in patients with CTS.

Outpatient Neuromodulation May Avert the Need for Surgery in Patients with Painful Cutaneous Neuromas.

Background: Traumatic neuromas are a result of abnormal neural regeneration after nerve injury. Neuropathic pain arising from neuroma can be debilitating. Methods: This was a retrospective review of a consecutive series of patients who presented with a painful cutaneous neuroma secondary to direct trauma or surgery. The diagnosis was made by the presence of neuropathic symptoms in the dermatome of a cutaneous nerve and a positive Tinel sign. Local anaesthetic injection was performed for confirmation of diagnosis. Each patient was offered optimisation of medical therapy and physiotherapy for desensitisation. Outpatient neuromodulation was offered as an alternative to neuroma surgery. The primary aim of treatment was symptom reduction such that neuroma surgery was no longer required. Results: This study included 50 patients with painful cutaneous neuromas. Surgery was the commonest cause. The most frequently injured nerves were superficial radial nerve, digital nerve and dorsal ulnar cutaneous nerve, together comprising over 60% of cases. After receiving neuromodulation, 18 (36%) patients experienced sufficient symptom relief and did not wish to pursue neuroma surgery. Conclusions: Surgery is the commonest cause of a painful cutaneous neuroma. Following optimisation of pharmacotherapy and physiotherapy, neuromodulation may offer symptom relief such that neuroma surgery may be avoided in approximately one third of cases.

Multimodal evaluation of donor site morbidity in transgender individuals after phalloplasty with a free radial forearm flap: a case-control study

In phalloplasty, there is a lack of standardized follow-up examinations of motor function and strength after harvesting oversized radial forearm free flaps (RFFF). We evaluated the donor site of 20 transmen after phalloplasty, using a multimodal, standardized approach, assessing the following parameters: opposition of the thumb, composite range of motion of the finger joints, grip strength, mobility of the wrist, lesion of the superficial branch of the radial nerve, the dorsal branch of the ulnar nerve, the sensation of pain, and cold intolerance. The contralateral, nonoperated forearm was used as a control. No impairment of the mobility of the thumb (Kapandji score median 10, range 5-10) or fingers (all fingers at both sides pulp-to-palm 0 cm, nail-to-table 0 cm) were detected. Grip strength (median 36,3kg, p=0.629) and wrist extension (62.5°vs.70°, p=0.357), flexion (70°vs.70°, p=0.535), pronation (90°vs.90°), supination (90°vs.90°), radial (30°vs.30°, p=0.195), and ulnar deviation (40°vs.50°, p=0.125) did not statistically differ between donor and control hand. Injury of the dorsal branch of the ulnar nerve was uncommon (0% hypoesthesia, 10% positive Tinel's sign). We did not observe any persistent pain of the donor forearm (NRS median 0, range 0-9). We did observe irritation of the superficial branch of the radial nerve (hypoesthesia 40%, neuroma 45%). The harvest of an oversized RFFF for phalloplasty does not cause any significant difference in motor function or strength between the donor and nonoperated hand. A potential risk of injuring the radial nerve branch is to be avoided. An aesthetic impairment could be addressed in future studies.

A Novel Technique of Arthroscopic Ankle Lateral Ligament Repair Using a Knotless Suture Anchor.

Background:Although arthroscopic lateral ligament repair (ALLR) with suture anchors for chronic lateral ankle instability has become widely accepted, some complications have been reported as well. Establishment of a new technique is essential for better clinical outcomes after ALLR.PurposeTo report a novel technique and good clinical results of ALLR using a knotless suture anchor.Study Design:Case series; Level of evidence, 4.Methods:We examined 30 patients (16 men and 14 women) who underwent ALLR. The mean age of the patients was 30.0 years, and the average period of postoperative monitoring was 21 months. The Japanese Society for Surgery of the Foot (JSSF) ankle-hindfoot scale was used for clinical evaluation postoperatively, and the Self-Administered Foot Evaluation Questionnaire (SAFE-Q) for patient-reported results. Surgical complications were also examined.Results:The JSSF ankle-hindfoot scale showed a significant improvement from preoperatively to follow-up (from 72.1 to 96.1; P < 0.001), and the SAFE-Q was significantly improved in all subscales (pain and pain-related, physical function and daily living, social function, shoe-related, and general health and well-being; P < 0.004 for all). Complications included residual joint pain due to remaining osteophytes in 1 case, scar pain of the accessory anterolateral portal in 2 cases, and positive Tinel sign indicative of superficial peroneal nerve irritation at the anterolateral portal in 1 case.Conclusion:The clinical results of the novel ALLR technique were overall satisfactory. Knot-related complications, one of the main reasons for postoperative complications, were reduced by using a knotless suture anchor.

Changing Concepts for the Diagnosis of Carpal Tunnel Syndrome in Powerlifting Athletes with Disabilities.

Objective To examine the prevalence of carpal tunnel syndrome in powerlifting athletes with disabilities. Methods The present study evaluated the presence and intensity of pain (numerical scale), nocturnal paresthesia (self-report), and nerve compression (Tinel and Phalen signs) in wheelchair- and non-wheelchair-bound powerlifting athletes with disabilities. The clinical diagnosis of carpal tunnel syndrome was confirmed by the presence of two or more signs/symptoms. Results In total, 29 powerlifting athletes with disabilities were evaluated. None of the athletes reported the presence of pain or nocturnal paresthesia. The Tinel sign was present in 1 (3.45%) wheelchair-bound athlete. A positive Phalen test was present in 3 (10.35%) athletes (1 wheelchair-bound and 2 non-wheelchair-bound). Concurrent positive Tinel sign and Phalen sign tests were found in 2 (6.89%) athletes (1 wheelchair-bound and 1 non-wheelchair-bound). Conclusion Carpal tunnel syndrome was clinically diagnosed in 2 (6.89%) out of 29 powerlifting athletes with disabilities.

Occipital Neuralgia - A Masquerading Cause of Concussion Symptoms.

Occipital neuralgia (ON) is an often-undiagnosed cause of head and neck pain. Potential etiologies of ON are wide and include head and neck trauma, such as whiplash and concussion injuries, atlantoaxial joint instability, or as a complication after radiofrequency ablation. Patients commonly complain of severe attacks of shooting or stabbing pain in the nuchal area around the greater occipital nerve (GON) distribution that is exacerbated by movement or palpation of the neck. Because of the location and characteristics of the pain and the associated symptoms, this condition can be easily mistaken for tension headaches with myofascial components, cervicogenic headaches, radiculopathies, or atypical migraines. If precipitated by head trauma, such as a concussion, ON typically presents subacutely between 1 and 3 months postinjury. Associated symptoms can include tinnitus, nausea, dizziness, and visual changes, which lends significant overlap between ON and postconcussive syndrome (1). Pearl: Consider a diagnosis of ON in patients with a recent history of concussion who have cessation of symptomatic improvement weeks after their injury, or have worsening symptoms including headache, nausea, dizziness, and/or photophobia. The physical examination of patients with ON can be extremely helpful in differentiating it from other types of headaches and other concussive sequelae. Tenderness to compression and/or a positive Tinel's sign can often be appreciated along the course of the GON, particularly at the proximal end of the GON typically located 2 cm inferior and 2 cm lateral to the occipital protuberance. Pain may radiate along the scalp as distal as the fronto orbital region, but need not be in a contiguous distribution. The lesser occipital nerve also may be affected, which may be found lateral to the GON along the superior nuchal ridge. Of note, the Buffalo Concussion Treadmill Test (BCTT) has been used to determine if symptoms during prolonged postconcussion recovery are because of the concussion (abnormal physiologic response to exercise) or because of a concomitant depression, cervical injury, vestibular/ocular dysfunction, or a posttraumatic headache syndrome (normal physiologic response to exercise) (2). In our clinical experience, the BCTT does not perform well at distinguishing between ON and concussion. This may be because of the communications between the occipital nerves and various cranial nuclei, including that of the vagus nerve, which may contribute to an abnormal physiologic response to exercise (3). Diagnostic confirmation of ON can instead be achieved via the use of a diagnostic nerve block on the affected occipital nerve. Pearl: A diagnostic nerve block may be superior to the use of the BCTT at distinguishing between concussion and ON symptom etiologies. There is no current consensus on the optimal treatment method for ON given the lack of randomized controlled studies. Treatment options include standard conservative methods (hot or cold compresses and postural readjustments), pharmacological approaches (nonsteroidal anti-inflammatory drugs and neuropathic medications), and various intervention options (botulinum toxin injections). In our clinical experience, diagnostic blocks of the occipital nerves often have significant therapeutic benefit, which is supported by the positive findings in one medium-sized prospective study (4). Pearl: Occipital nerve blocks can be efficacious in treating patients with ON. For those patients with a positive but temporary response to the block, radiofrequency ablation of the third occipital nerve commonly results in more sustained improvement.

Plexiform or multinodular schwannoma of posterior tibial nerve: case report with review of literature

&lt;p&gt;A schwannoma is a benign tumor that develops from the Schwann cells, which assists conduction of nerve impulses and located in the nerve sheath of peripheral or cranial nerves. Plexiform or multinodular Schwannoma of posterior tibial nerve is a rare presentation, can cause diagnostic dilemma with Lumbosacral radiculopathy, Tarsal tunnel syndrome, Entrapment neuropathy or Chronic regional pain syndrome. Unexplained leg pain, a positive Tinel's sign with or without a palpable swelling and Magnetic Resonance Imaging will clinch the diagnosis after excluding other causes. In symptomatic cases with long standing complaints, surgical resection yields satisfactory outcome. We present an interesting case of plexiform schawannoma along posterior tibial nerve with review of literature.&lt;/p&gt;