Nerve Lesions of Lower Limb (Muscle Testing of Lower Limb) - Book Report/Review Example

NERVE LESIONS OF LOWER LIMB (MUSCLE TESTING OF LOWER LIMB) Nerve lesions of lower limb (Muscle testing of lower limb) Lower limbs have a variety of nerves. For a proper understanding of the nerves, their functions and the dangers that they may suffer in the event of a lesion, the lower limb is divided into the nerves of the thighs and nerves of the legs. Compartment of the thigh is further divided into three compartments by three septa that extend from deep linea aspera of femur to deep fascia of the thigh (Christine 2010, 123) . To understand the lesions that nerves in the lower limb is most likely to suffer in the event of an injury or any other causative agent, it is necessary to understand the structure of the lower limb (Ward 2002, 48). Retrieved from (Ward 2002, 48) The thigh contains anterior compartment that contains the femoral nerve and the quadriceps femoris (Christine 2010, 123) . The posterior compartment of the thigh contains the sciatic nerve and hamstring muscles. The third compartment of the thigh section is the medial compartment that contains obsturator nerves and adductor muscles. Sciatic nerve is the largest nerve in the body. The nerve is the largest branch of sacral plexus. Sciatic nerve leaves the pelvis via the greater sciatic foramen. The nerve appears in the gluteal region below piriformis muscle. Other nerves in this compartment that will be discussed later in the task include femoral nerve and obturator nerve (Heinberg 2003, 173). Neurological supply of the lower limb is composed of spinal nerves that emanate from vertebral column. In the vertebral columns, the nerves exist as the spinal cord. The nerves that supply the lower limb leave the vertebral column from the lumbar vertebra 4 (Bilroy 2008, 28). They continuously exit the vertebral column at each level. The nerves leave the vertebral columns at L4, L5and S1 to S4. Together with additional branches from T12, the nerves are known as lumbo-sacral plexus (Rohkamm 2004, 32). They lie anterior and lateral to the vertebra column within the bony pelvis. Since the nerves branch from the spinal cord and do not supply the spinal cord, destruction of the nerves in the lower limb has local effects on the functionality of the lower limb. Spinal nerves connect the central nervous system to organs and effects. These include the muscles of the lower limbs. They emerge from the vertebra from the intervertebra fernamina between adjoining vertebrae. At the same time, some spinal nerves exit the spinal cord at levels higher than corresponding vertebra. The spinal cord comes to an end at the level of L2 (Bilroy 2008, 28). In addition to nerves of the thigh, there are nerves of popliteal fossa that include Tiblia Nerve and Pornoeal Nerve. More compartments are found in the leg region. The leg region contains anterior compartment, posterior compartment and latereal compartment (Himmel 1999, 83). The anterior compartment contains the deep peroneal nerves and tabealis anterior and long extension muscles. The posterior compartment contains the long flexor muscles, tibialis posterior and tibial nerve. Lastereal compartment, on the other hand, contains superficial peroneal nerve and the two peroneus and brevis muscles. Nerve lesions are injuries that may affect one or many of the nerves in the body. Several medical conditions and a variety of conditions cause nerve lesions (Penkert & Fansa 2004, 85). There is, therefore, an assortment of symptoms associated with nerve lesions. Its effective treatment depends on its timely location and determination of its cause. Sometimes, it becomes impossible for a medical practitioner to provide a proper prognosis for patients with nerve lesions. In the event of a complete nerve lesion, the nerve becomes so damaged that a signal can never pass through it (Pateson 2004, 84). The damage can often be permanent in nature. On the other hand, partial nerve lesion involves partial damage of the nerve; a condition that causes an interruption in the functioning of the nerve. The body is usually more likely to adapt to the physical changes due to partial lesions. For this reason, medical practitioners often get positive outcome while treating partial lesions. A number of factors cause nerve lesions. Foremost, there are the degenerative diseases of the nervous system. Burns, cuts, tumors and abrasive injuries such as those caused by bones that grate against nerves also cause nerve lesions. In all these cases, there is a damage caused to part of the nerve (Pateson 2004, 84). Myelin, the thick sheath that covers the nerve is usually partially or completely removed. Demyelinated nerves are difficult to treat. This becomes even more difficult to treat when the cause of the demyelination is a disease as is usually in the case of multiple sclerosis (Moore & Agur 2014). In sports medicine, exercise related leg pains are common yet difficult to manage. A number of causes of such symptoms exist. These include muscle compartment syndromes and stress structures. In addition, some less common yet significant conditions such as popliteal artery entrapment and other nerve entrapment syndromes lead to the strains of the lower limb. Distionction between the different medical causes of the conditions may be difficult even for astute medical experts since the symptoms overlap (Moore & Agur 2014). Sciatic Nerve Injury Sciatic nerve lesions result from common mechanisms such as comprtession, stretch, direct damage and ischaemia. Sitting positions, frog leg and the lithotomy have been largely implicated for the perioperative injury of the nerve (Millesi & Schmidhammer 2007, 84). The three issues are largely responsible for hyperflexion of the hips, extension of the legs that leads to stretching of nerves and abduction. Additionally, regional anaesthetic techniques as well as hip arthroplasty are possible causes of injury to the sciatic nerve. Incidences of injury of the nerve are high in men aged between the ages of 45 and 55 years and patients suffering from diabetes mellitus. In this form of lesion, the common peroneal component is usually affected. This is because the peroneal is more superficial than the tibial components (Millesi & Schmidhammer 2007, 84). Tibial nerve is the larger of the two terminal branches of the sciatic nerve. It is positioned in such a way that it nearly bisects the popliteal fossa (Meier 2007, 92). The dissection is from the upper angle to the lower angle. The nerve leaves the popliteal fossa at the lower boarder of the popleteal muscle. At this point, it continues into the posterior compartment of the leg and forms part of the posterior tibial nerve. An injury to this nerve would extremely affect the functionality of the leg given the critical position of the nerve (Meier 2007, 92). This is especially so given the muscular branching of the nerve into popliteal fossa including the following muscles: Soleus muscle Popliteus Plantaris muscle Two heads of gastrocnemius muscle (Last 2009, 12) The Common Pernoeal Nerve is the smaller of the two terminal branches of the sciatic nerve. Despite its small size and relatively les coverage of the lower limb, its lesion still extremely affects the functionality of the leg and hips. This is due to the strategic position that the nerve passes in the lower limb. The nerve passes downwards laterally via the medial boundary of the biceps towards the lateral angle of poplitea fossa (Last 2009, 12). The nerve curves forward lateral to the neck of fibula (Rohkam 2007, 22). In the event of injury to the nerve, therefore, it is sensible to conclude that the biceps and the fibula may lose sensitivity. Common Pernoeal Nerve pierces through the peroneus longus from where it divides into two terminal branches; the deep peroneal nerves and the superficial pernoeal nerves. Lesion of these nerves is detrimental to the functioning of the leg. In the clinical presentation of sciatic nerve injury, the lesion presents itself as paralysis of the hamstring muscles in addition to all the muscles below the knee. This leads to foot drop and weak knee flexion. All sensations below the knee with exception of the medial aspect of the foot and leg become impaired (McMinn & Last 2009, 09). Injury of the Obturator Nerve Obturator Nerve is the nerve of the medial section of the thigh. It is also a branch of the lumbar plexus, though smaller than the femoral nerve. Like the other nerves, lesion of this lower-limb nerve arises from a number of factors. Injury to the nerve results from common mechanisms such as comprtession, stretch, direct damage and ischaemia (McMinn & Last 2009, 09). Sitting positions and the lithotomy have been largely implicated for the injury of the nerve. These issues are largely responsible for hyper-flexion of the hips, extension of the legs that leads to stretching of nerves and abduction. Additionally, regional anesthetic techniques as well as hip arthroplasty are possible causes of injury to the sciatic nerve. Given the strategic and important position of the obturator nerve, its lesion has adverse effects on the lower limb. The nerve appears on the medial side of the psoas muscle in the abdomen (McMinn & Last 2009, 09). It is a significant connection between the abdomen and the lower limb, and is therefore one of the nerves whose injury causes complete non-functionality of a large portion of the body. The nerve leaves the pelvis via the upper portion of the obturator foramen. Its significance and need to be prevented against injury is evident in the significance of the muscles it supplies with neural impulses. Foremost, the nerve serves pectineus muscles, a group that is so vital that it is served by femoral nerve as well. Additionally, obturator nerve serves adductor longus and adductor brevis muscles (McMillan & Tyldesley 2012, 75). Furthermore, it serves adductor magnus and gracilis muscles. Femoral Nerve Injury Femoral Nerve can be injured with firmness at the pelvic brim by retractors as observed in abdomino-pelvic surgery (McMillan & Tyldesley 2012, 75). Additionally, the injuries can be caused by lithotomy positions with superficial abduction of the thighs and ischaemia associated with aortic cross-clamp. Furthermore, external rotation of the hips is the other potential cause of injuries to the femoral nerve (Habal & Himmel 1999, 56). It is also associated with invasive medical procedures to access hip athroplasty and femoral vessels. Femoral Nerve is the largest branch of the lumbar plexus situated within the psoas major muscle (Habal & Himmel 1999, 56). Given its size, an injury to this nerve renders the leg virtually functionless. It is the nerve of the anterior side of the thigh. The nerve appears on the lateral boundary of the psoas major from where it descends between the psoas major and the iliacus. Femoral Nerve passes behind the iliac fascia. Injuring the Femoral Nerves would mean lack of sensitivity to the thighs as the nerve enters the thighs behind the lingual ligament in a lateral manner to the femoral sheath situated on the outside. Femoral Nerve terminates about 1.5 inches below the lingual ligament from where it supplies the muscles of the front of the thigh. Femoral Nerve serves Sartorius, quadriceps femoris and pectineus muscles. Lesion of the nerve would, therefore, affect the functionality of these muscles, rendering the lower limb virtually dead (Habal & Himmel 1999, 56). Lesions on the femoral nerve are clinically presented by a loss of sensation at the front of the thigh. Further, medial aspect of the leg occurs, hinting an interference with the saphenous nerve. There also exists loss of extension of the knee and weak hip flexion. This causes difficulties in walking fast and climbing stairs. Finally, a decreased or an absent knee jerk flexes confirms the diagnosis of injured femoral nerve (Saurabh 2010, 76). Superficial Peroneal Nerve Injury Superficial Peroneal Nerve is also known as musculocutenous nerve. It is the nerve of lateral component of the leg. Superficial Peroneal Nerve offers muscular branches to muscles of the lateral constituent of the leg (Gould 2011, 85). These include peroneus longus and peroneus brevis. There is an incidence of 88 cases of 1000 in 2600 total knee arthroplasties attributed to surgical factors (Gould 2011, 85). Injuries to Superficial Peroneal Nerve are mainly caused by lithotomy. Additionally, lateral positions are common risk factors as Superficial Peroneal Nerve is potentially compressed at the fibular head. There is no association between the length of time in the lithotomy and the increased risk of development of PPNI. Injury of the Superficial Peroneal Nerve is clinically presented by loss of dorsiflexion and eversion of feet. This is known as equinovarus deformity. Sensory manifestation of the Superficial Peroneal Nerve injury is described along the anterolateral boundary of the dorsum of the digits and the leg. Exceptions are the portions of the leg supplied by sural nerves and saphenous nerves (Gilory & Ross 2008). Perioperative Peripheral Nerve Injuries (PPNI) Exact incidence of Perioperative Peripheral Nerve Injury is difficult to determine given quality and heterogeneity of studies in the related field. In a retrospective review of the general surgical patients, it is rare that a case of permanent neurological injury results from peripheral nerve block. This is regardless of the method used to determine the peripheral nerve blockage (whether through ultrasound or other traditional techniques) (Gilory & Ross 2008). Ultrasound guided methods lessen the risk of intravascular injection. However, the technique does not reduce the probability of neurological injury. Peripheral neuropathy of the lower limb may have a variety of causes. The central focus of this article is the focal central lesions given the neural entrapment that is associated with static mechanical compressions and dynamic stretching and compressions (Gilory & Ross 2008). Mechanical compressions of the muscles of the lower limb may relate to direct surgical injury, direct blunt trauma, frictional effects associated with fibrous bands and mass effects that result from mass lesions. At the same time, stretching neural injury may be related to abnormalities in the alignment such as hind foot pronation and plano-valgus hind foot (Feinberg & Spielholz 2003, 38). Additionally, recurrent inversion ankle injuries may also be effective cause of neural injury. For this reason, neural injury is associated with denervation of muscles that are supplied by the nerve. The gold standard for diagnosis of this kind of denervation remains Electromyography (EMG) (Feinberg & Spielholz 2003, 38). In addition to EMG, there is another diagnostic tool called diagnostic imaging that plays a complementary role. Diagnostic imaging provides solutions in extremely difficult situations and in cases dealing with anticoagulated patients. It clarifies etiology of EMG-demonstrated neuropathy. In addition to the above two methods of diagnosing denervation, ultrasound and magnetic resonance imaging are the other methods available for diagnosis of the condition. The method is used in peripheral nerve imaging to determine extrinsic compression lesions. Additionally, the method demonstrates focal neural lesions such as swelling and neural edama (Christian 2010, 74). Further, interneural ganglia and posttraumatic neuroma in continuity otherwise known as focal neural scarring are the other conditions that ultrasound and magnetic resonance imaging help determine. Furthermore, imaging helps determine the extent and effects of muscle denervation (Schunke 2010, 85). The focal areas of tenderness are highlighted using transducer palpation for ultrasound imaging and by the use of skin markers for magnetic resonance imaging. Ultrasound imaging can be particularly helpful in assessing intrinsic lesions in minute peripheral nerves given the superior spatial resolution of ultrasound devices in assessing superficial structures. In some instances, plain X-Rays and computed tomography scanning also reveal significant changes in bone structures and needs to be the initial imaging modality (Christian 2010, 74). Muscle Testing of the Lower Limb In addition to the nerves and their injuries described above, the lower limb contains a variety of muscles that perform specific purposes. Rectus femoris is the muscle responsible for extending the knee and flexing the thighs. Bicep fermoris flexes the knee in addition to extending the thighs (Buck & Buck 2013, 84). Additionally, there is the semimembbranosus muscle that is responsible for extending the thigh and flexing the knee. Furthermore, semitendinosus is also responsible for extending the knee thigh and flexing the knee. On the other hand, extensor digitorum longus is the muscle responsible for extending the toe. Adductor group is an assortment of muscles whose function is to adduct the thigh in situations such as when one stands still at attention. Tibialis anterior is the prime mover of the dorsiflexion of the foot. These muscles are overly important for the movement of the hind limbs. It is, therefore, imperative that they be tested regularly to ensure their steadfast health to carry out the functionalities of the lower limb (Buck & Buck 2013, 84). Before discussing the means and ways that are applicable in testing the muscles of the lower limb, it is significant to understand the functionalities of other muscles of the lower limb. Tibialis anterior is the other muscle of the lower limb that acts as a major foot inverter. Soleus muscle is the prime mover plantar flexion. In addition, gastrocnemius is the other muscle that is similarly responsible for prime movement of the ankle plantar flexion (Sommer 2001, 34). Gluteus maximus is used to extend the hip while climbing stairs. Tenser faciae latae is the muscle responsible for abducting the thigh to take the relaxed, at-ease stance. Similarly, gluteus medius abducts the thighs to assume the at ease stance too. Comprehension of the tactics that medics use in testing the muscles of the lower limb depends on the functionality and position of the muscle (Buck & Buck 2013, 94). Fibularis longus is a lateral compartment muscle that everts the ankle and plantar flex the ankle. In addition, fibilaris brevis is a lateral compartment muscle, which plantar flexes and everts the ankle. Flexor hallicis longus is the muscle that flexes the greater toe in addition to inverting the ankle (Akuthota & Herrings 2009, 12). Hip Examination Straining of the lower limb muscles often generate pain in the hip joints. The hip joint pain is commonly felt in the anterior of the thighs and the groin. In extreme cases, the pain radiates to the knee. Pain felt over the trochanter is usually trachenteric bursitis (Akuthota & Herrings 2009, 12). Testing muscles based on pains of the hip follows musculoskeletal history. It requires an answering of the following questions: How bad is the pain? What makes the pain better or worse? Where is the pain? When did the pain start? Does it keep one awake at night? What treatment has one had and did the treatment work? Additionally, there is the need to have specific history of the hip and answers to the following questions need to be obtained before further examinations on the lower limb muscles are carried out: How far can one walk? Does one use any assistive devices to walk? Does one limp? Can one tie his shoelaces, put on his socks or clip his toenails? Does one climb stairs normally or is it one stair at a time? Which foot moves first? How long can one sit? Does one have pain with the first step after sitting? Upon answering the questions above questions, the medical practitioner runs one or more of the following tests to determine which lower limb muscle is strained: Gait Analysis-Hip Trendelenberg Gait determines the weakness of abductor muscles. The pelvis drops away from the side of the hind limb affected. On the other hand, Abductor Lurch is a shoulder-shifting gait that moves the center of gravity towards the affected side to lessen the forces across the hip joint (Akuthota & Herrings 2009, 12). Hip Exam This aims at determining the range of motions to determine the affected lower limb muscle. The test includes flexion and extension tests, internal and external rotations, and adduction and abduction tests. The tests are done in several positions and it is imperative to know the exact position of the pelvis (Akuthota & Herrings 2009, 112). A comparison is made with contra lateral side as the standard situation. Testing Knee Flexion This is a test for all the hamstring muscles. It includes three basic muscle tests. Foremost, the examiner needs to test for aggregate of the three hamstring muscles. This is done with the foot in the middle. Testing for the hamstring muscle in aggregate involves the patient sleeping with limbs straight while the toes are hanging over the edge of the table. The test starts in 45 degrees of knee flexion. The examiner instructs the examined to bend his knee, hold it and not to let him straighten it. Medial hamstring test involves testing semitendinosus and semimembranosus muscles. The patient stays prone with his knee flexed to a little less than 90 degrees. The leg is placed in internal rotation with toes pointing the midline (Tank 2009, 93). The patient flexes the knee while maintaining the internal rotation with the heel towards the examiner and the toe pointing towards the midline. Testing Gluteus Medius The patient lies sideways with the test leg superior to the supporting leg. The patient’s test limb slightly extends beyond the midline and his pelvis rotates slightly forward. He flexes the supporting limb for stability. The therapist stands behind the patient with his test hand placed on the lateral surface of the ankle or the knee and the other hand proximal to greater trochanter of femur (Agur & Dalley 2013, 38). The test involves the patient abducting against some applied resistance without rotating or flexing the hip in either direction. The examiner applies resistance that is straight and downward. The examiner instructs the patient to try resisting as he pushes down his leg in the described position. Testing Gluteus Medius in the Gravity Eliminated Position for weak patients The patient stays in a supine position (Agur & Dalley 2013, 138). The therapist stands right on the side of the test limb. One of his hands supports and lifts the test limb by holding it under the ankle. There is no resistance or assistance offered in this case. The test involves the patient abducting the hip through the available range of motions (Tyldesley 2002, 43). The examiner instructs the patient to bring his leg to the side as he keeps his knee cap pointed to the ceiling. Testing the Gluteus Maximus The patient positions himself with the knee to be tested flexed to 90 degrees (Agur & Dalley 2013, 78). The therapist stands on the side of the limb to be tasted placing his testing hand over the posterior thigh above the knee. His other hand stabilizes the pelvis over the upper buttock. The test involves the patient extending his hip through the available range of motion while maintaining flexion of his knees at 90 degrees (Ward 2002, 18). The examiner applies resistance directly towards the ground. He instructs the patient to lift his legs towards the ceiling while keeping his knee bent. Testing Gluteus Maximus in Gravity Eliminated Position for weak patients Patient lies on the side with the limb to be tested superior to the supporting limb. The tested knee is flexed and the examiner supports it. The supporting limb remains flexed for flexibility. The therapist stands right behind the patient and cradles the test limb with the hand and forearm under the flexed knee. He keeps the other hand on the pelvis to ascertain alignment. The test involves the patient extending his hip while maintaining the remaining knee flexed (Ard 2002, 94). The examiner instructs the patient to move his leg towards him. Conclusion Maintaining a healthy neural system and muscles for the hind limb is the secret to walking strong for long. It is not only important for athletes and sportspersons to keep their lower limbs healthy. Everyone cherishes good health and keeping in a position to be economically productive. It is imperative to avoid risky lifestyles that may lead to lesion of the nerves of lower limbs and destruction of the muscles of legs and thighs. Strict adherence to the discussed facts will ensure any determined person a long, healthy walk. Reference List ARD, R. C. (2002). Foundations for osteopathic medicine. Philadelphia, Lippincott Williams & Wilkins. AGUR, A. M. R., DALLEY, A. F., & GRANT, J. C. B. (2013). Grant's atlas of anatomy. Philadelphia, Wolters Kluwer Health/Lippincott Williams & Wilkins. 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Peripheral nerve injuries in the athlete. Champaign, IL, Human Kinetics. BILROY, A. M., MACPHERSON, B. R., & ROSS, L. M. (2008). Atlas of anatomy. Stuttgart, Thieme. HIMMEL, H. N. (1999). Key issues in plastic and cosmetic surgery. Vol. 16 Vol. 16. Basel, Karger. Read More