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A presentation at Children’s Hospital Boston 12/23/10                    Stephan Esser MD                   www.esserhealt...
EMGfor the Sports Medicine Provider       Lower Extremity      Mono-neuropathies                     Stephan Esser USPTA, ...
Disclosures
Objectives• A Touch of History• Review Basic Neurophysiologic Concepts• Define EMGFU• Explore common LE Mono-neuropathies ...
What it is NOT!• The END of the conversation• A talk on neuropathy management• My recommendations on the selection of
“Animation”• 4 humors: sanguine, melancholic, choleric, phlegmatic• Chi of the Oriental Mystics• Soul of Christianity
1666: Franciso Redi: Electric Ray1773: Walsh: Eel could generate electricity
A touch of History• 1792: Galvani: Electricity can generate Muscle  Contractions• 1849: Dubois-Raymond: record electrical ...
EMG
Electro-diagnostic Studies• 2 Parts:  – Nerve Conduction Studies  – Electromyography• Purpose:  – Extension of the clinica...
Nerve Conduction Studies• Electrodes placed on the skin• Peripheral nerves are stimulated with low  intensity electrical i...
Basic NCS• Upper Extremity  – Motor: Median (APB), Ulnar (ADM)  – Sensory: Median, Ulnar, Radial, (MAC, LAC)• Lower Extrem...
Sural Nerve
Tibial: AHL
Peroneal: EDB
Endoneurium        PerineuriumEpineurium
12
Peroneal: EDB2   1                        A                            R
Basket of Reflexes• Based on age and height• H Reflex: Monosynaptic spinal reflex  – Side to side difference of 60%• F Wav...
Variables• Age• Technical :  –   Lab norms  –   Experience  –   Temperament  –   Temperature       • Velocity reduced by ≈...
Basic EMG/Needle• Sample muscles in affected/tested segment• At least 1 in each major myotome  – 5 in UE  – 5 in LE  – Par...
Electromyography                     Insertional• Needle Electrode   Resting• Ground             Exertional
In Review• “EMG”:  – Nerve Conduction Studies  – Health of the Nerves     • Sensory     • Motor  – Needle EMG  – Health of...
Mono-Neuropathies of the Lower Limb
Case #124 y/o recreational runner presents to clinic        unable to raise her right foot.
Differential Diagnosis• Peroneal Neuropathy• L5 Radiculopathy• Sciatic Neuropathy• Lumbo-Sacral Plexopathy• Vasculitis
Quick Review• Dorsiflexion and Eversion:  – Tibialis Anterior: dpn L4-L5  – Extensor Hallucis Longus dpn L4-L5  – Extensor...
Peroneal Neuropathy• Most Common mononeuropathy on the LE  – Causes: compression, entrapment, ischemia,    direct trauma, ...
Evaluation•   Rigorous history and physical•   Basic Labs: inflammatory panel etc•   Referral for EMG•   Safety: Appropria...
Peroneal Neuropathy• Routine LE Assessment  – NCS and EMG• NCS  – Sensory: sural, superficial peroneal  – Motor: peroneal(...
Fun Fact• The SHBF  • only muscle proximal to fibular neck that is innervated by    the peroneal nerve, so if peroneal neu...
Classic Findings• Reduced peroneal CMAP amplitude side to  side• Focal Slowing Across the fibular head• Normal sural senso...
What you want to see!• Associated Nerves are tested  – Peroneal motor, tibial motor, super. Per. Sensory,    sural sensory...
Case #2     25 y/o male golfer      presents to clinic          with pain  over the inner right ankle             andnumbn...
Differential Diagnosis• Tarsal Tunnel Syndrome• Plantar Fasciitis• L4 Radiculopathy• Ankle Sprain• Diabetic/Metabolic/Toxi...
Tibial Nerve:    2 sensory       M. & Lat.      Calcaneal Sensory   2 Mixed Motor and   Sensory     M. And Lat. Plantar
Evaluation• Rigorous history and physical• Intervention      vs:• Referral for EMG• ?Imaging: Lumbo-Sacral, Pelvic MRI
Tarsal Tunnel Syndrome• Described by Keck in 1962• compression neuropathy of the tibial nerve  – Flexor retinaculum• Commo...
Tarsal Tunnel Pressure• Trepman et al.:  – anatomic space pressure in the tarsal tunnel  – Pronated:  32 mmHg  – Neutral:...
Classic EMG Findings• Prolonged latency or low Amplitude Medial  or Lateral Plantar Sensory or mixed Nerve  Responses• Pro...
What you want to see!• Appropriate nerves tested• Associated Nerves are tested  – Sensory: Sural, Saphenous Sensory, Media...
Case #3              35 y/o male             Police OfficerPresents with numbness and occasional           “weird feelings...
Differential Diagnosis• L2-L4 Radiculopathy• Lateral Femoral Cutaneous Neuropathy• Lumbar Plexopathy  – Mass, Hematoma, Co...
Purely Sensory: NO Motor                              Origin: L2-3 via Lumbar plexusThrough the Pelvis                    ...
Meralgia Paresthetica                 Meros= thigh Algo= Pain• Obesity• Pregnancy• Tight clothing (low rise jeans), leanin...
EMG• NCS  – peroneal and tibial motor (with F wave)  – sural sensory, LFCN bilaterally• NEE  – L3-4: quadricep  – L4-5: ti...
Of Note• NCS: of the LFCN is technically challenging  and many patients are unable to tolerate• NEE: Anticipated to be “no...
Case #465 y/o female recreational swimmer        Presents concerned   With difficulty climbing stairs        and occasiona...
Differential Diagnosis• L2-L4 Radiculopathy• Femoral Neuropathy• Lumbo-Sacral Plexopathy• Intra-Aricular Knee or Hip Patho...
You Think• Knee Extension  – Quadriceps• Thigh Flexion  – Iliopsoas
LEVAN
Femoral Nerve           Motor                 Sensory•   Iliacus              • Saphenous Nerve•   Pectineus•   Sartorius•...
Femoral Nerve Neuropathy• Findings:  – Weakness in thigh flexion and knee extension  – Decreased sensation over anterior t...
EMG• NCS  – Motor: femoral (rectus femoris), peroneal and    tibial (with F wave)  – Sensory: sural, saphenous (bilaterall...
What you want to see!• Routine LE assessment• NCS - B femoral motor• NEE - at least 2 quads, iliopsoas, adductor  longus, ...
Expected EMG Findings• NCS:  – Motor: abnormal rectus femoris CMAP  – Sensory: abnormal saphenous findings, with    normal...
Quick Notes• Femoral Nerve:  – Distal or at Inguinal Ligament     • quads affected  – If both quads and iliopsoas affected...
Case #5 21 y/o male lineman         footballplayer presents to clinic  with complaints ofbeing unable to raise his        ...
Differential Diagnosis• Peroneal Neuropathy• L5 Radiculopathy• Sciatic Neuropathy• Lumbo-Sacral Plexopathy• Vasculitis• An...
Lumbar Innervation• L2-3-4                • L5-S1• Femoral               • Tibial  – RF, VM, VL, IP, S      – Gsc, PT, FDL...
Exam• Weakness  – Ankle Dorsiflexion  – Ankle Inversion• Decreased Sensation to LT, PP over medial  foot• Absent Hamstring...
Lumbar radiculopathy• NCS:  – Distal motor and sensory often normal in a single-    level radiculopathy.• Needle electromy...
Lumbar Radiculopathy• Clinical Findings:   – Pure Sensory> Sensorimotor> Pure motor
Expected EMG• NCS:  – Sensory: Normal  – Motor: Normal, or slightly reduced amplitude  – Reflexes: H Reflex: possibly abno...
Wrapping Up• EMG:  – “Extension of the physical exam”  – Only order if it will alter your management  – Order at least 3 w...
Personal Opinions• Meet your “neighborhood” EMG’r• Experience an EMG first-hand• Find an EMG’r who is well trained and you...
Personal Opinions• Send your patients to the same EMG’r once  you have done your research and found a  good fit• Ask your ...
Thank You!
Enjoy more powerpoints and   educational resources at    www.esserhealth.com
Emg for sports medicine providers2010
Emg for sports medicine providers2010
Emg for sports medicine providers2010
Emg for sports medicine providers2010
Emg for sports medicine providers2010
Emg for sports medicine providers2010
Emg for sports medicine providers2010
Emg for sports medicine providers2010
Emg for sports medicine providers2010
Emg for sports medicine providers2010
Emg for sports medicine providers2010
Emg for sports medicine providers2010
Emg for sports medicine providers2010
Emg for sports medicine providers2010
Emg for sports medicine providers2010
Emg for sports medicine providers2010
Emg for sports medicine providers2010
Emg for sports medicine providers2010
Emg for sports medicine providers2010
Emg for sports medicine providers2010
Emg for sports medicine providers2010
Emg for sports medicine providers2010
Emg for sports medicine providers2010
Emg for sports medicine providers2010
Emg for sports medicine providers2010
Emg for sports medicine providers2010
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Emg for sports medicine providers2010

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Emg for sports medicine providers2010

  1. 1. A presentation at Children’s Hospital Boston 12/23/10 Stephan Esser MD www.esserhealth.com
  2. 2. EMGfor the Sports Medicine Provider Lower Extremity Mono-neuropathies Stephan Esser USPTA, MD Harvard/Spaulding
  3. 3. Disclosures
  4. 4. Objectives• A Touch of History• Review Basic Neurophysiologic Concepts• Define EMGFU• Explore common LE Mono-neuropathies N• Run some cases• Wrap Up
  5. 5. What it is NOT!• The END of the conversation• A talk on neuropathy management• My recommendations on the selection of
  6. 6. “Animation”• 4 humors: sanguine, melancholic, choleric, phlegmatic• Chi of the Oriental Mystics• Soul of Christianity
  7. 7. 1666: Franciso Redi: Electric Ray1773: Walsh: Eel could generate electricity
  8. 8. A touch of History• 1792: Galvani: Electricity can generate Muscle Contractions• 1849: Dubois-Raymond: record electrical activity from a muscle contraction• 1890: Term Electromyography coined
  9. 9. EMG
  10. 10. Electro-diagnostic Studies• 2 Parts: – Nerve Conduction Studies – Electromyography• Purpose: – Extension of the clinical exam – Identify/Confirm neurologic dysfunction – Localize a lesion • Anterior horn cell, dorsal root ganglion, plexus, peripheral nerve, neuro-muscular junction
  11. 11. Nerve Conduction Studies• Electrodes placed on the skin• Peripheral nerves are stimulated with low intensity electrical impulses• Reference and active sensors then identify characteristics of the electrical wave traveling
  12. 12. Basic NCS• Upper Extremity – Motor: Median (APB), Ulnar (ADM) – Sensory: Median, Ulnar, Radial, (MAC, LAC)• Lower Extremity – Motor: Tibial (Abd Hall.), Peroneal (EDB) – Sensory: Sural, (Superf. Per., Saphenous, LFC)
  13. 13. Sural Nerve
  14. 14. Tibial: AHL
  15. 15. Peroneal: EDB
  16. 16. Endoneurium PerineuriumEpineurium
  17. 17. 12
  18. 18. Peroneal: EDB2 1 A R
  19. 19. Basket of Reflexes• Based on age and height• H Reflex: Monosynaptic spinal reflex – Side to side difference of 60%• F Wave: low amplitude late response reflex – Suggestive in Radicular rule out
  20. 20. Variables• Age• Technical : – Lab norms – Experience – Temperament – Temperature • Velocity reduced by ≈ 2.4m/s/ degree Cel. < 32 (89.6) – Timing • > 3 weeks post injury/ of symptoms – Placement • Too close, too far distorts computer calculations – Preparation • Oily skin/dispersion
  21. 21. Basic EMG/Needle• Sample muscles in affected/tested segment• At least 1 in each major myotome – 5 in UE – 5 in LE – Paraspinals where appropriate
  22. 22. Electromyography Insertional• Needle Electrode Resting• Ground Exertional
  23. 23. In Review• “EMG”: – Nerve Conduction Studies – Health of the Nerves • Sensory • Motor – Needle EMG – Health of the “Relationship” (nerve and muscle) • Insertional • Resting • Exertional
  24. 24. Mono-Neuropathies of the Lower Limb
  25. 25. Case #124 y/o recreational runner presents to clinic unable to raise her right foot.
  26. 26. Differential Diagnosis• Peroneal Neuropathy• L5 Radiculopathy• Sciatic Neuropathy• Lumbo-Sacral Plexopathy• Vasculitis
  27. 27. Quick Review• Dorsiflexion and Eversion: – Tibialis Anterior: dpn L4-L5 – Extensor Hallucis Longus dpn L4-L5 – Extensor Digitorum Longus dpn L4-L5 – Peroneus Tertius dpn L4-L5• Eversion: (weak plantar flexion) – Peroneus Brevis spn L5-S1 – Peroneus Longus spn L5-S1
  28. 28. Peroneal Neuropathy• Most Common mononeuropathy on the LE – Causes: compression, entrapment, ischemia, direct trauma, Knee dislocation or bicruciate injury, pneumatic compression devices – Ex: rapid weight loss, tight cast or brace, crossing legs, repetitive squatting, sitting on an airplane or positioning during surgery – Both> deep> superficial
  29. 29. Evaluation• Rigorous history and physical• Basic Labs: inflammatory panel etc• Referral for EMG• Safety: Appropriate Prosthetics• ?Imaging: Lumbo-Sacral, Pelvic MRI
  30. 30. Peroneal Neuropathy• Routine LE Assessment – NCS and EMG• NCS – Sensory: sural, superficial peroneal – Motor: peroneal(EDB, TA), Tibial(AHL) – contralateral peroneal motor (EDB, TA) and superficial peroneal sensory – Drop of >20% amplitude in CMAP is abnormal
  31. 31. Fun Fact• The SHBF • only muscle proximal to fibular neck that is innervated by the peroneal nerve, so if peroneal neuropathy at fibular neck the SHBF should be intact
  32. 32. Classic Findings• Reduced peroneal CMAP amplitude side to side• Focal Slowing Across the fibular head• Normal sural sensory, tibial motor• EMG findings of spontaneous activity and/or reinnervation• Normal findings in gastroc, quads, tib post, paraspinals, SHBF
  33. 33. What you want to see!• Associated Nerves are tested – Peroneal motor, tibial motor, super. Per. Sensory, sural sensory• Abnormalities differentiated• Contra-lateral side compared – Same nerves• Appropriate Muscles Sampled – TA,BFSH, BFLH or Semitendinosis, Post. Tib
  34. 34. Case #2 25 y/o male golfer presents to clinic with pain over the inner right ankle andnumbness on the sole of his foot
  35. 35. Differential Diagnosis• Tarsal Tunnel Syndrome• Plantar Fasciitis• L4 Radiculopathy• Ankle Sprain• Diabetic/Metabolic/Toxic Neuropathy
  36. 36. Tibial Nerve: 2 sensory M. & Lat. Calcaneal Sensory 2 Mixed Motor and Sensory M. And Lat. Plantar
  37. 37. Evaluation• Rigorous history and physical• Intervention vs:• Referral for EMG• ?Imaging: Lumbo-Sacral, Pelvic MRI
  38. 38. Tarsal Tunnel Syndrome• Described by Keck in 1962• compression neuropathy of the tibial nerve – Flexor retinaculum• Common Pre-Disposing Factors: – Pes planus with valgus hindfoot – crush injury, stretch injury, fractures, dislocations of the ankle and hindfoot – severe ankle sprains
  39. 39. Tarsal Tunnel Pressure• Trepman et al.: – anatomic space pressure in the tarsal tunnel – Pronated:  32 mmHg – Neutral: 1 mmHg – Inversion of the foot as well as plantarflexion of the ankle reduced the tarsal compartment pressure significantly.
  40. 40. Classic EMG Findings• Prolonged latency or low Amplitude Medial or Lateral Plantar Sensory or mixed Nerve Responses• Prolonged distal Latency of the medial or lateral plantar motor nerves• Decreased amplitude of the above• Spontaneous potentials
  41. 41. What you want to see!• Appropriate nerves tested• Associated Nerves are tested – Sensory: Sural, Saphenous Sensory, Medial and lateral plantar – Motor: Peroneal, tibial• Abnormalities differentiated• Contra-lateral side compared – Same nerves• Appropriate Muscles Sampled – Foot Muscles: ADM, FDM, Abductor hallucis, FDB
  42. 42. Case #3 35 y/o male Police OfficerPresents with numbness and occasional “weird feelings” over the front and side of his thigh
  43. 43. Differential Diagnosis• L2-L4 Radiculopathy• Lateral Femoral Cutaneous Neuropathy• Lumbar Plexopathy – Mass, Hematoma, Compression, Traction, Radiation• Femoral Neuropathy
  44. 44. Purely Sensory: NO Motor Origin: L2-3 via Lumbar plexusThrough the Pelvis Along the lateral border of the psoas muscleUnder the inguinal ligament ≈1cm medial to the ASIS
  45. 45. Meralgia Paresthetica Meros= thigh Algo= Pain• Obesity• Pregnancy• Tight clothing (low rise jeans), leaning against a table for work, uneven bar in gymnastics• Tool belts, military gear, recent weight loss• Diabetic and metabolic neuropathies• Other: masses, hematomas in the retroperitoneal space
  46. 46. EMG• NCS – peroneal and tibial motor (with F wave) – sural sensory, LFCN bilaterally• NEE – L3-4: quadricep – L4-5: tibialis anterior – L5-S1: glut. med. (L5) or max. (S1), tibialis post. or FDL, EDB – S1-2: medial gastroc., abductor hallucis – paraspinal
  47. 47. Of Note• NCS: of the LFCN is technically challenging and many patients are unable to tolerate• NEE: Anticipated to be “normal” but can help rule out “radiculopathy”
  48. 48. Case #465 y/o female recreational swimmer Presents concerned With difficulty climbing stairs and occasional falls because my “knee is buckling”
  49. 49. Differential Diagnosis• L2-L4 Radiculopathy• Femoral Neuropathy• Lumbo-Sacral Plexopathy• Intra-Aricular Knee or Hip Pathology• Poly-Myalgia Rheumatica
  50. 50. You Think• Knee Extension – Quadriceps• Thigh Flexion – Iliopsoas
  51. 51. LEVAN
  52. 52. Femoral Nerve Motor Sensory• Iliacus • Saphenous Nerve• Pectineus• Sartorius• Rectus Femoris• Vastus Lateralis• Vastus Intermedius• Vastus Medialis
  53. 53. Femoral Nerve Neuropathy• Findings: – Weakness in thigh flexion and knee extension – Decreased sensation over anterior thigh and medial leg – Loss of ipsilateral patellar reflex• Causes: – Compression (mass, hematoma), iliac aneurysm, trauma in surgery, femoral line placement,
  54. 54. EMG• NCS – Motor: femoral (rectus femoris), peroneal and tibial (with F wave) – Sensory: sural, saphenous (bilaterally)• NEE – L3-4: quadricep – L4-5: tibialis anterior – L5-S1: glut. med. (L5) or max. (S1), tibialis post. or FDL, EDB – S1-2: medial gastroc., abductor hallucis – paraspinal
  55. 55. What you want to see!• Routine LE assessment• NCS - B femoral motor• NEE - at least 2 quads, iliopsoas, adductor longus, upper lumbar paraspinals
  56. 56. Expected EMG Findings• NCS: – Motor: abnormal rectus femoris CMAP – Sensory: abnormal saphenous findings, with normal sural• NEE: – Abnormal activity in the femoral innervated muscles, normal findings elsewhere
  57. 57. Quick Notes• Femoral Nerve: – Distal or at Inguinal Ligament • quads affected – If both quads and iliopsoas affected must rule out lumbar radiculopathy vs retroperitoneal involvement.
  58. 58. Case #5 21 y/o male lineman footballplayer presents to clinic with complaints ofbeing unable to raise his right foot
  59. 59. Differential Diagnosis• Peroneal Neuropathy• L5 Radiculopathy• Sciatic Neuropathy• Lumbo-Sacral Plexopathy• Vasculitis• Ankle Injury/Intra-articular pathology
  60. 60. Lumbar Innervation• L2-3-4 • L5-S1• Femoral • Tibial – RF, VM, VL, IP, S – Gsc, PT, FDL, FDB• Obturator • Peroneal – G, AL – PL, PB• L4-5 • S1-2• Peroneal • Tibial – TA – So, AH • Sciatic – BFLH (t), BFSH(p), Sm, St
  61. 61. Exam• Weakness – Ankle Dorsiflexion – Ankle Inversion• Decreased Sensation to LT, PP over medial foot• Absent Hamstring reflex on the right• + SLR, XLR, Fem. Stretch Test• TTP of Lumbar Paraspinals
  62. 62. Lumbar radiculopathy• NCS: – Distal motor and sensory often normal in a single- level radiculopathy.• Needle electromyography: – High diagnostic yield. Timing is important, and the study should be performed less than 4-6 months (but >18-21 d) from symptom onset.
  63. 63. Lumbar Radiculopathy• Clinical Findings: – Pure Sensory> Sensorimotor> Pure motor
  64. 64. Expected EMG• NCS: – Sensory: Normal – Motor: Normal, or slightly reduced amplitude – Reflexes: H Reflex: possibly abnormal• NEE: – Abnormal Findings in L5 innervated muscles with normal findings in L2-L4 and S1 myotomes
  65. 65. Wrapping Up• EMG: – “Extension of the physical exam” – Only order if it will alter your management – Order at least 3 weeks after symptoms begin – Remember patient comfort
  66. 66. Personal Opinions• Meet your “neighborhood” EMG’r• Experience an EMG first-hand• Find an EMG’r who is well trained and you trust
  67. 67. Personal Opinions• Send your patients to the same EMG’r once you have done your research and found a good fit• Ask your patients about the experience and respond accordingly• Discuss concerning findings with the EMG’r
  68. 68. Thank You!
  69. 69. Enjoy more powerpoints and educational resources at www.esserhealth.com

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