This document discusses the classification and rehabilitation of peripheral nerve lesions. It classifies lesions as neurapraxia (first degree), axonotmesis (second degree), or neurotemesis (third degree). It then provides details on individual nerve lesions including signs, symptoms, prognosis, and rehabilitation approaches. Common nerves discussed include the radial, median, ulnar, femoral, sciatic, common peroneal, and posterior tibial nerves. Rehabilitation generally involves pain management, motor relearning exercises, sensory reeducation, and limb protection strategies.

1. PEREPHERAL NERVE
LESIONS

2. CLASSIFICATION:
Neurapraxia First degree Conduction block
(ischemic or local
demyelination)
anatomically normal
Axonotemesis Second degree Axonal interruption only
Neurotemesis Third degree Nerve fiber interruption
axon and myelin sheath
,with connective tissue
damage ( in partial
demyelination ) or with
nerve severance (in
complete damage)

3. 1.NEURAPRAXIA:
Temporary interruption of conduction without axonal interruption.
Pathology:
N.B: Basal lamina is preserved.
Clinical examinations and findings:
1.Weakness (or paralysis) in the muscles, decrease or loss of sensation
in regions.
2. Nerve conduction velocity is decreased.

4. Prognosis:
Completely reversible.
Rehabilitation:
1.Passive movement.
2.Electrical stimulation.
3.Splints; if needed.
4.Sensory reeducation.
5.Advises; to avoid injury.

5. 2.AXONOTEMESIS:
Interruption of nerve axon only. Basal lamina remains intact.
Clinical examinations and findings:
1.Weakness or paralysis, loss or decrease of sensation.
2.Nerve conduction velocity is reduced.
3. EMG shows fibrillation.
Prognosis:
Good, as basal lamina forms channels, in which proper regeneration
occurs .rate of recovery is 1-3 mm per day .
Rehabilitation:
As neurapraxia.

6. 3.NEUROTMESIS:
Interruption of all nerve.
Pathology:
Lesion of both basal lamina and neurolemmal sheath.
Clinical examinations and findings:
As complete axonotemesis.
Prognosis:
Regeneration is Poor, it needs surgical repair.
Rehabilitation:
As axonotemesis.

7. INDIVIDUAL PERIPHERAL NERVE
LESIONS
1-Suprascapular nerve lesion:
Signs and symptoms:
1.Weakness or paralysis of supraspinatous (shoulder abduction) and infraspinatous ( shoulder external
rotation).
2.Normal sensation.
3.Normal deep reflexes.
4.Atrophy of both muscles.
5.Deepshoulder pain (aching).
Rehabilitation:
1.ES then graduated active shoulder abduction and external rotation.
2.Pain management: A-Sling at acute stage.
B-Heat & TENS for pain.
3.Limp protection: Avoid heavy lifting.

8. 2-LONG THORACIC NERVE LESION:
• Signs and symptoms:
1.Winging of the inferior angle of scapula, due to weakness of serratus
anterior , lead to weak of functional shoulder flexion and abduction
due to altered scapula mechanism .
2.Normal sensation.
3.Normal deep reflexes.
Rehabilitation:
1.Passive, then graduated active exercises for serratus anterior, passive
Scapular mobilization.
2.Limb protection: as the previous.

9. 3-MUSCULOCUTANEOUS NERVE
LESION:
Uncommon
Clinical assessment :
1.Weakness or paralysis of biceps, brachialis (+ - ) coracobrachialis. This lead to
functional weakness in combined flexion-pronation elbow.
2.Sensory loss over lateral forearm.
3.Loss of biceps deep tendon reflex.
4.Atrophy of biceps and brachialis may occur.
Rehabilitation
1-Passive movement. ES then graduated active exercises.
2.Limb protection:
A- Sling
B- Avoid heavy lifting.
C-Avoid high velocity elbow extension.

10. 4-AXILLARY NERVE LESION:
Clinical assessment:
1.Weakness or paralysis of deltoid and teres minor. functional
weakness of shoulder flexion ,abduction ,lateral rotation .
2.Sensory loss over lateral aspect of shoulder
3.Normal deep reflexes.
4.Atrophy of deltoid.
5.May be shoulder pain.

11. REHABILITATIO
N:
1.Exercises:
1.Passive movement.
2.Scapular mobilization.
3.ES then graduated active exercise .
2.Pain management:
1.Sling.
2.Heat & TENS.
3.Limb protection:
1.Avoid heavy
2.Avoid bad positions

12. 5-RADIAL NERVE
LESIONS:
1.Axillary level:
Due to shoulder dislocation or from Axillary crutches pressure.
Clinical assessment:
1.Weakness or paralysis of triceps and all muscles supplied by radial
nerve. Functional loos of extension of elbow ,wrist and fingers
2.Sensory loss dorsal radial hand.
3.Loss of triceps and brachioradialis deep reflexes.
4- Drop wrist

13. 2.SPIRAL GROOVE LEVEL:
Duo to sleeping against hard surface & from slings.
Clinical assessment:
1.Weakness or paralysis of all muscles innervated by radial nerve(
including brachioradiails), except triceps, which leads to loss of
functional extension of wrist and hand only.
2.Same sensory loss.
3.Loss of brachioradialis deep reflex only.

14. 3.PROXIMAL FOREARM LESION
(POSTERIOR INTEROSSEUS BRANCH):
It is a pure motor nerve. It occurs due to lesion at the level of head of
radius.
Clinical assessment:
1.Weakness or paralysis in muscles distal to supinator and extensor
carpiradialis, This leads to loss of fingers extension and wrist
extension-ulnar deviation.
2.Normal sensation.
3. Normal deep reflexes.

15. 4-SUPERFICIAL SENSORY
BRANCH OF RADIAL NERVE
• Site of lesion in forearm at radial dorsal site
• Clinical assessment
• 1- Normal motor power
• 2-Sensory loss over dorsal radial hand
• 3-Normal deep reflexes

16. REHABILITATION OF RADIAL
NERVE LESION
• 1- Pain management :
• Heat and TENS
• 2-Motor relearning :Passive movement to affected joint
• ES then graduated active exercise to affected muscles
• 3-Senseory reeducation :
• 4- Limb protection:
• -cock up splint in mild extension
• -avoid heavy lifting
• Avoid wrist extension and supination

17. 6-MEDIAN NERVE LESIONS
• 1- upper arm lesion
• Clinical assessment
• 1-Weakness or paralysis in muscles supply by nerve including pronator
teres
• Loss of pronation , radial wrist flexion ,index flexion distal thumb
flexion and thumb opposition
• 2- sensory loss in thenar muscles
• 3-Atrophy of forearm and thenar muscles
• 4-Normal deep reflexes

18. 2-AT ELBOW LEVEL (PRONATOR
TERES SYNDROME)
• Clinical assessment:
• 1-Weakness or paralysis in muscles supply by nerve except pronator teres
• - Functional loss of radial wrist flexion ,index flexion and distal thumb
flexion and thump opposition
• Pronation is functionally intact but weak (no pronator quadratus)
• 2-Sensory loss in thenar muscles
• 3-Atrophy of forearm and thenar muscles
• 4-Normal deep reflexes
•

19. 3-ANTERIOR INTEROSSEUS NERVE LESION
• Clinical assessment
• 1-Weakness or paralysis in pronator quadratus ,FPL and FDP to
middle and index fingers
• Patient can not make zero by both thump and index
• 2- Normal sensation
• 3-Atrophy of distal anterior radial forearm forearm.
• Normal deep reflexes

20. 4-LESION OF MEDINA NERVE AT WRIST
(CARPAL TUNNEL SYNDROME)
• Clinical assessment :
• 1-Pain ,numbness ,and weakness in thumb index and middle fingers.
• pain radiate to elbow and shoulder
• Pain increase at sleeping ,driving and using hand
• 2-Weakness of thumb opposition.
• 3-Decrease or lost sensation in 3 and halve fingers
• 4-Atrophy of thenar muscles
• 5-Normal deep reflexes

21. REHABILITATION OF MEDIAN
NERVE LESION
• 1- Pain management:
• Deep cold LASER
• TENS
• US continuous
• Wrist splint in neutral position
• 2- Motor relearning:
• Passive movement to affected joint
• ES then graduated active exercise to affected muscles
• 3- Sensory relearning
• 4 -limb protection

22. 7-ULNAR NERVE LESION
• 1- Upper limb lesions
• Clinical assessment :
• 1- Weakness or paralysis of muscles supply by ulnar nerve
• Loss of ulnar wrist flexion, fingers add &abd and fingers flexion in little
and ring fingers and flex DIPJ and weak thumb adduction
• 2-Sensory loss in all ulnar nerve distribution
• 3- Normal deep reflexes
• 4-Atrophy of ulnar hand &ulnar forearm muscles
• 5-Mild claw in ulnar 2 fingers.

23. 2-AT ELBOW LEVEL WITHIN
CUBITAL TUNNEL
• Clinical assessment :
• 1-Weakness or paralysis of all muscles innervated by ulnar nerve except
flexors carpi ulnares.
• Functional loss of fingers add&abd ,thumb add and flexion of little fingers and
ring fingers at distal interphalangeal joints
• 2-Sensory loss in all ulnar nerve distribution
• 3- Normal deep reflexes
• 4-Atrophy of ulnar hand &ulnar forearm muscles
• 5-Mild claw in ulnar 2 fingers,

24. 3-AT WRIST LEVEL
• Between pisiform and hook of hamate
• clinical assessment :
• 1- Motor loss is only in ulnar innervated intrinsic hand muscles and
hypothenar muscles
• Loss of thumb add. And fingers add and abd .
• 2-Sensory loss
• 3-Atrophy of ulnar innervated intrinsic muscles

25. REHABILITATION OF ULNAR NERVE
INJURES
• 1- Pain management:
• Heat &TENS
• 2- Motor relearning:
• Passive movement to affected joint
• ES then graduated active exercise to affected muscles
• 3- Sensory reeducation
• 4 -Limb protection

26. 8-FEMORAL NERVE LESION
• Compressed at level of inguinal ligament
• Clinical assessment :
• 1-Weakness or paralysis of quadriceps and weak hip flexors
• -Functional loss of knee extension only
• 2-Sensory loss anteromedial aspect of thigh ,leg and foot
• 3-Decrease or lost knee jerk
• 4-Atrophy of quadriceps

27. REHABILITATION OF FEMORAL
NERVE LESION
• 1- Pain management:
• Heat &TENS
• Cane if there is pain during walking
• 2- Motor relearning:
• Passive movement to affected joint
• ES then graduated active exercise to affected muscles
• 3- Sensory relearning
• 4 -Limb protection

28. 9-SCIATIC NERVE LESION
• Clinical assessment :
• 1-Weakness or paralysis of hamstring &and all distal tibial
and peroneal nerve innervated muscles
• Functional loss of knee flexion and all ankle &toes
movement
• 2-sensory loss over the whole foot
• 3-lost knee jerk
• 4-Drop foot with high steppage gait

29. REHABILITATION OF SCIATIC
NERVE LESION
• 1- pain management:
• Heat &TENS
• Cane if there is pain during walking
• Leg elevation to increase venous return
• 2- Motor relearning:
• Passive movement to affected joint
• ES then graduated active exercise to affected muscles
• 3- Sensory reeducation
• 4 -Limb protection ankle foot orthosis
•

30. 10-COMMEN PERONEAL NERVE
LESION
• Lesion at fibular head level
• Clinical assessment :
• 1- Weakness or paralysis of toes extensors & ankle dorsiflex and
evertors
• Functional loss of ankle dorsiflexion and eversion withn toes extension
• 2-Sensory loss over dorsal foot
• 3-Normal ankle reflexes
• 4- High steppage gait

31. REHABILITATION OF SCIATIC
NERVE LESION
• 1- Pain managment:
• Heat &TENS
• 2-Motor relearning:
• Passive movement to affected joint
• ES then graduated active exercise to affected muscles
• 3- Sensory reeducation
• 4 -Limb protection ankle foot orthosis
• Avoid position that compress the nerve on fibular head
• -Sitting cross
• -Sleeping with legs externally rotated

32. 11-POSTIOR TIBIAL NERVE LESIONS
• 1-lesion at the knee level:
• Clinical assessment
• 1- Weakness or paralysis of calf muscles ,tibialis posterior and toes
flexors
• patient can not make planter flexion& inversion, and toes flexion
• 2-Sensory loss over planter and lateral foot
• 3-Loss of ankle deep reflexes
• 4-Atrophy of calf and intrinsic muscles except extensor digitorum
brevis

33. REHABILITATION OF POSTERIOR
TIBIAL NERVE LESION
• 1- Pain management:
• Heat &TENS
• 2-Motor relearning:
• Passive movement to affected joint
• ES then graduated active exercise to affected muscles
• 3- Sensory reeducation
• 4 -Limb protection
• -Cane if gait is painful
• Leg elevation if vascular return is problem
•

34. POSTERIOR TIBIAL NERVE AT
TARSAL TUNNEL
• Clinical assessment
• 1- Weakness of foot intrinsic muscles except extensor
digitorum brevis
• 2-Sensory loss over medial and or lateral planter surface
• 3-Normal ankle reflexes
• 4-Atrophy of intrinsic muscles except extensor digitorum
brevis

35. REHABILITATION OF
POSTERIOR TIBIAL NERVE
• 1- Pain management:
• Heat &TENS
• 2-Motor relearning:
• Passive movement to toes
• Mobilization of tarsal and metatarsal bones
• Strengthening exercise to affected muscles
• 3- Sensory reeducation : in desensitized areas
• 4 -Limb protection:
• -Avoid wearing shoes that compress medial aspect of foot and ankle