As a certified hand therapist, my approach to managing peripheral nerve compressions involves meticulously evaluating the entire upper extremity, emphasizing the interconnectedness of the nervous system. The prevalence of double and triple crush phenomena underscores the need for such an approach. These syndromes occur when nerves are compressed at multiple levels along their pathway, resulting in amplified symptoms and challenges in recovery.Many adults spend approximately 1,920 hours typing on a keyboard each working year (calculated as 8 hours per day, 5 days a week, for 48 weeks, accounting for a standard 2-week vacation). Yet, how many of these individuals are ever taught essential upper-extremity maintenance skills to prevent and address conditions like carpal tunnel syndrome—a condition that many of my patients mistakenly assume is an unavoidable consequence of their work?
The Interconnected Nature of Nerve Compression
As described by Upton and McComas, the double crush syndrome posits that a nerve compressed at one site is more vulnerable to additional compressions along its pathway. This vulnerability arises from impaired axoplasmic transport and changes in ion channels, leading to nerve dysfunction. Research highlights that patients with carpal tunnel syndrome (CTS) often have concurrent compressions, such as at the lacertus fibrosus or the cubital tunnel, which may otherwise go undiagnosed (prevalence of double an…).
Peripheral nerve compressions, particularly those in distal regions like the hand and wrist, mirror the pathway of electrical impulses through a circuit with the compression sites acting like resistors that modulate the flow of current.
The Importance of Holistic Examination
The therapeutic process begins with a thorough history. Patients presenting with seemingly isolated neck or shoulder pain may have nerve compressions further along the upper extremity. This mindset has guided my successful treatment of thoracic outlet syndrome; I zoom out to hone in. For example, although considered rare, proximal compressions in the forearm can manifest as persistent symptoms that are resistant to traditional neck or shoulder treatments. This pattern calls for broader diagnostic strategies, incorporating physical examinations and provocative testing tailored to identify subtle nerve entrapments. The underdiagnosis of these conditions, as highlighted in clinical studies, delays proper treatment and may lead to chronic discomfort(prevalence of double an…).
It is not uncommon for patients to undergo multiple tunnel decompression surgeries without a detailed assessment of surrounding compression sites. This oversight is partly due to the limitations of electrodiagnostic testing (EMG), which cannot conclusively capture the multifocal nature of double and triple crush phenomena. The reliance on EMG alone risks missing the broader picture, leading to inadequate treatment and recurrence of symptoms.
Evidence-Based Assessment and Management
Recent studies have demonstrated the high prevalence of double crush syndromes among patients undergoing surgical decompressions. For example, compressions at both the carpal tunnel and lacertus fibrosus were found in 78% of median neuropathy cases(prevalence of double an…). These findings stress the importance of comprehensive assessment protocols that integrate physical exams, imaging, and, when necessary, surgical evaluations.
My practice involves:
- Integrating tests such as Tinel’s sign.
- Soft tissue palpation.
- Taping to localize compression sites.
The ultimate goal is to address all levels of compression, minimizing the likelihood of recurrence or revision surgeries.
Implications for Clinical Practice
The double and triple crush phenomena provide a framework for understanding the complexity of nerve compression syndromes. By considering the entire upper extremity in diagnostic and therapeutic processes, clinicians can avoid the pitfalls of localized treatment. Dr. Elisabeth Hagert shared a manual found invaluable in targeting my manual therapy and taping strategies and is pivotal in preventing chronic conditions that arise from missed diagnoses. Dr. Donald Lalonde has highlighted that proximal median nerve compression can coexist with carpal tunnel syndrome. He recommends that if a patient has symptoms after carpal tunnel release, the hand should be examined for lacertus syndrome (lacertus syndrome…)
This holistic perspective reinforces the need for collaboration across diagnostic scopes in their practices. The interconnected nature of nerve pathways demands nothing less.