#16 - It’s Not Carpal Tunnel: Now What?! With Dr. Spencer Lindholm, Part 1

Factor, spelled F-A-K-T-R, stands for Functional and Kinetic Treatment with Rehabilitation. Over the past decade, this unique approach to treating pain and dysfunction has been utilized by healthcare providers on 6 continents, serving as a framework that guides clinical decision-making in patient visits around the globe on a daily basis. With this podcast, our goal is simple: to bring the best and brightest in clinical education to the forefront and empower practitioners with cutting-edge, evidence-based content that improves patient outcomes and inspires healthcare providers to continually evolve their approach to treatment. In each episode, we will feature a training or interview with some of the top minds in healthcare in a short format that is easy to digest with actionable information that you can implement into practice right away. Let's get started. Hi guys, welcome to a new episode of The Factor Podcast. I'm your host, Jessica Riddle. If this is your first time tuning in, welcome and thanks for listening. In today's episode, we kick off a new training with Dr. Spencer Lindholm titled, It's Not Carpal Tunnel, So Now What? Dr. Spencer Lindholm is originally from Minnesota, where he excelled as a 2-sport athlete, playing hockey and running track. He competed in college track while completing his undergraduate studies at UW-Eau Claire and played hockey for the Palmer College of Chiropractic team while earning his doctorate. Dr. Lindholm completed his chiropractic residency at a rural hospital in northern Minnesota, where he was able to practice in an interdisciplinary setting, treating complex conditions and cases. After graduating from Palmer, Dr. Lindholm then completed numerous certifications and continuing ed courses on the evaluation and treatment of soft tissue and sports-related injuries. He now utilizes this training and his experience as an athlete to help active individuals get back to activity and focus on performance. Dr. Lindholm currently practices in Denver, Colorado, and is the owner of Kinetic Sports Medicine and Rehab. He has worked extensively with dozens of professional athletes from various sports, including many of the Denver Broncos. Now, as we mentioned, today's topic is carpal tunnel. And carpal tunnel is the most common peripheral nerve entrapment diagnosed, accounting for 90%— yes, you heard that correctly— 90% of all peripheral nerve entrapments that are diagnosed. But is that because the prevalence of this condition is really so profound? Or are clinicians simply not well-versed on other similar conditions that present like carpal tunnel syndrome? In today's episode, Dr. Spencer Lindholm, one of our co-developers of the Factor PNE course, discusses why CTS gets diagnosed so frequently and why many carpal tunnel surgeries tend to fail. Topics discussed include the importance of a thorough neuromusculoskeletal exam, proper manifestations of peripheral nerve entrapments, and a review of the median nerve anatomy. Dr. Lindholm will then walk us through a real-world case study that presented in his office, taking us step by step through his assessments, differential, and final diagnosis in part 1 of this 2-part training. With all of that being said, guys, let's dive into our training. I'd like to introduce Dr. Spencer Lindholm, the co-developer of our Factor PNE, which stands for Peripheral Nerve Entrapment course that is now fully online. And I will give you the floor, Dr. Lindholm.

All right. Yeah. Thank you for the introduction. Hi everyone. Thanks for taking your time to join us today for a fun little webinar about carpal tunnel syndrome. So we are going to talk about kind of the overdiagnosis dilemma that we see with median nerve entrapments. And how does that relate to the multiple other peripheral nerve entrapments and other conditions that can overlap with that? And why does CTS get diagnosed so frequently? And what are those reasons why surgeries tend to fail on those? And we're gonna go through a lot of anatomy review to kind of show you all the intricacies of what goes into diagnosing peripheral nerve entrapments and go through a little case study too of a case that the surgeon thought was CTS that actually wasn't. And how did I get to a different diagnosis on that? So. A little bit about me. I am a 2016 graduate from Palmer Davenport. I did my final chiropractic residency up at Big Fork Valley Hospital with Dr. Mike Olson. And Dr. Olson is actually the co-developer of the Factor PNE course along with myself. So him and I have spent extensive time researching all these peripheral nerve entrapments and put together what we think is a really great course with information that's just not easy to find elsewhere, along with how can you use those factor treatment principles and protocols to address a lot of these peripheral nerve entrapments. Currently, I am out in Denver, so I am the owner and full-time clinician for my own practice, Kinetic Sports Medicine and Rehab. So I tend to work a lot with more sports injuries, but just a lot of active, everyday, healthy individuals. And then with the sports and the Olympic Training Center and everything out here, I work with a lot of higher-level athletes too— professional, Olympic, collegiate, and just amateur athletes. And so that's really where my passion's at, is getting people moving and keeping them moving and doing things that really contribute to a That's the thing where you see a lot of peripheral nerve entrapments that mask themselves as sports injuries and other things that it's really great to have that diagnostic knowledge to be able to differentiate those, but also know how you're going to vary your treatment based on those. So when we're talking about peripheral nerve entrapments, the main thing that we really use as far as a treatment protocol is Factor. Hopefully been introduced at some point or had the chance to take a course, but FACTOR stands for Functional and Kinetic Treatment with Rehab. So this is more of a methodology of patient progression. So it's not one specific technique. It's emphasizing the use of many techniques. So we have lots of different things we can do from compression flossing to corrective exercises and using instrument-assisted and manual therapy and trying to find what's the best technique in that scenario or multiple techniques to accomplish that goal and have really effective treatment. When we're looking at using these FACTOR principles and protocols, really we're guiding our treatments based off of pain, other symptoms that can be present like peripheral nerve entrapments or functional deficits. And then really we want to get movement into the system. That's what the human body's meant to do is move. And so we use movement a lot during those treatments as well. Along with the FACTOR principles and protocols, many things that those can help treat, which we'll review here, peripheral nerve entrapments are another thing that it's been addressed within the FACTOR system for a while. But I don't think as many people have the diagnosis knowledge maybe, or the recognition knowledge to take these factor principles and apply them to these peripheral nerve entrapments. And so it's honestly my go-to as far as treatment when I'm looking at peripheral nerve entrapments is using these factor principles and adding in some other helpful things like neurodynamics to really help free up that peripheral nerve entrapment. So the 5-factor concepts, right? If somebody is having pain just on palpation with no movement, then we're going to treat them in that static position. Then we want to incorporate movement. Which is non-resistance or weight-based. And then we want to add some resistance into that system and treat that painful or provoking movement through a resisted exercise or movement. And then functional. Is there something specific that causes that pain? Is it, is it somebody that has wrist pain while they're typing at their keyboard? Can you recreate that function that they're performing and then treat those symptoms or that area within that functional realm? And then proprioceptive would be that last one, that final stage of this is where we want to get you through kind of the progressions that we're going through. With the FACTOR principles of treatment. So some of the clinical indications, there's lots of things we can use these FACTOR principles for treating patients. And I would say this list is nowhere near inclusive enough too. We could include a lot more things on here, but tendinopathies, bursitis, any myofascial issues tend to respond very well. We can use it for edema reduction, ligament injuries. With me working with athletes, I use it for DOMS, delayed onset muscle soreness, all the time using compression flossing and instrument-assisted and having people go through. If they did 300 air squats a couple days ago and they're still sore from that is I'm going to make them do some air squats with compression flossing and instrument assisted and see if we can really speed up that recovery time with that delayed onset muscle soreness. And the area that we're really going to focus on today is nerve entrapment syndromes. So peripheral nerve entrapments and some of the things that we do cover in the course would be nerve root impingement coming from the spine. But a lot of what we're focusing on is a lot of those distal entrapments. So the big ones that people tend to be familiar with, even your patients, carpal tunnel syndrome, sciatica. Those are the big ones people know, but the knowledge tends to dwindle after we get past the kind of hot-button peripheral nerve syndromes. And that's where having the knowledge of knowing where they're located, what the symptoms are, is probably the hardest part because from there, the treatments don't vary a whole lot and you just need to be able to get that correct diagnosis. And then you already have a lot of the tools that you need to really address that. So peripheral nerve entrapments, remember those nerves exit the spine and then they course throughout the body. And so they've got to go through a lot of different tissues and wind through a lot of different structures, and they are susceptible to getting compressed, or we'll say kind of bound up anywhere along that path that they flow. And so they can get chronically compressed. And this is a lot of what I see in my practice is the repetitive motion type injuries to those nerves where we're doing the same thing over and over and over again. And at some point, there's something that either is causing compression, edema in the area, or creating neural tension. And so we've got to help free up that chronically compressed nerve. And then we can have acutely entrapped Peripheral nerve entrapments, which are going to be those more, those focal injuries, right? A football player that takes a hit on the side of the knee and now he's got a common peroneal nerve entrapment at the fibularis head because he got a helmet straight there. So those are the more kind of obvious ones, at least from what I find in practice, to diagnose because you got your patient telling you, yeah, I was hit here and now I'm feeling this, and your anatomy, you kind of know where you're going. But those chronically compressed ones are the ones that you're going to see more often. And that's a lot of what we know with carpal tunnel syndrome too, is that repetitive motion is what's leading to a lot of that. So when we're looking at the nerves as far as a diagnosis standpoint or trying to figure out which nerve is involved and how bad is it, like how bad is that nerve actually affected, we want to look at what does the nerve do. So some nerves are sensory only, some are motor only, and then some have combined, right? So they have reflexivity, so they can help a muscle move, they can transmit sensation afferently or efferently, and then when they're entrapped in the body, we can have altered sensation, lack of sensation, sometimes hyper hyperesthesia. And then you can also have weakness, which oftentimes is telling us that there's maybe a little more chronic, a little more acute focal compression happening there. But those are really those big factors that we want to look at as far as addressing is, are they having some type of neurologic symptom? And that should tell you that you're most likely not dealing with just a simple tendon muscle joint problem. It could be in conjunction with that, but you need to be looking at a nerve when you're getting these symptoms happening. So with your traditional factor course, if you've gone through that, how do we know what to treat, right? Is we're looking at the site of pain or the complaint. Obviously that's why that person walks through your door. They're in pain typically, and they want to be out of pain. They want your help resolving that loss of range of motion, right? So if we're not moving right, it's a good chance that at some point we're going to have pain either at the site of pain or distally. And so we want to address that loss of range of motion both from an immediate treatment standpoint, but from a functional standpoint of long-term, of making sure that this doesn't come back or that we're not just banging our heads against the wall treating something. That is missing that, that other part to really address why they're having this pain. And then loss of function, right? Which range of motion could be tied into that. But if they're having weakness due to pain or weakness due to nerve impingement in some cases. And with the Factor P&E course, we're still looking at those same things, but now you need to have a really thorough neuromusculoskeletal exam. So you gotta be able to assess, do they have loss of strength? Is there altered or decreased reflexes? Is there loss of sensation or altered sensation? And then can we reproduce those symptoms? If you can produce the symptoms by stretching, compressing, and activating in that area, there's a really, really good chance that you're on the right spot. And so we'll talk about that a little bit more, but that's one of our main tools that we use from a diagnostic standpoint is stretch, compress, activate. If we get that muscle stretched out that that nerve's coursing through, we add some compression with our hand over that area, and then we activate and make that muscle contract. We should be able to reproduce those symptoms if that person is simply having those symptoms at rest without doing those provoking tests or movements on them. And then the other thing, which is one of our bigger things we're going to look at today, is you got to look at the course of the entire nerve. So median nerve, for example, we can have entrapments at 8 different locations in the forearm alone. Most people can only name carpal tunnel syndrome. Some people can name 1 or 2 more. And so you got to know your anatomy once again to know the course of that nerve and where it's going so that you can look and check those entrapment sites. And if you're not looking at the multiple entrapment sites for a nerve, but you know that that nerve's involved, you're maybe missing a piece of the puzzle. At the worst, it's going to confirm your diagnosis by telling you that those other areas aren't the problem, but you'll be surprised how often you go check some other areas of entrapment and you get a positive finding in those areas when you thought it was something else. So peripheral nerve entrapment symptoms, right? So altered sensation, muscular weakness, atrophy. A big one is that you do oftentimes have local pain at the site of entrapment. So sciatica, oftentimes they're going to have local pain within the glute. Carpal tunnel syndrome, pronator teres syndrome, quadrilateral space syndrome, they're all very characterized by where that nerve's getting entrapped. There's also a tight muscle there. There's a whole chemical response as far as inflammation around that nerve. And so you should expect them to have some type of local pain at that site of entrapment. And then the nerve should not, or is rarely involved in anything proximal to that site of entrapment, right? So we should have some type of distribution of altered sensation or pain distal to that site of entrapment. And those are, again, almost all neurologic symptoms other than local pain. And you gotta really have a good NMS exam and look at these different neurologic symptoms to know if it's even a nerve involved. And then it can really help you differentiate which nerve is involved and where is that involved.

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He spends about 6 to 8 hours a day on the computer, does lots of typing, he's on his phone, IT professional, former bodybuilding competitor, also a yoga instructor, so surprisingly mobile. Find that often, that throws a little kink at you when you expect somebody that's very big and muscular to be very tight and wound up, but very different presentation as far as when you're looking at nerve entrapments with muscles. He was actually very, very limber when it comes to stretching and muscular work. And then he, although former professional bodybuilder, lifting weights still recreationally about 5 times a week. So he had originally presented to his primary care physician, which is oftentimes with neurologic symptoms, people tend to find themselves at their PCP more often than not. And then primary care physician referred him to a hand specialist. So the hand surgeon was the one who originally examined him and diagnosed him with carpal tunnel syndrome. This was about 2 months after the symptoms had first started that he Wound up at the hand surgeon, and the hand surgeon prescribed night splints and then had him go to PT. So the patient was prescribed for 12 visits of PT, and they gave him 2 months to get those 12 PT visits done and then had him wear the night splints. And he made it about 2/3 of the way to that treatment plan, and he was not experiencing a whole lot of improvement. So they decided to do a corticosteroid injection. He did it bilaterally, even though the right side was It's kind of progressing and getting a little bit worse, but relief of numbness and tingling. So the patient did have some relief, but it, it wasn't anything significant like you would expect with a corticosteroid injection. So kind of a little murky as far as the results there. But he definitely could still provoke those symptoms. So if he spent a lot of time on the computer, in the weight room, is he could still exacerbate those symptoms. It may have just taken a little bit longer for that to build up. So there was a nerve conduction study done. So they did an NCV and The hand surgeon was the one who ordered it, and I believe that they performed that in office, but they had an increased latency of the nerves, meaning that the signal was traveling slower through the median nerve distally is where they examined that. So they had some positive signs that median nerve was not transmitting at the same speed that it normally does, which again kind of gives you a point toward carpal tunnel syndrome. So after about 5 months symptom duration, he just wasn't experiencing a lot of improvement and he was starting to get a little bit of weakness in the right hand that was worrying him. And so met with the surgeon again. They did a second round of corticosteroid injections, even though the first round wasn't what I would say terribly successful. And then he got about 4 weeks again of just kind of moderate relief that he could still provoke things with the activities. And then the surgeon recommended surgery. He wanted to start him with the right hand because that was the more progressive one and then consider the left hand at a later date. And I think really that was, hey, let's take care of the problem child and then if this works, we'll go for the left one too. So the patient wound up in my office after what this would have been about 4 weeks or so, not long after he'd met with the surgeon. And he was at about 6 months total symptom duration at this point. Really, he wanted to avoid surgery. And so this is kind of an example of how you can have a really broad spectrum of being able to treat a lot of things, but then having specialties. And so for me, sports injury, but peripheral nerve entrapments, the area I'm in, I've been in for about 4 to 5 years, and I've treated enough and helped resolve enough of them that those are kind of those You're a miracle worker responses from patients because a lot of other providers do get stumped. And to patients, nerve entrapments are not fun. They're worrisome if you're having numbness and tingling in your hand. That's a pretty significant symptom and it tends to alter your activities of daily living and function. And so this patient was actually referred to me by another patient that I had helped resolve an ilioinguinal nerve entrapment going through the psoas about 2 years prior. So kind of random that he wound up in my office, but first thing he said was his goal was to avoid surgery. And so I wanted to see Hey, is this the right diagnosis? And if not, can I switch up and do anything different from what the PT did? So on the initial visit, they were still having numbness. Initial presentation. So the patient showed up to my office, still having bilateral numbness and tingling in those first 3.5 digits, and then in the thenar eminence as well. Weakness with right-hand grip strength. So we used a dynamometer compared to the left side, which I would say in this case, we don't have a great normal to look at. And with him being a stronger individual, We demonstrated right-hand weakness compared to left, but I suspect there was a little bit on both sides. Some discomfort and tightness in the anterior forearms, right? So through the whole flexor compartment, just some kind of broad palpation. Everything was pretty tender through there, and especially a couple different points. The symptoms were still getting provoked by computer and phone use, and then really being in the weight room too. And there's very specific exercises that we discussed that were kind of provoking this on days that he noticed it. He would get paresthesia at night. This is a pretty classic presentation for carpal tunnel syndrome. And I'll say, we'll go into it in a bit, but most of the other median nerve entrapments, that's not a big one that we see. But he was getting infrequent, so not every night. And then some nights it would be there for just a short period of time. Other nights he would have it all night and sometimes even multiple nights in a row. So very just kind of off and on, off and on. The only couple things that he had found that helped, stretching his wrist flexors, and then he was taking ibuprofen daily, multiple times a day, and he, and he still was. He didn't find that the night splints helped. At times he felt that they actually made them worse. And then the corticosteroid injections, moderate relief. And so that did provide some benefit, but nothing really significant in that sense. So initial examination, like I said, very muscular, well-developed. So he's got some massive forearms on him like Popeye. And he noted that he had previously used anabolic steroids as a bodybuilder, and he currently is on testosterone replacement therapy. So other factors that you want to take into account, right, is do a nice thorough history as well as a review of symptoms just to make sure that there aren't any factors you need to take into account. Because those are a couple things I was looking at initially with him, and I wanted to check the research and see if there was anything that correlated on that end. Otherwise, health history and family history pretty clean, nothing as far as neurologic disorders go. One of the things you want to rule out with any nerve entrapment, right, is, is it coming from the spine? And so No history of any C-spine issues. We went through examination and all the ortho tests were negative for any disc or nerve root issues. He had full range of motion, moving great, passed the whole top-tier SFMA screen. And then we found a couple things in the shoulder and thoracic spine that I thought from a functional perspective we need to look at, but nothing glaring that I would say, okay, we have to address this for peripheral nerve entrapment's sake. But again, always address all those things that could be leading to this. Now the obvious stuff, right? Wrist and elbow extension range of motion was decreased bilaterally. We could barely get his elbows to full extension, and even then they were just wound up and wanting to rebound out of there based on that muscular tension. And that was unchanged for active or passive, so both sides were pretty equal on that as well. Lots of tenderness to palpation, and then quite a bit of hypertonicity and even spasming within the entire forearm, all the flexor muscles, that whole compartment, and then as well as the pronator teres muscle bilaterally. And there's a little more ropiness and hypertonicity Tonicity on that right side, as well as some edema in those areas. So a little bit of palpable edema, which kind of throws up some flags for you, hopefully. As far as sensory goes, so the left side was he could feel a little bit more. He had a little more of that sensory intact. So sharp touch felt just fine. Light touch was diminished on the left side. So in the lateral three and a half digits, right? So thumb, index, middle finger, and half of the ring finger, as well as the thenar eminence. And then the right hand diminished sharp touch in those same areas, and then light touch not present at all. Couldn't even feel that I was doing light touch. So positive pinch grip test, positive Tinel's at pronator teres, positive resisted pronation test, and positive median nerve compression test at pronator teres, which is just one of the tests that we use within the peripheral nerve entrapment course. That's the stretch, compress, and activate. And then a couple of notable negatives, right, is obviously I checked out carpal tunnel syndrome and Tinel's at the transverse carpal ligament was negative. And then phalanx and reverse phalanx, neither of those provoke symptoms even with a full minute of compression there. Very, very mildly on the right side, and that was after 45 seconds of compression. So we called that a negative on both sides there. And then when we did some deeper palpation over the pronator teres, extremely focal pain to the point of almost jumping away and really a burning sensation, almost like a hot poker is how the patient would describe it underneath your thumb. And then he would feel increased paresthesia or numbness and tingling throughout the distribution of that median nerve going down the arm. All right, so a little median nerve anatomy review because we're going to kind of focus in on, well, what— where could this median nerve entrapment be coming from? So if you remember, median nerve comes from C5-C7 lateral cord and C8-T1 medial cord. So it arises that inferior margin of the teres major muscle in the back of the shoulder, and then it courses down through the biceps brachii and the brachioradialis It goes through that cubital fossa and it's medial to that brachial artery, and then it comes out between the 2 heads of the pronator teres. It travels between the flexor digitorum superficialis and the profundus down the arm, and then it pops up about 5 centimeters right above the flexor retinaculum, and then that's where it enters the carpal tunnel. And the other structures within that carpal tunnel, right, the main ones that we're looking at as far as the tendinous involvement is flexor digitorum superficialis, profundus, and then that flexor pollicis longus. So median nerve supplies the muscles for the front of the forearm and then the thenar eminence as well, provides sensation to the palmar side of the index, thumb, middle finger, and half of the ring finger. So there's about 8 potential median nerve entrapment sites between the elbow and the wrist alone. There's not all of them listed in this description, but I don't know how many people reading through that description look at that and go, oh yeah, I see 1, 2, 3, 4, 5. Yeah, we could have Quite a few spots there that could be entrapped. It really is anywhere that that nerve is coursing through any connective tissue or muscle is where we're going to find most of those entrapment sites, especially when we're looking through the forearms here. So looking at differential diagnosis based off that initial examination, the patient's history, as well as their response to previous treatment. So we could look at cervical spine, right? C5, C6, maybe C6, C7, C7, T1. Maybe we're looking at another neurologic disorder. So we're looking at is this polyneuropathy possibly presenting or? Kind of masquerading as carpal tunnel syndrome, MS, syringomyelia, double crush syndrome. So lots of options there, but honing in on peripheral nerve entrapments, it looks like we really have a median nerve involvement. So could that be carpal tunnel syndrome happening at the wrist, pronator teres syndrome happening at that pronator teres muscle? Could it be ligamentous struthers, flexor digitorum superficialis, Ganser muscle, which is often kind of foreign to a lot of people? Or bicipital aponeurosis, and there's even a few more there. So lots of things that we need to consider, and most people's differential diagnosis list might be a little bit shorter than this, but again, anatomy knowledge and condition knowledge can, can take you to a broad spectrum. And then it's not that I'm seriously considering every single one of these as a big potential factor there, right? But you need to consider them. And so you need to think, okay, what is polyneuropathy? What are the symptoms that causes? Could that affect this median nerve? And does it explain all the symptoms that are going on? Same thing, MS. I'm looking at just C6, C7. You need to at least explore from, we'll say, a mental standpoint. What are the symptoms associated with that? What's my patient dealing with? And does this match up? And maybe you still keep that on your differential diagnosis list, but it's a little lower down the list. And so you kind of start to build that most likely to least likely and really include all those considerations because during your examination, you're likely going to address them to one degree or another. So as we're working through a differential diagnosis, what were some of the main findings that we found, right? So spasm, edema, and acute tenderness at that pronator teres muscle. Wouldn't expect that with carpal tunnel syndrome. Several positive nerve entrapment tests at that pronator teres. And then we had multiple negative carpal tunnel syndrome tests. That right there should be a giant flag. And we'll talk about what the research says about that. But if you are having negative carpal tunnel syndrome tests, Unless there's some type of error on the clinician or diagnostician's part with those tests, there's a good chance it's not carpal tunnel syndrome or that it's extremely mild. So this patient had a previous nerve conduction study. It, I'll say, was inconclusive for carpal tunnel syndrome. But if you look at only the 2 main findings that were presented, which was decreased distal motor and sensory, the hand surgeon kind of decided to only do part of a nerve conduction study. So when I looked at the results, he had only done the distal segments. It's really hard to differentiate any of the peripheral nerve entrapments that are further up the forearm if you're only looking in the hand. And so we'll talk about that a bit more, but you go into a diagnostic, like a nerve conduction study, and you decide that you're only going to look at one component of that, you're kind of going into that with tunnel vision, right? You're saying, well, this is what I think it is, and you're going into it with maybe a little bit of confirmatory bias at that point. You got to do a complete examination, and the research really says that, especially with those nerve conduction studies, the findings are relatively conclusive in the sense of they should show carpal tunnel syndrome and they should show no nerve conduction loss in other areas along the course of that nerve. You got to do a complete study there, and that was kind of a red flag that went up for me. The patient said in the initial examination, so this is more of a side note on the subject, findings, but that the surgeon had only done a brief and light palpation of the forearms and said, oh, you've got some tightness in the forearms. This is contributing to your carpal tunnel syndrome. And that was about it. Other than that, there was not a whole lot of palpation anywhere in the forearms, only from the wrist down was performed at any subsequent visits as well. So the positive ortho tests for carpal tunnel syndrome that were reported during that examination, I'm not sure that hand surgeon likely, I would hope so, did have positive orthopedic tests Sometimes we get mimicking or overlapping. If we're having median nerve entrapment at pronator teres, it's not too far-fetched to say, well, yeah, I could see if we compress down at the carpal tunnel syndrome distally that we might reproduce some of those symptoms as well. So the patient also failed carpal tunnel syndrome non-surgical interventions. Not that I think night splints are the be-all end-all, and I don't know the exact protocols the physical therapist was using, but we would have expected some type of improvement there if we were on that right diagnosis. When I stretch compressed and activated, so our kind of our main nerve compression tests that we do, or nerve entrapment tests that we do, I got a big positive there right over those pronator teres muscles. And as I checked the median nerve throughout the rest of that forearm, there was really nothing that kind of screamed at you like that pronator teres when the patient jumps off the table and you feel that edema there. So I'm really starting to think, okay, maybe we don't have carpal tunnel syndrome, which I was a little skeptical of. At least from the results I've had from sending those out, that tends to be a little more conclusive or kind of clear-cut. But so there's other tests you can do too, right? You don't have to just rely on your physical examination or another provider's EMG and CV like that.

That's all for today's episode. Be sure to tune in for episode 17, where Dr. Lindholm reveals his process for arriving at his final diagnosis for the case study presented and walks us step by step through his treatment plan. In this tactical portion of the training in Part 2, we will discuss how to differentiate between multiple entrapment sites of the same nerve and how to progress with active treatment and rehabilitation. Dr. Lindholm will then walk us through what the literature says regarding the misdiagnosis of carpal tunnel syndrome and which other similar conditions are most commonly mistaken. You won't want to miss it. Episode 17 drops in 2 weeks, or 1 week for our Patreon subscribers. You can subscribe to The Factor Podcast on Apple, Spotify, iHeartRadio, or the podcast app that works best for you. Give us a 5-star rating to help us grow the show. Every little bit helps. And last but certainly not least, please be sure to visit the show notes for a link to download the PDF of today's full presentation, as well as more information about our Factor P&E course, That is now fully online with Drs. Lindholm and Olson. We'll see you next time. Hey guys, if you like what you heard today, I encourage you to visit our website at factor-store.com. That's spelled F-A-K-T-R-store.com to find out more information about all that we have to offer. variety of online offerings as well as our hands-on Factor Rehab System course scheduled in cities around the globe. Be sure to also check out our event calendar and bookmark any of these upcoming live webinar dates coming up in the near future so you can join us live. And of course, the biggest compliment we can receive is for you to help us spread the word to your friends, colleagues, and classmates. You'll find all the important links as well as info about our sponsors in the show notes, so be sure to check those out.