Median Nerve

Authors
Affiliations

Nate Yomogida, PT, DPT

Doctor of Physical Therapy

B.S. in Kinesiology

Chloë Kerstein, PT, DPT

Doctor of Physical Therapy

B.A. in Neuroscience

Transverse section of distal forearm1

Transverse section of distal forearm

Transverse cut of the Hand1

Transverse cut of the Hand

Muscles of the thumb1

Muscles of the thumb

Origin

C6-T1

Motor Branches

Direct Muscular branches of Median N. ()

Warning: No 'path' link found for variable 'ref-1st-hand-lumbrical' in YAML data.
Warning: No 'path' link found for variable 'ref-2nd-hand-lumbrical' in YAML data.
Warning: No 'path' link found for variable 'ref-3rd-hand-lumbrical' in YAML data.
Warning: No 'path' link found for variable 'ref-4th-hand-lumbrical' in YAML data.
Warning: No 'origin' link found for variable 'ref-1st-hand-lumbrical' in YAML data.
Warning: No 'origin' link found for variable 'ref-1st-hand-lumbrical' in YAML data.
Warning: No 'origin' link found for variable 'ref-2nd-hand-lumbrical' in YAML data.
Warning: No 'origin' link found for variable 'ref-2nd-hand-lumbrical' in YAML data.
Warning: No 'origin' link found for variable 'ref-3rd-hand-lumbrical' in YAML data.
Warning: No 'origin' link found for variable 'ref-3rd-hand-lumbrical' in YAML data.
Warning: No 'origin' link found for variable 'ref-4th-hand-lumbrical' in YAML data.
Warning: No 'origin' link found for variable 'ref-4th-hand-lumbrical' in YAML data.
Warning: No 'insertion' link found for variable 'ref-1st-hand-lumbrical' in YAML data.
Warning: No 'insertion' link found for variable 'ref-1st-hand-lumbrical' in YAML data.
Warning: No 'insertion' link found for variable 'ref-2nd-hand-lumbrical' in YAML data.
Warning: No 'insertion' link found for variable 'ref-2nd-hand-lumbrical' in YAML data.
Warning: No 'insertion' link found for variable 'ref-3rd-hand-lumbrical' in YAML data.
Warning: No 'insertion' link found for variable 'ref-3rd-hand-lumbrical' in YAML data.
Warning: No 'insertion' link found for variable 'ref-4th-hand-lumbrical' in YAML data.
Warning: No 'insertion' link found for variable 'ref-4th-hand-lumbrical' in YAML data.
Warning: No 'innervation' link found for variable 'ref-1st-hand-lumbrical' in YAML data.
Warning: No 'innervation' link found for variable 'ref-1st-hand-lumbrical' in YAML data.
Warning: No 'innervation' link found for variable 'ref-2nd-hand-lumbrical' in YAML data.
Warning: No 'innervation' link found for variable 'ref-2nd-hand-lumbrical' in YAML data.
Warning: No 'innervation' link found for variable 'ref-3rd-hand-lumbrical' in YAML data.
Warning: No 'innervation' link found for variable 'ref-3rd-hand-lumbrical' in YAML data.
Warning: No 'innervation' link found for variable 'ref-4th-hand-lumbrical' in YAML data.
Warning: No 'innervation' link found for variable 'ref-4th-hand-lumbrical' in YAML data.
Warning: No 'action' link found for variable 'ref-1st-hand-lumbrical' in YAML data.
Warning: No 'action' link found for variable 'ref-1st-hand-lumbrical' in YAML data.
Warning: No 'action' link found for variable 'ref-1st-hand-lumbrical' in YAML data.
Warning: No 'action' link found for variable 'ref-1st-hand-lumbrical' in YAML data.
Warning: No 'action' link found for variable 'ref-2nd-hand-lumbrical' in YAML data.
Warning: No 'action' link found for variable 'ref-2nd-hand-lumbrical' in YAML data.
Warning: No 'action' link found for variable 'ref-2nd-hand-lumbrical' in YAML data.
Warning: No 'action' link found for variable 'ref-2nd-hand-lumbrical' in YAML data.
Warning: No 'action' link found for variable 'ref-3rd-hand-lumbrical' in YAML data.
Warning: No 'action' link found for variable 'ref-3rd-hand-lumbrical' in YAML data.
Warning: No 'action' link found for variable 'ref-3rd-hand-lumbrical' in YAML data.
Warning: No 'action' link found for variable 'ref-3rd-hand-lumbrical' in YAML data.
Warning: No 'action' link found for variable 'ref-4th-hand-lumbrical' in YAML data.
Warning: No 'action' link found for variable 'ref-4th-hand-lumbrical' in YAML data.
Warning: No 'action' link found for variable 'ref-4th-hand-lumbrical' in YAML data.
Warning: No 'action' link found for variable 'ref-4th-hand-lumbrical' in YAML data.
Table 1: Median Nerve Muscle Innervations
Muscle Origin Insertion Innervation Action
1st Lumbrical (hand) Tendon of flexor digitorum profundus 2nd dorsal digital expansion Median n.
C8 - T1		 2nd digit: MCP Flexion, PIP & DIP Extension
2nd Lumbrical (hand) Tendon of flexor digitorum profundus 3rd dorsal digital expansion Median n.
C8 - T1		 3rd digit: MCP Flexion, PIP & DIP Extension
3rd Lumbrical (hand) Tendon of flexor digitorum profundus 4th dorsal digital expansion Median n.
C8 - T1		 4th digit: MCP Flexion, PIP & DIP Extension
4th Lumbrical (hand) Tendon of flexor digitorum profundus 5th dorsal digital expansion Median n.
C8 - T1		 5th digit: MCP Flexion, PIP & DIP Extension
Abductor digiti minimi (hand) hand_flexor_retinaculum Base of 1st proximal phalanx (radial sesamoid) Median n.
C8 - T1		 CMC: Abduction
Abductor pollicis brevis Scaphoid
Trapezium
Flexor retinaculum		 1st proximal phalanx via radial sesamoid Median n.
C8 - T1		 CMC: Abduction
Flexor carpi radialis Medial epicondyle Base of 2nd Metacarpal
(Sometimes base of 3rd Met)		 Median n.
C6 - C7		 Wrist: Flexion, Radial deviation
Flexor digitorum profundus Proximal 2/3 of Ulna
Interosseous_membrane		 Palmar surface of Distal phalanges 2-5 Median n. (digits 2-3)
Ulnar n. (digits 4-5)
C8 - T1		 Wrist: Flexion
MCP, PIP, & DIP 2-5: Flexion
Flexor digitorum superficialis Medial epicondyle
Coronoid process
Anterior proximal half of Radius		 Sides of middle phalanges 2-5 Median n.
C8 - T1		 Elbow: Weak flexion
Wrist: Flexion
2-5 MCP & PIP: Flexion, Flexion
Flexor pollicis brevis Flexor retinaculum
Capitate
Trapezium		 1st proximal phalanx via radial sesamoid Median n.
Ulnar n.
C8 - T1		 CMC: Flexion
Flexor pollicis longus Midanterior Radius
Adjacent Interosseous membrane		 Distal phalanx of thumb Median n.
C8 - T1		 Wrist: Flexion, Radial deviation
1st CMC, IP, MCP: Flexion
Opponens pollicis Trapezium 1st metacarpal (radial border) Median n.
C8 - T1		 CMC: Opposition
Palmaris longus Medial epicondyle Palmar aponeurosis Median n.
C6 - C7		 Elbow: Weak flexion
Wrist: Tightens aponeurosis
Pronator quadratus Distal 1/4 of anterior Ulna Distal 1/4 of anterior Radius Median n.
C8 - T1		 Elbow/Forearm: Pronation
Distal RUJ: Stabilization
Pronator teres Medial epicondyle
Coronoid process		 L:ateral radius distal to supinator Median n.
C6 - C7		 Elbow: Weak flexion, Pronation
Table 2: Indirect Median nerve innervations via Anterior Interosseous Nerve
Muscle Origin Insertion Innervation Action

Sensory Branches

  • Articular brs.: Capsules of the elbow and wrist joints
  • Palmar br. of median n. (thenar eminence)
  • Communicating br. to ulnar n. 
  • Common palmar digital nn. 
  • Proper palmar digital nn.

Pathway

  1. Branches off of the medial and lateral cords just distal to the coracoid process
  2. Enters the axilla into the anterior compartment
  3. In the medial brachium, the median nerve travels with the brachial artery along the medial intermuscular septum
  4. Crosses the elbow in the cubital fossa medial to the biceps tendon and brachial artery
  5. Dives between the heads of the pronator teres into the anterior compartment of the antebrachium
  6. Passes through the fibrous arch of flexor digitorum superficialis
  7. Gives off the Anterior Interosseous Nerve
  8. Dives deep to the flexor/pronator mass descending the antebrachium in the anterior compartment
  9. Runs along the anterior surface of the interosseus membrane
  10. Terminates in the anterior capsule of the carpals
  11. Median nerve continues down the antebrachium deep to flexor digitorum superficialis and superficial to flexor digitorum profundus
  12. Crosses the wrist at the carpal tunnel where it branches into the RECURRENT BRANCH and PALMER DIGITAL BRANCH of the median nerve.

Entrapment Sites

  1. Ligament of Struthers
  2. Pronator Teres Syndrome
  3. Anterior Interosseous Syndrome
  4. Carpal Tunnel Syndrome

Ligament of Struthers

Ligament of Struthers: present in 1% of population and is an alternate attachment site of the pronator teres (rather than the medial epicondyle). The ligament is found at the distal- medial humerus near the Arcade of Struthers -May include sensory and motor loss in a median nerve distribution. Muscles receiving motor innervation from both the median nerve and the anterior interosseous nerve will be affected as this entrapment is proximal to the any peripheral branching. -Can include vascular symptoms due to brachial artery passing under ligament along with nerve

Tinnel’s over the median nerve at the Cubital Fossa (here the nerve lies medial to the brachial artery and biceps Tendon)

Pronator Teres Syndrome

Pronator Teres Syndrome: Entrapment as it passes through the two heads of pronator teres

Same motor and sensory loss as described above Mechanical compression over the pronator teres muscle

Anterior Interosseous Syndrome

Anterior Interosseous Syndrome: Entrapment after the anterior interosseous nerve branches off of the median nerve

Clinical Presentation

  • Motor impairment in the pronator quadratus, medial 1⁄2 of FDP and flexor pollicis longus
  • No sensory loss

Testing

“Okay” Sign: when asked to make an “okay” symbol, a patient will demonstrate pad- to-pad approximation of the distal phalanx of the first and second digits rather than tip- to-tip contact (due to weak of the FDP & FPL)

Carpal Tunnel Syndrome

  • Entrapment within carpal tunnel
  • Very common

Palsy

Clinical Presentation

  • Sensory loss over the palmar surface of the hand in a median nerve distribution
  • Can have motor weakness of thenar muscles and 1⁄2 lumbricals

Evaluation

  • Tinel’s at carpal tunnel

Median Nerve Tensioning

  • ULTT1

  • ULTT2a

  • Patient in supine

  • Stand on the ipsilateral side, facing the patient

  • Bring the forearm into supination

  • Wrist and finger extension

  • Use your thigh to support and control the patient’s elbow

  • Use your other hand to pull the patient’s shoulder into depression.

Entrapment

Reading list
  • Median nerve p372

Examination

  • Wrist Flexion and Median Nerve Compression
  • Median Nerve Compression Test/Pressure Provocation Test.
    • The clinician sits opposite to the patient and holds the patient’s hand with the clinician’s thumbs directly over the course of the median nerve as it passes under the flexor retinaculum between the FCR and the palmaris longus. The clinician places gentle sustained pressure with the thumbs for 15 seconds to 2 minutes. The clinician then removes the pressure and questions the patient on the relief of symptoms, which may take a few minutes. A positive test is the reproduction of pain, paresthesia, or numbness distal to the site of compression during the compression in the distribution of the median nerve.
  • Phalen’s Test
  • Reverse Phalen’s
  • Tinel’s Test

Ape hand

Wasting of thenar eminence due to median n. palsy.

Median Claw Hand

Strain Counterstrain

Treatment

References

1.
Gray H. Anatomy of the Human Body. 20th ed. (Lewis WH, ed.). Lea & Febiger; 1918. https://www.bartleby.com/107/
2.
Gilroy AM, MacPherson BR, Wikenheiser JC, Voll MM, Wesker K, Schünke M, eds. Atlas of Anatomy. 4th ed. Thieme; 2020.
3.
Kolar P. Clinical Rehabilitation. 1st ed. Dynamic Neurological Stabilization; 2014.
4.
Dutton M. Dutton’s Orthopaedic Examination, Evaluation, and Intervention. 5th ed. McGraw Hill Education; 2020.

Citation

For attribution, please cite this work as: