A patient reports being unable to drive due to difficulty reaching forward to grasp the steering wheel secondary to weakness, though they deny the presence of pain. Which of the following conditions would MOST likely be associated with this type of activity limitation?

1. Rotator cuff impingement
2. Peripheral nerve entrapment
3. Adhesive capsulitis
4. Cervical facet impingement

Welcome back to the Scorebuilders’ Question and Answer Podcast! This podcast provides members of the Scorebuilders’ team with the opportunity to explore challenging multiple-choice examination questions with students actively preparing for the licensing examination. My name is Scott Giles and I will be your host for today’s journey.

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A patient reports being unable to drive due to difficulty reaching forward to grasp the steering wheel secondary to weakness, though they deny the presence of pain. Which of the following conditions would MOST likely be associated with this type of activity limitation?

1. Rotator cuff impingement
2. Peripheral nerve entrapment
3. Adhesive capsulitis
4. Cervical facet impingement

This question has a very different feel to it. Interesting! Answering this question correctly requires a student to be familiar with the clinical presentation of each of the four conditions or options.

The million dollar question here is:
Which condition would most likely result in an individual being unable to drive due to difficulty reaching forward to grasp the steering wheel secondary to weakness, without the presence of pain?

The individual’s difficulty grasping the steering wheel is clearly more related to weakness than lack of range of motion. In addition, there is no indication that the activity is painful. These two pieces of information should be weighed heavily when attempting to identify the best option.

Let’s explore each of the options.

Option 1 - Rotator cuff impingement
Rotator cuff impingement is caused by the humeral head and the associated rotator cuff attachments migrating proximally and becoming impinged on the undersurface of the acromion and the coracoacromial ligament. A painful arc of motion (i.e., 70-120 degrees abduction) and pain with overhead activities are common signs and symptoms associated with impingement syndrome.

I feel this is a tempting option. However, difficulty reaching for the steering wheel would be more likely due to pain rather than weakness with rotator cuff impingement.

Survey Says….Plausible, but not terribly compelling

Option 2 - Peripheral nerve entrapment
In the upper extremity, peripheral nerve injuries can result from trauma, penetration, traction or compression. Let’s explore common etiologies of upper extremity peripheral nerve injuries:

Axillary: fracture of the neck of the humerus, anterior dislocation of the shoulder
Musculocutaneous: fracture of the clavicle
Radial: compression of the nerve in the radial tunnel, fracture of the humerus
Median: compression in the carpal tunnel, pronator teres entrapment
Ulnar: compression in the cubital tunnel, entrapment in Guyon’s canal

The three classifications of nerve injury in order of severity (from least to most severe) are neurapraxia, axonotmesis, and neurotmesis. The degree of injury is related to the severity and duration of compression (i.e., entrapment). Symptoms include paresthesias, pain, and weakness depending on the severity of the nerve injury.

Peripheral nerve entrapment is the most likely of the options to impact the ability to drive due to weakness causing an inability to reach forward and grasp the steering wheel. Peripheral nerve entrapment can cause wasting of muscles and weakness, as well as diminished or absent sensation to the area supplied by the nerve, depending on the severity of the injury. Pain may or may not be present with a peripheral nerve injury.

Survey Says….Solid! Peripheral nerve entrapment provides a strong rationale for the described weakness when attempting to reach forward to grasp the steering wheel.

Option 3 - Adhesive capsulitis
Adhesive capsulitis (i.e., “frozen shoulder”) is characterized by inflammation and fibrotic thickening of the anterior capsule of the shoulder. Loss of motion occurs in a capsular pattern with the greatest restriction of motion being lateral rotation, then abduction, then medial rotation. With adhesive capsulitis, difficulty reaching for the steering wheel would more likely be due to pain and/or limited motion rather than weakness.

Survey Says….No! The absence of a range of motion limitation or pain makes adhesive capsulitis extremely unlikely.

Option 4 - Cervical facet impingement
Cervical facet impingement (“facet syndrome”) is characterized by inflammation and pain in one or more of the facet joints of the cervical spine. The facet joints are true synovial intervertebral joints with a joint capsule that can become impinged.

Due to the natural coupling motion in the spine, painful and limited rotation and lateral flexion of the neck to the same side is typically seen in cervical facet impingement.

Although driving may be difficult, it would more likely be due to difficulty turning the head rather than reaching forward to grasp the steering wheel.

Survey Says….Not likely! Weakness can be caused by the pain associated with cervical facet impingement. However, the clinical scenario indicates the absence of pain.

The correct answer is Option 2

Let’s explore the all student data:
11% of students selected Option 1, Rotator cuff impingement
53% of students selected Option 2, Peripheral nerve entrapment, the correct response
26% of students selected Option 3, Adhesive capsulitis
10% of students selected Option 4, Cervical facet impingement

System Classification
This question is a Neuromuscular and Nervous Systems question which represents approximately 24% of all exam items.

Content Outline Classification
This question is a Foundations for Evaluation, Differential Diagnosis, & Prognosis question which represents approximately 33% of all exam items.

Level Classification
This question is a Level 2 question since the question requires students to integrate numerous pieces of information or to apply knowledge in a given clinical scenario. Remediation of Level 2 questions occurs by increasing flexibility with academic content and by carefully analyzing decision making processes when answering applied examination questions.

Academic Focus Area
Looking to review related academic content? Check out page 270-272 in PTEXAM: The Complete Study Guide.

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