When the problem is neural,
localization changes everything.

Median nerve compression at the wrist commonly causes numbness or tingling in the thumb, index, middle and radial half of the ring finger, often at night. Later findings may include pinch weakness or dropping objects; the little finger is usually spared.

Assessment and treatment

Diagnosis is clinical, with nerve studies/EMG or ultrasound used when appropriate. Night splinting, load modification, injection or carpal tunnel release may be considered according to severity, weakness and evidence of nerve injury.

Ulnar nerve compression at the elbow may cause tingling in the little and ring fingers, elbow-region pain, and weakness of finger spread, key pinch or grip. Prolonged elbow flexion may aggravate symptoms.

Assessment includes sensation, intrinsic strength, nerve stability and alternate compression sites. Initial care may include positional changes and avoiding sustained night flexion; progressive weakness or advanced compression may require decompression and, selectively, anterior transposition.

Ulnar nerve compression at the wrist can produce motor, sensory or mixed patterns depending on the zone. Preserved dorsal-ulnar hand sensation can support a distal site but does not establish the diagnosis alone.

Potential causes include a ganglion, repetitive pressure, hamate-region injury or a vascular lesion. Focused examination and selected EMG, ultrasound or MRI guide treatment of both the nerve and the cause of compression.

Burning, numbness or hypersensitivity over the outer thigh without muscle weakness may reflect LFCN entrapment. Assessment separates a local nerve problem from spinal, hip or pelvic causes.

Burning pain or tenderness along the medial knee and leg may follow surgery, trauma or compression in the adductor canal. As this is a sensory nerve, muscle weakness is not typical.

Perineal pain aggravated by sitting requires a broad differential diagnosis. Care may include seating modification, pelvic-floor therapy, medication and image-guided blocks; surgery is reserved for selected cases.

Sudden unilateral weakness may cause mouth-corner droop, difficulty smiling or closing the eye, altered tearing or taste, and sometimes pain around the ear.

If recovery remains incomplete, care may include specialist facial therapy, botulinum toxin for synkinesis and tailored surgery.

Options include timely nerve repair or grafting, nerve transfers, cross-face nerve grafting, free functional muscle transfer and static support. A recent palsy and longstanding paralysis require different strategies.

Neck, shoulder, arm or hand pain; tingling—sometimes involving the ring and little fingers—arm fatigue and weakness may occur. Overhead activity can aggravate symptoms, but no single manoeuvre establishes the diagnosis.

Assessment combines the history, neurologic and mechanical examination, and differentiation from cervical, shoulder and distal nerve disorders. TOS-specific physiotherapy is commonly first-line.

Sudden swelling, heaviness or blue discoloration may indicate venous involvement. A cold or pale hand, reduced pulse, ischemic pain or fingertip ulceration may indicate arterial compromise.

Management is not identical for every patient. Neurogenic TOS usually starts with rehabilitation; surgery is considered when the diagnosis is coherent and substantial symptoms persist despite appropriate care.

Decompression may include scalene, brachial plexus and pectoralis minor release. First-rib resection is not automatic; anatomy, subtype and findings guide the operation.

Management is individualized to the diagnosis and attack burden and may include acute and preventive medication, trigger management and coordinated headache-neurology care.

When indicated, options may include CGRP-targeted biologic therapy, onabotulinumtoxinA (Botox) for chronic migraine, and diagnostic or therapeutic nerve blocks. Surgery is considered only after structured diagnosis, appropriate nonsurgical treatment and careful selection.

Sharp, shooting or stabbing posterior scalp pain, often with focal tenderness and upward radiation, may fit occipital neuralgia. Migraine, cervicogenic headache and other causes must be distinguished.

Greater occipital nerve

Arising mainly from C2, it travels from the occiput toward the posterior and superior scalp. Near-midline tenderness with upward radiation can follow its course.

Lesser occipital nerve

Usually arising from the C2–C3 cervical plexus, it travels along the lateral occiput behind the ear. Lateral occipital or postauricular pain may follow this pathway.

Assessment combines the pain pattern, tenderness map, cervical examination and neurologic evaluation. Temporary improvement after local anaesthetic block may support the diagnosis but is not sufficient alone.

Options may include medication, physiotherapy for a cervical component, blocks and injections. Nerve decompression or another operation is reserved for persistent, well-localized pain after appropriate investigation and conservative care.

Compression near the fibular head may cause numbness over the dorsum of the foot and weakness lifting the ankle or toes. New foot drop requires early assessment.

Burning or numbness in the sole may reflect compression of the tibial nerve or one of its branches. Assessment also considers spinal disease, neuropathy and local foot pathology.

Burning forefoot pain radiating into the toes, sometimes described as a pebble in the shoe, is often aggravated by narrow footwear and forefoot loading. Treatment begins with footwear modification and progresses according to findings.