Therapist massaging patients right arm.

Going to the Root of Nerve Pain to Avoid Needless Imaging, Surgery

By Jeff Rogers Jr., DPT, PT, FAAOMPT | 06/02/2021

United against unnecessary costs in injury care

No ValueEmployers, payors, and best-in-class physical therapists share a desire to avoid needless imaging and surgery, along with their associated costs. When an employee’s injury is nerve-related, employers, payors, and clinicians who understand the science of evaluating and treating nerve irritation/inflammation (neurodynamics) can avoid unnecessary imaging and surgery while supporting more effective diagnosis and treatment. Approaches using neurodynamics can seem illogical to one unfamiliar with the science behind it. For example, why might neurodynamics lead a physical therapist to treat an employee’s neck to help resolve pain experienced in the employee’s arm? I’ll discuss this example more later.

Two reasons nerves can cause pain

Two of the most common causes of nerve-related pain in orthopedic injuries are from nerve compression or nerve irritation/inflammation.1 Nerve compression – when a nerve is blocked from getting the oxygen and nutrients it needs, such as in a herniated disc – is not the focus of this article. Nerve compression is well studied and can be confirmed by multiple tests. Advanced imaging and nerve tests are reliable diagnostic tools for nerve compression, which is treated through decompression, therapy and traction, or surgery.

Instead, as introduced earlier, this article’s focus is on nerve irritation/inflammation, which is more common and more difficult to diagnose. Irritated or inflamed nerves likely won’t show up on an MRI, so a clinician who relies on imaging is at risk of not properly diagnosing and treating this type of nerve-related injury. This can lead to recommendations for surgery that has no effect on alleviating the injured employee’s distress.

A clear understanding of neurodynamics to diagnose and treat nerve irritation/inflammation can help avoid:

  • Unnecessary imaging costs (imaging likely won’t detect it)
  • Prolonged or incomplete recovery (by ignoring the root cause of the pain)
  • Misunderstanding of needed procedures to identify and treat the root cause of pain (because they seem remote to the areas of the body where the employee is experiencing pain)

Advanced training in the evaluation and treatment of nerve irritation/inflammation is not commonplace. It’s most often taught in post-graduate-level education and not in standard medical or therapy schools. If you suspect nerve irritation/inflammation, ask your medical or therapy clinician to investigate neurodynamics.

A key understanding for employers and payors

Identifying pain as being nerve-related and even classifying it as either compression or irritation is often not enough to develop a treatment plan. The root cause of nerve-related pain must be identified to provide effective treatment. This can be complex because nerve-related pain can result from numerous factors occurring simultaneously. Giving medication to an employee to relieve nerve pain is not an ultimate solution because the root cause of the nerve irritation must still be addressed. Some pain medications, such as non-steroidal anti-inflammatory drugs (NSAIDs), are unlikely to help at all because the molecules they contain are too large to enter the nerve.

A case study will help illustrate how neurodynamics allowed the therapist to get to the root cause of pain from nerve irritation/inflammation while avoiding unnecessary costs and specialist treatment.

Case study: TJ’s “frozen shoulder” that wasn’t

TJ was injured at work while throwing a trash bag into a large dumpster. She felt immediate pain in the right shoulder. Initially, she was given NSAIDs to relieve pain and referred to physical therapy for two weeks, but she didn’t improve. Imaging revealed her rotator cuff (muscles and tendons surrounding the shoulder joint) had a full-thickness tear, which was repaired through surgery.

After six weeks of physical therapy, TJ still was not progressing in her recovery. She was diagnosed with adhesive capsulitis, commonly referred to as frozen shoulder. She was scheduled for a closed manipulation, which is when the joint is forcefully pushed to end ranges while under anesthesia.

Prior to the procedure she saw a different therapist, who was trained in neurodynamics. This therapist determined that her shoulder limitations were due to nerve irritation and was not frozen shoulder at all. After one session of neurodynamics treatment, TJ had full range of motion in all directions. TJ was able to cancel her appointment with a specialist for closed manipulation.

Shoulder problems like TJ experienced in the case study can occur in virtually any industry – and not just in jobs we think of as highly physical. Shoulder disorders often result from the cumulative effects of manual handling (heavy lifting, pushing, pulling, carrying), working above shoulder height, repetitive work, vibration, and working in awkward postures. In addition, certain psychosocial factors may contribute to shoulder disorders, such as demanding work, long hours, lack of job control, lack of social support, and job strain.2

Shoulder disorders are only one of many types of injuries that may involve nerve irritation or nerve inflammation.

A true neurodynamic treatment approach

Most often, a physical therapist will provide this treatment. The first step is to decrease irritation or inflammation in the nerve to restore normal mobility. Treatment properly done should not increase irritation or pain symptoms. When treating an employee with a high level of irritation, the physical therapist should use a light mobilization approach – first on the spine and then through the extremities. Eventually, full tension can be applied to the nerve until the point where the irritation has subsided.3

One more example illustrates the error in not diagnosing and treating the root cause. Let’s say you have an employee with strained forearm muscles that originate in the lateral epicondyle, or the bony bump on the outside of the elbow. The strain results in what is commonly called “tennis elbow.” There is a nerve tension point due to the radial nerve that runs down the back of the forearm, just as muscles do. The problem in the radial nerve won’t show up on an MRI or in standard testing, so the problem might not be correctly diagnosed or treated. The employer and payor have incurred costs of various procedures but the employee is still in distress because the root cause of pain was not correctly diagnosed as nerve irritation.

In conclusion

The nervous system – consisting of the brain, the spinal cord, sensory organs, and all the nerves that connect these organs – controls the muscles and sends pain signals by communicating to and from the brain to the rest of the body. The nervous system and the musculoskeletal system are intimately tied to each other but when they produce pain, the root causes are unique to each system and need to receive the appropriate treatment.

Increasing knowledge about nerve-related pain and how to treat it effectively is a balm of healing to employees who may have suffered silently and even been mislabeled as malingerers, complaining without cause. Employers, payors, and clinicians can avoid a vortex of medical care that doesn’t address the real problem by thoroughly understanding a specially trained physical therapist’s use of neurodynamics.


Jeff Rogers Jr., PT, DPT, FAAOMPT, is the director of therapy operations for Concentra in eastern Pennsylvania, Delaware, Maryland, and northern Virginia. Jeff is a leader in manual therapy research and advancing industry knowledge to achieve positive outcomes. Since joining Concentra in 2004, Jeff has conveyed physical therapy practices and trends as a guest lecturer to employers, workers’ compensation insurance companies, and universities. He is involved in manual therapy research at the University of the Sciences in Philadelphia (USciences). Jeff has a doctor of physical therapy degree from USciences and is a Fellow of the American Academy of Manual Physical Therapists (FAAOMPT). His most recent research was nominated for an orthopedic poster presentation of the year at the American Physical Therapy Association's Combined Sections Meeting.


NOTE

  1. Neuropathic Pain. Physiopedia.
  2. Linaker CH, Walker Bone K. Shoulder Disorders and Occupation. Best Practices in Research Clinical Rheumatology. 2015; 29(3):405-423.
  3. Shacklock M. Neurodynamics. Physiotherapy. 1995; 81(1):9-16.