Cranky Nerve Syndrome - Part 2

August 2020

In a previous post we introduced a patient who was a typical example of someone with upper limb pain from sensitisation of her peripheral nerves - cranky nerve syndrome. What we saw was a person with no specific injury to her elbow, but with quite severe pain across the outside of the elbow region during all sorts of normal daily tasks - especially picking up and holding her 18-month-old son. When we explored the underlying causes of her pain we found a wide range of issues - including poor sleep, stress, and low physical capacity in relation to the tasks she was routinely doing. Even her past history of anxiety and depression were probably contributing to her pain problem. This kind of problem needs to be understood holistically, and her treatment plan also needed to consider the whole person - not just the sore elbow in isolation.

We started with lots of education and reassurance. She needed to learn that pain in the elbow did not equate to damage in the elbow. She grasped this concept well intellectually, but months of pain often result in habits of avoidance or habits of pushing through pain. This patient was very much in the 'tough it out' mould - she just wanted to get the job done, and would put up with significant elbow pain in the process. Like many of us, she had used this strategy successfully over the years - all sorts of minor injuries and niggles had been ignored or pushed through, and had just got better with time. Unfortunately, with cranky nerve pain, even though the pain does not indicate any damage, this strategy simply doesn't work. Her story is typical - the more she tried to tough it out, the worse her pain got.

Various treatments can help a 'tough it out' patient - education, pre-planning of activities, pacing strategies for aggravating tasks, movement strategies to put less load on the sore nerve, taping techniques, and regular 'desensitising' exercises can all provide short-term reductions in pain. This patient responded really well to K-taping of her shoulder into a slightly elevated position. Her pain-free movement and grip strength immediately improved.

She was taught two exercises in her first physio session. First, a gentle 'nerve slider', deliberately putting tension on the cranky nerve but in a controlled and non-threatening way to help desensitise it. And second, the start of her upper limb strengthening program. We tried an overhead press - lifting a dumbbell overhead with the affected arm - but this kept irritating her pain, even with modifications. Rowing worked well for her, though. A simple theraband row with both hands was pain free, so we tried her with a bent-over dumbbell row. This was also pain free, and was preferable because it fatigued her arm much faster.

This was a good start to her therapy - education, taping and introductory exercises. She left feeling very reassured that her arm was safe, and empowered to make better decisions about which activities to continue and which ones to avoid. But where to from here? How do we take a patient like this from her first steps towards recovery to being pain-free and confident in all of her usual activities?

Part 3 will be coming soon...