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November 2, 2000 Newsletter

Do I or Do I Not have a Nerve Problem?

One of the most common reasons why a patient is sent to me is to determine the probable cause of a chronic pain problem. For most of these individuals, the problem is a combination of muscle and nerve pain called "myofascial neuropathy". 

Myofascial neuropathy is a spinal or limb muscle disorder that creates direct or indirect (from bone) nerve compression from muscle. Below are some of the clues that a "myofascial neuropathy" might be at play.

One of the best clues that a muscle dysfunction / neuropathy pain disorder is at work is the tendency for the pain to increase at rest. That is while sitting, sleeping or standing. 

This phenomenon is quite common. Why does this suggest muscle and nerve problems? This is because there is a common muscle principle that I commonly quote- 

"all muscles shorten at rest." 

As muscles shorten they cause more joint and nerve compression and therefore more pain and joint stiffness. This is probably the reason why many of us complain of the "Four Am aches and pains". For example, our knee aches probably because the muscles around the low back shortened contributing to nerve related pain in the knee. As a result, muscles around the knee shorten because of an alteration in their nerve function (Cannon's Law). This results in increased knee compression and resulting stiffness and pain.

When we get up and walk around, this helps to stretch the spinal and limb muscles, thereby reducing some of the pain until the next time we sleep or sit. This is also why I have suggested that we should perform our nerve conduction studies in the middle of the night, so that an assessment of our patient's worst pain episodes can be properly assessed.

Another clue that a muscle dysfunction / neuropathy pain disorder is at work, can be tingling or numbness in a limb. Many patients have come to me thinking that they might have a vascular (blood vessel) blockage narrowing in their arms or legs causing numbness and tingling in their feet or hands. Although this may be true, it is unlikely. 

A blocked or narrowed blood vessel does cause pain, weakness and unusual sensations in a limb. They occur most commonly in the legs and sometimes, although very rarely, in the arms.

A blocked leg artery causes a pain that is generally only present while walking and stops within a minute or so after you stop walking. The pain should come back within about the same time when you begin walking again. This condition is known as intermittent claudication and occurs most commonly in smokers, diabetics and the elderly. Many doctors and patients may confuse arterial claudication with low back related nerve compression. Most of these low back disorders will not be well demonstrated on CT scans or X-ray.

In general, a myofascial nerve disorder will ache at rest and at movement. It will tend to increase at night and at rest, especially after doing exercise. It may also increase with walking because the nerve may suffer even more compression during the walk. A large component of the "pain" will be numbness and tingling but the pulse in the legs should be good. The patient will usually have stiff knees. In myofascial nerve disorders, the pain, numbness and tingling may improve with stretching of the hamstrings and calves.

Another clue to myofascial nerve disorders may be that the pain may improve with exercise. Early on in pain syndromes, pain and stiffness is present when static or at rest but improves with resistance or even aerobic activity. For example, one of my colleagues asked me about his back pain that disappeared when he jogged. He felt great when jogging but within hours his back was sore. This was probably because his jogging exercise was active enough to loosen his paraspinal muscles in the low back such that the compressive pain that typically occurs at rest would decrease during his jogging. It is important to realize that jogging is not considered a therapy for back pain, although many will find this to be so. The point was that this would be a clue to his source of pain.

Yet another clue, may not be pain but abnormal function of a part. I read a study once, where joggers were found to have improved hearing when jogging. Those performing the study felt that the improvement in hearing was probably due to increased blood flow during jogging. I found this unlikely because if the people were joggers, they probably did not have significant blood flow abnormalities, otherwise a heart attack would have probably soon followed. This group probably represents my finding that neck problems may cause hearing abnormalities such as decreased hearing, middle ear congestion, ringing of the ears and even vertigo or dizziness. The joggers were likely demonstrating a group of individuals who had very mild cerviconeuropathic middle ear congestion and deafness; often misdiagnosed as eustachian tube defect. The point being that myofascial nerve disorders are not reserved to pain only but may affect function as well. Ringing of the ears and muscle weakness can be clues to myofascial neuropathy.

In summary, some of the points to remember about myofascial-nerve pain disorders include-  increasing pain in rest or sleep and decreasing pain with gentle exercise (unless severe muscle abnormalities are present; in which case pain is usually always present and it will increase with almost any exercise).

Stretching will increase the pain at the time of stretching but usually offers relief for minutes to hours after the stretch.

Numbness and tingling is typically nerve related but not always. If the pain problems seem to move around or include painful parts that come and go, a nerve is often involved. Sometimes, if you close your eyes and concentrate, you may be able to trace the pain originating from the spine as a dull ache. If the pain is consistently associated with a spinal pain, it probably is originating from that segment of the spine. 

Finally, ask your doctor if the pain you suffer could be coming from a part of your spine. 

As always, keep long and strong.

G. Blair Lamb MD, C.C.F.P.  O.P.P.A.
Pain and Rehabilitation Consultant
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