Being the wires that transmit signals throughout our body , nerves are designed to carry messages from our central station to our peripheries. These structures are delicate , complex little things that have an immense impact on how we initiate , perform and maintain our functional abilities. However ,at least once in your lifetime you would have encountered a “dead leg” or perhaps a snuggle with your significant other and suddenly your arm goes numb. These are simple signs of nerve irritations and through this article we will be looking at nerve injuries and everything relating to them.

Whether you’re an athlete or a simple sedentary human , nerve injuries can affect anyone , regardless of age body type or activity levels. Sustaining a nerve injury is a common injury , with a reported incidence rate of 43 million people annually in the US as traumatic nerve injuries account for up to 3% in the emergency room.

By not being able to transmit messages effectively into your peripheries , they give the platform for many secondary complications which in turn reduces your functional ability and well being. Furthermore , due the slow recovery of nerves , their complexity and and many ways to injure them , clinicians often struggle in returning full function to their patients.

Fortunately for you , we are experts at nerve injuries and wrote this article with you in mind! As you sit tight and begin the first step of your journey to greatness we will go through all the particulars relating to your nerve injury as what to expect , how to manage it and what not to do!

Nerves are built up of multiple structures that work in unison to transmit signals from your brain into your peripheries. The main component of a nerve is the neuron. This is made up a cell body and a long slender tube known as the axon which is the main structure responsible for carrying and transmitting signals throughout your body. The axon is incased in a segmented sheath called the myelin which enables signals to be transmitted at a rapid pace from node to node. Diving a bit deeper into the genetic make up of a nerve , you then have some connective tissue structures which provide support , protection and strength for function and repair. These structures are your Endoneurium (Blood supply to your nerve), Perineurim (Forms the blood nerve barrier) and Epineurium (Primary protective layer).

There are multiple ways to sustain a nerve injury be it through an autoimmune disorder , traumatic injury or non – traumatic instances. Lets say you sustain an injury whereby you fall from a tree but as you falling , you fortunately manage to grab onto a branch with one arm. As you reach up and catch onto the branch , there’s a sudden sharp electrical sensation running from your neck into your entire arm and fingers. Due to the immense amount of stretch occurring throughout your arm as you hang from the branch , the force of the stretch itself disrupts the myelin sheath causing inflammation and disruption of the neural pathway , but keeping the axon intact. This is known as a neurapaxia and is the mildest form of a nerve injury.

Keeping with the same mechanism of injury , although this time you fail the grab the branch and end up falling quite hard on an outstretch arm. You feel a sudden onset of sharp excruciating pain and additionally , you’ve sustained a fracture in your arm. The stretching pull going through your nerve as you fail to reach and grab a branch along with the crushing force as you land leads to the nerve body being overly stretched and then suddenly compressed. This can also be typically seen in an motor accident , whereby an external force applied simply disrupts the internal structure and integrity of your nerve and connective tissue , think of the strings of rope being torn apart. This is certainly more severe in nature and will lead to a more intense and severe form of nerve injuries known as Axonotmesis or Neurotmesis.

The internal bleeding , nerve scarring and cellular disruption caused by a more intense injury will directly affect how long it takes to recover and regain neural stimulation along the affected pathway. Furthermore , secondary injuries sustained to the surrounding structures such as a muscular tear , bone bruising or fracture will also add to the healing process as a high grade nerve injury rarely occurs in isolation.

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Nerve injuries vary in how they present , the type of symptoms they present with and how severe they can be. These can range from a “small” nerve injury such as a Neurapraxia to a more “bigger” nerve injury such as a Neurotmesis. Lets go through some details that will enable you to gauge just about where you fall in the spectrum of “less severe” to “most severe”.

Using an unfortunate but realistic example of a car accident whereby your arm gets trapped or bumped up against the dashboard , fast forward 36 hours later and you cant seem to shake the feeling of a dull sharp ache referring into your fingers. The pain is localised to your arm and some fingers and although not constant , you can feel that the intensity of the discomfort differs during the day. You have a decrease in your ability to grip and generate power with your arm and your movement is limited and stiff. You will have little to no sensory deficits but you will feel that touching items are slightly different. These are all clinical metrics that indicate you have a mild to medium nerve injury (Neurapaxia) , which luckily for you – has an excellent prognosis outcome.

Keeping with the same example of a car accident , fast forward 36 hours later and there is a severe feeling of a sharp , tingling and numbing feeling radiating throughout you arm and into all your fingers. The pain is constant and even touching your skin feels like its on fire. The intensity of the pain is unbearable regardless of what you do and can only be eased with medication. Moving the arm feels impossible and the joint is extremely stiff. You notice that you have a severe loss of motor control and power in your affected arm and your sensory abilities has now decreased to a point where you struggle to feel anything. These are all clinical metrics that indicate you have a medium to severe nerve injury (Axonotmesis to Neurotmesis) which needs immediate intervention as prognosis is slow but not impossible. irreversible

With our professional expertise and clinical knowledge we can make the Physiotherapy diagnoses for your nerve injury a easy , uncomplicated and well understood process. We are skilled enough to calmly guide you through a structured assessment process whereby we can confirm or even rule out neurological injuries.

We are able to isolate and break down the affected nerve and corresponding complications in order to get the best possible clinical presentation of you. Lets have a look at the thorough steps we will guide you through as we identify and confirm your nerve injury:

Subjective Assessment

Getting an idea of the events and mechanism of injury leading up to your nerve damage injury as any relevant previous history , medication or chronic conditions you may have gives us a better insight into your path that lead you to us. The better we are able to understand this , the better and easier we are able to plan your rehabilitative journey. Another important aspect of this is to go through your goals and expectations as we strive towards getting you back into the tasks that are important to you within a realistic and objective approach.

Physical Assessment

This is where we assess your physical ability in relation to your nerve injury and surrounding structures. We are able to isolate the root of nerve and use a variety of special tests to ensure we get the best clinical picture of your injury. We are able and skilled enough to break your neurological system down by testing your reflexes , sensory and motor capacity in relation to your nerve injury.

Once we able to objectively tick these boxes we are now able to successfully commence your rehabilitative journey. If we suspect any further investigations , we are able to provide you with a referral to get it done. We are proactive in our approach and pride ourselves in taking responsibility as your primary health care provider.

We understand how the body works and know how to mitigate any secondary issues that may arise when having a nerve injury. Allow us to take on that responsibility while you focus on a structured rehabilitation program to get you back to your best.

Nerves cannot be seen seen on an x-ray, so it will not be effective in diagnosing a nerve injury. X-rays will however show the integrity and alignment of any affected joints or bone in relation to your nerve injury. This is only validated if you had a traumatic accident and would like to rule out any bone fractures.

Your physiotherapist can refer you to get x-rays taken if necessary.

An EMG along allows us to see exactly where the nerve is damaged , the severity of it and to what extent it’s hampering your functional fallout.

By assessing the ability of your nerve to conduct signals to a specific muscle , we are able to assess how much signal is being conducted through the nerve by assessing the muscle it innervates.

We are able to perform a EMG at our expert practice.

Known as a MR neurography , this type of MRI scan has the ability to zone out other structures in order to isolate and view nerves. This allows us to see the extent of nerve damage , compress or tear of the nerve itself as well as any surrounding structures.

If your physiotherapist suspects a MRI is needed , we are able to refer you to the right specialist.

The healing journey of a nerve injury can be an extremely complex process. Unlike other structures in your body where you can get away with no treatment (such as a simple muscle strain) , even the simplest nerve injury needs to be attended to. Nerve rehabilitation needs to be a guided process and not a “wait and see” process. There are numerous factors that needs to be understood effectively and managed in order for your nerve injury to heal correctly. Lets explore some of these issues as to why your pain is just not resolving.

The severity of your nerve injury directly affects the healing time. The more intense the nerve injury , the more time it will take for regeneration of the nerve axon and epineurium which is essentially the blueprint of recovery for a nerve. Now if your nerve has been completely cut and you have not found intervention , the nerve ends will not connect by themselves. This inevitably means there is no pathway for the regenerating nerve ends to follow or transmit a signal , which will result in you still being in severe pain and at a functional loss.

Scar tissue formation and disorganized fibrous tissue is what you can expect in a untreated nerve injury. This is a massive roadblock in your healing journey as when your injured nerve attempts to heal without proper guidance, the regenerating tissue fibers will grow , but in a way that is not aligned with your natural tissue formation. These usually manifest in a painful mass of nerve tissue called a neuroma which not only prevents functional recovery but also becomes a source of chronic pain and joint stiffness.

Nerves innervate muscles and when a muscle loses its nerve supply, it begins to waste away (atrophy). The “use it or lose it” model comes into affects as if your nerve does not regrow and reconnect with its target muscle within about 12 to 18 months, the connection between the nerve and muscle dies off permanently. This makes your full recovery extremely difficult as even if your nerve fully regenerates, it has no viable muscle to control, and the loss of function becomes irreversible.

We are experts at preventing and setting you on a path to correct these complications before they become permanent. Do not let it worsen or restrict you from the basic daily activities that you should be able to do. Have us guide you through this journey with care , passion and clinical mastery.

Complications arising from nerve injuries are extremely common in clinical practice. We have experience and skill in identifying any shortfalls in your recovery and more importantly , find out why you still have neuropathic pain , even though you may have “recovered” already. These misconceptions and shortfalls about nerve recovery is popular amongst individuals who do not seek the correct intervention or have simply just not had the best care given. Below are some of the issues we see in clinical practice , which ultimately delays the rehabilitation progress as the secondary complications have now taken a front seat which means that more time needs to be spent on these issues before getting to the actual nerve injury itself.

Misdiagnoses can lead to more damage than good. Understanding the difference and being able to differentiate between a nociceptive or neuropathic pain is clinically , the first step that needs to be correctly identified when dealing with a nerve injury. Misdiagnoses whereby individuals who seem to think its just a muscle or a stiff joint often leads to further complications later in their recovery and more importantly , delays the prognosis even more. The nerve gets further damaged as it was never identified as being the root cause of your pain.

Muscle wasting or atrophy is common in all nerve injuries. As the nerve innervates the muscle , the electrical signal cannot reach the muscle fibres. This leads to the muscle not being used sufficiently and “use it or lose it” comes to play. This is also found in individuals who waited too long to get it seen to as the muscle atrophy , stiffness and pain only gets worse as the nerve conduction to the muscle is limited.

Chronic pain is often seen as a consequence of ill treated nerve injuries. Complex regional pain syndrome (CRPS) is a popular type of syndrome we see in individuals , whereby the amount of joint stiffness , neuropathic pain and swelling is disproportionate to the initial injury. This is usually accompanied by loss of sensation , motor control and limited functional abilities.

Within our domain , we are absolute professionals and experts as we strive ourselves on our ability when it comes to the clinical assessment and treatment protocols we use to treat nerve injuries. We are confident , systematic and use a guided approach to establish the extent of your nerve injury and any secondary issues it has caused on the interface surrounding it. We can ensure that you get the best treatment and care while we use an array of different modalities and techniques to aid you through your rehabilitative journey.

We begin by assessing and confirming the extent of your nerve injury. This is achieved by undergoing our thorough assessment protocols whereby we not only focus on your nerve in isolation but also on the associated joint and muscle. Once we’re able to assess the severity and get a clinical diagnoses we can then proceed on a plan of action. Primarily this is focused on accelerating axonal regeneration and improving nerve conduction , we would also want to decrease any inflammation surrounding the nerve tissue as well as improving muscular interfaces and joint mobility.

We are experts in our field and have extensive experience in achieving a better improved functional outcome based on your objectives. We are able to make us of a variety of refreshing and clinically sound treatment protocols. Allow us to get you back to where you need to be , in the most timely manner possible.

Following a peripheral nerve injury , research shows that the average rate of nerve regeneration is about 1 to 3mm per day. This can be equated to about 2.5cm a month! This is not a lot of growth and therefore the total recovery time for more severe injuries is directly related to the distance the nerve must regrow. Additionally , age plays an important factor in your healing as younger individuals have a stronger chance of healing faster. The location of your nerve injury is also pivotal in your recovery as nerves injured closer to your affected muscle will regrow faster as it’s less distance compared to a longer nerve that innervates a further muscle. Direct clean cuts to your nerve usually heals easier than a stretching or crushing type of nerve injury. Lastly , timed intervention also plays a part in your prognosis. Muscles that are innervated by your affected nerve will begin to waste away if the nerve has not been treated , therefore leaving you with functionally decreased abilities and massive muscle atrophy.

Lets go through the details of each nerve injury and how it affects your healing time.

• Neurapraxia: Graded on the Sunderland score as a Gr1 nerve injury , these are considered to be the mildest form of injury. Basically the nerves signal or conduction is blocked but the nerve itself is usually unharmed. Recovery is spontaneous and nerve conduction typically occurs within 0 – 12 weeks.
• Axonotmesis: When the axon of the nerve is damaged , it’s considered a medium / moderate injury and is graded as a Gr2 injury on the Sunderland score sheet. As the axon of the nerve is damaged , the nerve still has it’s protective outer layer in tact which is imperative to healing as this can guide the regrowth of the nerve and axon. Healing is slow , but expected although the time frame associated with it can take months up to a year depending on the injured site.
• Neurotmesis Grade 3 , 4 & 5: These are considered severe injuries as the entire nerve has been incomplete or completely ruptured. As the internal structure of the nerve itself has been damaged , the scarring tissue , nerve endings and conduction needs time to regain it’s capabilities. Spontaneous recovery is not possible , therefore even after successful surgery , rehabilitation is often anticipated to take months and often years to heal.

As we continue to strive towards giving you the best care we possible can, lets have a look at some of our strong alternative and additional forms of treatment that can aid us in your rehabilitation journey:

• If need be , a referral to your local GP will aid us in the appropriate medication for your healing and rehabilitation process. Nerve injuries require a specific type of medication as the usual anti-inflammatories would not work (Ibuprofen or Paracetamol). We are able to guid you into which of these medications are needed.
• Splints and braces can be used to manage the consequences of muscle imbalance and to improve function without the flare up of nerve symptoms. Be keeping the affected joint in a neutral position , we can prevent further damage to your nerve injury , improve your functional in your day to day activities and more importantly – protect the structure by keeping it immobilised.
• Electrical neurostimulation – In order to “kickstart” your axon and nerve regeneration we are able to treat and rehabilitate this effectively by applying a low frequency trans electrical stimulation along your nerve pathways. Research has shown that providing a charge of 20Hz current for one hour to the nerve proximal to the repair site has great effects by increasing intracellular levels and shows significant acceleration of axonal regeneration and earlier innervation of targeted muscles.

Surgical intervention for your nerve injury is mainly dependant on the type of nerve injury, severity of the injury and the prognosis of the nerve healing on it’s own. The goal of surgery for a nerve injury is to reattach the loose endings as to provide a stable pathway for conduction to take place. Lets have a look at some of the clinical signs that are indicated for a surgery:

A high grade injury such as a Grade 4 or 5 on the Sunderland nerve injury score sheet is a massive indication for surgery as the nerve has completely torn or ruptured and the indications for it healing independently are near impossible. Furthermore , even on a Grade 3 score , if a conservative approach has failed after a period of at least 6 months , surgery would be considered by the surgeon as to determine the return of function of the injured nerve.

In certain instances surgery is needed immediately to restore the injured nerve’s pathways. Lets have a brief look at what this entails:

• Direct trauma – Sharp cuts such as a knife or massive lacerations to your limb will require surgery as these types of injuries usually completely or partially sever’s the nerve itself.
• Tumor – Benign or malignant tumor’s can directly compress the nerve therefore surgery would be aimed at removing the tumor as well as repairing any nerve damage the tumor has caused.
• Wounds , crushing or scarring injuries – Traumatic injuries that compress , stretch and infect the nerve beyond repair needs to be removed so that the nerve can be realigned and begin regenerating.

The different type of surgeries will also vary dependant on what needs to be achieved. Below is a brief outline on the different types of surgeries for your nerve injury:

• Autografts – Using your own body’s tissue and a donor nerve is what makes this type of surgery the preferred choice of nerve surgery. By harvesting a donor nerve in your body , a surgeon is able to use it to fill in the gap of your injured nerve , allowing natural healing to occur.
• Allografts – When a autograft is not available , another type of surgery is where a nerve is taken from another human donor (usually a cadaver). This is then processed until it’s appropriate and then used to fill in th gap of the injured nerve.
• Nerve Conduits – These are used for smaller nerve injuries (3cm or below) whereby a artificial hollow tube is sutured at the end of the injured nerve stumps. This then provides a safe conduction “tunnel” for the nerve axon to regenerate and heal.
• Neurorrhapahy – This term refers to a direct end to end repair when the nerve has been completed cut in two. The surgeon is able to trim away the injured nerve endings and tissue , ensuring the healthy ends are reattached with precision and without any tension on the nerve as this way hinder the healing abilities of your injured nerve.

Surgery is merely the first step in a rehabilitation journey as we will then guide you through your unique post-operative rehabilitation program , whereby we strive to get the nerve to regenerate , desensitise and conduct efficiently.

• Neuritis – Inflammation of a nerve due to injury.
• Peripheral neuropathy – An umbrella term associated with neurological pain in the body and limbs.
• Radiculopathy – Associated with back pain whereby a nerve is known to be “pinched”.
• Stingers or Burners – A term used in sports whereby the plexus of the nerve group is injured due to a direct contact.

• Pinched nerve
• Compressed nerve
• Nerve root irritation