Hi El Paso, welcome to the Stay Healthy El Paso Podcast. I'm your host, Dr. David Middaugh, specialist physical therapist over at El Paso Manual Physical Therapy. I'm going to be talking to you today all about pinched nerves in the neck and shoulder.
We get clients asking us about this all the time. Sometimes they come in for treatment specifically for a pinched nerve problem. It's just gotten way out of hand and they don't know what else to do. At times, it just is a pester that bothers people from time to time. It's not really something that they are looking for treatment for. They are actually in here for a foot problem or knee or back problem. But they still ask, Hey, I've got this issue, this pinched nerve that bothers me from time to time.
I wanted to answer the questions of what is it? Why does it happen? And what does it feel like. Then we'll go into some other tangents likely, why does it need surgery and how to relieve it. So stay tuned, you are going to hear all the details about pinched nerves and the neck and shoulder.
What is a pinched nerve?
Let me talk to you about the anatomy just a bit here. The spine is made of a ton of bones. It starts in your tailbone and goes all the way up to the base of the skull. The top seven bones right below the skull are the cervical spine on the side of those bones, between them actually, there are little holes where the nerves come out that go all the way down into your arm. And those holes are called transverse framing.
But were all those nerves come out, they all bundled together after they come out of the spine. And then they separate again and muddled together, they go through this area called the brachial plexus, which is right behind your collarbone on either side. Then once it passes that area, the nerves split up in a bunch of different directions, and they go down in your arm. Some make it all the way down to your fingertips.
The reason for those nerves is, of course, to provide the connection to the muscles so that you can use your arm and hand and everything. They also provide sensation to the skin, and they do a bunch of other things too, that aren't normally talked about. They control the blood vessels in your body, they control all kinds of other things that just aren't normally talked about and people don't really need to know in depth about unless that's your specialty.
But anyways, when we talk about pinching a nerve along the pathway, all the way from the neck to the fingertips, there are several opportunities for the nerve to get compressed or pinched. And if that happens, then it impedes the function of the nerve. It may not shut it off completely, you may not, sever the nerve or you won't cut it off. It will just usually put some pressure on it. And the way that it feels, to most people, is a low level of discomfort or pain and achiness. Sometimes it's a burning sensation. And then if they move in a specific way that they may not always know, it really bites them. I
t's a 10 out of 10 pain and just jolts the individual and they snap to stop what they are doing for moments, and then it usually starts to wear off over the course of a few seconds, maybe a few minutes at most. That's the typical presentation for pinched nerve.
If you've ever had that experience, you likely just had it once in a while here and there, but then for some people it becomes more frequent, it starts to happen more often, to the point where it happens daily, multiple times a day. Then people start to pinpoint “every time I reach out to grab the laundry from the washing machine, or to put something in the dishwasher. When I go to open the car door. I just know it's going to bite me and I'm not looking forward to it. Or if I'm in bed and I pull up the covers, it just bites me when it's a heavy blanket.” Another one is picking up a pot of coffee, or certain times when exercising, it can really set off that pinched nerve sensation.
That's typically what it feels like. And when it's really bad, when it's happening very frequently. It can be debilitating. I mean, it won't let you sleep at night, just little simple movements start to become painful, they start to set off a pinched nerve, and then that low level of discomfort, becomes a medium level of discomfort. and then eventually I high level of constant discomfort. Because that pinched nerve is just getting irritated and more irritated over time. And it doesn't get a chance to calm down and normalize.
Why does it happen?
Let's talk about that next. How do the passageways for the nerve become compressed? Because usually there's no injury involved in most people, they just start to have this. There wasn't an accident, there wasn't a car accident, they didn't fall or get hit somehow. It just started to gradually happen.
Well, some of the most common places to pinch a nerve is right where the nerve comes out of the spine, right between the bones where that hole is the transverse frame, and if you have arthritis issues in your neck, you've had a history of neck problems. Because that hole is made up of the top half is one bone, the bottom half is another bone. If the disc between the two spine bones begins to change, shorten or lose its height, then that hole can also shrink.
Another thing is if your postures chronically not great, over time that can also cause that hole to be smaller. They call that pyramidal stenosis, this is when any hole becomes smaller in the body like you hear about spinal stenosis, that's what that would be, spinal pyramidal stenosis. So that's one way to pinched nerve.
Another one that's less talked about, but I see here all the time, is if your upper body is pretty weak, especially around your neck and shoulders, your collarbones can sink down. And because those nerves eventually bundled together and pass behind the collarbone, they can put some compression on the nerves.
Occasionally, you hear doctors diagnose patients with something called Thoracic Outlet Syndrome. And what they are talking about is that space behind the collarbone, where those bundles of nerves pass, and the bundle of nerves by the way is called the brachial plexus. If that gets chronically compressed, it can impede the function of the entire arm. Everything below the nerves there can begin to become affected.
Now what happens with people that have not the greatest posture, weak upper body, they begin to use some muscles on the sides of their neck for stability that they are not supposed to be using. They are called the scalene. The scalenes are some interesting muscles they attach from the neck to your first rib and your second rib, which are right behind your collarbone.
A lot of people don't grasp that your ribs go that high. They always think of the ribs being around their torso area, but your first and second rib are way up right at the base of your neck. Because these scaling muscles can become overused at times when they shorten, they can actually yank the first and second rib upwards. And those nerves that I was telling you, at the brachial plexus, they come right over the first and second ribs. If those ribs are getting pulled up, and then your collarbone is sunken down, it creates a sandwiching effect on your poor brachial plexus on those nerves that go down the arm.
That's another place that people often get a pinched nerve sensation. Now, to just make it worse, those scalene muscles that I was telling you about, you have three pairs in your body. You have an anterior scalene, middle scalene, and posterior scalene between the anterior and middle scalene, the front of the middle one is where the brachial plexus passes out from the spine and begins to go under your collarbone. So if you are chronically overusing your scalenes, just like any other muscle, if you use it and use it and use it, it gets bigger.
Those scalenes can get really hard and begin to compress on the nerves as well. Basically, you'll get a triple effect on those poor nerves in the in the brachial plexus area. You can get the collarbone sunken down, the ribs yanked up, and then compression from the scalenes. When we see that, it's a monster to fix, and it's not an easy task, but it can be fixed.
What it feels like?
Typically, people just get this jolt of pain when they turn a certain way. They can't get comfortable at night, they always have this low level of discomfort that runs to their neck and shoulders. They may also get knots in the area, especially around the neck and the upper trap are on the back of the shoulder. They'll get lumps. Wen those ribs pop up, they can feel really hard. They can feel like really hard lumps that be rubbed out, but they never really go away. It's because it's bone. Usually it doesn't go away. It just needs to be shifted down and those muscles need to be calmed down so that they aren't perpetually yanking the ribs up. It's a it's a process for sure.
Another common place, and this will be the last one I'm going to go into, because I can just go on and on. The last on is in the shoulder itself at the ball and socket joint. So those nerves, the brachial plexus, once they pass about the shoulder joint, they start to turn into a bunch of different other nerves. They label them differently because they go to different parts of the arm and connect to different muscles.
The big ones are the radial nerve, the ulnar nerve, the median nerve, and the muscular cutaneous nerve. That's the one that goes to the bicep. All these nerves can get pinched around the ball and socket joint. If your ball and socket joint is having problems moving, if you have issues with it. Issues like a rotator cuff tear, a biceps tear, subacromial impingement, or shoulder impingement is the more common term for it.
Those issues usually mean that the ball and socket joint is not moving normally, and because it's not moving normally, it doesn't allow for normal movement of the nerves which can begin to pinch them. What I often find, that clients are not really aware of, and I guess because this is what I studied and trained in, and live, sleep and breathe all this physical therapy stuff. But nerves move.
If you think about it, your nerves, like I said go from your neck to your shoulder, and all the way to your hand. And every time you move your arm around or your leg around, the nerves within that body part are moving along with it. And it's healthy for your nerves to move, it's necessary. It actually is vital to the health of the nerve that you get in some movement.
This is another reason why exercise is so important. But anyways, if that ball and socket joint is not moving normally or you are babying the shoulder because it's injured, it can begin to also pinch your nerves, and that can feed into that pinched nerve sensation.
When we see people here in the clinic that are coming in directly for a pinched nerve problem. Oftentimes I tell them that this is a massive problem. It's not just a one or two visit deal. We are going to see it for a couple of months likely, potentially longer, as we fix problem by problem. We have to go one step at a time.
The analogy that I like to use is, if you visualize a water hose, it comes out of your backyard, and you turn on the faucet where the hose is attached to the side of your house or the front of your house. And water is flowing through the hose and you see water coming out at the end. Well visualize, somebody's going to go step on the hose a bit, not hard enough to completely cut off the flow, but enough to impede it.
Then they put their other foot on it a little further down the hose and it impedes it just a bit further. So now you have less water flowing at the end of the of the hose. And then let's say two more people come down further the hose, and they step on it and put both feet on it. Eventually you have six spots where the hose is being impeded. Now you got just a trickle at the end, and nobody's even pressing that hard. It's just enough to cut off the flow little by little.
It's the same idea within nerves. Nerves, when they get pressure, then they can still function, but their function is impeded. It's not going to work. Normally it's reduced function. You are going to get pain of course, because that's the nerve telling you “Hey, I'm hurt!” or something's not right. But then you are also going to experience some weakness.
Eventually, if you don't take care of that you can run into other problems like a rotator cuff tear, or further an arthritis problem, or some sort of strain or sprain. Oftentimes, we see muscle spasm because the muscles freak out because the nerve connection from where it's getting pinched is not normal.
The muscle can sometimes react in a way where it spasms. It can cause that spasming. A milder sensation that people get is something called facilitations. But that's muscle twitching. A lot of people when I bring that up, they are like, Yes, I get that. I've been getting that for a while now. I'll be sleeping at night, or I'll be sitting down at work, or watching a movie or something. And all of a sudden, my tricep is just going crazy. It's just twitching, and I can't make it stop, I have to shake my arm out for it to go away. But then next time I sit down again for a while, it starts to twitch again.
That's just the muscle freaking out, it's getting pinched a bit. So those are common sensations people get and that's how we have to approach the problem. By taking one foot off the hose at a time, then taking the next foot off, and it's always a process.
In the description that I outlined for the common ways that this happens. We have to free up the neck joints to make sure that the holes in the side of the spine are open enough to allow free mobility of the nerve. We have to calm down those spaces and muscles, which can mean a combination of massage, and, of course, moving the neck joints so that they free up better. Moving the rib joints, and then also training the person on how to have better posture, and how to exercise in a certain way to calm down the scalenes.
Then we have to look at the upper body strength and find the weakest parts of that. To strengthen that, you have to look at any joints that aren’t moving well. Sometimes a lot of times the shoulder blade isn't moving very good, the collarbone isn't moving very good. The upper back joints in the spine aren’t moving very good, and all the ribs associated with that, we have to get that moving.
Sometimes we have to look at the chest muscles as well and see how flexible, or how strong those are. The ball and socket joint as well, we’ll look at how well aligned that joint is, and how the quality of motion within that joint, and then all the muscles that control it. Of course, the rotator cuff muscles are the big one. But there are a bunch of other muscles that contribute to its mobility that we have to look at.
It's a big long process and it's not even a direct treatment for the nerves. This is all indirect. But there are even times where we have to do specific techniques to the nerves to get them to begin to operate more normally. That's a whole other ballgame. But the good news with all this is that rarely does anybody need surgery.
Usually, when people get surgery for this type of problem, they are getting a surgery in their neck where they, I say this in air quotes, they clean it up, they clean up the neck. Where I said that there are holes in the side of the neck, and you can get stenosis where the hole narrows a bit. They can go in there and widen the holes surgically. But I always tell people that are looking to get that procedure done, it's probably going to close again if you don't fix your posture or address your strength. But you have to consider what got you to close the hole in the first place.
Because if you begin to undo that, maybe you have a shot at opening it up on your own naturally, without having to go in for a surgery that may only last for a year or two, before it closes down again. And then you are going to be stuck with, I'm going to have to have another surgery or go through physical therapy anyway, like I should have the first time potentially.
Now there are cases where it's severely pinched. And usually this person has of course, immense pain, but they also will have lost completely loss of strength, like they can't use your hand. The muscles in one hand look completely different compared to the other, the bicep will be weak, the tricep will be very weak. I mean, you can tell a notable, massive difference. Most people have some minor differences. If they take their shirt off and look in the mirror, they just look at their arms and they'll notice a small difference in muscle size from one side to the other.
But when it's pretty massive, when it's obvious, and other people can tell pretty easily. There's usually either a chronically pinched nerve, and when I say chronic, it's probably been years, potentially decades, or it's just been so hard that it has almost no nerve input. And it's just gotten weaker and weaker over time, very, very quickly. Over the course of a few months, it's lost all its strength.
That's a situation where you might actually need surgery. But to my knowledge, I don't know surgeons that will operate on the first and second rib to put it down. That's something that's done by hand here in the clinic. And then to increase mobility in the spine. That's a combination of hands on work from a specialist physical therapist, and then also exercise that a patient has to go through, that's guided by a specialist physical therapist as well.
But I, to this date, I've never worked with a client that ended up having surgery for a pinched nerve, we've helped everybody just fine. The good news is it gets better. We have an awesome success rate with these clients, and they get tremendously better. They get to the point where they are exercising, if that's what they wanted to do, they are sleeping fantastic.
We know we have to talk about posture, so they are sitting better at work, they are driving better whenever they are in the car, they are having a meal much more comfortably, and most importantly, they have the confidence to move without that fear that something is going to bite them in their neck and shoulder area. So, it's extremely fixable.
Thanks for listening today. I hope you learned a lot. If you want to learn more information about neck and shoulder problems, there are tons of blog articles on our website. Our YouTube channel is very active if you want to get notified right away when we release a new YouTube video, go to our YouTube channel El Paso Manual Physical Therapy and hit subscribe, and you'll get all our latest information about the neck and shoulder as well as other body parts.
I hope you have the best day and if you are out there with a neck and shoulder pinched nerve problem, please get some help as soon as possible. Don't let it get really bad.
