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Nerve Injury

Back Clinic Nerve Injury Team. Nerves are fragile and can be damaged by pressure, stretching, or cutting. Injury to a nerve can stop signals to and from the brain, causing muscles not to work properly and losing feeling in the injured area. The nervous system manages a great majority of the body’s functions, from regulating an individual’s breathing to controlling their muscles as well as sensing heat and cold. But, when trauma from an injury or an underlying condition causes nerve injury, an individual’s quality of life may be greatly affected. Dr. Alex Jimenez explains various concepts through his collection of archives revolving around the types of injuries and condition which can cause nerve complications as well as discuss the different form of treatments and solutions to ease nerve pain and restore the individual’s quality of life.

General Disclaimer *

The information herein is not intended to replace a one-on-one relationship with a qualified healthcare professional or licensed physician and is not medical advice. We encourage you to make your own health care decisions based on your research and partnership with a qualified health care professional. Our information scope is limited to chiropractic, musculoskeletal, physical medicines, wellness, sensitive health issues, functional medicine articles, topics, and discussions. We provide and present clinical collaboration with specialists from a wide array of disciplines. Each specialist is governed by their professional scope of practice and their jurisdiction of licensure. We use functional health & wellness protocols to treat and support care for the injuries or disorders of the musculoskeletal system. Our videos, posts, topics, subjects, and insights cover clinical matters, issues, and topics that relate to and support, directly or indirectly, our clinical scope of practice.* Our office has made a reasonable attempt to provide supportive citations and has identified the relevant research study or studies supporting our posts. We provide copies of supporting research studies available to regulatory boards and the public upon request.

We understand that we cover matters that require an additional explanation of how it may assist in a particular care plan or treatment protocol; therefore, to further discuss the subject matter above, please feel free to ask Dr. Alex Jimenez or contact us at 915-850-0900.

Dr. Alex Jimenez DC, MSACP, CCST, IFMCP*, CIFM*, ATN*

email: coach@elpasofunctionalmedicine.com

Licensed in: Texas & New Mexico*

 


Nerve Conduction Velocity: Key Insights on Nerve Health

Nerve Conduction Velocity: Key Insights on Nerve Health

Should individuals experiencing nerve pain or various sensations get a nerve conduction velocity study to examine nerve health and function?

Nerve Conduction Velocity: Key Insights on Nerve Health

Nerve Conduction Velocity

A nerve conduction velocity (NCV) is a noninvasive test that measures the speed and strength of nerve stimulation using electrical probes placed on the skin. It’s used to diagnose nerve damage or disease, often alongside an EMG (electromyogram) to differentiate between nerve and muscle problems. It can also evaluate sensory issues, pain, and weakness of the extremities.

  • This test involves safe electrical shocks that can be slightly uncomfortable but not painful.
  • Nerve conduction velocity (NCV) measures the speed at which electrical impulses travel along a nerve fiber, which measures how quickly electrical signals travel through a nerve.
  • This information indicates nerve health and function.
  • Electromyography (EMG) is a nerve test that involves placing tiny needles into the muscles.
  • A slower NCV can indicate nerve injury or dysfunction.

Test Uses

Generally, the test is ordered to assess peripheral nerve diseases, those that connect from the muscles, organs, and skin to the spinal cord or brain. It can help identify the type and location of nerve damage.

  • Peripheral nerve conditions typically cause pain, sensory loss, tingling, or burning.
  • Mild weakness and diminished reflexes can be detected during a neurological examination.

Conditions

Nerve conduction studies are performed to help diagnose conditions.

  • Herniated disc disease
  • Sciatic nerve problems
  • Carpal tunnel syndrome
  • Guillain-Barré syndrome
  • Nerve damage (neuropathy), such as from diabetes, chemotherapy, or autoimmune disorders
  • Charcot-Marie-Tooth disease

Nerve compression

  • Many different conditions, including trauma, inflammation, and tumors, can compress one or more nerves.

Radiculopathy

  • Often described as a pinched nerve, radiculopathy can affect an arm or a leg, causing pain and weakness.

Peripheral Neuropathy

  • This nerve damage begins in the most distal nerves, those farthest from the center of the body, such as the toes and fingers. It is often due to chronic alcohol misuse, uncontrolled diabetes, nutritional deficits, and inflammatory diseases. (Ferdousi M. et al., 2020)

Carpal Tunnel Syndrome

  • Commonly caused by inflammatory diseases or overuse of the wrists, such as from assembly line work, carpal tunnel syndrome causes numbness, pain, and weakness of the fingers and hands. (Tada K. et al., 2022)

Ulnar neuropathy

  • This common condition causes arm pain and sensory changes, usually due to repetitive movements or a prolonged position that causes pressure on the ulnar nerve.

Guillain-Barré syndrome (GBS)

  • This inflammatory condition causes demyelination, or loss of the insulating covering around nerves, which results in leg weakness.
  • It begins in the motor nerves, which send signals to muscles in the legs. (Shibuya K. et al., 2022)
  • The inflammation travels to nerves of the upper body, often affecting the muscles that control breathing.
  • Respiratory support is necessary until the condition improves.

Chronic Demyelinating Polyneuropathy (CIDP)

  • This condition is a chronic, recurrent form of GBS that usually affects the legs and causes episodes of weakness.

ICU neuropathy

  • Metabolic changes, severe illness, and not moving enough can cause nerves to develop a pattern of weakness and sensory loss.

Myasthenia gravis (MG)

  • This autoimmune condition affects the junction between the nerves and the muscles.
  • Myasthenia gravis causes drooping eyelids and weakness of the arms and shoulders.

Amyotrophic lateral sclerosis (ALS)

  • ALS is a serious, degenerative disease affecting the spinal cord’s motor neurons.
  • Amyotrophic lateral sclerosis progresses rapidly, resulting in substantial weakness of muscles throughout the body.

How it’s Done

  • Surface electrodes are placed on the skin over nerves, and a small electrical current is applied to stimulate the nerve.
  • The time it takes for the electrical signal to travel between the electrodes is measured, and this time is used to calculate the NCV.

Values

Normal NCV values are generally between 50 and 70 meters per second. However, these values can vary depending on the nerve and the individual.

NCV Factors

Various factors can influence NCV.

  • Age
  • Sex
  • Medical conditions like diabetes

Interpretation

  • A slower NCV can indicate nerve damage or demyelination (loss of the myelin sheath, which insulates nerve fibers), while an EMG can help determine if the problem is with the nerve or the muscle.

Results

The results of NCV testing can be used to determine the type, severity, and location of nerve damage. The results will be ready in report form about a week after the test.

  • The test measures velocity (how fast a nerve transmits signals) and amplitude (how many nerve fibers were activated). (Tavee J. 2019)
  • The measurements are transmitted to a computer and shown as waves and numerical values.
  • The values are compared to a standard measurement based on the tested nerve.
  • The distance between the electrodes.
  • The person’s age.

Compared to the standard, the NCV results can identify certain patterns of nerve damage. (Tada K. et al., 2022) Outcomes include: (Tavee J. 2019)

  • If one or more nerves are affected.
  • If motor nerves (control movement), sensory nerves (transmit sensory signals), or both are affected.
  • Whether a nerve is blocked or damaged.
  • The severity of the damage.
  • The type of nerve damage
  • Axonal (damage to the nerve itself)
  • Demyelination (damage to the protective fatty layer around the nerve)

The results can help point to certain diagnoses.

Preparation Before the Test

Individuals will not need to change their diet before having an NCV. However, patients will be asked to avoid lotions or creams on their skin before the test. Individuals who are also having an EMG at the time of their NCV might be asked to stop taking medications or supplements that increase the risk of bleeding and bruising. If a healthcare provider says not to stop taking the medicines for health reasons, the patient might be warned that they could have some bruising after the EMG test.

  • NCV may advise against getting the test for those with electrical device implants.
  • Make sure your healthcare providers are aware of your whole medical history.

Injury Medical Chiropractic & Functional Medicine Clinic

Injury Medical Chiropractic and Functional Medicine Clinic works with primary healthcare providers and specialists to develop an optimal health and wellness solution. We focus on what works for you to relieve pain, restore function, and prevent injury. Regarding musculoskeletal pain, specialists like chiropractors, acupuncturists, and massage therapists can help mitigate the pain through spinal adjustments that help the body realign itself. They can also work with other medical professionals to integrate a treatment plan to resolve musculoskeletal issues.


Peripheral Neuropathy and Chiropractic Care


References

Ferdousi, M., Kalteniece, A., Azmi, S., Petropoulos, I. N., Worthington, A., D’Onofrio, L., Dhage, S., Ponirakis, G., Alam, U., Marshall, A., Faber, C. G., Lauria, G., Soran, H., & Malik, R. A. (2020). Corneal confocal microscopy compared with quantitative sensory testing and nerve conduction for diagnosing and stratifying the severity of diabetic peripheral neuropathy. BMJ open diabetes research & care, 8(2), e001801. doi.org/10.1136/bmjdrc-2020-001801

Tada, K., Murai, A., Nakamura, Y., Nakade, Y., & Tsuchiya, H. (2022). In Carpal Tunnel Syndrome, Sensory Nerve Conduction Velocities Are Worst in the Middle Finger Than in the Index Finger. Frontiers in Neurology, 13, 851108. doi.org/10.3389/fneur.2022.851108

Shibuya, K., Tsuneyama, A., Misawa, S., Suzuki, Y. I., Suichi, T., Kojima, Y., Nakamura, K., Kano, H., Ohtani, R., Aotsuka, Y., Morooka, M., Prado, M., & Kuwabara, S. (2022). Different patterns of sensory nerve involvement in chronic inflammatory demyelinating polyneuropathy subtypes. Muscle & Nerve, 66(2), 131–135. doi.org/10.1002/mus.27530

Tavee J. (2019). Nerve conduction studies: Basic concepts. Handbook of Clinical Neurology, 160, 217–224. doi.org/10.1016/B978-0-444-64032-1.00014-X

Pinched Nerve in the Neck: When to Seek Help

Pinched Nerve in the Neck: When to Seek Help

Can physical therapy help individuals with a pinched nerve in the neck?

Pinched Nerve in the Neck: When to Seek Help

Pinched Nerve In The Neck

A pinched nerve in the neck can cause pain, numbness, and weakness that extends through the neck, shoulder, and arm. (American Academy of Orthopaedic Surgeons, 2024) Over-the-counter pain medications, resting the muscles, and gentle stretching can help. However, if you’re still in pain after a few days, see a healthcare provider. Common treatments include:

  • Rest
  • Over-the-counter (OTC) pain meds
  • Physical therapy
  • Steroid injections
  • Wearing a neck collar

Surgery is rarely needed, but it can provide relief if other treatments don’t help. Most of the time, a pinched nerve resolves within days or weeks.

How a Pinched Nerve in the Neck Feels

The term for neck nerve pain is cervical radiculopathy (cervical spine pain). Common symptoms of a pinched nerve in the neck are: (American Academy of Orthopaedic Surgeons, 2024)

  • Sharp pain that extends into the shoulder and arm.
  • The pain worsens, or there is a shooting sensation when turning the head.
  • Tingling or feeling of pins-and-needles in the fingers or hand.
  • Weakness in the arm, shoulder, or hand.
  • Numbness or loss of feeling.

Often, these symptoms occur only on one side. Some find their pain less when they lift their hand onto their head, which can relieve pressure on the nerve.

Causes

The cervical spine is the spinal cord area around the neck. It’s made up of seven vertebrae. Nerves branch off the spinal cords in the spaces between the vertebrae. Nerve compression occurs when the space between two vertebrae is reduced, putting pressure on the nerve, pinching it, and causing pain. Pinched nerves develop from age because the spinal discs between the vertebrae become compressed over time. Age causes about 70% to 80% of nerve compression. Other factors that cause pinched nerves include: (Harvard Health Publishing, 2021)

  • Degenerative disc disease
  • A herniated disc
  • Injuries like car accidents falls, or other trauma to the spine
  • Spinal stenosis

Self-Care Relief

If you have nerve pain and think it is a pinched nerve, self-care can help (National Institute of Neurological Disorders and Stroke, 2025)

Rest

  • Find a comfortable position and try to allow the muscles in your neck to relax and rest.

Heat or Ice

  • Warmth and coolness can relieve pain and inflammation.
  • Use a warm or cool compress for 15 minutes at a time.

Over-The-Counter Pain Medications

  • Pain medications, including nonsteroidal anti-inflammatory drugs (NSAIDs), can help bring relief.

Treatment for Severe Symptoms

If pain doesn’t resolve within a few days, or if it is so bad that you can’t go about daily activities, it’s recommended to see a healthcare provider. They can diagnose a pinched nerve after a physical exam and may also recommend imaging, including an X-ray, CT scan, MRI, or EMG, to reveal what’s causing the symptoms. After diagnosing the condition, the healthcare provider will develop a personalized treatment plan, which may include the following (Harvard Health Publishing, 2021)

Physical Therapy

  • Physical therapy can help build strength and flexibility in the neck.
  • This is especially important if there is frequent nerve pain in the same spot.

Cervical Collar

  • A soft cervical collar is a brace that fits around the neck.
  • It supports your head so the neck muscles can relax, facilitating healing.
  • The collar can also keep the head from turning in painful ways.

Oral Corticosteroids

  • Oral steroids like prednisone can help reduce inflammation.
  • If inflammation or swelling in the neck puts more pressure on the nerve, they can help.

Steroid Injections

  • Steroid shots right into the painful tissue reduce inflammation right away.

Muscle Relaxers

  • These medications keep the muscles in the neck from seizing up.
  • As the muscles relax, this brings pain relief.

Narcotic Pain Medications

  • Narcotic pain medications can be used short-term by individuals who have severe pain.
  • A healthcare provider will inform the patient of the benefits and drawbacks of these medications, which include opiates.

Neck Exercises

Gentle stretches can help alleviate the pain and strengthen the muscles. (National Health Service, 2025)

Chin to chest

  • Bring your chin toward your chest.
  • Hold for 20 seconds, then return to a neutral position.
  • Do this five times.

Eyes to Sky

  • Lean your head back and look toward the sky.
  • Hold for 20 seconds, then return to your starting position.
  • Do this five times.

Side to Side

  • Turn your head to the right as far as possible, bringing your chin in line with your shoulder.
  • Hold for 20 seconds, then turn as far as possible toward the left.
  • Repeat four times.

Ear to Shoulder

  • Bring your ear down toward your shoulder.
  • Hold for 20 seconds, then repeat the exercise on the other side.
  • Alternate between the right and left, stretching each side five times.

While it’s normal for exercises to hurt from stretching the muscles, they should never hurt more than a five on a pain scale of 1 to 10. If they do, stop exercising (National Health Service, 2025)

Healing Time

Healing and recovery depend on the severity of the injury. Some individuals find that the pain from a pinched nerve goes away in days, while for others, it can last for weeks. The pain goes away and then returns. If pain doesn’t go away with the conservative treatments or lasts more than a few days, talk with a healthcare provider or return for a second visit. Rarely do individuals need surgery to bring pain relief. The healthcare provider will discuss whether surgery is the best option and what to expect regarding pain relief. (American Academy of Orthopaedic Surgeons, 2024)

Injury Medical Chiropractic and Functional Medicine Clinic

Injury Medical Chiropractic and Functional Medicine Clinic works with primary healthcare providers and specialists to build optimal health and wellness solutions. We focus on what works for you to relieve pain, restore function, prevent injury, and mitigate issues through adjustments that help the body realign itself. The clinic can also work with other medical professionals to integrate a treatment plan to resolve musculoskeletal problems.


Revitalize and Rebuild with Chiropractic


References

American Academy of Orthopaedic Surgeons. OrthoInfo. (2024). Cervical radiculopathy (pinched nerve). orthoinfo.aaos.org/en/diseases–conditions/cervical-radiculopathy-pinched-nerve/

Harvard Health Publishing. Publishing, H. H. (2021). Treating a pinched nerve. www.health.harvard.edu/pain/treating-a-pinched-nerve

National Institute of Neurological Disorders and Stroke. (2025). Pinched Nerve Definition. Retrieved from www.ninds.nih.gov/health-information/disorders/glossary-neurological-terms#-P-

National Health Service. Service, N. H. (2025). Exercises for neck problems. www.nhsinform.scot/illnesses-and-conditions/muscle-bone-and-joints/neck-and-back-problems-and-conditions/exercises-for-neck-problems

Managing Alcoholic Peripheral Neuropathy: Treatment Options

Managing Alcoholic Peripheral Neuropathy: Treatment Options

Excessive alcohol consumption: what is alcoholic peripheral neuropathy?

Managing Alcoholic Peripheral Neuropathy: Treatment Options

Alcoholic Peripheral Neuropathy

Alcoholic peripheral neuropathy (ALN) is a condition that damages the nerves in the body due to chronic alcohol consumption. It can cause sensory, motor, and autonomic dysfunction, which can lead to disability. This damage prevents the nerves from communicating information. Most symptoms generally start as mild but typically worsen over time as the neuropathy progresses. The most common symptoms are: (National Library of Medicine, 2023)

  • Numbness or tingling sensation in the extremities
  • Pain or a burning sensation in the extremities
  • Difficulty walking
  • Difficulty urinating
  • Difficulty talking or swallowing

Affected nerves include the peripheral and autonomic nerves, which help regulate internal body functions. Around 46% of chronic alcohol users will eventually develop the condition. (Julian T., Glascow N., Syeed R., & Zis P. 2019)

Causes

The exact cause of alcoholic neuropathy is unclear. But it is directly related to heavy and long-term alcohol consumption. (Julian T., Glascow N., Syeed R., & Zis P. 2019) It is believed overconsumption of alcohol can directly harm and hinder the nerves’ ability to communicate information. Unhealthy nutritional habits are often associated with it as well. Research shows that decreased thiamine/B vitamin plays a role, while others suggest an overall dietary deficiency may play a role. (Julian T., Glascow N., Syeed R., & Zis P. 2019) However, alcoholic neuropathy can also occur without the presence of malnutrition. (Julian T., Glascow N., Syeed R., & Zis P. 2019)

Neuropathy Development and Progression

Alcoholic peripheral neuropathy develops depending on many factors, including the amount of daily/nightly alcohol consumed, age and overall health, nutritional intake, and other individual factors. In most cases, the neuropathy takes several years or decades to develop, depending on the amount of alcohol consumed.

Symptoms

Symptoms are usually related to nerve dysfunction and include: (National Library of Medicine, 2023)

  • A tingling or pins-and-needles sensation in the extremities.
  • Numbness of the extremities, most commonly in the legs or feet. (Julian T., Glascow N., Syeed R., & Zis P. 2019)
  • Pain or burning sensation in the arms, legs, or feet.
  • Symptoms that occur in the arms and legs typically affect both sides.
  • Cramps, aches, or weakness of the muscles.
  • Constipation or diarrhea.
  • Nausea and vomiting.
  • Difficulty urinating or incontinence.
  • Difficulty walking.
  • Difficulty talking or swallowing.
  • Heat intolerance.
  • Erection difficulties.

Most symptoms begin as mild and usually worsen over time as the neuropathy progresses. Alcoholic neuropathy affects individuals who consume excessive amounts of alcohol over a long time. (Julian T., Glascow N., Syeed R., & Zis P. 2019)

Diagnosis

Symptoms can vary significantly so that a diagnosis may take time. It usually involves a combination of the following (National Institute of Neurological Disorders and Stroke, 2024)

Medical History

  • Healthcare providers will collect data involving past medical history and all current symptoms.

Physical Exam

  • This exam looks at other medical conditions contributing to symptoms, like diabetes or high blood pressure.

Neurological Exam

  • This is a noninvasive exam to determine the location and extent of neurological damage.
  • Healthcare providers may ask patients several questions and have them complete a series of small movements to check neurological function.

Blood and Urine Tests

  • These tests can detect diabetes, liver and kidney problems, infections, vitamin deficiencies, and other conditions that can cause neuropathic conditions.

Chronic alcohol use can also affect how the body stores and uses vitamins necessary for healthy nerve function. Vitamin levels that a healthcare provider may check include: (National Library of Medicine, 2023)

  • Vitamin A
  • Biotin
  • Folic acid
  • Niacin, or vitamin B3
  • Pyridoxine, or vitamin B6
  • Pantothenic acid

Liver Disease

Individuals with chronic liver disease often have neuropathy. The severity and stage are associated with a higher incidence of neuropathy. (Pasha MB, Ather MM, Tanveer MA, et al. 2019)

Treatment

Alcoholic neuropathy is not reversible, even when quitting drinking. However, individuals with the condition can make healthy changes to minimize symptoms and receive help for chronic alcohol use. The first step is stopping alcohol consumption. (Chopra K., & Tiwari V. 2012) Talk to a healthcare provider about what options are available. Treatment can include:

  • In-patient or outpatient rehab
  • Therapy
  • Medication
  • Social support from groups like Alcoholics Anonymous

A combination of treatments will likely be utilized. Other treatment options involve symptom management and preventing further injuries and may include:

  • Physical therapy
  • Keeping the head elevated while sleeping.
  • Orthopedic splints to maintain limb function and positioning.
  • Wearing compression stockings.
  • Adding vitamins and supplements.
  • Eating extra salt for those without hypertension
  • Medications to reduce pain and discomfort.
  • Intermittent catheterization or manual expression of urine for those with difficulty urinating.

Individuals with neuropathy may have reduced sensitivity in the arms and legs. If this occurs, additional steps need to be taken to prevent other injuries, that include (National Library of Medicine, 2023)

  • Wear special footwear to prevent foot injuries.
  • Checking feet daily for wounds.
  • Prevent burns by ensuring that bath and shower water is not too hot.

Injury Medical Chiropractic and Functional Medicine Clinic

Injury Medical Chiropractic and Functional Medicine Clinic works with primary healthcare providers and specialists to build optimal health and wellness solutions. We focus on what works for you to relieve pain, restore function, prevent injury, and help mitigate issues through adjustments that help the body realign itself. They can also work with other medical professionals to integrate a treatment plan to resolve musculoskeletal problems.


Peripheral Neuropathy Myths and Facts


References

National Library of Medicine. (2023). Alcoholic neuropathy. Retrieved from medlineplus.gov/ency/article/000714.htm

Julian, T., Glascow, N., Syeed, R., & Zis, P. (2019). Alcohol-related peripheral neuropathy: a systematic review and meta-analysis. Journal of Neurology, 266(12), 2907–2919. doi.org/10.1007/s00415-018-9123-1

National Institute of Neurological Disorders and Stroke. (2024). Peripheral neuropathy. Retrieved from www.ninds.nih.gov/health-information/disorders/peripheral-neuropathy

Pasha MB, A. M., Tanveer MA, et al. (2019). Frequency of peripheral neuropathy in chronic liver disease. Med Forum Monthly, 30(8), 23-26. medicalforummonthly.com/index.php/mfm/article/view/3761

Chopra, K., & Tiwari, V. (2012). Alcoholic neuropathy: possible mechanisms and future treatment possibilities. British journal of clinical pharmacology, 73(3), 348–362. doi.org/10.1111/j.1365-2125.2011.04111.x

The Role of Nociceptors in Sensing and Responding to Pain

The Role of Nociceptors in Sensing and Responding to Pain

Can understanding how nociceptors function and their role in processing pain signals help individuals who are managing injuries and/or living with chronic pain conditions?

The Role of Nociceptors in Sensing and Responding to Pain

Nociceptors

Nociceptors are nerve endings that detect harmful stimuli, such as extreme temperatures, pressure, and chemicals, and signal pain. They are the body’s first defense against potentially damaging environmental inputs.

  • Nociceptors are in the skin, muscles, joints, bones, internal organs, deep tissues, and cornea.
  • They detect harmful stimuli and convert them into electrical signals.
  • These signals are sent to the brain’s higher centers.
  • The brain interprets the signals as pain, which prompts the body to avoid the harmful stimulus.

Nociceptors, often called pain receptors, are free nerve endings all over the body. They play a pivotal role in how the body feels and reacts to pain. The main purpose of a nociceptor is to respond to damage to the body by transmitting signals to the spinal cord and brain. (Purves D, Augustine GJ, Fitzpatrick D, et al., editors. 2001) If you bang your foot, the nociceptors on the skin are activated, sending a signal to the brain via the peripheral nerves to the spinal cord. Pain resulting from any cause is transmitted this way. Pain signals are complex, carrying information about the stimuli’s location and intensity. This causes the brain to fully process the pain and send communication back to block further pain signals.

Classification

There are different classes of nociceptors, which are based on which type of stimuli they respond to (University of Texas McGovern Medical School, 2020)

Thermal

  • Thermal nociceptors respond to extreme hot or cold temperatures.
  • For instance, when touching a hot stove, the nociceptors, which signal pain, are activated immediately, sometimes before you know what you’ve done.

Mechanical

  • Mechanical nociceptors respond to intense stretching or strain, such as pulling a hamstring or straining a tendon.
  • The muscles or tendons are stretched beyond their ability, stimulating nociceptors and sending pain signals to the brain.

Chemical

  • Chemical nociceptors respond to chemicals released from tissue damage.
  • For example, prostaglandins and substance P or external chemicals like topical capsaicin pain creams.

Silent

  • Silent nociceptors must be first activated by tissue inflammation before responding to a mechanical, thermal, or chemical stimulus.
  • Most visceral nociceptors are located on organs in the body.

Polymodal

  • Polymodal nociceptors respond to mechanical, thermal, and chemical stimuli.

Mechano-thermal

  • Mechano-thermal nociceptors respond to mechanical and thermal stimuli.

Pain Transmission

Nociceptors are also classified by how fast they transmit pain signals. Transmission speed is determined by the type of nerve fiber known as an axon a nociceptor has. There are two main types.

  • The first type is A fiber axon, fibers surrounded by a fatty, protective sheath called myelin.
  • Myelin allows nerve signals/action potentials to travel rapidly.
  • The second type is C fiber axons, which are not surrounded by myelin and transmit slower. (University of Texas McGovern Medical School, 2020)

Because of the difference in transmission speed, the pain signals from the A fibers reach the spinal cord first. As a result, after an acute injury, an individual experiences pain in two phases, one from the A fibers and one from the C fibers. (Ngassapa D. N. 1996)

Pain Perception Phases

When an injury occurs, the stimulated nociceptors activate the A fibers, causing a person to experience sharp, prickling pain.

  1. This is the first phase of pain, known as fast pain, because it is not especially intense but comes right after the stimulus.
  2. During the second phase of pain, the C fibers are activated, causing an intense, burning pain that persists even after the stimulus has stopped.
  3. The fact that the C fibers carry burning pain explains why there is a short delay before feeling the sensation.
  4. The C fibers also carry aching, sore pain caused by organs within the body, such as a sore muscle or stomachache. (Ngassapa D. N. 1996)

Injury Medical Chiropractic and Functional Medicine Clinic

Injury Medical Chiropractic and Functional Medicine Clinic works with primary healthcare providers and specialists to build optimal health and wellness solutions. We focus on what works for you to relieve pain, restore function, prevent injury, and help mitigate issues through adjustments that help the body realign itself. They can also work with other medical professionals to integrate a treatment plan to resolve musculoskeletal problems.


From Injury To Recovery With Chiropractic Care


References

Purves D, A. G., Fitzpatrick D, et al., editors. (2001). Nociceptors. In Neuroscience. 2nd edition. (2nd ed.). Sunderland (MA): Sinauer Associates. www.ncbi.nlm.nih.gov/books/NBK10965/

University of Texas McGovern Medical School. (2020). Chapter 6: Pain Principles. nba.uth.tmc.edu/neuroscience/m/s2/chapter06.html

Ngassapa D. N. (1996). Comparison of functional characteristics of intradental A- and C-nerve fibres in dental pain. East African medical journal, 73(3), 207–209.

The Role of the Long Thoracic Nerve in Shoulder Stability

The Role of the Long Thoracic Nerve in Shoulder Stability

Can understanding the anatomy and function of the long thoracic nerve help individuals make informed healthcare decisions after an injury to the nerve?

The Role of the Long Thoracic Nerve in Shoulder Stability

Long Thoracic Nerve

Also referred to as the posterior thoracic nerve, the long thoracic nerve/LTN is a thin superficial nerve that runs from the cervical spine to the chest wall side of the trunk. It supplies motor function to the thorax’s serratus anterior muscle, helping stabilize the shoulder blade. Injury to this nerve can cause limited or abnormal shoulder and shoulder blade motion, including difficulty raising the arm during overhead reaching.

Anatomy

The long thoracic nerve originates from the ventral rami of cervical nerves C5, C6, and C7. (Waxenbaum JA, Reddy V, Bordoni B. 2023) In some individuals, the root from C7 is absent; in others, a small nerve root branches from C8. The nerve roots from C5 and C6 go through the medial scalene muscle to join the C7 nerve. It travels behind the brachial plexus axillary artery and vein and courses down the lateral side of the thorax. The long thoracic nerve terminates at the lower portion of the serratus anterior muscle, sending small nerve tendrils to each muscle’s projections, which attach to the ribs. Because the long thoracic nerve is located on the lateral side of the chest, it is vulnerable to injury during sports or surgical procedures. The nerve also has a smaller diameter than other cervical and brachial plexus nerves, which increases its potential for injury.

Function

The long thoracic nerve attaches to the underside of the shoulder blade and inserts as muscular slips into the ribs. It supplies motor function to the serratus anterior muscle, essential for normal shoulder motion. When it contracts, it pulls the shoulder blade against the ribs and thorax, helping to move and stabilize the arm as it moves forward and up during shoulder motions. Injury to the long thoracic nerve causes a condition called scapular winging. This occurs when the serratus anterior muscle becomes weakened or paralyzed after injury. (Lung K, St Lucia K, Lui F. 2024)

Susceptibility to Injury

The LTN is relatively unprotected and can be damaged by several things, including:

  • Heavy backpacks
  • Sports
  • Activities the body is not used to, like digging
  • Using crutches

Conditions

Injury to the long thoracic nerve may occur as a result of trauma, lifting heavy weights above the shoulder, or a surgical procedure. Surgical procedures that may place the nerve at risk for injury may include: (Lung K, St Lucia K, Lui F. 2024)

  • Axillary lymph node dissection
  • Improperly placed intercostal drains
  • Chest tube placements
  • Mastectomy
  • Thoracotomy

The long thoracic nerve is protected during these procedures by the surgeon and proper surgical technique, but occasionally, difficulties arise during surgery, and the nerve may become injured. Individuals may also have an anatomical variance that places their nerves in varying positions. The surgeon may not see it and accidentally injure their nerves during surgery.

The superficial long thoracic nerve may also be injured during sports or trauma to the trunk. A blow to the side or a sudden overhead stretch to the shoulder may be enough to damage the nerve, paralyzing the serratus anterior muscle.

Weakness or paralysis of the serratus anterior muscle will result in a winged scapula. To test for this:

  • Stand about two feet from a wall, facing it.
  • Place both hands on the wall and gently push against it.
  • If one of the shoulder blades sticks out abnormally, it could be a winged scapula.
  • Have a family member or friend stand behind you and check the shoulder blade position.
  • If you suspect a winged scapula, visit a physician who can assess the condition and determine if there is a long thoracic nerve injury.

Winging the scapula may result in difficulty lifting the arm overhead. The serratus anterior muscle works with other scapular stabilizers, such as the upper trapezius and levator scapula, to properly position the shoulder blade when lifting the arm. Failure of the serratus to stabilize the shoulder blade may make lifting the arm impossible.

Clinical examination is usually used to diagnose a long thoracic nerve injury. X-rays and MRIs cannot show the nerve injury directly, although an MRI can show some secondary signs to help confirm the diagnosis. An electromyographic or EMG test may also be performed to examine the function of the long thoracic nerve.

Treatment and Rehabilitation

Treatment for LTN pain and reduced movement may include:

  • Rest
  • Heat or ice
  • Anti-inflammatory pain medication
  • Neck support or a pillow
  • Avoiding strenuous activity and driving

If the long thoracic nerve is severely injured and the serratus anterior is completely paralyzed, the best course of action is to be active and monitor the condition. Full recovery of arm function can take one to two years. If permanent nerve injury has occurred, surgery may be an option to restore shoulder motion and function. Several different kinds of surgery can be used to address winged scapula. (Vetter M. et al., 2017)

  • One involves transferring the pectoralis major tendon to the scapula (Vetter M. et al., 2017) so it functions as the serratus.
  • Often, the tendon has to be lengthened, which may be done using part of the hamstring tendon.
  • After surgery, individuals will likely wear a sling on their arm for a few weeks, and then gentle range-of-motion exercises will be initiated.
  • After eight to ten weeks, gentle progressive strengthening of the new tendon can begin.
  • Full shoulder motion and strength recovery are expected six to 12 months after surgery.

Physical therapy may be used to help improve serratus anterior functions. (Berthold J. B., Burg T. M., & Nussbaum R. P. 2017) Exercises to strengthen serratus function may include:

Supine Punches

  • Lie on your back and raise both arms toward the ceiling.
  • Make a fist and punch up toward the ceiling.
  • Ensure the motion is steady and deliberate, and keep the elbow straight.
  • Hold the position for three seconds, then slowly lower the arm to the starting position.
  • Perform 10 to 15 repetitions.
  • Holding a small dumbbell in your hands can make the exercise more challenging.

Pushup

  • Lie on your stomach and place your hands flat on the ground by your shoulders as if you were going to perform a pushup.
  • Perform a pushup and press further, allowing the shoulder blades to wrap around the thorax.
  • Hold this position for three seconds, and slowly release.
  • Perform 10 to 15 reps.
  • If this is too difficult, perform the pushup against a wall to reduce the effect of gravity on the exercise.

Scapular Winging in Depth


References

Waxenbaum, J. A., Reddy, V., & Bordoni, B. (2024). Anatomy, Head and Neck: Cervical Nerves. In StatPearls. www.ncbi.nlm.nih.gov/pubmed/30844163

Lung, K., St Lucia, K., & Lui, F. (2024). Anatomy, Thorax, Serratus Anterior Muscles. In StatPearls. www.ncbi.nlm.nih.gov/pubmed/30285352

Vetter, M., Charran, O., Yilmaz, E., Edwards, B., Muhleman, M. A., Oskouian, R. J., Tubbs, R. S., & Loukas, M. (2017). Winged Scapula: A Comprehensive Review of Surgical Treatment. Cureus, 9(12), e1923. doi.org/10.7759/cureus.1923

Berthold, J. B., Burg, T. M., & Nussbaum, R. P. (2017). Long Thoracic Nerve Injury Caused by Overhead Weight Lifting Leading to Scapular Dyskinesis and Medial Scapular Winging. The Journal of the American Osteopathic Association, 117(2), 133–137. doi.org/10.7556/jaoa.2017.025

Effective Treatment for Nerve Injuries: Causes and Solutions

Effective Treatment for Nerve Injuries: Causes and Solutions

Can individuals with nerve injuries incorporate non-surgical treatments to reduce pain sensations and restore motor function to their bodies?

Introduction

The human body is a complex machine of nerves, bones, organs, tissues, and muscles that help the individual be mobile, flexible, and stable during various activities without pain and discomfort. However, when numerous factors start to hurt the body, it can lead to multiple overlapping risk profiles that can affect the body’s extremities and nerve injuries. Dealing with nerve injuries can lead to referred pain in the musculoskeletal system, and many people think it is muscle pain instead of nerve injury. When that happens, many individuals will begin to seek treatment to reduce not only the symptoms of nerve injuries but also reduce the pain associated with the nerves. In today’s article, we will look at what causes nerve injuries and how non-surgical treatments like chiropractic care and acupuncture can help with reducing the overlapping symptoms of nerve injuries and provide relief to the body. We discuss with certified medical providers who inform our patients about how nerve injuries can impact the musculoskeletal system. While asking informed questions to our associated medical providers, we advise patients to incorporate non-surgical treatments like chiropractic care and acupuncture to restore motor function to the body. Dr. Alex Jimenez, D.C., encompasses this information as an academic service. Disclaimer.

 

What Causes Nerve Injuries?

Do you constantly feel tingling or numbness in your legs, arms, feet, and hands? Do your muscles feel so weak that holding objects seems difficult? Or do you feel pain in your extremities, making it difficult to do everyday tasks? The body has trillions of nerves that branch out from the central nervous system and are intertwined with the muscles, tissues, and organs for motor-sensory function. Traumatic injuries, accidents, and normal environmental factors impact the nerves and cause overlapping risk profiles. More often than not, many individuals deal with non-mechanical and mechanical nerve injuries that can occur to the body. With nerve injuries, many individuals can feel various symptoms depending on the severity. Neuropraxia, a moderate form of nerve injury, causes nerve compression in the upper and lower extremities that causes motor dysfunction. (Carballo Cuello & De Jesus, 2024)

 

 

Additionally, neuropraxia can lead to functional impairment to the motor-sensory dysfunction that disrupts the peripheral nervous system, signaling this blocks nerve conduction and transient weakness or paresthesia. (Biso & Munakomi, 2024) When this happens, many individuals dealing with peripheral nerve injury that is associated with neuropraxia can experience structural and functional impairment to the sensory-motor skills in the extremities, which leads to physical disability and neuropathic pain, thus affecting a person’s quality of life. (Lopes et al., 2022) Many individuals dealing with nerve injuries can have various recovery periods depending on the severity. Many people often think they are dealing with musculoskeletal pain in their neck, shoulders, back, and extremities, but it is associated with nerve injury. When this happens, many individuals can seek out treatment to reduce the pain-like symptoms from nerve injuries.

 


Is Motion The Key To Healing?- Video


Non-Surgical Treatments For Nerve Injuries

When it comes to treating nerve injuries, it depends on the severity of the symptoms they cause. Surgical options are recommended to restore motor-sensory function if severe mechanical factors cause nerve injury. However, many individuals will opt out of surgical treatments due to their high cost and will often take over-the-counter medication to ease the pain. However, if the nerve injury is non-mechanical, many individuals can seek non-surgical treatments to reduce the nerve injury affecting the musculoskeletal system. Many non-surgical treatments are preferable to many people because they are cost-effective and can ultimately enhance a person’s care and improve their recovery outcome. (El Melhat et al., 2024) Non-surgical treatments can come in many forms, from chiropractic care to acupuncture, to help reduce the effects of non-mechanical nerve injuries and help restore the sensory-motor function of the musculoskeletal system.

 

Chiropractic Care

Chiropractic care is one of the many non-surgical therapies that use mechanical and manual manipulation of the spine to realign the body and help restore the sensory-motor function to the extremities. With nerve injuries, chiropractic care can help with neural mobilization to release trapped nerves in the affected muscle areas, thus reducing pain-like symptoms of tingling sensations. (Jefferson-Falardeau & Houle, 2019) Additionally, chiropractic care can help increase ROM (range of motion) in the extremities and reduce numbing and tingling sensations.

 

Acupuncture

Acupuncture is another non-surgical treatment that can also help reduce non-mechanical nerve injuries to the body. When a professional acupuncturist uses small, thin needles at different pressure points to rewire the neuron signaling and restore the body’s energy flow, acupuncture can help improve the clinical efficacy of nerve pain intensity and help enhance the person’s quality of life. (Li et al., 2023) Additionally, acupuncture can help improve nerve injury’s emotional and cognitive function and can be combined with other non-surgical treatments. (Jang et al., 2021) When it comes to reducing pain-like symptoms correlated with nerve injury, non-surgical treatments can provide the relief many individuals seek and lead to a happier, healthier life.

 


References

Biso, G., & Munakomi, S. (2024). Neuroanatomy, Neurapraxia. In StatPearls. www.ncbi.nlm.nih.gov/pubmed/32491678

Carballo Cuello, C. M., & De Jesus, O. (2024). Neurapraxia. In StatPearls. www.ncbi.nlm.nih.gov/pubmed/32809336

El Melhat, A. M., Youssef, A. S. A., Zebdawi, M. R., Hafez, M. A., Khalil, L. H., & Harrison, D. E. (2024). Non-Surgical Approaches to the Management of Lumbar Disc Herniation Associated with Radiculopathy: A Narrative Review. J Clin Med, 13(4). doi.org/10.3390/jcm13040974

Jang, J. H., Song, E. M., Do, Y. H., Ahn, S., Oh, J. Y., Hwang, T. Y., Ryu, Y., Jeon, S., Song, M. Y., & Park, H. J. (2021). Acupuncture alleviates chronic pain and comorbid conditions in a mouse model of neuropathic pain: the involvement of DNA methylation in the prefrontal cortex. Pain, 162(2), 514-530. doi.org/10.1097/j.pain.0000000000002031

Jefferson-Falardeau, J., & Houle, S. (2019). Chiropractic Management of a Patient With Radial Nerve Entrapment Symptoms: A Case Study. J Chiropr Med, 18(4), 327-334. doi.org/10.1016/j.jcm.2019.07.003

Li, X., Liu, Y., Jing, Z., Fan, B., Pan, W., Mao, S., & Han, Y. (2023). Effects of acupuncture therapy in diabetic neuropathic pain: A systematic review and meta-analysis. Complement Ther Med, 78, 102992. doi.org/10.1016/j.ctim.2023.102992

Lopes, B., Sousa, P., Alvites, R., Branquinho, M., Sousa, A. C., Mendonca, C., Atayde, L. M., Luis, A. L., Varejao, A. S. P., & Mauricio, A. C. (2022). Peripheral Nerve Injury Treatments and Advances: One Health Perspective. Int J Mol Sci, 23(2). doi.org/10.3390/ijms23020918

 

Disclaimer

Exploring the Axillary Nerve: Structure and Innervation

Exploring the Axillary Nerve: Structure and Innervation

An axillary nerve injury can cause pain, weakness, and shoulder mobility loss. Can physical therapy help restore and maintain shoulder joint flexibility?

Exploring the Axillary Nerve: Structure and Innervation

Axillary Nerve

The axillary nerve, or the circumflex nerve, is a peripheral nerve that runs through the shoulder and supports movement and sensation in the upper limbs. It originates in the neck at the brachial plexus, a network of nerves that extends from the neck and upper torso to the shoulders and arms. Its primary purpose is to supply nerve function to the shoulder joint and three muscles in the arm and also innervates some skin in the region.

Anatomy

Except for the cranial nerves, all the body’s nerves branch off from the spinal cord, emerge from between vertebrae and continue to branch off as they travel to various muscles and other structures. The axillary nerve is named after the axilla, the medical name for the armpit. Individuals have two, one on each side. After leaving the spinal column, the axillary nerve runs behind the axillary artery and continues to the shoulder blade’s lower edge of the subscapularis muscle. It winds back and travels down the arm along the posterior humeral circumflex artery, which then passes through the quadrangular space (a small area of the shoulder blade just above the armpit where there is a gap in the muscles that allows nerves and blood vessels to pass through to the arm before it divides into terminal branches, which are:

Anterior Division

  • Supplies motor innervation to the deltoid’s anterior and middle heads, allowing the arm to abduct or move away from the body.
  • It winds around the neck of the humerus/funny bone, goes beneath the deltoid muscle, and then connects to the forward edge of the deltoid.
  • A few small cutaneous branches serve the skin in that area.

Posterior Division

  • Innervates the teres minor muscles and the lower part of the deltoid.
  • It enters the deep fascia and becomes the superior lateral cutaneous nerve.
  • It then wraps around the lower edge of the deltoid, connects to the skin over the lower two-thirds of the muscle, and covers the long head of the triceps brachii.

Articular Branch

  •  Comes from the trunk of the axillary nerve and enters the glenohumeral joint, which is in the shoulder, below the subscapularis muscle.

Anatomical Variations

In a case report, healthcare providers noted an incidence of the nerve branching directly off the upper trunk of the brachial plexus rather than the posterior cord. (Subasinghe S. K. and Goonewardene S. 2016) In this case, it innervated the subscapularis muscle, latissimus dorsi, and the deltoid and teres minor muscles and also had a communicating branch to the posterior cord. Another case documented multiple abnormalities in the course of the axillary nerve in an individual with pain and severely limited shoulder mobility. (Pizzo R. A. et al., 2019) During reverse shoulder arthroplasty, the surgeon discovered that the axillary nerve ran beside the coracoid process instead of underneath and stayed close to the subscapularis muscle instead of traveling through the quadrangular space. The case noted earlier reports of axillary nerves not running through the quadrangular space. In those cases, the nerve pierced the subscapularis muscle or split into branches before reaching the quadrangular space.

Function

The axillary nerve functions as a motor nerve that controls movement and a sensory nerve that controls sensations like touch or temperature.

Motor

As a motor nerve, the axillary nerve innervates three muscles in the arm and includes:

Deltoid

  • Allows flexing of the shoulder joint and rotating the shoulder inward.

Long Head of the Triceps

  • It runs down the back of the outer arm, allowing straightening, pulling the upper arm toward the body, or extending it backward.
  • The radial nerve can also innervate this muscle.

Teres Minor

  • One of the rotator cuff muscles starts outside the shoulder and runs diagonally along the bottom edge of the shoulder blade.
  • It works with other muscles to allow for the external rotation of the shoulder joint.

Sensory

In its sensory role, the nerve carries information to the brain from the following:

  • Glenohumeral joint or the ball-and-socket joint in the shoulder.
  • The skin on the lower two-thirds of the deltoid muscle through the superior lateral cutaneous branch.

Injuries and Conditions

Problems with the axillary nerve can be caused by injuries anywhere along the arm and shoulder and by disease. Common injuries include:

Dislocations

  • Of the shoulder joint, which can cause axillary nerve palsy.

Fracture

  • Of the surgical neck of the humerus.

Compression

  • This stems from walking with crutches, also known as crutch palsy.

Direct Trauma

  • This can be from an impact sports, work, automobile accident, collision, or laceration.

Added Pressure

  • This can be from wearing a cast or splint.

Surgical Accidental Injury

  • An injury or damage can come from shoulder surgery, especially arthroscopic surgery on the inferior glenoid and capsule.

Quadrangular Space Syndrome

  • This is where the axillary nerve is compressed where it passes through that space, which is most common in athletes who perform frequent overhead motions)

Nerve Root Damage

  • Between the fifth and sixth cervical vertebrae, where the nerve emerges from the spinal cord, which can be caused by traction, compression, spinal disc prolapse, or a bulging disc.

Systemic Neurological Disorders

  • Example – multiple sclerosis

Erb’s Palsy

  • A condition often is the result of a birth injury called shoulder dystocia, in which a baby’s shoulder/s becomes stuck during childbirth.

Axillary Nerve Palsy

  • Damage can result in a type of peripheral neuropathy that can cause weakness in the deltoid and teres minor muscles.
  • This can result in losing the ability to lift the arm away from the body and weakness in various shoulder movements.
  • If the damage is severe enough, it can cause paralysis of the deltoid and other minor muscles, resulting in flat shoulder deformity, in which individuals cannot lay their shoulders flat when lying down.
  • Axillary nerve damage also can lead to a change, reduction, or loss of sensation in a small part of the arm just below the shoulder.

Nerve Injury Statistics

  • Three times more common in men than women.
  • It may be present in as many as 65% of shoulder injuries.
  • The risk of injury due to dislocation is significantly increased after age 50.

Tests

If a healthcare provider suspects a problem with axillary nerve function, they’ll test the shoulder’s range of motion and skin sensitivity. A difference in the range of motion between the shoulders can indicate a nerve injury. Individuals may be sent for electromyography and a nerve conduction study to verify nerve palsy. In some cases, an MRI and/or X-rays may be ordered, especially if the cause of possible nerve damage is unknown.

Rehabilitation

Depending on the severity and cause of the injury, non-surgical treatments may be recommended, with surgery as a last resort. Non-surgical treatment can include some combination of immobilization, rest, ice, physical therapy, and anti-inflammatory meds. Physical treatment typically lasts about six weeks and focuses on strengthening and stimulating the muscles to prevent joint stiffness, which can impair long-term function.

Surgery

If conservative treatments don’t work, surgery may be recommended, especially if several months have passed without improvement. Surgical outcomes are generally better if surgery is performed within six months of the injury, and regardless of the time frame, the prognosis is considered positive in about 90% of cases. Surgical procedures performed for axillary nerve dysfunction or injury include:

Neurolysis

  • This procedure involves targeted damage/degeneration of nerve fibers, interrupts the nerve signals, and eliminates pain while the damaged area heals.

Neurorrhaphy

  • This procedure stitches a severed nerve back together.

Nerve Grafting

  • Grafting involves transplanting a portion of another nerve, usually the sural nerve, to reconnect severed nerves.
  • This helps, especially when the damaged portion is too large to be repaired by neurorrhaphy.
  • It allows a pathway for signals and encourages the regrowth of nerve axons.

Neurotization or Nerve Transfer

  • Similar to grafting but used when the nerve is too damaged to heal.
  • This procedure involves transplanting a healthy but less important nerve, or a portion of a nerve, to replace the damaged one and restore function.

Injury Medical Chiropractic and Functional Medicine Clinic

Injury Medical Chiropractic and Functional Medicine Clinic works with primary healthcare providers and specialists to develop an optimal health and wellness solution. We focus on what works for you to relieve pain, restore function, and prevent injury. Regarding musculoskeletal pain, specialists like chiropractors, acupuncturists, and massage therapists can help mitigate the pain through spinal adjustments that help the body realign itself. They can also work with other medical professionals to integrate a treatment plan to resolve musculoskeletal issues.


Shoulder Pain Chiropractic Treatment


References

Subasinghe, S. K., & Goonewardene, S. (2016). A Rare Variation of the Axillary Nerve Formed as Direct Branch of the Upper Trunk. Journal of clinical and diagnostic research : JCDR, 10(8), ND01–ND2. doi.org/10.7860/JCDR/2016/20048.8255

Pizzo, R. A., Lynch, J., Adams, D. M., Yoon, R. S., & Liporace, F. A. (2019). Unusual anatomic variant of the axillary nerve challenging the deltopectoral approach to the shoulder: a case report. Patient safety in surgery, 13, 9. doi.org/10.1186/s13037-019-0189-1