Simple Ways to Tell if You Have a Nerve or Muscle Problem!

Summary

In this conversation, Beau Beard discusses the critical differences between muscle strains and nerve injuries, emphasizing the importance of accurate diagnosis and treatment. He outlines the grading systems for muscle strains and nerve injuries, provides insights into self-testing methods for patients, and highlights the significance of movement in recovery. The discussion is aimed at both clinicians and patients, offering practical advice for managing these common sports-related injuries.

Transcript

Beau Beard (00:00.128)

Okay, today we are differentiating between nerve injuries and muscle strain. So over the past decade of treating athletes in the field and both in the clinic, you wouldn't believe how many times, you know, the athlete or other clinicians kind of get confused by this. So I wanted to, you know, talk on a clinical level, but I also want to throw in some tidbits for patients of how you can self-test to determine, you know, do I have a muscle strain or am I dealing with a nerve injury and, know, how those two things are going to need different care.

So the first thing we want to do is break down, okay, muscle strains. This is the easy one to diagnose when we have a significant enough muscle strain. So the grading system for muscle strains is one through three. We can kind of have a plus where we have a one plus, a two plus. So let's work backwards. So you're going to know if you have a grade three. Most often we've seen people with some evulsions.

Like their hamstring off their ischial tubes the bone in your hip where it actually pulls off they operate for Quite a while without knowing they know they had an injury but maybe not a full, you grade three of Olsen if you have a muscle rupture, you know of the The muscle itself the musculoskeletal junction you're going to have diffuse swelling, know, this is where you know Somebody's leg can look black or severely bruised significant loss of function strength for whatever muscles affected

Sometimes you'll get recoils to say it's the biceps, say it's the quad. If you have a full rupture, may get, you know, I think of when in the old cartoons, when they kind of be wearing a necktie and the necktie rolls up in their face, you can get this recoil effect. So that's a grade three. So it's a severe full rupture, significant pain. Yeah, grade two. So involves partial tearing. You're still probably going to have significant swelling, bruising, discoloration. Noticeably we...

weakness, loss of function, we just don't have a complete rupture. So in these scenarios where we suspect grade two, grade three, we may get imaging depending on, is this an athlete or a weekend warrior, just kind of somebody that's operating around the house? What do they have coming up in the near future? And the way that we're going to, the examination that we need for this from imaging is an MRI. And sometimes when there's diffuse edema and swelling,

Beau Beard (02:16.686)

You know, a grade two or a gr you know, a full rupture, maybe, you know, it gets mistaken for a grade two, vice versa, but a grade two, we're going to still know diffuse swelling, bruising, all these things. When we get into the grade one, this is where we start to need to differentiate between, you know, is this a grade one muscle strain, which is going to have minimal muscle fiber damage, uh, you know, mild pain and tenderness, which is going to be dependent on the person and you know, their pain tolerance and sensitivities and things like that. Um,

No significant loss of strength or movement. It's going to be sore. It's going to be tight. No visible bruising or swelling. And you can recover anywhere from a few days to a week or two. What can take part is that we can have a grade one, maybe even a grade two, or a subgrade two, so a one plus muscle strain.

a recent example. So baseball player was rounding first base. sees it, the throws coming into second faster than he thought it was going to. And instead of turning around, he thinks he's going to make it. takes off of that, you know, next gear and feels a pop in his hamstring. And, know, then the parents call in and say, Hey, my son had a hamstring pole. Can you treat them? So we bring them in, no visible swelling, no visible bruising.

Significantly sore reduced range of motion. So he goes to touch his toes. It hurts We'll talk about some other tests here pretty soon But immediately now I have to differentiate will act is it actually a grade one muscle strain? which is going to be somewhat of a Diagnosis by exclusion that it's not grade three grade two and I'm going to rule out the nerve injury and then we're like down to a grade one muscle strain Or we have a nerve injury or we have a little bit of a tandem So I think this athlete in particular had a little bit of a tandem

So I'll go ahead and explain this case and we'll keep going through the nerve injury part. So I he did have a grade one strain of the bicep femoris, kind of right below the musculatina junction, so not up where it attaches your pelvis, but you know, a little bit below that. more affecting him more acutely, I believe was the nerve sensitivity and the way that we went through testing and treatment retest.

Beau Beard (04:33.646)

kind of proved that and has proven that. I'll actually see this athlete again tomorrow for the fourth time since the injury, twice a week now for two weeks just to kind of get them back up there. I think it's gonna take about five visits to get them back out. But I think it's more neurologic irritation sensitization rather than the muscle strain. And again, grade one is gonna heal on its own and then we have to make sure that we decrease that sensitivity or the nerve traction injury. So three grades of muscle strains. Now we can go through.

You know, there's two different classification systems for a true nerve injury, sedans and then sunderlands. Sunderlands is a five tier sedans is a five or three. Let's just go over the sedans just for ease of use on this. So the first injury, the mildest neuropraxia, this is you almost get neuropraxia anytime you, you know, maybe you occlude a neurologic activity due to the position that you sit in, a traction injury, like a quick traction, you reach for something, you fall.

So there's no what's called wallerian degeneration. Wallerian degeneration is basically a slight or progressive, depending on how severe the injury, demyelination. So the myelin is basically the fatty covering or protection around that neuronal sheath that helps the nerve basically stay insulated but also conduct its signal appropriately. This can recover in days to weeks. Like this is quick and this is a mild injury. We go above that, we go into axonotmesis. So this is a moderate injury. This is where we have

could be a more acute aggressive injury or could be a more prolonged sub acute injury. So let me give examples. A very common thing would be the hamstring pull, take off into third gear or we trip and fall on the trail and we extend that leg and we get a fast traction injury on the nerve. Nerves can stretch, right? The sciatic nerve can stretch the most of any nerve in the body, but it's still around a half an inch or something like that.

It's not a lot. And when we try to stretch it fast and hard, and maybe there's excess muscle tension because we're falling and we need those muscles to be on, the nerve gets traction and that traction can create a lot of irritation or sensitization. But it could also be sub-threshold. It's not this acute thing. So think of the case of maybe degenerative change in an area of your spine. So the holes where a nerve exits are called the neuroframina. Neuroframina maybe gets a little more bone around it as we age and have some degeneration.

Beau Beard (06:54.058)

little by little that nerve is just kind of having some more mechanical input and it can go, you know, through axonotmesis. So it has this kind of, can move and offload it. So there's positions that help, but if we maintain one position for too long and then that can kind of build, which leads us to the third classification, which is neurotmesis. This is severe. So this is where we have maybe a crush injury. have a full blown traction injury with actual damage, physical damage to the nerve.

We obviously have wall layering degeneration in both axonotmesis and neurotemesis, but the degree, the onset, because it only takes around minimum 12 hours of compression to create the first signs of wall layering degeneration. you know, think of somebody going to sleep. I'm not saying you're sleeping for 12 hours, but you get into that window of eight to nine hours, somebody wakes up and they're like, man, I just have radiating pain down my arm or, you know, peristhesia, numbness, tingling. This is where the difference between these two is,

where axonotmesis has the ability to recover. So when we look at the research says recovery is possible through axonal regeneration, one millimeter per day or one inch per month is the clinical expected outcomes and regenerative change. So it can take a long time. Neurotmesis, we've had basically permanent damage. So we're not going to have remyelination of this nerve. this is going to, you know, even if we had a complete like...

know, rupture of that nerve from a traction injury. If we repaired, it's not going to, you know, have the same nerve conduction. And, you know, a small tangent nerve conduction velocity study or an NCV. There's a lot of research on the clinical efficacy, wouldn't say efficacy because the test works on how important that data is. So if we have a nerve conduction study that shows up with more than 30 % decrease in nerve conduction, that's supposed to be clinically relevant.

I'm just telling you, I've seen enough of these tests that like that doesn't tell us a whole lot because we don't know if that was present before or caused by what we're treating at the present moment. So three grades of muscle strain, we could have three to five. I'm going with the three due to just ease of use, nerve injuries. So how do we start to differentiate between these two? So going back to the baseball player. So if I just go through a couple of pieces of clinical information here, if we haven't been over and touch his toes, he has

Beau Beard (09:09.814)

on the first visit had some pain, reduced range of motion noted from him because I don't know what it looked like before. What's normal. It's reduced today, but I don't know what his normal toe touch looks like. Then we take them through some actual clinical tests and these are some things that we can do at home. So if you bend over to touch your toes, if you've had a hamstring injury, right. And let's just use that as the example here. It's probably going to hurt whether you have a muscle strain or nerve injury. So, okay.

The next test would be what's called a slump test. And you'll see a video here of somebody kind of rounding their back, rounding their neck. And then we're kind of seeing, A, if we're not moving the leg, can we reproduce symptoms in the legs? So that's the first portion of the slump test. If we do, and we're not moving the leg, the likelihood of that being just a muscle injury or a muscle injury at all is going down. But then we can add in tension on each leg. And again, if I stretch the hamstring,

in this scenario, it's probably gonna cause pain. But now I'm trying to also see if I stretch the other side. Do I create any symptoms on the injured side? And I can go through that test. So that's something you do at home and kind of see like, if I just round my back and don't move my knee, as you can see from this, you know, little video here, there's pain. Well, you know, maybe there's more neurologic sensitivity. The other thing that we have to make sure of or that we can kind of rule out, like I said, if we're moving our back into flexion or tractioning our spinal cord, which in essence then pulls on the nerve,

then I could play around with, okay, if flexion hurts, I could kind of go through some cobras or extensions, my low back repeatedly, and then retest some of these things. So I could go through and, know, in our office, if somebody had a restriction and extension, which would be a qualifier, but at home, you could just do it. No harm, no foul. As long as it doesn't cause pain or discomfort or, you know, more symptoms, go through some lumbar extensions or some cobras, maybe 20, 30 reps and retest your toe touch, your slump test.

Just kind of see better or worse same and then that starts giving you more of an idea. The first thing that you need to do is determine what is a bruising, swelling, things like that. If you have bruising and swelling, you for sure have a injury to the tissue. And again, you can have both. You could have a nerve injury and a tissue injury. But when we determine nerve versus tissue, we're doing three things. we're being clinically or diagnostically specific.

Beau Beard (11:28.738)

The specificity leads us to the second thing, leads to appropriate timelines. So if have a grade one muscle strain or a grade one nerve injury, neuropraxia, we're in that same time threshold of days to weeks to recover. We get into grade two muscle injuries, we're a couple weeks to, if we look at this, three to six weeks is the norm. If we look at a grade two, that kind of axonotmesis injury, we're talking, we said the one millimeter per day, one inch per month.

This is weeks to months, depending on the severity of it. So we might have to determine what we're telling the person, the expectations. The third thing would be what we're actually doing to treat. So if we're treating a muscle strain standalone, we know with muscle strains, it's not necessarily that we need to immobilize. Immobilization of tissue injuries is about the worst thing you can do, depending on whether it's a tendon, a ligament, any of these things. We need movement and we can't do too much or we risk further injury.

But if we don't have load and load management these appropriately, which means movement early, trying to make sure that we're, you know, stressing the lines of tissue. So I would encourage you to listen to the podcast out of a Keith bar on tendonopathies and how to load the lines of a strain line of injury specifically, we're going to have healing that's delayed, but also not as a, it doesn't heal as well. So it takes longer and it's not as good. So we need to move these things early and often.

And then let's say it's okay. So now we go through a load management protocol. There's a little bit of protect there with the muscle injury, a nerve injury. If it's minor, right? So it's just this kind of neuropraxia, a little bit of attraction. We're ruling out muscle. It may be, we've got to go through some nerve, you know, gliding and sliding, maybe calm down some tissue tension around the nerve, because maybe the nerve can't slide and glide. So we got to make sure it can move through those tissues.

And you know that could look like a sciatic flossing maneuver gliding maneuvers you can see pictured here and that you know when you hit your head your first inclination is to rub it that mechanical input competes for pain and if we've had a little bit of a traction injury, yeah, there may be sensitivity, but if you remember with neuropraxia and I would even argue into the you know, Maybe we have a one plus neuropraxia injury where we have mild wallering degeneration How do we get you know anterior what's called an interior grade and retrograde?

Beau Beard (13:52.91)

nutrition to the nerve, well, it's movement. It's the same thing. So you need movement. So if the nerve is being strangled by an entrapment, whether that's muscular or other, you myofascial, get it moving. But even if it's movement where we're not creating too much tension and exacerbating the injury or the sensitization is going to bring nutrition to that nerve to help it heal as fast as it can. So again, if we kind of review, we have the three grades of muscle strains, three grades of nerve injuries.

There's simple tests and I'm using a sciatic nerve injury. Again, there's also all sorts of neurodynamic tests because what we're really trying to make sure of once it's a nerve injury, right? If we haven't had a crush or a full blown, you know, car accident with a full, you know, traction injury is where on the what's called patho neurodynamics. So the aberrant movement of the nerves, what's causing that? Is it, you know, around the spinal mechanics, the nerve can't move through those neuro-foraminar around the vertebral complex.

in the tissues that it's moving through. have common entrapment sites and nerves, how we move, so ranges of motion. All of these things matter because then that again gives us more information to be more specific with the treatment. But at home with the example of the sciatic nerve injury, muscle strain, so is it a hamstring strain or is it a nerve injury? They're simple tests that you can do. then, you know, as we move out into other areas, we would have to have more specific tests, but that would be a tall order to go over all of those in one video.

So I hope that helps as a clinician. I hope that helps as a patient differentiating between muscle strains and nerve injuries.