Pinched Nerve: Symptoms, Causes, and Treatment

A pinched nerve occurs when a nerve is compressed by a surrounding structure, disrupting its conduction of electrical signals. A nerve can be compressed anywhere along its length, from its origin (at the brain or spinal cord) to the peripheral structure it communicates with (1). A pinched nerve can cause mild pain and tingling, or if left untreated, permanent nerve dysfunction and even nerve death (2). The more formal term for a pinched nerve is a “compressed nerve”.

A pinched nerve can arise from poor posture, poor body mechanics, repetitive movements, prolonged positions, soft tissue (muscle, tendon, ligament, fascia) tightness, or inflammation due to injury. Complications from surgery can also cause nerve compression.

Anatomical Causes of Pinched Nerves

Nerves are more likely to be compressed when they traverse narrow spaces, like the nerves that exit the spinal column, or the median nerve that traverses the carpal tunnel of the wrist.

Nerve compression is more likely in areas in which there’s minimal soft tissue to protect the nerve. An example is the ulnar nerve at the elbow, which runs between two bony structures and is protected by just a thin band of soft tissue known as the retinaculum.

Functional Causes of Pinched Nerves

Poor posture, especially in the neck and shoulders, can compress the nerves that exit the upper spinal cord and run along the arms. The area in which nerves and blood vessels exit the neck en route to the arm is called the thoracic outlet (3). Thoracic outlet syndrome occurs when these structures are compressed by a rib, a collarbone, or tight musculature, which can be a sequelae (medical consequence) of poor posture (3).

Poor posture and poor body mechanics may also cause disc herniation. Repetitive movements, such as bending or twisting with poor posture, can compress the disc between two vertebrae, causing the inner contents of the disc to leak, or herniate, out. The herniated disc and associated inflammation and swelling can pinch spinal nerves, often causing radiating pain in the leg. Repetitive movements in the wrists and hands, such as typing, can cause swelling in the carpal tunnel and compression of the median nerve, resulting in carpal tunnel syndrome (CTS) (4).

The narrowing of the space between vertebrae, due to spinal stenosis or spondylolisthesis, is yet another possible cause of nerve compression. Nerve compression in the lower (lumbar) spine or muscle spasm or tightness in the back or buttocks may cause lumbar radiculopathy (spinal nerve root compression) or sciatica (sciatic nerve pain) (5).

Pinched nerves may cause pain (sharp, aching, or burning quality), tingling (paresthesia), numbness, or muscle weakness, typically in the arms or legs.

Nerve compression can be divided into three stages of symptoms (1):

• Stage 1: Patient experiences pain at rest and an intermittent “pins and needles” sensation that worsens at night.
• Stage 2: Patient experiences numbness, “pins and needles”, and possibly weakness that does not disappear during the day. 
• Stage 3: Patient experiences constant pain, muscle atrophy (muscle wasting), and permanent sensory loss.

Symptoms of a pinched nerve almost always occur distally (further from the middle of the body) from the site of compression. For example, if a nerve is compressed in the buttock, the patient may experience leg pain and numbness, even down to their toes. A pinched nerve root in the upper spine may cause neck pain, shoulder pain, or arm pain.

Most commonly pinched nerves occur in the following locations:

• The lower (lumbar) spine, with radiating symptoms to the buttock and back of the leg due to lumbar radiculopathy or sciatic nerve syndrome.
• The upper (cervical) spine, with radiating symptoms to the shoulder and down the arm due to cervical radiculopathy or thoracic outlet syndrome.
• The wrist, due to swelling in the carpal tunnel, with compression of the median nerve and pain in the wrist, hand, or fingers, known as carpal tunnel syndrome (CTS) (4).
• The elbow, due to compression of the ulnar nerve as it passes through the cubital tunnel, causing pain in the elbow, forearm, wrist, or hand, known as cubital tunnel syndrome.

Your healthcare provider can diagnose a pinched nerve by looking at a complete medical history, physical examination, and special tests or imaging if indicated.

When providing your physician with your history, be sure to include:

• The mechanism of injury: Can you pinpoint a specific event that caused the onset of pain and symptoms?
• Description of symptoms (location, quality, and severity).
• Easing factors: What brings you pain relief?
• Aggravating factors: What makes you feel worse?
• Medications.
• Significant past medical history, including any surgical history. 
• Description of occupation or hobbies.

Physical examination will include objective assessment of pain, strength, range of motion, and posture, as well as palpation (assessing the body tissues through touch) and observation of the injured area.

There are a number of simple clinical tests that can assist with diagnosing nerve pain (6). One example is a neural tension test, which is a maneuver that stretches a specific nerve from its origin to its end in an attempt to replicate pain (7). Compression or pinching anywhere along the nerve will limit its normal range of motion, causing discomfort or pain. The straight leg raise or Lasègue's sign is the neural tension test for the sciatic nerve (8).

Your doctor may also use electromyography (EMG) or nerve conduction studies to confirm a nerve compression diagnosis or localize the site of a pinched nerve (9). The gold standard test in the diagnosis of carpal tunnel syndrome is a nerve conduction study (4).

If your pinched nerve does not respond to conservative treatment after 6 - 8 weeks, your doctor may recommend a CT scan or an MRI to rule out a more serious condition, such as an infection or a malignancy (8, 10). An X-ray is typically ineffective due to its poor visualization of nerves, discs, and soft tissue structures (8).

Initial treatment for a pinched nerve almost always includes 6 - 8 weeks of conservative treatment (8). This primarily consists of physical therapy, over-the-counter pain medications, and patient education (8).

Over-the-counter pain medications for the treatment of nerve pain include acetaminophen and non-steroidal anti-inflammatory drugs (e. g., ibuprofen). For severe or chronic pain, your physician may recommend prescription-strength ibuprofen or acetaminophen, or a stronger medication for pain management (e. g., certain antidepressants) (11).

Your physician or physical therapist will educate you on the suspected source of your nerve pain and how to manage it. It is best to stay active with normal daily activities and avoid bed rest during recovery (8).

A physical therapist may educate you on exercises to help relieve your nerve symptoms. These may include nerve glides, which are repetitive movements that move the nerve through its full range of motion and help to break up fibrosis or connective tissue restrictions that prevent the natural movement of the nerve (7). A physical therapist may also recommend ergonomic changes to your workspace to reduce pain from carpal tunnel syndrome, or sleeping position modifications, such as sleeping with your elbows extended, to reduce stress on the ulnar nerve (4, 12).

Your physical therapist will adjust your plan of care and home exercise program to limit side effects such as muscle soreness or increased pain. If you experience increased pinching, pain, or discomfort as a result of performing your prescribed exercises, stop immediately and discuss with your physical therapist at your next visit.

Over-the-counter medications carry adverse effects when taken regularly and should be discussed with your healthcare provider before beginning treatment.

NSAIDs may cause gastrointestinal, cardiovascular, or renal (kidney) side effects (13). Mild side effects include indigestion or heartburn (13). In more severe cases, especially in the elderly, NSAIDs can cause stomach bleeding, high blood pressure, heart attack, or stroke (13). NSAIDs may also interact with other medications, potentially amplifying these adverse effects (13).

The primary adverse side effect of acetaminophen is a skin rash or some other kind of hypersensitivity reaction. In more serious causes, acetaminophen can cause kidney or liver issues (14).

Medications, even over-the-counter ones, should always be taken for the shortest duration, and in the lowest effective dose possible to minimize risks and adverse effects (13). Avoid taking any medication for long periods of time.

Seek medical advice if you suspect a pinched nerve is causing your neck pain, arm pain, back pain, or leg pain.

Physical therapy and regular activity are always included in initial conservative treatment, along with over-the-counter pain medications. If over-the-counter medications don’t bring relief, you may want to discuss prescription-strength pain medications with your provider.

If you are still experiencing pain and functional limitations after 6 - 8 weeks, it’s time to discuss more advanced treatment options for persistent nerve pain with your provider.

If nerve pain does not diminish following a 6 - 8 week course of conservative care, surgery may be an option. This is especially true in cases that do not respond to prescription-strength pain medications, such as antidepressants (11). Your physician may refer you to a neurosurgeon or orthopaedic surgeon to determine your surgical treatment options.

Research shows that surgery diminishes pain in the short term, however, pain and function levels are the same between conservative care and surgical patients after one to two years (8).

Your doctor may also recommend steroid injections if conservative care is ineffective. However, research shows that steroid injections may only provide pain relief in the short-term (15). One study reported no evidence of positive short term effects of corticosteroid injections in patients with lumbar radiculopathy (16).

A pinched nerve, or nerve compression, often causes radiating pain in the arm or leg. Your healthcare provider will likely be able to form a diagnosis around nerve compression based on your medical history and a physical examination. Physical therapy, NSAIDs, posture awareness, and regular physical activity are the best initial treatment options for nerve-related pain. After 8 weeks of conservative treatment, injections and surgery may be worth considering if pain persists.