26 Neuropathic Pain

Neuropathic pain

Neuropathic caused by a lesion or disease of the somatosensory nervous system. Peripheral and central neuropathic pain are classified here.

Pathophysiology: The Nervous System Becomes Sensitive When it is Exposed to a Pathological Environment

As peripheral nerves pass through the body they may be exposed to mechanical or chemical irritation at different anatomical points. Prolonged compression or fixation of a nerve may result in a reduction of intraneural blood flow. This then triggers the release of pro-inflammatory substances (calcitonin gene-related peptide and substance P) from the nerve. This by product is referred to as neurogenic inflammation and it can disrupt the normal function of nerves even without overt nerve damage, it can also contribute to the initiation and propagation of chronic pain (Barbe et al., 2020Bove et al., 2019; Matsuda et al., 2019). 

Clinical Examination: Clinical Sensory Testing Can Be Used to Assess for Increased Sensitivity of the Nervous System

A thorough health history intake can be done to gather information about patients’ limitations, course of pain, and prognostic factors for delayed recovery (e.g., low self-efficacy, fear of movement, ineffective coping strategies, fear-avoidance, pain catastrophizing) and answers to health-related questions. Screen patients to identify those with a higher likelihood of serious pathology/red flag conditions. Then undertake a physical examination: neurological screening test, assess mobility and/or muscle strength.

Outcome Measurements

Incorporate one or more of the following outcome measurements when assessing and monitoring patient progress:

  • Self-Rated Recovery Question
  • Patient Specific Functional Scale
  • Brief Pain Inventory (BPI)
  • Visual Analog Scale (VAS)

Physical Examination

Incorporate one or more of the following physical examination tools to determine the likelihood of neuropathic pain and interpret examination results in the context of all clinical exam findings. If there is an irritated peripheral nerve, clinical sensory testing can be used to assess for areas of hypersensitivity. In addition to orthopedic testing this could involve palpation (neural and non-neural structures). If a hypersensitive peripheral nerve has been identified, a treatment plan is then implemented based on patient-specific assessment findings and patient tolerance.

Upper Limb Neurodynamic Tests 








ULNT – Median (1)  

Shoulder girdle stabilization

Shoulder abduction

Wrist/finger extension

Forearm supination

Shoulder external rotation

Elbow extension

ULNT – Median (2)  

Shoulder girdle depression

Elbow extension

Shoulder external rotation

Forearm supination

Wrist/finger extension

Shoulder abduction

ULNT – Radial (3)  

Shoulder girdle depression

Elbow extension

Shoulder internal rotation

Forearm pronation

Wrist/finger flexion

Shoulder abduction

ULNT – Ulnar (4)  

Wrist/finger extension

Forearm pronation

Elbow flexion

Shoulder external rotation

Shoulder girdle depression

Shoulder abduction

Lower Limb Neurodynamic Tests 









Hands behind back

Thoracic flexion

Extend one knee

Dorsiflex foot

Cervical flexion


Straight Leg Raise  

Supine position

Raise the leg with the knee extended

If pain radiates when the angle of the leg is between 30 and 70 degrees (positive)

Increased pain on dorsiflexion of the patient’s foot increases sensitivity of the test



Femoral Nerve Test 

Prone or side lying

Knee flexion

Extension at the hip






Place foot into full dorsiflexion & eversion

Hold for 5-10 sec.



Synopsis of Common Peripheral Nerve Complaints

Affected Nerve


Peripheral Nerve Palpation Point

Head, Neck & Upper Limb

Occipital nerve

Pain, numbness or tingling at the base of the occiput

Base of the occiput

Suprascapular nerve

Shoulder pain, weakness in shoulder abduction and external rotation 

Suprascapular notch 

Dorsal scapular nerve

Upper and mid-thoracic pain, stiffness

Medial border of rhomboids

Long thoracic nerve

Pain, numbness or tingling over lateral flank. Winging of the scapula is possible 

In-between scapula and chest wall 

Median nerve

Pain, numbness or tingling in the thumb, index, middle, and ring fingers.

Upper arm, pronator teres and carpal tunnel

Ulnar nerve

Pain, numbness or tingling in ring and little finger

Upper arm, cubital tunnel

Radial nerve

Pain, numbness or tingling over common extensor tendon

Triangle interval, spiral grove, epimysial groove – extensor, snuff box

Back & Hip

Spinal nerve (dorsal cutaneous ramus)

Dysesthesia on the upper back between the vertebra and scapula (T2-T6)

Deep to back muscles

Intercostal nerve

sharp or shooting thoracic pain  

Anterior cutaneous branches of the thoracoabdominal (T7 –11) and subcostal (T12) nerves – lateral border of the rectus muscle 

Cluneal nerve

Pain, numbness or tingling along iliac crest or into gluteus muscles

Superior rim of the iliac crest

Sciatic nerve

Pain, numbness or tingling felt in the buttock, back of the thigh down to the calf, into the toes

Popliteal fossa

Lateral femoral cutaneous nerve

Paresthesia of the lateral upper thigh

Distal to inguinal ligament

Lower Limb

Saphenous nerve

Knee pain or paresthesia medial thigh

Adductor canal

Tibial nerve

Pain, numbness or tingling over medial ankle and arch of the foot

Tarsal tunnel, posterior to the medial malleolus

Medial & Lateral plantar nerve

Sharp or stabbing heel pain 

Deep to plantar muscle – running under the calcaneus 

Peroneal nerve

Pain, numbness or tingling over lateral ankle and dorsum of foot

Over peroneal muscle belly & dorsum of foot 

Sural nerve

Pain, numbness or tingling over entrapment site and lateral calf

Mid-belly of the gastrocnemius, lateral ankle


UBC Medicine Neurology Clinical Skills – Motor, Sensory, and Reflex Examination

Treatment Considerations


Provide patient education on condition and management options and encourage the use of active approaches (lifestyle, physical activity) to help manage symptoms.

Manual Therapy

The responses to neural mobilization are complex and multifactorial – physiological and psychological factors interplay in a complex manner. Systematic reviews have shown that neural mobilization combined with multimodal care can improve symptoms, decrease disability and improve function for patients who suffer from peripheral nerve entrapment (Basson et al., 2017).

The biopsychosocial model provides a practical framework for investigating the complex interplay between manual therapy and clinical outcomes. Based on this, the investigation into mechanisms of action should extend beyond local tissue changes and include peripheral and central endogenous pain modulation (Bialosky et al., 2018).

Central Response
Neural mobilization has a modulatory effect on peripheral and central processes via input from large sensory neurons that prevents the spinal cord from amplifying the nociceptive signal. This anti-nociceptive effect of massage therapy can help ease discomfort in patients who suffer from peripheral nerve entrapments.

Peripheral Response
Neural mobilization may also involve specific soft tissue treatment to optimize the ability of mechanical interfaces to glide relative to the neural structure. The application of appropriate shear force and pressure impart a mechanical stimulus that may attenuate tissue levels of fibrosis and TGF-β1 (Bove et al., 2016Bove et al., 2019). Furthermore, passive stretching may help diminish intraneural edema and/or pressure by mobilizing the peripheral nerve as well as associated vascular structures (Boudier-Revéret et al., 2017Gilbert et al., 2015).

Self-Management Strategies

Massage therapists not only provide hands-on treatment they can also develop self-management programs to help patients manage symptoms. Home-care recommendations such as hydrotherapy, stretching, splinting and home exercises have been shown to be useful for people with neuropathic pain.


In terms of research evidence neural mobilization has been shown to be particularly helpful for common forms of back, neck, leg and foot pain (Basson et al., 2017). An observed favorable outcome may be explained by overlapping mechanisms in the periphery, spinal cord, and brain, including but not limited to affective touch, contextual factors, neurological factors, and mechanical factors.

Key Takeaways

Contemporary multimodal massage therapists are uniquely suited to incorporate a number of rehabilitation strategies for neuropathic pain based on patient-specific assessment findings including, but not limited to:

  • Manual Therapy (soft tissue massage, neural mobilization, joint mobilization)
  • Education that is Person-Centered (e.g., biopsychosocial model of health and disease, self-efficacy beliefs, active coping strategies)
  • Stretching & Loading Programs (e.g., concentric, eccentric, isometric exercises)
  • Hydrotherapy (hot & cold)
  • Self-Management Strategies (e.g., engaging in physical activity and exercise, social activities, and healthy sleep habits)

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