Use of the abdominal muscles can add additional insult. Too much traction on the bundle from behind or from pulling in front will cause the bundle to be “strummed” against the ring, which then causes irritation and swelling even before herniation occurs.Īnything that increases pressure behind the abdominal wall can cause the bundle to herniate through the fibrous ring and aponeurotic opening.
Herniation of the bundle through the ring due to too much pressure from behind or from pulling from in front will compress the bundle’s vessels and the nerve itself. The hypothesis that nerve ischemia is caused by localized compression of the nerve at the level of the ring is deduced from juxtaposition of the soft bundle to the hard ring. Positioned anterior to the ring, the rectus aponeurosis provides a hiatus for the exiting bundle. At a point located about three quarters of the way through the rectus muscle (from back to front), there is a fibrous ring that provides a smooth surface through which the bundle can slide. In the rectus channel, the nerve and its vessels are surrounded by fat and connective tissue that bind the nerve, artery, and vein into a discrete bundle capable of functioning as a unit independently from surrounding tissue. The most common cause of abdominal wall pain is nerve entrapment at the lateral border of the rectus muscle. Abdominal cutaneous nerve entrapment syndrome. (Adapted and reproduced by permission of the publisher, of the author, and of the illustrator, Nelva M Bonucchi, from: Applegate WV. Compiled from my own experience and that of other investigators who have written about ACNES, the information presented here should give readers the tools necessary for diagnosing and treating this condition. To avoid causing the patient unnecessary anxiety and tension, loss of work time, and both the expense and possible hazard of multiple diagnostic procedures, the first physician examining the patient must establish the diagnosis of ACNES if this condition is present. Chronic and recurrent cases are more likely to be seen in the daytime throughout the year. In my own primary care practice, I have seen one or two patients with this diagnosis for every 150 patients overall but have seen as many as three such patients per consultation session in a busy evening clinic where 15 or more clinicians were on duty.Īcute cases of ACNES are usually seen in the evening, especially in spring and summer, when people are more active. In fact, the most common cause of abdominal wall pain is nerve entrapment at the lateral border of the rectus abdominis muscle 3, 5, 8, 9, 12 Carnett, 3 in the early 20th century, called this syndrome “intercostal neuralgia” and claimed to have seen three patients per week with this diagnosis and as many as three per day in consultation sessions. Many of these patients were given a psychiatric diagnosis when the actual diagnosis could not be determined. Hershfield 6 listed preliminary diagnoses of patients referred to him as irritable bowel, spastic colon, gastritis, psychoneurosis, depression, anxiety, hysteria, and malingering. In 2001, Thompson et al 11 noted that an average of $6727 per patient was required for previous diagnostic testing and hospital charges. In a study of 117 patients in 1999, Greenbaum 10 estimated that the amount of money expended on unnecessary workup was $914 per patient. These articles state that abdominal wall pain is often wrongly attributed to intra-abdominal disorders and that this misdirected diagnosis can lead to unnecessary consultation, testing, and even abdominal surgery, all of which can be avoided if the initial examiner makes the right diagnosis. When a patient is seen for abdominal pain without other clinically significant symptoms, ACNES should be high on the list of likely diagnoses.īeginning in 1792 with J P Frank’s description of the condition he named “peritonitis muscularis,” 1 a sampling of pertinent medical literature on this subject 2– 9 shows how often the subject has been written about over the years. Abdominal cutaneous nerve entrapment syndrome (ACNES) may sound like an esoteric condition rarely seen by clinicians but is a common condition.
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