Nerve Adaptation in Response to

Mechanical Loading
Marko Bodor MD
Physical Medicine and Rehabilitation,
Spine and Sports Medicine
Napa, California
Voluntary Assistant Professor
Departments of Neurological Surgery
University of California San Francisco
Physical Medicine and Rehabilitation
University of California Davis

Disclosure
No disclosures relative to the current
presentation.

Skin

Skin adapts to mechanical loading by

getting thicker.

Muscle

Muscles adapt to mechanical loading by

getting larger.

Bone

From Ireland A et al
Med Sci Sports 2013

Bones adapt to mechanical loading by

increasing in thickness and diameter.

Nerve

Do nerves adapt to mechanical loading?

Tires

How is it that a 2000 kg car has tires that

need only 2.5 ATM pressure while those of
an 80 kg bicycle/rider require 5 ATM?

Largertiresallowlowertirepressures.

1) 2.5 ATM 2.5 kg force/cm2.

2) Contact area = 20 x 25 cm
= 500 cm2.
3) 2.5kg/cm2 x 500 cm2 =
1250 kg.
4) 4 tires x 1250 kg/tire = 5000
kg support for the car.

1) 5 ATM 5 kg force/cm2
2) Contact area = 3 x 5 cm =
15 cm2.
3) 5 kg/cm2 x 15 cm2 = 75
kg.
4) 2 tires x 75 kg/tire = 150
kg support for bike & rider

TireNerveAnalogy

Larger nerves will have lower intraneural

pressure for the same externally applied load.
100 gm load on a 5 mm2 nerve = 20 gm/mm2 200 kPa
100 gm load on a 10 mm2 nerve = 10 gm/mm2 100 kPa

EvidenceforNerveEnlargement#1

Gitlin G Concerning the gangliform enlargement

(pseudoganglion) on the nerve to the teres minor
muscle. J Anat 1957.

Nerveenlargementobservedin26/36
normalcadaversatquadrangularspace

Gitlin G Concerning the gangliform enlargement

(pseudoganglion) on the nerve to the teres minor
muscle. J Anat 1957.

EvidenceforNerveEnlargement#2

Ulnar nerve
enlargement
seen at medial
epicondyle (ME)
in 12/12
cadavers:

P6

ME

D4

Neary D, Ochoa J, Gilliat RW. Subclinical

entrapment neuropathy in man. J Neurol Sci 1975

EvidenceforNerveEnlargement#2
7/12 no
pathologic
changes
5/12 bulbous
swellings and
intercalated
segments.

P6

ME

D4

Neary D, Ochoa J, Gilliat RW. Subclinical

entrapment neuropathy in man. J Neurol Sci 1975

EvidenceforNerveEnlargement#3
Median nerve
enlargement
seen at flexor
retinaculum in
12/12 cadavers:

RB

P6

RB

RB

ME

Renaut bodies (RB)

seen in all nerves at
level of retinaculum

D4

Neary D, Ochoa J, Gilliat RW. Subclinical

entrapment neuropathy in man. J Neurol Sci 1975

EvidenceforNerveEnlargement#3
7/12 - no
pathologic
changes

RB

P6

RB

5/12 bulbous
swellings and
intercalated
segments

RB

ME

D4

Neary D, Ochoa J, Gilliat RW. Subclinical

entrapment neuropathy in man. J Neurol Sci 1975

EvidenceforNerveEnlargement#4
Wrist-forearm ratio:
1.6 in 89 controls
2.4 in 161 patients
with CTS

P6

ME

D4

Visser LH, Smidt MH, Lee ML. Diagnostic value of

wrist-forearm ratio in carpal tunnel syndrome

EvidenceforNerveEnlargement#4
Therefore:
It is normal for
median nerves to be
enlarged up to 1.6x
at the wrist.

P6

ME

D4

Visser LH, Smidt MH, Lee ML. Diagnostic value of

wrist-forearm ratio in carpal tunnel syndrome

EvidenceforNerveEnlargement#5
Median Palmar Cutaneous Nerve enlargement
between the wrist and palm - Case #1:
P6

D4

Wrist - 0.6 mm2

Palm 1.8 mm2

Bodor M, McAuliffe M, Derrington S, Uribe Y. preliminary

unpublished data

EvidenceforNerveEnlargement#5
Median Palmar Cutaneous Nerve enlargement
between the wrist and palm - Case #2:
P6

Wrist - 0.9 mm2

D4

Palm 2.4 mm2

Bodor M, McAuliffe M, Derrington S, Uribe Y. Preliminary

unpublished data

EvidenceforNerveEnlargement#5
Limitations:
-

P6
Two cases shown were weight-lifters
- predisposing
to MPCN enlargement at the palm.
Presence of enlargement has been inconsistent
among other subjects.
MPC has a variable course and may enlarge slightly
next to FCR tendon in wrist.
D4

Bodor M, McAuliffe M, Derrington S, Uribe Y. Preliminary

unpublished data.

P6
Isthereapointatwhichnerve
enlargementbecomesmaladaptive?

D4

MedianNerveDMLvsCSAatCarpalTunnel
amongControls()andPatients()

P6

ME

Adapted from Fujimoto K et al. Diagnosis of severe

carpal tunnel syndrome using electrodiagnosis and
sonography. Ultrasound Med Biol 2015 Oct.

UlnarNerveNCVvs.Diameter
amongUNEPatients

P6

D4

Adapted from Beekman R et al. Clinical, electrodiagnostic

and sonographic studies at the elbow. Muscle & Nerve
2004.

Whichgraphshowsabettercorrelation
betweenNerveSizeandVelocity?

P6

ME

Median (Fujimoto 2015)

Ulnar (Beekman 2004)
Note Difference in Population and Parameters!
CSA and DML for Median, Diameter and NCV for Ulnar.

Whichgraphshowsabettercorrelation
betweenNerveSizeandVelocity?

1/NCV

P6

ME

Median (Fujimoto 2015)

Ulnar (Beekman 2004)
Note Difference in Population and Parameters!
CSA and DML for Median, Diameter and NCV for Ulnar.

Conclusions:
Nerve enlargement can occur in the absence
disease at locations of mechanical stress
susceptible to compression neuropathies.
Nerve enlargement can be a normal adaptive
response which reduces intraneural pressure.
Nerve enlargement within the confines of a bony
space such as the carpal tunnel or spinal canal
becomes maladaptive after a certain point.
Disclaimer: Not all enlargement is adaptive - it
can be secondary to disease.

Nerve Adaptation - Flattening

6
N

6
N

Nerve Adaptation - Flattening

6
N
3
2

6
N
3

2
3

2
3

1.5

1.5

1.5

1.5

Lateral Femoral Cutaneous

Nerve

Sciatic Nerve

Mediancompressionatproximalretinaculum
withsevereflatteningofnerve.

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