Jonathan Aarons M.D.

Tired of Chronic Pain?

Anterior Cutaneous Nerve Entrapment Syndrome

Anterior Cutaneous Nerve Entrapment Syndrome
Anterior Cutaneous Nerve Entrapment Syndrome

Anterior cutaneous nerve entrapment syndrome (ACNES) is a condition that causes chronic pain of the abdominal wall. It occurs when terminal branches of the lower thoracic intercostal nerves (7-12) are ‘entrapped’ in abdominal muscles, causing a severe localized neuropathic pain that is usually experienced at ventral portions of the abdomen. It is frequently overlooked and unrecognized, although the incidence is estimated to be 1:2000 patients.  Anterior Cutaneous Nerve Entrapment Syndrome was originally described in 1792 by Dr. Frank and has been written about over the years. Since it is a rare syndrome, patients are often misdiagnosed as irritable bowel, spastic colon, gastritis, psychoneurosis, depression, anxiety, hysteria, and malingering.  Once ACNES is considered based on the patient’s history, the diagnosis can easily be made via a thorough physical examination: looking for a painful spot, which worsens by tensing the abdominal muscles as in lifting the head (Carnett’s sign). Almost always, a small area of maximal pain is covered by a larger area of altered skin sensibility with somatosensory disturbances such as hypoesthesia as well as hyperesthesia or hyperalgesia and change of cool perception. Pinching the skin between thumb and index finger is extremely painful compared to the opposite non-involved side.  Symptoms of ACNES can be acute or chronic. The acute pain is described as localized, dull, or burning, with a sharp component (usually on one side) radiating horizontally in the upper half of the abdomen and obliquely downward in the lower abdomen. The pain may radiate when the patient twists, bends, or sits up. Lying down may help but sometimes worsens the pain.  Treatment of Anterior Cutaneous Nerve Entrapment Syndrome begins with conservative modalities such as heat, ice, rest, non-steroidal anti-inflammatories and physical therapy.  Injection into the muscles of a local anesthetic and a steroid can be both diagnostic and therapeutic.  In severe cases, surgical exploration to release the entrapped nerve may be indicated.be indicated.

23 comments on “Anterior Cutaneous Nerve Entrapment Syndrome

  1. Jonathan Aarons MD says:

    I agree with your doctor. I would continue intermittent injections. There is no long term solutions. Surgery does not work. Tens unit is good. The pain may diminish over time but there are no long term studies. I do not think the nausea is related to the injection but sometimes steroids can cause GI distress. Hope this helps.

    Dr A

  2. Shelia says:

    My 16 y/o daughter has just been diagnosed with ACNES a few months ago after 4 years of many doctors, procedures, surgeries, lots of medication and wrong diagnoses. She is currently seeing Dr Harken in Greensboro NC. He has given her 3 sets of of cortisone injections which have been very helpful and has helped her to be able to have a life. She isn’t 100% but is so much better. She plays volleyball for her high school so it still causes pain from time to time but we have found a TENS unit will help her get through the pain when it does happen. My questions are… Dr Harken says that he thinks that it will heal itself over time. I constantly research this and I have never read this anywhere.Do you agree? He wants to continue with the shots every 2-3 months. He doesn’t seem to want to do anything else about it. Right now my daughter is doing ok. But I want to know what to do if the injections stop working, it seems this happens with most people after awhile. And she does seem to need them that often. She has also had constant nausea with this that Dr Harken says he doesn’t think has anything to do with ACNES. But everything I read says it does. Your opinion? He has been great but I’m not sure he knows enough about this to continue seeing him. We are in Charlotte NC. Anyone around us or surrounding states you know about or recommend? Thank you for your time. Shelia

  3. Jonathan Aarons MD says:

    I would repeat the injection. In general the injection is both diagnostic and therapeutic. The absence of improvement after the injection calls into question the diagnosis. Good luck

    Dr A

  4. Dr Aaron I’m pretty sure that my daughter has ACNES although the pain clinic we are working with (children’s hospital) has not heard of this nor do they know how to help us. We have previously had magnesium and lidocaine injections in her pain spot which alleviated the pain completely but only for a week at a time. These injections stopped working for some reason. She’s just recently had a lidocaine and cortisone injection as close as possible to abdominal wall. The lidocaine gave her some relief but only for 24 hours but not fully. The cortisone has not kicked in. …and it’s been 3 weeks. Doctor here do not suggest surgery. If her next two injections do not work..I don’t know what options I have. Any suggestions? Elaine

  5. Jonathan Aarons MD says:

    Elaine- I am not aware of any particular specialist in ACNES in Ottawa. In general, any board certified interventional pain doctor should be able to diagnose and treat ACNES. There is no definitive test for ACNES. The diagnosis is made with a proper patient history and physical exam along with the exclusion of other potential causes. An injection into the area of a local anesthetic and a steroid may be diagnostic. Hope that helps.

    DR A

  6. Elaine says:

    Hi Doctor Aaron – Is there a specialist in Ontario (or Canada) that specializes in ACNES. We are in Ottawa and the children’s hospital is at a loss as to why my daughter has this localized pain in her abdomen. Thanks

  7. My husband had a very large cyst removed from his kidney 2 years ago and has suffered with this pain which is undiagnosed. We thought it might be fascial trauma and he went to PT to see if massaging the area and stretching would help him. It is still very bad and he pushes through the pain still working out and trying to figure out factors that make it better or worse. Do you know of a physician in the Dallas Fort Worth Texas area that you can recommend? He is at his breaking point with this severe pain. Please help him.

  8. Linda says:

    Dr. Aaron, I live in Canada, Edmonton. I had surgery in October for partial mesh removal from my bladder. Mesh complications since 2007 to last surgery. Two major surgeries. I believe I am now suffering from ACNES (doctor said was nerve trapped) Is physio better or should a pain clinic be my better option?

  9. Jonathan Aarons MD says:

    Sometimes the first injection is not successful. You can try another injection. If the second injection is not successful then I would question the diagnosis

    DR A

  10. Donna Somma says:

    Hi Dr Aaron. I have been diagnosed with ACNES and had 1 Injection of Nerve Block and Steroid. The pain got worst. Is that common and should I try more injections?

  11. Jonathan Aarons MD says:

    I do not know. I am in Florida. I would call around to the bigger hospitals and ask for the Interventional Pain Management program. Probably any university setting would have one.

    DR A

  12. Ineta Yaghoubian says:

    Where to go in New York?

  13. LD says:

    Wow, thank you for the quick reply I certainly wasn’t expecting that. Okay, they keep saying her abdominal wall (we thought it was the rib area) so I didn’t know with the entrapped nerve and talk of rectus and abdominal wall if this is what they meant. Thanks again

  14. Jonathan Aarons MD says:

    That can be part of it

    DR A

  15. LD says:

    Is this the same thing as if you have a fibrin knot on/in your Upper Left Rectus Abdominus/Rectus Sheath causing a nerve entrapment?

  16. Jonathan Aarons MD says:

    Sorry. No one I know on the west coast :(. Try a university interventional pain clinic. I am sure there are several out there

  17. JB Jennings says:

    My husband has been suffering for 5 years without an answer. He is the healthiest sick person I know. All vitals and organs are normal but no GI, urologist, general surgeon or neurologist can make a diagnoses that is outside of the norm. My husband has been poked, prodded has swallowed cameras and has spent many days in the ER with no results. We were given some information about ACNES a few days ago and I started to cry…this was it. When I mentioned it to a few doctors we have been seeing, they looked at us like I was from another planet. They can’t diagnose my husband but are very sure that he could not possibly have ACNES because they claim it is so rare. We are in California and are looking for a specialist closer to the West Coast that we can consult with…do you have any West Coast referrals?

  18. Jonathan Aarons MD says:

    Yes. Call 954-580-8838

  19. Melissa says:

    I am 100% certain that this is what I have been suffering from for 18 months. I can’t locate a locate doctor that has any familiarity with this syndrome. Are you accepting new patients for ACNES evaluation and/or treatment?

  20. Jonathan Aarons MD says:

    The diagnosis of abdominal pain can be complex. ACNES is only one possible cause, and not a frequent one. Every doctor should be open minded to other possibilities if no easy resolution to the problem is forthcoming. If you don’t like these doctors’ opinions, the only options is to find one who will listen to you. Good luck!

  21. Michael says:

    Dr Aaron do you have any suggestions to get a pain doctor to explore this possibility. Mother in law 87 years old chronic pain left side abdomen. Increases with movement she has had injections in spine T 1,12, but no relief. Carnetts test was positive, blood test, MRI and upper GI were negative for any other issues. I have given two different doctors the. Information on ACNES but they will not entertain this being the issue

  22. Jonathan Aarons MD says:

    There are many therapeutic modalities that may be useful including ultrasound and electrical stimulation or thermo- therapy. You can not manipulate a nerve out of entrapped but these modalities combined with injections can be helpful

  23. Kristie says:

    Hi Doctor Aaron. I appreciate your article. I’m an RN and I’m quite sure that I have ACNES-positive Carnett’s sign. My pain is not severe but uncomfortable and my skin is very sensitive to touch an pressure from my clothing. I am wondering what types of physical therapy exercises might be helpful? Is it possible to manipulate the abdominal muscle to un-entrap the nerve? Thank you. Kristie

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