Pain Blog

Intercostobrachial Neuralgia (Armpit Nerve Pain)

(If you suffer from intercostobrachial neuralgia, feel free to call my office at 206-395-4422, or to schedule an appointment online.)

Intercostobrachial neuralgia is a rare but very bothersome nerve pain issue. This is a nerve pain issue in which nerves coming from the upper thoracic spine and going into your armpit upper inner arm, and upper chest wall are damaged and cause pain in this region. You can learn more about the intercostobrachial nerve anatomy on wikipedia by clicking here.

intercostobrachial neuralgia

Intercostobrachial Nerve (labeled ICBN)

Intercostobrachial neuralgia is most common in people (mostly women) who have had breast surgery for cancer such as mastectomy. This is known as post mastectomy pain. It also happens after radiation therapy to the lungs and upper chest wall. Trauma to the ribs such as rib fractures can cause intercostobrachial neuralgia. People who have had thoracotomy surgery also develop it. This is known as postthoracotomy pain. I have had a handful of men present to me with this problem, so intercostobrachial neuralgia is not exclusive to women by any means.

Intercostobrachial neuralgia is occurs in 25-60% of patients surviving breast cancer surgery!

The unfortunate aspect of intercostobrachial neuralgia is that very few physicians are aware of it, and the pain it can cause. Thousands of people suffer annually from this pain after getting surgery or radiation therapy and their surgeons never tell them what is causing the pain. Frankly, I suspect many of the surgeons do not know this can cause a serious pain issue! Secondly, most surgeons do not enjoy dealing with chronic post operative pain, in particular neuropathic (nerve damage) pain. Neuropathic pain is rather difficult to treat appropriately.

The first important step is a proper diagnosis. If I see a patient with a history of the above medical issues, I will see if their pain fits the anatomic distribution of the intercostobrachial nerve. I test the function of the nerve by testing sharp sensation, testing vibration sensation, testing cold sensation, and testing light touch. If I find these sensations impaired or painful, my suspicion of intercostobrachial neuralgia is raised.

Next, I generally suggest a diagnostic and hopefully therapeutic block of the intercostobrachial nerves using a strong local anesthetic and steroid medication. Typically I will use x-ray or ultrasound guidance to see the 1st through 3rd thoracic nerves as they pass between the ribs. These three nerves collectively form the intercostobrachial nerve. I will then inject some strong numbing medicine and some anti-inflammatory medication onto these nerves. This is called an intercostal nerve block.

Intercostal Nerve Block

Intercostal Nerve Block

If, when I inject this medication mixture onto the nerves the patient’s pain goes away and they become completely numb to sensory testing in the typically painful area, I can confirm the diagnosis. The numbing medicine typically lasts 4-12 hours during which time the patient is usually very happy as this is often the first and only pain relief they have ever had for this issue.

Next, the numbing medicine wears off and the pain may return. We then wait a few days for the anti-inflammatory medication to take effect and produce longer term pain relief. I have had a handful of patients get 100% complete resolution of intercostobrachial neralgia after these injections. Many, however, get a few months of relief and then the procedure can be repeated as needed if the pain returns.

If I find that my patient gets excellent short term but poor long term relief from the intercostobrachial nerve block, we can consider a procedure called pulsed radiofrequency treatment of the nerve. You may read about it on wikipedia here.  This treatment uses radiofrequency energy to deliver electromagnetic pulses to the injured nerves. It is safe and non-destructive. Through mechanisms we do not understand fully, this procedure can help restore normal function of the nerves. This is called neuromodulation in general terms.

If the above does not work, we can consider a pain reducing device called a spinal cord stimulator (SCS). This device is like a pacemaker for pain. A thin wire is placed alongside the spinal cord where the nerves forming the intercostobrachial nerve emerge from the spine, and a small electrical current is used to block the pain signals from reaching the brain. This is a surprisingly very safe device that is used for many types of intractable nerve pains, not just intercostobrachial neuralgia.

There are also medication options which help reduce nerve pain that can be used as well. Unfortunately by the time most patients with intercostobrachial neuralgia see me, they have tried most of them. However, one medication very few have tried is called Qutenza. This is a very interesting medication. It consists entirely of the concentrated extract of chili peppers. This extract is called capsaicin. Many people have tried this medication in an over the counter preparation of 0.025%. This can be helpful but is often too weak. Qutenza is 8% capsaicin! This is much stronger and sometimes will work where nothing else has.

Physical therapy is, unfortunately, generally ineffective for intercostobrachial neuralgia given the nerve is usually too damaged. Sometimes the nerve may be irritated by tight muscles or scar tissue, which physical therapy can address. If I think that PT will help, I always like to get it on board with my patient.

In summary, if you have had chest wall or breast surgery or chest wall radiation therapy and are suffering from burning, tingling pain coming from your upper thoracic spine, going into your armpit, upper inner arm, and upper chest wall, you may be experiencing intercostobrachial neuralgia. The good news is that there are treatment options available.

If you suffer from intercostobrachial neuralgia (or think you might), feel free to call my office at 206-395-4422 (Seattle) or 425-247-3359 (Bellevue), or to schedule an appointment online.

About the Author

Jason G. Attaman, DO, FAAPMRDr. Attaman is board certified and Anesthesiology-fellowship trained in the medical subspecialty of Pain Medicine and Interventional Pain Management. He is also residency trained and board certified in the specialty of Physical Medicine and Rehabilitation. He is one of only a few with such extensive qualifications in the state of Washington. Connect with Dr. Attaman on Google+ | LinkedIn | Facebook If you are in pain, call Dr. Attaman's Seattle office (206-395-4422) or Bellevue, WA (425-247-3359) office.View all posts by Jason G. Attaman, DO, FAAPMR »

  1. Rachel L
    Rachel LOct 12, 2016

    I found your web page very informative.
    I had a bilateral mastectomy with chemotherapy, radiation, and finally reconstruction. Oncologist tried Gabapentin with no success. I tried acupuncture with no success. Physical Therapy has helped some with the tightness across chest, cording, and lack of range of motion of shoulders.
    It has been almost 3 years. Most of the areas around and in between the scars are numb. However, sometimes the chest is so over sensitive that I can’t stand to wear clothes sometimes. The constriction pain can be so tight around the chest and left arm with stress that you feel like you are wrestling with a boa constrictor. Unexpectedly, you will jump from nerves that feel like biting ants. In addition to the tightness and the bungee cord feeling and ants, there is also the duct tape feeling and now a burning sensation. The burning sensation is on the sternum and under the left breast. Like the ants, it comes and go. Then there is the phantom stabbing nipple pain and pain that I felt in the left breast before the cancer diagnose in the right breast. I have difficulty squeezing a lemon, grating food, or the hand over hand action. Pushing overhead, I am still real weak. Lately, I started having muscle spasms in the right pectoral muscle especially during hand cross over body. If I do not exercise, it gets tight and stiff still. Scars on the chest sometimes feel and look like adhesions. They still pull a little with certain activities and exercises.
    I am at a point where I wish to address the nerve pain again but don’t even know who I should schedule an appointment with in Oklahoma. What specialty? Do you have any suggestions?

    • Jason G. Attaman, DO, FAAPMR
      Jason G. Attaman, DO, FAAPMRDec 17, 2016

      Dear RL,

      Thank you for your kind comments.

      The type of specialist you need is an Interventional Pain Management specialist. I do not know anybody specifically in Oklahoma. If you cannot find anybody locally, we routinely host interstate and international patients here at my clinic in Seattle. If you would like to schedule a consultation and possible treatment, I am happy to see you.

      Unfortunately, there are very very few physicians worldwide that treat intercostobrachial neuralgia, or even understand that the condition exists…

      Kind Regards, Dr. Attaman

  2. Linda H
    Linda HDec 08, 2016

    I recently fractured a rib, and since then I have been experiencing pain under my arm and it runs into the side of my breast. It is very painful when I lay down, turn over begin to sit up and I tell my husband that it feels like a burning charlie horse or severe cramp. I have been wondering if I should get a mammogram but because of the rib fracture that is out. Should I get seen by a doctor for this matter?

  3. Sheila K
    Sheila KMar 20, 2017

    I have never had surgery of any kind but have had this pain in my left breast for years. The pain has been increasing to the point that I am often unable to leave the house. Doctors are unable to diagnose me, much less treat me. I am a 62 year old woman.

  4. Julie S
    Julie SMay 19, 2017

    I have been diagnosed with small fiber neuropathy in my feet and legs. That was 6 years ago but a few months ago I started getting pulsing burning in my right breast and under upper arm. I’ve had 2 Drs manually check me for lumps and lymph nodes. Normal. I had a mammogram. Normal. The pain will be bad for periods of time and then ok. I have not had any surgeries in this area. I do have an appt. with my Neurologist and getting another opinion with a surgeon who specializes in breasts..not that I’m getting surgery.

    Does this sound like the nerves you are describing here?

    • Jason G. Attaman, DO, FAAPMR
      Jason G. Attaman, DO, FAAPMRJun 08, 2017

      I cannot diagnose you over the internet, but the intercostobrachial nerve certainly does course though the area you describe. Best of Luck, Dr. Attaman

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