Nerve damage seems to be the most common serious injury (as opposed to minor injuries like rope marks, bruising, etc) that occurs in bondage scenes.Nerve damage is much more of a concern for bondage than decreased circulation (though the two can and do happen concurrently).

There are two types of nerves we are concerned about with bondage – motor nerves, which control movement, and sensory nerves, which transmit sensation. Generally speaking, motor nerves are better protected than sensory nerves, so sensory symptoms often (but not always!) proceed motor nerve damage.

Danger signs for nerve damage include pain (generally described as sharp/shooting), weakness, tightness, stress, tingling, and numbness. These generally occur QUICKLY, sometimes instantly, and should be acted on immediately to prevent long term damage.Keep in mind that symptoms of nerve damage will occur "outward" (the medical term is "distal") from the injury site. So if nerve impingement is caused by rope across the radial nerve on the upper arm, symptoms will manifest in the forearm/wrist/hand.Nerve damage can occur either by stretching of the nerve (ex: over-extending the arms over the head for extended periods of time), by compression (ex: rope pressing tightly up against the armpit), or by shearing force (ex: tight rope pulling across the upper arm). Shearing force refers to parallel surfaces sliding past one another and is particularly problematic for your nerves – if you ever had a grade school classmate do a "snake bite" on your arm, you have some idea of what this type of force feels like.The interplay of 6 basic factors contribute to nerve injury:

1. Individual differences in nerve vulnerability.31 Some people seem to have bombproof nerves, some people seem to get nerve damage if you look at them funny

2. Anatomical location: where on the body you are tying. Some locations are higher risk than others. Locations where nerves are closer to the surface and/or to bone, such as joints and the upper arm, are generally higher risk areas.31

3. Duration of compression. Nerve damage happens in stages – removing bondage at the first signs of injury can keep a minor injury from becoming a major one.1

4. Severity of compression/amount of shearing force.1The increased severity of compression and risk of shearing is part of what makes suspension bondage generally higher risk than floor work. Spreading the load over a larger area can help decrease risk.

5. Stretch/stress positioning. This also has a lot of individual variance. Keep in mind that stretching/stress positioning may also make nerves more vulnerable to compression.

6. Environment (internal & external)

   • Read much more about these 6 factors here!

Most incidents of nerve damage involve many (if not all) of these 6 factors.

As a general rule: The more force and the longer the time, the greater the damage will be."Mechanisms of nerve injury include direct pressure, repetitive microtrauma, and stretch- or compression-induced ischemia. The degree of injury is related to the severity and extent (time) of compression."1

It’s possible for nerve damage to occur without any warning/symptoms at all, and even with an experienced top who does “everything right.”

Nerve irritation that is immediately resolved leads only to temporary nerve damage (numbness that goes away quickly). Any prolonged irritation can lead to semi-permanent damage (nerves need weeks or even months to heal!) or to permanent loss of function. “Recovery of nerve function is more likely with a mild injury and shorter duration of compression.”7

Next: Signs and symptoms of nerve damage

See this page for references

It’s possible for nerve damage to occur without any warning/symptoms at all, and even with an experienced top who does “everything right.” Generally, the type of bondage pain that is going to cause long term damage is a type of pain that will set off alarm bells in the bottom’s head.

It will not feel erotic, it will just hurt! Bottoms must also be alert to numbness and tingling (which also doesn’t feel erotic to most people), not just to sharp shooting pain. If you’ve ever hit your “funny bone” then you know where your ulnar nerve is and how it feels to have trauma to it- not sexy for anyone I know.

Sometimes nerve damage may be focused on a particular area rather than the entire limb. For example, the ulnar nerve covers, among other areas, the pinky and half of the ring finger. So, if a bottom reports numbness and tingling only in a specific “zone” rather than an entire limb, that’s a good clue that the symptoms are due to nerve compression. HOWEVER the fact that the entire limb is numb/tingling should not be taken to mean that the damage is NOT due to nerve damage.

Several very experienced bondage bottoms have told me that they can tell there is an issue with their radial nerve because the top of their thumb goes numb. They therefore monitor for this during a scene by rubbing their index finger on the top of their thumb periodically to make sure they can feel it.

Even “minor” nerve damage can have major consequences. A relatively mild injury to the radial nerve, if on the bottom’s dominant arm, can easily render them unable to write or type for days or weeks – a major problem for most people. 

Next: How to address signs of nerve damage during a scene

See this page for references

As a top, what should you do if your bottom reports numbness, tingling, tightness, or pain? You need to immediately take steps to address it. If the bottom’s symptoms are minor, experienced bondage tops may sometimes address the problem by removing or redirecting tension, shifting ropes, or changing the bottom’s position. A key component of this is making adjustments, then quickly checking back in with the bottom to be sure the problem has resolved.

In the following cases we recommend immediately untying the effected limb:

• If you or your bottom are beginners with rope

• If symptoms the bottom reports are severe and/or sudden – “I feel my right arm just went numb.” “I have sharp pains going down my left leg” etc.

• If initial steps taken (loosening the rope, changing position, etc) don’t resolve the problem

• Anytime you have any doubt, err on the side of caution and untie.

If untying the limb still doesn’t solve the problem (symptoms are ongoing a few minutes later), stop the scene and begin first aid steps. Many nerve injuries appear to have a cumulative aspect. Therefore, if you had any issues with nerve damage in a scene, avoid risking re-damaging that nerve, particularly in the first week following the injury (even if it was very minor). If you're going to tie again, avoid load-bearing rope on the injured area (keeping in mind that symptoms appear distal to the actual injury site). 

Next: As a top, how do I monitor my bottom for nerve damage?

The bad news about nerve damage is that the top often has no way to know when it is happening, other than communicating with their bottoms! This means that rope tops have a serious responsibility to educate their bottoms to alert them when they have bad pain/sensations so that they can release/adjust the bondage.

Other than educating and empowering their bottoms, tops can help prevent these injuries by knowing basic nerve anatomy and symptoms of nerve damage. Anecdotally, it seems that most problems with bondage are caused by damage to the radial nerve (aka “honeymoon palsy” or “Saturday night palsy”), in most cases due to tight or load bearing ties across the upper arms. The radial nerve wraps around the upper arm and is close to the surface around the bottom of the deltoid, where people love to put rope (especially in box ties and the like). Other forearm nerves include the medial and ulnar nerves. Note that the exact location of these nerves varies from person to person, and both location and degree of exposure will vary based on position!

Tops should watch for signs of trouble – signs like wiggling fingers and adjusting ropes are good cues that it’s time to check in with the bottom and adjust the bondage.During the scene a bondage top can check CSM (circulation, sensation, and movement) in all sorts of fancy medical ways (capillary refill, point differentiation, etc)- however, it's important to keep in mind that the main predictor of bad outcomes seems to be the bottom’s subjective experience in the bondage. Pay attention to body language and check in frequently.

In addition to testing for sensation, there are several motor "tests" the top can do:

• The Kumar Test is designed to check all three of the nerves of the hand (radial, ulnar, and median). This test basically involves making the "OK" sign with the hand/fingers – please follow the link for details. 17

• Ask the bottom to touch the tip of each finger to their thumb. Inability to do this can indicate a problem with the radial, ulnar, or median nerve. 16

• If the bottom is in a position to do so, have them make their wrist and fingers a straight line with their forearm. Put your hand on the fingernail side of their hand. Have them extend their wrist (bend at the wrist towards your hand, away from the direction of their palm- this is called "wrist extension"). Inability to do this generally indicates a problem with the radial nerve (often from a box/TK tie).

• Ask the bottom to spread out ("extend") their fingers, by themselves and against resistance. Inability to do this indicates a problem with the radial nerve, or if they specifically cannot extend the thumb, the median nerve.

• Ask the bottom to squeeze your fingers and *maintain* a grip. Inability to do this can indicate damage to the medial nerve or the ulnar nerve.2

• If the bottom "fails" any of these tests, that is an indication that they have some nerve impairment and should be untied.

• However, “passing” any of these tests is NOT an “all-clear” that would indicate everything is definitely OK.

Making frequent shifts in the rope – just a slight reposition, adjusting the tension, or temporarily releasing the pressure to allow the underlying tissues to readjust- can make all the difference. This may be as simple as running fingers under the rope or as complicated as rearranging a suspension so the bottom is in an entirely different position.

Next: When a limb "falls asleep" in bondage

See this page for references

We have all had a limb “fall asleep” in a non-bondage context, and we all recovered, I imagine? That sensation is usually caused by a combination of reduced circulation and minor nerve injury. The two are inseparable to some extent – reduced circulation reduces circulation to everything, including the nerves, which causes them to go a bit haywire when circulation is restored.9Despite the fact that most of the time your body will recover when you experience these symptoms, the damage that can be done by bondage is a bit different than the type caused by crossing your legs for too long (it’s more focal compression, for one thing). Also, you can suffer from nerve damage just from crossing your legs for too long or too often.8 Thus, in a bondage context, I would never dismiss complaints of limb numbness as “just” being a “sleeping” limb. 

Next: Rope placement to help prevent nerve damage

See this page for references 

The radial nerve in the mid upper arm area is a common site of nerve injury for bondage. "The radial nerve is the most frequently injured major nerve in the upper extremity."29 When you are first learning bondage, or just getting started with suspension, consider completely avoiding tight and/or load bearing ties around this area. Suspension in “box” or “takate-kote/TK” style ties require very specific training and mentoring, and are high risk for nerve damage.

Avoid wrapping any rope that will bear load or be under more than a minor amount of tension around the bottom’s knees, elbows, groin, and armpits. These are places that major arteries, veins, and nerves are near the surface. Studies have documented nerve damage to both the radial and medial nerves caused by blood pressure cuffs positioned too distally on the arm (not high enough, overlapping with the elbow area) – the recommendation of these articles was to be sure blood pressure cuffs are placed proximally (close to the center of the body) enough to avoid overlap with the bend of the arm.3 4 5

Try to stay on the “meaty” parts of the extremities.The lateral femoral cutaneous nerve (LFCN) seems to be the most commonly injured lower extremity nerve. Injury to this nerve causes numbness to a patch of the outer thigh. This most commonly occurs in ebi/"shrimp" positions (where the bottom is bent over, with their torso pressed to their legs) or in face down or side suspensions using a hip harness where rope applies load in the hip area (along the panty line).

You can dramatically reduce compression by having more bondage material against the skin – this is what makes tying up someone's wrists with a fluffy scarf generally lower risk than restraining them with a zip tie. If you're using rope, this means making more wrapping turns or thicker rope (8mm is the thickest I would recommend, thicker than that is very difficult to work with).

Often, hands are the first area where the bottom experiences problems. If possible, arrange the bondage so the hands can be easily released without having to undo everything else first.

Next: Pre-disposing factors for nerve damage

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Diabetes is a serious risk factor for nerve injury. About half of diabetics develop nerve damage (“peripheral neuropathy”) due to their diabetes,10 and pre-existing/chronic nerve damage is an important predisposing factor for acute nerve damage.11 12 Very thin people are at higher risk for acute compression nerve injury.11Other conditions that can make people more prone to nerve damage include alcoholism, poor nutrition or vitamin deficiency (especially vitamins B6 and B12), thyroid disease, kidney disease, and autoimmune diseases like lupus or MS.14 "Systemic conditions such as obesity, diabetes, rheumatoid arthritis and other neuropathies will similarly render a given individual more susceptible to the development of... compressions."27 Existing subclinical (asymptomatic) nerve injury is a risk factor to develop a symptomatic nerve injury.11 Studies of baseball players have shown that cumulative microtrauma from repetitive overuse places them a risk for peripheral nerve injury of the upper extremities.13 "A proximal level of nerve compression could cause more distal sites to be susceptible to compression."30 In a bondage context, there is anecdotal evidence that bondage injuries are cumulative. This means that perhaps a bottom who has been put in a box tie the exact same way 50 times and never had symptoms of nerve damage might the 51st time suffer from a symptomatic nerve injury, even though there was nothing special, different, or “wrong” that 51st time. A cold environment may be a risk factor for nerve damage. Interaoperative nerve damage is very similar to bondage nerve damage in many ways – it is generally compression/position related. A relevant study found that, all other things being equal, patients who are cooled during surgery have more incidence of intraoperative nerve damage than those who are NOT cooled.3 So it's likely risky to do suspensions in an icebox, and if the bottom warms up prior to the scene, this may help prevent injury.

Next: Signs of nerve damage after a scene

See this page for references

Signs of nerve damage that may be noticed after a scene include weakness (often focal depending on the affected nerve), numbness, tingling, pain, difficulty with fine motor control, and specific signs like “wrist drop” (which generally indicates radial nerve damage).

It is possible for these symptoms to resolve over an hour or so. It is also possible that recovery could take months or years, or that the injury could be permanent. An indication that experienced bottoms report regarding recovery time is that if there is notable improvement over the hours following the injury, generally recovery will take place within a few days, perhaps a week. If it takes days to see improvement, it will likely take weeks to recover. Longer time to initial improvement = longer time to full recovery. Take further action and begin first aid steps as outlined on this page.

The most commonly reported bondage-related nerve injury seems to be radial nerve compression damage from box or TK ties. The three main effects of radial nerve damage are decreased range of motion, altered sensation, and impaired strength. Bottoms who have experienced this injury have reported that range of motion came back first, then strength, and finally sensation.

Next: First aid for nerve damage

This is a quick summary. A detailed discussion of this topic can be found here.

Avoid stretching out the affected area. Remember that stretch is often a contributing factor in getting the injury in the first place.

Avoid compressing the affected area. Again, compression is a causative factor and more compression will not be helpful. "Compression" includes: wrapping with an ACE bandage, massage, or even sleeping on the affected limb.

We no longer recommend applying ice as part of routine care after a bondage-related nerve injury. If you do choose to ice, do so only for the first day. Apply ice to the site of damage for 10 minutes every hour while awake, being sure to use a padded ice bag that does not cool too aggressively.

It's important to remember is that the site of the damage may not be immediately clear or intuitive. For example, if there is radial nerve damage (and subsequent wrist drop) from a box tie, the temptation is to think that the wrist is injured, when the injury probably originates in the upper arm.Generally, nerve injuries resulting in mild symptoms in isolation likely do not require a trip to the emergency room right this second, but if there are any concerns that there may be further or more severe injury (ongoing circulation compromise, severe deficits, ongoing pain, deformity of the limb, hematoma (large bruise) which could compress the nerve, etc) then a trip to the ER would certainly be appropriate. As a guideline: the “deader” the limb and the slower it resolves, the more urgently they should visit the local ER. So, if they have a bit of tingling in their pinky from hitting their funny bone, they can easily wait. If the whole arm is numb, pale and doesn’t get ANY better in 10-20 minutes – rush to the ER immediately. And remember: Tell the ER docs the truth. They won’t judge you, and they need to know exactly what happened. The more authentic the story you’re telling is, the less likely they will suspect any abuse.

See an MD (a neurologist if possible) within a few days if symptoms persist.

After the first few days, you can consider using gentle heat.

Gentle mobilization as soon as possible is recommended, with use of braces only as needed to prevent further injury. Consult a physical therapist if possible.Consider taking a pain & anti-inflammatory medication like ibuprofen. This is somewhat controversial from and "optimal healing" perspective, however if you are having pain, these medications may help by facilitating mobilization.Nerve damage can be exacerbated by vitamin B-12 deficiency. Taking B-12 supplements, if it’s OK’d by your doctor, could help with healing.

Next: More detail about first aid for nerve damage, perhaps? Or read about some bondage myths and misconceptions?