Circulation Loss vs. Nerve Compression

Circulation Loss

Generally speaking, circulation isn’t a major concern, and neither is the discoloration that typically accompanies it. In fact, discoloration is a particularly unhelpful guide for assessing risk because of the extreme variability among people: some discolor quickly and drastically, others show little to no change regardless of the degree or time involved in circulation loss.

In addition, in most cases, a limb can be without circulation up to 4 hours with no negative long-term effects and between 30 to 45 minutes with no changes to the muscles at all. (However, note that individuals with pre-existing circulation issues — such as Raynaud’s syndrome, peripheral vascular disease, diabetes, etc. — are at greater risk.) To be safe, of course, most people will err on the side of safety and not allow blood flow to remain restricted for more than 15 to 20 minutes.

However, the larger concern with reduced circulation is that it can mask damage to the nerves. For example, loss of sensation could be due to loss of blood flow … or it could be the result of a compressed nerve. Therefore, it’s important to realize that when circulation is reduced, the risk of missing other important warning signs is increased, and the most common type of injury in that situation is nerve damage.

Nerve Compression

Nerve damage is the most insidious danger of rope bondage. It can happen instantly or gradually over multiple scenes. It can be masked by circulation problems. It can heal in an hour or a month or a year … or never.

Therefore, it’s important that both tops and bottoms learn as much as they can about the types of nerve injuries possible during rope bondage and how best to mitigate the risks, recognize the symptoms, and respond to injuries should they occur. It’s also important that bottoms learn as much as they can about their bodies in order to help tops tie them in ways that are most appropriate for the bottoms’ specific needs.

Once a bottom indicates that they’re experiencing numbness due to circulation, the burden shifts to the top to closely monitor for signs of nerve compression. And if the bottom allows the tie to continue to the point of one or more limbs going completely numb, the top must monitor closely and continually. In those situations, the bottom should recognize the additional risks they are taking.

Nerve Functioning & Common Indicators

The nerves in your body serve one or both of the following functions:

• Provide sensation (referred to as “innervation”) to a particular part of the body
• Provide motor functions (referred to as “mobility”) to a particular part of the body

When nerves are compressed or otherwise damaged in some way, the following symptoms typically occur (though not always and not always immediately):¹”Stop Getting On My Nerves! Nerve anatomy for rope bondage.” MissDoctor

• tingling or burning sensation
• numbness or loss of sensation
• weakness or loss of mobility

Though many people report that these symptoms tend to occur in that order, one or more symptoms may occur at the same time. It’s also possible that no warning symptom will present until after damage is done.

Common Causes & Contributing Factors

There seem to be three common causes of nerve injury that relate to rope bondage:

• Direct mechanical stress on the nerves: meaning that the rope is on or very near to the nerve, and the pressure of the rope causes stress or compression to the nerve, resulting in injury
• Indirect stress on the nerves: meaning that the pressure of the rope and/or the positioning of the body causes stress or compression to the nerve indirectly (which can happen even when the rope isn’t positioned over the nerve) resulting in injury; this can result from ties that cause a great deal of stretching, torsion, and similar kinds of physical stress
• Anoxia/ischemia of the nerves: meaning that the oxygen and blood supply to the nerve is restricted and causes slowing or cessation of both sensory and motor nerve function

There are also a few common indicators associated with an increased chance of nerve compression injury, including: history of smoking, diabetes, familial neuropathies, alcoholism, and anatomic anomalies.

Another potential factor is the “Double-Crush Symptom,” which theorizes that nerve compression at one site can cause an increased chance for compression injury at another site.²Mackinnon, Susan E. & Christine B. Novak “Compression Neuropaties” Green’s Operative Hand Surgery 28, 921-958, 2017. Electronic. To be safe, if addressing the immediate, suspected area of concern doesn’t have a positive effect, remove all rope along the system (or, if unsure what that system is, remove all rope).

It’s also worth noting here that people with “loose” skin (elderly, someone who experienced recent, drastic weight-loss, etc.) or people with large amounts of subcutaneous tissue (typically comprised mainly of fat cells) may be at greater risk of experiencing nerve injury through the shearing forces that usually occur at the edge of a cuff or band of rope. This is because the rope will hold to the skin, but the skin itself may allow the rope and the skin to rotate back and forth, causing shearing, which can injure the nerve. In these cases, take extra precautions to make sure the cuff is tensioned evenly, to make sure the cuff is tensioned correctly to fit the shape of the body part being tied, and to make sure the band is wide enough to appropriately distribute the load it will take.

One other contributing factor to the likelihood of nerve compression injury is physical variability: some people are simply more prone to nerve compression injury than others. Palpating common vulnerable nerves and noting both sensitivity and location can help reduce risk. In addition, certain types of diseases (such as multiple sclerosis (MS) and other demyelinating diseases) can make people more vulnerable to nerve compression injuries.

Prevention through “Tying Well”

Throughout this course, we will try to provide specific recommendations, exercises, and tips to help tops “tie well,” to help bottoms recognize when something is or isn’t being tied well, and to help both communicate effectively. However, the following general guidelines relate directly to mitigating risk of nerve injury:

• The more vulnerable the location, the greater the risk. Certain nerves are more vulnerable in some anatomical locations than in others. Learning the general areas of vulnerability and tying in ways that avoid or minimize compression in those areas is an important first step. Learning about the specific vulnerabilities of the person(s) you are tying is an essential second step. Putting these two things in the context of the other issues discussed on this page is a necessary third step.
• The longer the rope is on the body, the greater the risk. One implication is that “more intense” or “more risky” rope should be shorter in duration. Another implication is that the top’s control and efficiency are an important safety factor.
• The greater the tension of the rope, the greater the risk. Tension should always be “sufficiently tight” but not tighter. What constitutes “sufficiently tight” will vary depending on the tie, the purpose of the tie, and the body being tied; however, in general, you want the minimal tension required to prevent the rope from moving, shifting, or changing tension throughout the scene. This is also why partial suspension work typically involves greater risk than floor work and why full suspension work typically involves the greatest amount of risk.
• The more uneven the tension in the band, the greater the risk. If one wrap or one line in a band of rope is tighter than the others, the body will primarily suffer the stress of that tighter wrap or line. In other words, if one line in a cuff is noticeably tighter than all the others, the cuff acts as if it consisted of only that single line. Which leads to …
• The more narrow the band, the greater the risk. A wider band can distribute the pressure across that band more evenly (assuming even tension in the band), thereby reducing the risk of injury.

When we combine these concepts with the common causes above, it becomes clear that merely “putting the rope in the right place” or “avoiding putting the rope in the wrong place” is only one part of mitigating the risk of nerve injury. Therefore, as helpful as diagrams like the ones below may be, they are not all we need to consider when thinking about preventing nerve injury.

Repetitive Injury

It’s also worth noting here that repetitive injury, to one degree or another, seems to be fairly common among experienced rope bottoms. This means that the nerve (and usually the same nerve or group of nerves, typically related to the same tie and similar placement) is stressed incrementally over many different rope sessions — none of which are severe enough to cause noticeable injury individually. However, over time, those micro-injuries can add up until a particular rope session causes the injury to become apparent.

This can happen even if the rope is “tied well” each time. Remember, the type of rope bondage we practice is inherently dangerous and injury (including micro-injury) happens even to experienced bottoms being tied well by experienced tops.

In that case, it’s important to note that this latest rope session may not have “caused” the injury by itself, and so the top during that session isn’t “to blame” (provided the top was tying well, good communication happened, and other precautions were taken). This is simply one of the risks of rope bondage that both tops and bottoms should understand in order to practice rope in a risk-aware manner.

Some “False Negative” Tests

There are a number of indicators and checks that both tops and bottoms can do to help them distinguish between circulation loss and nerve compression. However, we call these “false negative” tests because it’s possible to “pass” them and still end up with some type of nerve damage. Still, they’re the best we have, and are worth doing regularly.

• Speed of the Sensation Loss: Loss of sensation due to circulation loss appears gradually, and usually in stages (slight tingling, fat fingers, more intense pain, complete numbness … the specific sensations and steps may vary from person to person). Loss of sensation due to nerve compression could be gradual or sudden. Therefore, sudden sensation loss warrants immediate attention, but gradual sensation loss doesn’t necessarily mean you can attribute it to circulation.
• Area of Sensation Loss: Loss of sensation due to circulation tends to affect the entire limb or hand/foot. Loss of sensation due to nerve compression tends to affect only a portion of the hand or foot (see below).
• Mobility Checks (establish a baseline before tying): The inability to move the hands or feet in particular ways can indicate nerve compression. See below for details.
• Capillary Nail Refill (establish a baseline before tying): Press on the nail of a finger or toe until it turns white. Release, and see how quickly color returns to the nail. If it takes longer than a second or two, circulation loss is likely.

Major Areas to Watch

Most rope practitioners are warned early on about the dangers of tying tightly around joints. Not only are joints weaker areas of the body, but nerves are typically exposed in these areas, so compression is more likely.

In addition to the general caution to avoid or be extra careful around joints, we recommend that you familiarize yourself with these nerve locations:

• Brachial Plexus – particularly as it exits the neck, branches at the front of the chest, and runs under the armpit and the implications for rope passing over or under those areas ³See “The Brachial Plexus – Animated Review” and “The Brachial Plexus II: Animated Review“
• Radial Nerve – particularly as it runs around the upper arm and the implications for rope passing over the arms; this is the nerve most-commonly injured by ties that include rope over the arms; in general, the radial tends to pass around the back of the arm to the forearm at or just below the midway mark of the upper arm ⁴Hasan, Syed & B Rauls, Russell & L Cordell, Cari & S Bailey, Mark & Nguyen, Thao. (2014). Zone of Vulnerability for Radial Nerve Injury: Anatomic Study. Journal of surgical orthopaedic advances. 23. 105-10. 10.3113/JSOA.2014.0105.
• Ulnar Nerve – particularly as it runs behind the elbow and the implications for rope passing over the back of the arms near the elbow
• Lateral Femoral Cutaneous Nerve – particularly as it runs across the outside of the hip and the implications for rope passing over the hips and loaded in face-down suspensions; this is the nerve most-commonly injured by ties that include rope around the hips⁵See “Rope Incident Report – Injury to the Lateral Femoral Cutaneous Nerve” for detailed discussion
• Obturator Nerve – particularly as it exits the groin on the inner thigh and the implications for ropes that bind tightly around the upper thigh
• Ilioinguinal and Iliohypogastric Nerves – particularly as they ride along the iliac crest and the implications for hip ropes in an inversion
• Saphenous Nerve – particularly as it runs behind the inside of the knee and the implications for rope tied around the lower thigh near or behind the knee
• Peroneal Nerve – particularly as it runs from behind the knee and across to the outside of the knee and the implications for rope passing over the legs near the knee

The diagrams below should give you a general sense of the path and sensory innervation for these nerves. However, please note that we provide these only as general reference! Statistically, for around 80-85% of people, the location of any given nerve will roughly line up with the diagram below, but that means that this diagram is not accurate for 15-20% of people (roughly 1 in 5) for any given nerve (not to mention that this diagram is not drawn to scale)! This diagram is a helpful general reference, but each body is unique, and spending time learning about the particular concerns of each body in rope is time well spent.

NervesHip HarnessArms FoldedBox TieArms BackArmbinder

A Closer Look at the Arm

Because so many nerve-related injuries affect the arms, we wanted to provide a closer look and point out a few particularly problematic areas: the armpit region, the lower back region of the upper arm, and the wrist.

Indicators

Checking both sensation and mobility frequently may help you identify nerve-related concerns sooner.

Thigh / Groin

Decreased sensation, numbness, tingling, or a burning sensation in the region of the groin could indicate compression of the ilioinguinal or iliohypogastric nerves.

Decreased sensation, numbness, tingling, or a burning sensation along the top of the thigh or knee, or weakness of the knee or leg when bearing weight (and particularly in movements or positions similar to walking down stairs) could indicate compression of the femoral nerve.

Calf / Foot

Decreased sensation, numbness, tingling, or a burning sensation along the inner side of the lower leg and/or calf could indicate compression of the saphenous nerve.

Decreased sensation, numbness, tingling, or a burning sensation along the top of the foot, or the inability to flex the toes up towards the shin, could indicate compression to the peroneal nerve.

Innervation
Mobility

Hands

Decreased sensation, numbness, tingling, or a burning sensation in a given area of the hand can indicate possible nerve compression or damage to the corresponding nerve somewhere along the arm (see the diagram below).

In addition, the inability to move the hand in particular ways can indicate a problem with a specific nerve as well:

• Ulnar Nerve – difficulty turning the hand (as if turning a door knob) in the direction of the pinky
• Median Nerve – difficulty bending the hand forward (toward the forearm)
• Radial Nerve – difficulty flexing the hand backwards or giving a “thumbs up”

Innervation

Mobility

Responding to Injury

At the first sign of potential nerve compression injury, take all necessary steps to relieve pressure in the affected area and/or possible sources of the compression. This may involve shifting the position to relieve pressure from the rope (which bottoms may also be able to do for themselves), but likely involves removing/untying the rope and/or ending the session completely and removing all rope.

The level of experience and risk profile of both the top and the bottom will determine your response. However, if changing position doesn’t cause immediate and noticeable relief, and untying in the specific area doesn’t cause immediate and noticeable relief, we advise ending the session and removing all rope. Please note that time is a significant factor in nerve compression injuries, and the sooner you address the issue, the more likely the issue will be minor and will heal quickly on its own. Every minute you delay can greatly increase the damage.

The current commonly-accepted initial treatment for nerve compression injuries is listed below. However, note that there are some disagreements in the medical community. We recommend reading “First aid for nerve damage” for a more complete understanding.

Assess Severity of the Injury

• If the injury involves sensation loss but no loss of mobility, and if the sensation returns within a few hours, there is likely no need to treat the injury beyond avoiding additional compression for a while to allow full healing.
• If the injury includes some loss of mobility, you should consider first-aid treatment as indicated below, monitor closely, and seek professional help if mobility does not improve within a few hours.
• In general, the more severe and/or longer lasting the symptoms, the more immediately you should seek professional help.

Response & Treatment

• As soon as indicators are detected, remove compression as soon as possible (in a controlled manner). It is typically best to avoid moving the body in any way that could cause “shearing forces” in the problem area. For example, don’t attempt to transition or rotate the bottom in rope before attempting to remove the pressure of the rope.
• Don’t stretch or massage the area and/or potential source location of injury. Your goal is to avoid any additional compression to the affected area until fully healed. (Remember that the actual site of the compression may not be in the area that is experiencing sensation or mobility issues.)
• Rest the area in the first few days of injury. (This may involve using a splint, depending on location and severity.)
• However, careful mobilization within the first week is also important. If the injury is significant enough to require more than a day or two to fully recover, physical therapy with a trained professional is recommended for finding the proper balance of rest, protection and mobility.

A mnemonic commonly used in the rope bondage community is SWEAR (attributed to Noble Manqué):

• S = Stop – stop the activity and remove all rope or other forms of constriction
• W = Water / Ice – Ice can help reduce inflammation and relieve pain (10-15 minutes/hour; indirect) and water/hydration can help with inflammation. However, use of ice as a treatment is not advised by all medical professionals.
• E = Elevate – moderately elevate the affected area
• A = Anti-Inflammatory – non-steroidal, anti-inflammatory medication (NSAIDs)–such as ibuprofen (Advil) and naproxen (Aleve)–are often recommended because they have pain relieving and anti-inflammatory properties (maintain consistent dosage for a few days to be effective; beware of allergies, side effects, and interactions). Others recommend nerve-specific treatments such as Keltican or ALANerv
• R = Rest the affected area; avoid massaging or stretching to “fix it,” but do maintain consistent and moderate mobility

In all cases, and regardless of the first aid approach used: if symptoms do not lessen in two to three days — or if there is pain and/or other symptoms accompanying the injury — see a doctor as soon as possible (with urgency determined by degree of mobility loss and/or pain).

Additional Information & Resources

Please spend time carefully reviewing these additional resources:

Remedial Ropes is an excellent resource for rope-bondage-related safety information.