Recognisable with one finger. And still missed for years.
The cruel thing about ACNES: no expensive scan is needed. The condition gives itself away through a few clear signs and a simple test from 1926. The problem is not that it cannot be found. The problem is that no one thinks of it.
Five things typical of ACNES
Not every sign has to fit, but together they form a recognisable picture that clearly differs from organ pain.
👉 Pinpointed with one finger
The pain sits in one specific spot, usually on the edge or in the middle of the rectus abdominis muscle, and can be pointed to with one fingertip. More often below than above the navel.
🏃 Worse with exertion
The pain worsens when bending, getting up, coughing, vacuuming, exercising or walking, so with anything that tenses your abdominal muscles. With relaxation it eases.
🌙 Usually not at night
Strikingly: the pain is almost never present when you lie still at night, except sometimes when you lie on the affected side.
⚡ Sharp, burning or stabbing
The pain is often described as sharp, burning or stabbing, sometimes radiating to the side or the back, along the course of the skin nerve.
🧠 Changed sensation around the spot
Around the pain point, the feeling in the skin is often altered: oversensitive, or numb, or a different sense of cold. Pinching the skin there hurts disproportionately.
💡 The pattern matters
None of these points proves ACNES on its own. But pain you can point to with a finger, that worsens with tensing and eases with relaxation, belongs in the conversation about the abdominal wall, not only about the organs.
Carnett's sign
Almost a hundred years old, simple, and still the most important way to tell abdominal wall pain from organ pain. A doctor can do it in a minute.
You lie on your back. The doctor uses one finger to find the point where the pain is most intense (the punctum maximum), usually along the edge of the rectus abdominis muscle.
The doctor asks you to lift your head or raise your straightened legs. This tenses the abdominal muscle while the finger keeps pressing on the pain point.
Does the pain get worse or stay the same? Then the test is positive and points to the abdominal wall (ACNES). Does the pain actually decrease? Then the test is negative and points more towards an organ, because the tensed muscle then shields the organ.
Abdominal wall or organ?
This is where it goes wrong in the consulting room. With abdominal pain, the organs are thought of first. ACNES only comes into view if you know what to look for.
Fits ACNES
- Pain that can be pointed to with one finger
- Worse when tensing the abdominal muscle
- Carnett's test positive
- Altered skin sensation around the spot
- Scans and scopes find nothing
Fits visceral pain more
- Pain diffuse, hard to pinpoint exactly
- Decreases when tensing the abdominal muscle
- Carnett's test negative
- Linked to eating, bowel movements or urinating
- Abnormalities visible on tests
Imaging such as ultrasound or MRI shows nothing in ACNES, and is mainly used to rule out other causes. That is exactly why ACNES so often gets stuck: "nothing found" is confused with "nothing wrong".
"Test after test came back negative. Only when someone pressed one finger on the right spot and had me lift my head did the penny drop."
What you can ask
You cannot give yourself a diagnosis, but you can put the right question on the table.
Where this information comes from
Signs and symptoms of ACNES
Carnett's sign
Abdominal wall versus organ, and the role of imaging
🏎 Need help right now?
New, severe or suddenly different abdominal pain should be assessed by a doctor: call your GP or out-of-hours service, and in case of immediate danger 112. Feeling low or having thoughts of suicide? In the Netherlands you can call or chat day and night with 113 via 0800-0113. Outside the Netherlands, contact your local emergency line.