Cortisone injection into the palm of the hand

That depends a bit on exactly what is meant by 'palm' and how the needle was angled. Some people do insert a needle into the carpal tunnel from the palm end for CTS, but injections in the palm are also given for trigger digits and sometimes for osteoarthritis. There are also approaches from the forearm end and from the side, with or without ultrasound guidance. In practice it doesn't seem to make much difference exactly where you put the injection. JB

Thank you for your prompt reply and reassuring message. I did not look to see how the needle was angled but the incision was next to the fleshy part of the palm below the thumb - around the flextor pollicis brevis perhaps. 48 hours after the injection my middle, index fingers and thumb are still extremely numb as is a large section of my palm. There is a sharp pain when I bring my thumb and fingers together to grip an object or open a jar. I wonder if this is normal and if so what sort of recovery time I should expect? Thank you again for any guidance

What it feels like is largely determined by whether they inject a local anaesthetic with the steroid - something which many people do but which I have never understood the rationale for. By 48 hours after injection however it should really be feeling better and if there are more symptoms now than there were before injection I would begin to feel concerned. It's hard to know what you can do about it in Thailand though. JB

Thank you again for your time. If symptoms get worse I will travel to Bangkok and see a hand specialist. I am sure there are quality hospitals there. Either way I will send feedback here in 2 weeks incase others are interested in the outcome

I'm certainly interested, especially in reports of adverse results from injection. There is surprisingly little literature documenting problems with injection for CTS despite guidance from orthopaedic surgeons describing them as 'hazardous'. In our experience they are much safer than surgery but that does not mean they are completely risk free. The published literature suggests a serious complication rate of < 1:3000 whereas in my own service it seems to be <1:1000. Given that they are such rare events all reports of problems are welcome. What has turned out to be an interesting 'perk' of running this site is the chance to gain some insight into how CTS is perceived and treated in other parts of the world. We have had visitors from almost every country in the world now but I think you are the first to actually post from Thailand. JB

I have followed this whole site with interest but in particular I am interested in the results of the injection. I developed CTS about two years ago and the GP gave me an injection which had no effect whatsoever. After 18 months my referral to a consultant came through in the beginning of May this year and the first thing he did was to do another injection which he said would help with the diagnosis although having read this site I am not certain how.
Following the injection the symptoms became worse and have remained worse . A call to the consultants office elicited the response that it was usual for the symptoms to worsen initially but if I had any concern to refer to my GP. It is now 6 weeks since the injection and there is no doubt that the symptoms are worse than before the consultant's injection and have remained that way. The numbness that was largely confined to the finger tips has now spread up the length of both fingers and to the edge of the palm. I do recall the GP saying before he administered his injection that the symptoms might worsen temporarily but he gave the impression that was only likely to be the position for 48/72 hours. The GP's injection did not contain an anesthetic component but the consultant injection did.
The follow up visit with the consultant is due early next month but I don't think he envisioned that the symptoms would worsen as a result of his intervention so quite what he will make of it is unknown at this time.DRC

We generally do not find that the symptoms of CTS themselves worsen after injection - though numbness would of course increase for a while if a local anaesthetic was used - but some people do get transient pain in the wrist and forearm so they may have been referring to that. The sense in which it helps in diagnosis is that a definite response to injection does help to confirm that the problem really is CTS and to some extent correlates with the subsequent response to surgery. In your case what we really need to know is what your nerve conduction studies or ultrasound imaging look like. JB

It is now 12 days since the injection into the palm of my hand. Seems like I was given Triamcinolone 1 ml plus my medical report cites Voltaren 20 + Norgesic 20 + B1-6-12 20. I'm not sure if these were the pills i was sent home with or part of the injection.

After the injection the doctor said there would be pain for 10 days and he was right. The palm of my hand was numb and extremely sensitive to touch. Also any action that brought the thumb close to the index and middle finger resulted in sharp pain inside the palm of the hand. For example trying to twist open a bottle was impossible. There is still some pain and an area of numbness in the palm of my hand but slowly seems to be getting better.

Of the CTS there a big improvement. For example before the injection I was unable to go running more than 5 minutes before my whole hand was tingling with pain. Now I am able to run for 30-40 minutes with only occasional slight tingling in the finger tips. To alleviate this tingling I use my good hand to flex back to CTS hand - stretching at the wrist.

I never did have any pain when lying down at night as many people describe in this forum. My pain often came from raising my hand up above the heart level: i.e. speaking on a phone, holding a steering wheel, riding a bicycle although my running would be a big exception to this.

I can't see any literature anywhere on-line that mentions injection into the palm and that's worrying for me. But still I'm hopeful that this unorthodox treatment may have fixed my CTS - or at the very least not created other permanent damage to my hand.

Triamcinolone would be the injection - it should state the dose really. We use 40mg but other people use more, or less. The other things are the tablets, including what looks like a mixed b-vitamin supplement which will have been of no use whatsoever unless you are a strict vegan or have pernicious anaemia. Do you end up paying for the pills in Thailand?

I do have a paper somewhere on injection from the palm, from some Turkish authors if I remember correctly and claiming that it was less painful - but we find that only a few injections result in significant pain anyway.

You tend to hear quite a lot about pain because people are motivated to talk about it but in the majority of cases the early symptoms are tingling and numbness rather than pain as such.

It sounds as though your CTS is responding at any rate. There is of course a high risk of recurrence but if you are lucky it will not come back for some time. JB

When I say pain I mean pain - very distict spasms of shootnig pain as if from a tendon or muscle contracting inside the palm. Thats on top of the tingling and numbness.

In Thailand they love to give as many pills as possible - even at the best hospitals - and even if only paracetamol. Yes the customer pays :-) I guess in many cases the tourists holiday insurance pays and its cheaper than being ill in Europe or North America so its a big gravy train and everyone is making money out of it...

Thank you again for all your help!

Now 2 months since my injection. I am able to use the hand more than before the injection (cycling, running, holding a phone up to my ear) but not 100% cured. Still experience tingling in the finger tips on all the previous mentioned activities. Not sure whether to go for second injection or try surgery...

Second injections are fairly harmless and convenient - though given the experience with the last one I would try to find someone who uses a more mainline approach, injecting above the wrist crease. They should rarely be painful. Surgery is of course more likely to produce a permanent solution but is a bit riskier and more inconvenient. The degree if relief of symptoms is also, on average, a little greater with surgery. I find a check on the nerve conduction to see if they are getting better or worse helpful in deciding what to do but we haven't studied enough patients yet to be sure whether that really is the case or if I am deluding myself. JB

I went to have a 2nd injection last week but the doctor (here in Thailand) said I need to wait min 6 months between injections. Do you agree?

At the moment I can hold a knife and fork to eat one mouth full and then need to put my left hand down on my lap to relieve the tingling. Same for any activity that raises the left hand above chest level. But on the diagnostic tests I only score 24% probability of CTS. I can't understand why this would be. Are these not the symptoms of CTS? Is my pain not severe enough? The wrong type of tingling or the wrong fingers?

Thank you again for your valuable opinions and time

It will be the fact that you are male, relatively young and have no nocturnal symptoms that is pulling the score down mainly. The tingling is in the right distribution and symptoms on raising the hands are fairly typical. The severity of pain is not very useful diagnostically (interesting one that!). There is no widely agreed limit on the frequency of injection, and indeed no scientific consensus on whether more than one injection is even advisable. Most people therefore set themselves some arbitrary rule. Mine, at present is not more than once every 6 months on average - which means I will allow consecutive intervals of 8 months and 4 months for example - but "m trying to collect data to reach a more evidence based conclusion about this. JB

Is 55 years old "relatively young"? I'm happy to hear that. I did report nocturnal symptoms which continue in spite of wearing a splint. Anyway just got an email from carpal-tunnet.net asking my to complete a new questionnaire so I will give that a go and see if I can improve my score :-)

Good timing becuase I have just come back from my 2nd injection. Did someone say injection in the wrist is not painful? Well not the way they do it in Thailand! I experienced very severe tingling and shooting pain down most fingers. So painful that at one point I told him to stop and that I could not go on. But it's done now so lets see. Not again though. Operation next time if needed...

That injection report is slightly worrying - most injections for CTS are not painful. Did you get the shooting pains on needle insertion or while they were injecting, or both? JB

I am too squeemish to watch when the needle is being inserted so I can't say what was going on. Before we started the doctor told me to tell him if I felt tingling in the fingers. It did not take long before I was shouting the pain was so intense and he asked me where and I said in the fingers. Then the pain eased off from the fingers and there was more of a dull pain from the fleshy part of the hand below the thumb. It felt like he had removed the needle and re-inserted into the hand but when it was all over and I looked there had been only one incertion.

Now 6 hours later there is no consistent pain but tinging in the fingers when I use the hand like now to type. This tingling is far more than before the injection. I hope he has not made a worse job than the first doctor who injected into my hand...

That sounds as though the needle hit the nerve when first inserted and was then re-positioned. You would normally not withdraw it entirely from the skin and go in through a new hole so you would only see the one pin-prick after the procedure. If the injection is actually given directly into the nerve it can cause quite serious symptoms so hopefully that was not the case here. If there is no serious injury then hopefully the CTS symptoms will improved over the next 48h. JB

Dear Dr Bland

It is so kind of you to continue giving this advice. I am extremely grateful especially since I am here on a small island in the Gulf of Thailand without native English speaking medical professionals to consult .

It is now 7 days since my 2nd Cortisone injection and I am still experiencing tingling pretty much accross all fingers of left hand. The tingling is less severe than before the injection. Day to day activities like drivng a car and holding a phone to my ear are easier but not pain/tingle free.

When I clench my fists my hands have equally strong grasp with no pain in the fingers but when I grab hold of something using also my thumb there is a slight pain in the bottom center of the palm.

I have a couple of questions if I may

(1) is it usual (or even possible) to take over a week to feel the benefits of a Cortisone injection or is this more likely to be a sign of incorrect procedue, dose or medication?

(2) one of the most severe effect of all this is for my life is that I am not able to go running. The simple activity of jogging even 10 minutes has been impossibe for 6 months now. How can this be? Is this an expected symptom of CTS? I would have thought with the arm and hand down at waist level and the body in movement this would be good for blood flow.

(2) Either way I need to do whatever necessary to try and solve this problem. I can't let it carry on much longer. My next logical step would be to have the operation. Is there a period of time I should wait post Cortisone before operation?

Thank you so much
Adam

1) We occasionally see late responses to injection, up to about 6 weeks. It's always difficult to know whether it is actually the injection having the effect after that long or if the CTS is just getting better anyway. Most cases respond within 48 h. I wonder if you are feeling the consequences of the needle hitting the nerve before it was repositioned this time.

2) Jogging does not normally aggravate CTS- but probably few of my patients are runners. Do you clench your fists when running?

3) Surgery does sound like the next logical step. There is no need to wait any set length of time after injection, but I would be inclined to repeat the NCS first so that there is an up to date baseline result in case of problems with surgery. JB

No I never clench my fists when running. Actually I have never had a nerve conduction test. I guess that will now be my next step but that will involve a trip to Bangkok. What is the procedue? Have NCS, then have surgery same day, then back for 2nd NCS some time after?

Thank You

Have the NCS done and then think about whether surgery is a good idea or not. If you end up making a journey to get them done make sure you get a full copy of the results. JB

Dear Dr Bland

By way of an update I wanted to report that it was 2-3 weeks after my 2nd Cortisone injection that I started to feel relief. That gave me 3 good months where I was able to resume all physical activities (running, cycling etc).

Now in the 4th month most day-to-day activities (speaking on the phone, holding steering wheel) are still much better but the extreme numbness and tingling is starting to return when running. I am worried that this is the first sign of the Cortisone wearing off...

One question: is physical activity that brings on sever pain to be avoided (will it make the carpal tunnel worse) or can it be beneficial (working through the pain) ??

Thank You

I don't think anyone really knows the answer to that last question for sure but I would tend to err on the side of caution myself and avoid activities which precipitate severe pain. Did you ever manage to get any NCS done? JB

I have today finally had the NCS done at the Royal Free Hospital. The doctor administering the test said definitely CTS in the left hand and recommends surgery. I have appointment with the consultant in a few months time and hope he will concur and book me in for surgery.

Did you ask for a copy of the results? There is more infomation to be gained from NCS than just a positive or negative answer. JB

Yes indeed I have a copy of the results. Can I send to you?

Are there two types of surgery? Conventional one and endoscope ?

Is it true to say the first one can be done on local anesrhesia in day case but lt may made pillar scar that can cause pain, whereas the second one uses a brachial block, leaving a smaller wound and no pillar scar...?

These claims made by hospital in Bangkok offering carpal tunnel release surgery

Many Thanks

Yes you are welcome to email me a copy - scanned or whatever. Both conventional and endoscopic surgery have many minor variants. Both are usually done under local anaesthesia and both can cause pillar pain I'm afraid - meta analyses of studies comparing the two methods generally conclude that the outcomes and complication rates are identical - the only consistent difference is slightly faster recovery from the endoscopic operation. However other factors have a much bigger influence on recovery times than which type of surgery is used. There's a fair amount about the two methods in the treatment section of the site here and as I'm not a surgeon I don't have any particular brief to sell 'my' way of doing things where surgery is concerned. I think it's actually more important to find a surgeon who does lots of carpal tunnels and is interested in the condition rather than worrying about which variant of operation he/she does. JB

Thank you so much for agreeing to look at my NCT results. I have been trying to find a way to send them. Cannot seem to paste a file into this forum and can't find your email address anywhere. Please advise.

I have just returned from a hospital visit in Bangkok where I saw a specialist in carpal tunnel release. He offered the release surgery there and then but I am hesitating and want to collect more facts.

My case seems a bit unusual because there is no loss of strength in the hand and no pain at night. The only severe pain is in cold weather and when engaged in running and cycling activity. First thing in the morning I wake up with stiff hand and slightly numb but the rest of the day very mild symptoms.

Having read the treatment and outcomes section of your website there is a question in my mind as to what the chances are that surgery will result in 100% cure.

Reading between the lines of the NCT I'm wondering if the problem could be from the elbow rather than the wrist

Thank you again for your valuable input

I have now found your email address and sent you a jpg of the test results
Many Thanks

Looking at those results, the probable grading is grade 3 in the left hand and normal in the right, though there is something a bit odd about the left hand results in that there is a more marked motor than sensory abnormality and in most cases of CTS it is the other way around. We also don't have either the recorded waveforms or the normal ranges for that laboratory to work with so I can only say 'probable'. The suggestion of ulnar nerve problems at the elbow is, I think, based on local slowing of nerve conduction around the elbow - 38 metres per second compared to 60 metres per second in the forearm segment of the same nerve but again I can't see anything very wrong with the right side. It may be that the person carrying out the test had more information available which does not appear in the report. Another issue with the NCS results is that the prior injections might have had some influence on this. You can look up the surgical success rates by grade in the surgical prognosis section of the website. I'm working on more sophisticated ways of predicting outcome but they are not really ready for public use yet. JB

Just wanted to update you on my current condition nearly 1 year since I first messaged you here.

Basically most of the pain seems to have gone away on its own! Day to day activities are almost symptom free and I find that I am able to run for 1 hour about 10k with only very minor symptoms. I discovered that having the arm bent at the elbow during running aggravated the tingling and numbness and that by stretching out the arm I can reduce these symptoms.

Moving between the heat of Thailand and the cold of the UK I always wondered if symptoms were aggravated by ambient temperature. There is no doubt that in London in March in 8 degrees the pain was severe just walking on the street and then April back to Thailand in 35 degrees I started to feel so much better.

Maybe just a coincidence but long may it last and I certainly can live in my current condition without corrective surgery. I hope that I won't be contacting you again in a few months with another story. Thank you so much for all your time and help

You are very welcome. Though discussing things with patients here on the website is not remotely like dealing with you in person it all adds to the overall picture I have of the range of clinical manifestations of CTS and is therefore useful experience. I hope it remains under control. JB