?bilateral recurrence

That's certainly a very difficult one and it does sound likely to be in some way work related. I suppose my first guess would be that the original symptoms were not quite 'classical' CTS, in that they may have been more a manifestation of direct irritation of the median nerve by your work rather than a true entrapment in the wrist. That would fit in fairly well with the symptoms being particularly evident on use rather than at night and with the fact that NCS signs of entrapment in the carpal tunnel were mild/normal. Despite that formulation of the problem however I think one has to say that you did also have some degree of raised pressure in the carpal tunnel, perhaps secondary to the nerve irritation, and that relieving this surgically explains the improvement in symptoms and NCS with surgery. Following that line of argument further we would now be seeing the same pathological process again but in a situation where the usual entrapment site for the nerve has been surgically modified so that you no longer develop a secondary CTS. Apart from the nerve size on ultrasound now I would also be interested in whether the transverse carpal ligament has been fully divided, whether there is any thickening of the epineurium around the nerve, how mobile it is in relation to the tendons, how superficial it is at the heel of the hand, and whether there is any evidence of hypervascularity of the nerve on doppler imaging which might indicate ongoing inflammation. One could explore the option of further surgery with things like a fat pad interposed between the nerve and skin but I would be wary of predicting the outcome and it may be that, in the end, the only real solution to this is a change of work.The possibility of pathology in the neck or brachial plexus is also worth exploring and I see that that is being looked into but it may well draw a blank. There is a full section of this website devoted to my thoughts on 'double crush' syndrome.

As a final thought this is one of the unusual post-surgical cases in which it would be interesting to know whether the 'CTS' symptoms responded to local steroid injection in the region of the carpal tunnel - though doing this is a bit of an experiment. JB

I had expected the ultrasound to show tenosynovitis irritating or compressing the nerve as there was visible tenosynovitis in my thumb a few weeks earlier when i had the trigger thumb release. However, that was normal too. Epineurium checked out, Surgical site 'beautiful', ligament fully divided. glides normally. Scanned up to my elbow and there was no evidence of compression in the forearm.
Off work x 2 months avoiding anything that works the small muscles of the hand. Avoiding use controls the pain (minimal at rest) but the tingling/numbness is increasing over time. Guessing this will either resolve or declare itself!

If nothing shows up on the further investigations will try a steroid injection.
I'll post follow up when I have it.
Thanks for running this forum!

Update:.
I have been having physiotherapy for recurrent repetitive strain injuries. Some improvement in pain at rest but continue to have numbness and tingling. I returned to work part time though it is uncomfortable. I had a closer look at my nerve conduction studies -- compared with preop they have improved but are not normal. CT scan of the neck shows bulging discs at c5/6 and C6/7 with mild central narrowing but no nerve compression.
However my vit B12 has come back at 142 (normal range at this lab 150) and 2 yrs ago it was low normal at 164. Normal HgB 135 but high normal MCV 100. Have some other symptoms of B12 deficiency (mild glossitis, brittle nails,....). will be worked up for pernicious anemia.

Looks like vitB12 deficiency. The pattern of my nerve symptoms really does follow the median nerves, though i now get numbness in ulnar distribution with bent elbows. Could vitB deficiency preferentially effect the median nerve due to remyelination problems in repair of nerve damage caused by my previous carpal tunnel? Though would have thought that would have shown up on the NCS.....

There are certainly some people whose nerves are unusually susceptible to pressure/stretch. The best known example is the inherited condition hereditary liability to pressure palsy (HLPP), another may be Wartenburg's sensory neuritis in which small cutaneous nerves appear to be mechanically sensitive.There are almost certainly others. B12 deficiency is not known to be especially linked to nerve problems at entrapment sites but as one factor of many affecting the state of your nerves it may be a contributor even when, as in your case, apparently fairly mild. It will be interesting to see if correcting it makes any difference. Thanks for the update. JB

I thought I’d follow up in case this is helpful to anyone else experiencing this frustrating injury. In 2015 after returning to work my symptoms got significantly worse and my EMG/NCS became abnormal on the left (median nerve motor and sensory). This was within 1 month of returning to work and about 3 months after the more or less normal studies I had previously. My hands continued to deteriorate and pain became untenable. I worked part time from 2015-2017 until the pain was completely unmanageable. I’ve not been able to return to my job.
I recently came across a very interesting paper on chronic compartment syndrome as a cause of work-related upper limb disorder by Pritchard et al 2005 in Rheumatology 44(11) https://doi.org/10.1093/rheumatology/kei037.
Its the first time I’ve seen anything written that describes my experience. My forearms become rock hard with use, and this is accompanied by increasing pain and neuro symptoms. Stretching helps momentarily. I’m left with palpably tender forearm muscles for days. I am awaiting compartmental pressure testing. I could find little else published on this subject save for the occasional case report and it appears generally over looked as a mimic of CTS. I will let you know how it turns out.

It's one of those conditions with slightly fuzzy boundaries. I think it probably does exist and there are classic cases which seem to do well with treatment but it's also a convenient dustbin label for all sorts of arm symptoms which can't be satisfactorily explained and is probably also overdiagnosed. Good luck, and thanks very much for staying in touch over a 5 year period. That takes real perseverance. JB

I know its been 10 yrs but I think I finally have an answer. I have been diagnosed with a mitochondrial myopathy on the basis of a large deletion in mtDNA. I have low heteroplasmy which I guess fits with my relatively ‘mild’ disease — myalgia with prolonged low intensity activity of affected muscles (hands/forearms) and ptosis which developed about 3y ago.. The pain has always felt like an exercise induced lactic acid type pain but it seemed so disproportionate to the ‘exercise’ — typing, writing etc . Its the ptosis that triggered the investigation.
It took 10 yrs and at least a dozen different physicians — who really pushed to try to find answers for me.
Posting this update in case it helps others and to provide resolution to a very odd presentation.

Thankyou so much for coming bak to update this thread and that is a fascinating eventual diagnosis. I wonder how many more patients there are out there with exercise induced myalgia and this sort of problem. I'm going to lock the thread now though to keep the spammers off it. JB