Pre-op Jitters
First off, I want to thank you and this site for helping me think about the possible solutions and their risks. There are a few horror stories out there, but I’m trying to remain optimistic. I’m leaning towards open CTR at the suggestion of my doctor a month ago and would really appreciate a second experienced option.
During typing my fingers start to feel extra sensitive and an odd feeling of weakness. I tend to squeeze the tips of my fingers and message the base of my thumb in an attempt to drive out the uncomfortableness. I occasionally have pain at the top of my hand or in my palms. If I continue to use them, which my work requires, the uncomfortableness turns to exhausting weakness and aching. While resting, I have difficulty finding a comfortable hand position. Symptoms reduce slightly after an hour of rest and I’ve been fortunate to have sleep be a welcome relief and reset.
I’m a 23 year old American and landed my first full-time position August of 2018 out of college. About a month into the new job, I started experiencing symptoms. After work, I would come back home to continue hand use playing games until I went to bed. A dream lifestyle that I now fantasize and regret.
Initially, while typing, my little fingers alternated with a ‘sore muscle’ sensation about a week apart for a month so I avoided their use during typing. Maybe a month after this I started developing the symptoms I have now in my right hand first and then my left two weeks or so after.
While my fingers are used extensively, their use doesn’t extend beyond others my age. I can’t to help to think it’s something besides overuse that lead to my CTS. I believe have a small wrist at a 15.24 cm circumference. Is this known make me more susceptible?
I’m on the fence of whether to wait it out and continue taking it slow, what I’ve been doing for a little less than a year, or to bite the bullet and conduct an open CTR on my right hand (dominate and most problematic). Do my symptoms match what you would expect from CTS? I’d be more than happy to link my NCS and EMG results if you think they would help. Thanks again for your time.
Thanks for the quick response Dr. Bland. Would it be okay to post the exam's results while keeping out the personal information? I'd like to offer some numerical reference for others.
You can try but it's sometimes hard to make out which value is which without seeing the full tabular layout. I don't neeed the person info of course - it's just the tables of measurements. JB
Motor Nerve Survey
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Median Nerve
Rec Site: APB Lat (ms) Dur (ms) Amp (mV) Area (mVms) Dist (mm) C.V. (m/s)
Stim Site L R L R L R L R L R L R
Wrist 4.5 4.3 7.2 7.3 11.9 11.5 53.2 49.5
Elbow 9.0 9.2 7.3 7.3 11.8 11.3 51.7 48.5 279 293 62.0 60.6
Ulnar Nerve
Rec Site: ADM Lat (ms) Dur (ms) Amp (mV) Area (mVms) Dist (mm) C.V. (m/s)
Stim Site L R L R L R L R L R L R
Wrist 3.8 3.4 7.6 6.9 8.0 8.7 40.9 37.5
B.Elbow 7.6 6.8 7.8 7.0 8.9 10.5 39.2 42.0 223 228 59.5 68.4
A.Elbow 9.5 8.4 7.6 7.3 9.1 9.3 38.8 37.7 123 122 64.2 73.2
Sensory Nerve Study
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Median Nerve
Rec Site: Wrist Lat (ms) Pk Lat (ms) Amp (uV) Dist (mm) C.V. (m/s)
Stim Site L R L R L R L R L R
Index 3.4 3.1 4.0 4.1 17.7 20.0
Ulnar Nerve
Rec Site: Wrist Lat (ms) Pk Lat (ms) Amp (uV) Dist (mm) C.V. (m/s)
Stim Site L R L R L R L R L R
5th dig 3.0 3.1 3.8 4.1 17.0 24.8
Fyi, the empty parts are blank on my sheet as well.
Oh looks like the forum removes all the spacing anyway like you said. I sent you an email as well for a better reference.
I've replied by email but so far as one can tell from those results this is at most pretty mild CTS (The lab did not give their normal ranges so it's a bit hard to be sure. If you take them as grade 1 on my severity scale and have a look at the section of the site on surgical prognosis you will see why I m not keen to leap into surgery for early/mild CTS. JB
Thanks for the quick response. I verified that the sensory measurements are 14 cm and the motor measurements are 8 cm. The normal ranges for the sensory measurements are: median = 2.8 - 3 and ulnar = 2.9 - 3. The doctor said that to him the biggest tell was the motor latency on L & R hands because they were above a 4. I hope that clarifies some of the numbers.
You mentioned in the email that my CT might be a "bystander" from another issue, which leads me to explain another problem that might be related or the core issue. I didn't mention it at first because it's not as big of an problem.
About a month after getting my new job, after work I was experiencing uncomfortable weakness in my right index finger while playing games. I frequently pressed the trigger button on my controller an average of 2 hours almost every night, but I had been playing this particular game for about 5 months now with no problems of course.
I assumed this was trigger finger and starting playing with a foot pedal instead. However now the base of my thumbs ache from pressing buttons or moving the joysticks after 15 mins. Do you think these issues relate to my pain during typing? What are some serious alternatives I can try if not surgery? Would an MRI or ultrasound help to identify the issues? Thanks again for your help.
So by those normal ranges both the median and ulnar sensory latencies are slightly prolonged. In my lab (and also the general recommendation from the AANEM for labs that do not have their own normal value for distal motor latency) the upper limit of normal for the DML is 4.5 msec so that measurement would have been normal. You could interpret your results either as showing mild CTS (grade 2 if we accept those normal limits, grade 1 in my lab perhaps), or as indicating general slight sensory slowing affecting the ulnar nerves as well. Such slowing is certainly in the range that can result from temperature variation - NCS changes by about 2 m/sec for every degree C of warming/cooling. The temperature is not recorded in the report so we can only guess at that but I am bothered by the fact that ulnar sensory conduction was equally slow so I would not really consider it safe to make a diagnosis of CTS on these results in the presence of a clinical history which is not obviously CTS.
Pain at the thumb base on use is most often a sign of arthritis in that joint rather than CTS but you are rather young to have worn out your thumbs. That's more the territory of your orthopaedic clinic than mine. JB
Thanks a ton for the analysis, I'll do my best to conduct another study at another city where there is a AANEM lab.
I'm starting to wonder if I shouldn't have started with a orthopaedic surgeon due to (what seems like) basis based on the initial NCS study. What practicer do you recommend seeing first in a case like this when my symptoms are inconsistent?
Have you seen/heard of posture playing a big role in symptoms similar to mine? I've never had good posture, even as a child, but was one of the first things I started fixing.
At some risk of offending the surgeons I would generally prefer to consult a medical subspeciality about most musculoskeletal or nerve symptoms, either rheumatology or neurology depending on whether the clinical istory suggests a more bone and joint issue or a more nerve related one. Quite a few musculoskeltal aches and pains seme to be posturally related (I have a few myself). JB
They are not really typical symptoms of CTS, though milder cases are often a bit odd. I'd be happy to look at your NCS and tell you what I think. Just email them to me.