Should I request re-referral to consultant?

I have to say that I personally would not make a decision about what to do there without knowing what your nerve conduction studies show, but there are plenty of surgeons around who would simply operate without further ado and their opinion has as much authority as mine. If you have not developed permanent disability after 13 years then one would guess that your CTS is perhaps not very aggressive but there is no guarantee that it will necessarily continue to follow the same pattern in the future.

Get your partner or one of the older boys to check the strength of your thumb muscles. This is hard to explain but I will try! Think of the palm of your hand as a flat plane, laid out palm up in front of you on a table. At rest the thumb should be lying more or less alongside the palm. From this rest position there are several movements you can make with the thumb, keeping the palm and wrist still. If you keep it in the same plane as the palm but stick it out to one side so that it remains in contact with the table that movement is called 'extension' of the thumb. Secondly you could bend the joints of the thumb so that it curls across the palm but stays as nearly as possible in contact with it - that movement is 'flexion' of the thumb. Thirdly you could move it across so that the tip of the thumb touches the tip of the little finger - to do this you have to move the joint at the base of the thumb and flex the little finger too - this movement is called 'opposition'. Finally, and hardest to explain, you can keep the thumb itself fairly straight but point it up away from the table - moving it in a plane perpendicular to the palm. This last movement is called 'abduction' of the thumb and it is this one which becomes weak in advanced carpal tunnel syndrome. Get someone to place the tip of their index finger against the tip of your thumb and try to resist you making that movement using only their finger - a bit of finger wrestling if you like. Your thumb should be stronger than the average person's index finger in this contest. If it is not then that is a worrying sign of advancing median nerve damage (at least in the context of carpal tunnel syndrome) and would suggest that you need to think seriously about having it treated. Note however that CTS is not by any means the only possible cause of weakness of the thumb so this is not an absolute guide to treatment - just one possibly significant sign you can check for yourself. At some point I will try to arrange for a photograph on the site to illustrate this and please let me know if you managed to make sense of this paragraph. Your GP should certainly know how to check this of course. Confusingly, at least one website I found uses the term abduction for what I would call extension, as well as for what I call abduction - you can't win with anatomists :-) If you look at this web page and look at video number 55 on it you can see various movements of the hand being tested. Abduction of the thumb is shown 24 seconds into the video though this examiner uses two of his own fingers to provide resistance to the movement being tested.

In most areas of the country nerve conduction tests can be arranged by your GP directly with the local neurophysiology department though that does not apply everywhere I'm afraid. Most departments manage to run these tests with very short attendance/waiting times because they are fairly predictable in duration, unlike out-patient consultations, so appointment systems tend to work fairly well. I hope this helps. JB

Thank you for your comments. Having studied anatomy at Uni I am fortunate enough to have been able to understand what nis meant by abduction of the thumb, and this has at least given my husband and I a laugh as we tried to put this test into action! The website that you directed me to showed them doing this in mid air which seems s bit strange as then the whole hand moves! I am still a little bemused as my husband was pushing quite hard and prevented any movement, but I am assuming that this is far too much pressure? There are times when I get frustrated with my hands as the pain stops me doing something, but I do have a fairly high pain threshold having had five children! Thank you for your quick response. I will have to consider this some more before I make a decision, but you have provided food for thought. Is is usual to also have numbness in the ring and little fingers? Most nights my whole hand goes 'numb' and this drives me mad as shaking does not really help for more than a few seconds! I also have very sore areas on the bony outer side of my elbows currently which I assume is tennis elbow, although I cannot think what activity I have been doing to cause it!! Thanks again!

SAWalsh

Lots of points there. I agree that web video does not demonstrate perfect technique but it is better than many non-specialist doctors will achieve when trying to test the abductor pollicis brevis muscle and I thought it was a useful supplement to my attempt to describe it. The really hard part is trying to describe just how to arrange the examiners hand and the patients in such a way that the mechanical advantage, given a normal patient thumb and examiner index finger SHOULD be in favour of the thumb. The trick with all of these muscle power tests is to come up with an arrangement where even a weedy patient should be able to successfully resist a rugby playing orthopaedic surgeon as examiner!

Little and ring fingers? Not usually a part of CTS - at least not the side of the ring finger adjacent to the little one. The little finger and that adjacent side of the ring finger are connected to the ulnar nerve which passes outside the carpal tunnel but this nerve often runs into trouble at the elbow. Having said that, some CTS patients do seem to experience at least some symptoms in the entire hand so it's not an absolute rule. If we were testing you with that story we would probably test the ulnar nerve at the elbow as well as the median nerve at the wrist.

The outer side of the elbow could well be lateral epicondylitis ('tennis' elbow - though it rarely seems to have anything to do with tennis) - again it needs competent clinical examination to get to grips with all three of these possibilities really. I hope you manage to get them sorted out. JB

Thought I would come in here, as I was browsing through for any useful information regarding the E.S.A appeal which I am preparing! I found the explanation of those tests very interesting. I wonder how many GPs would know how to test like this -certainly specific examinations play no part in the ESA medical, which I hope is being recognised by more and more people as being completely wrong.

I am still trying to work out how bad my other hand is (already had surgery on the first one, and not expecting miracles yet).
I had thought that it was getting better, maybe because I have now been taking Thyroxine for a few months, and therefore was hoping that surgery might not be needed, but I've been getting pins & needles and some numbness again in the last few weeks. Have also been getting aching in the muscles of both arms if I do anything very physical ( I have been trying to do normal things where possible) and still cannot carry things properly. I can't do this test properly on my own, but having tried to get my hands into position - firstly I find this very uncomfortable - my arm muscles seem to be struggling, and secondly my 'at rest' position is fingers and particularly thumbs curling up considerably. To keep them flat does not feel like resting. Also my thumbs are nowhere near flat on the table.

Anyway, at an attempt at doing it, my abduction of both thumbs doesn't seem to be very strong. In connection with this I am a bit puzzled why in your pages on symptoms you say that 'there is not usually much demonstrable weakness of grip'.
Surely in order to grip things like electric kettles and lift them you are abducting the thumb, or is that not the case? I am certainly still feeling weakness with things like that. - But thank you for giving the information, because there is very little detail on the complications of CTS on other sites.

You abduct the thumb in order to get it into position around something in order to grip it but the movement of power grip -what you use to do pull-ups on a pole or to pull a heavy object or grip a bottle top or jar requires force to be exerted to flex the fingers and thumb and this movement of flexion is predominantly achievd by the forearm muscles which are attached to the fingers and thumb by long tendons. As the nerve supply of these muscles does not pass through the carpal tunnel they are not weak in people wth CTS and power grip is generally quite well preserved. People with CTS do drop things a lot but I think the reasons for that are complex - not simply a matter of the muscles not being strong enough. We spend a fair bit of time teaching the medical students this sort of thing so they should know it by the time they enter practice but we all forget things which we learn in medical school if they are not things that we use every day. I think it is pretty hard to explain and teach it online but I thought I would have a try. You don't really need to have the hand literally flat to test abduction of the thumb - it just helps to think of the plane of the palm and fingers as one dimension and the plane in which you wish to move the thumb as another one perpendicular to it. The examiner can also support the hand to provide something for the patient to push against using the other hand. I really will try to produce an illustration on here at some stage. JB