confused

Quick answers

1) Yes - probably about 5% of cases

2) Yes

3) Yes - CTS can completely resolve without any treatment - even rest!

4) If the diagnosis of CTS remains plausible then repeat NCS in 3-12 months will sometimes show an abnormality when the first test did not.

5) No-one is really sure what makes CTS worse but most patients find that any heavy use of the hands will temporarily exacerbate symptoms once you have the condition - whether that is the same as making the pathology advance is a slightly different issue

Who did the ultrasound - there are not many people in the UK who are interested in ultrasonography for CTS. JB

I did the ultrasound in Canada. at the riverside campus in Ottawa. I saw my family doctor yesterday. Currently i have a strange loss of sensation in the knuckleside of the index and thumb, very intermittent and mild, almost unnoticeable inmy left and right hands( she did the test of poking it with pins to see a difference). Now for the past 2 days i have a weird sort of sensation in the tip of my thumb that i suppose resembles tingling but im not sure. My doctor would not give me a steroid injection, nor would she perform a repeat nerve conduction test. My first nerve conduction test was completely normal according to the technician and neurologist who looked at the results. My neurologist labelled this as a soft tissue injury, and my family doctor said that because my grip is very strong, my phalens test negative, and because my sleep is not being interrupted that I should just wait for 2 months.
my questions
1) should i be more aggressive about getting a second NCS so soon after getting the first one
2) if I were to get a second NCS and it were to be normal, my question is could flexor tendonitis cause numbness and tingling ( i have that currently)
I test very low on your questionnaire by the way.

It's hard to be sure where you are describing the location of the numbness. Essentially we can refer to the palm side of the hand or the 'back' of the hand. If the sensory disturbance is the 'back' side of the index finger and thumb then that may be the territory of the radial nerve rather than the median nerve. The very tip of the thumb however would usually be median. You really need to see this and map it out. The traditional way of doing it for a case report would be to draw directly on the patient where sensation is disturbed and then photograph it!

I would generally recommend about a three month gap before repeating NCS unless there was an obvious deterioration in symptoms and signs. Overall it does sound as though you have quite a few features against the diagnosis being CTS.

Flexor tendonitis does not usually cause tingling - at least so far as one can tell from talking to people - it's always very hard to be sure exactly what sensation people mean by any given word. JB

the tingling seems all over the index and thumb now, both sides, very mild not painful. i guess the next step is for me to somehow get a nerve conduction test done even though my gp doesn't think i need it. I may also see a rheumatologist. if my nerve conduction results are negative again, then how would I go about making the case that I have cts and that it will not be diagnosed in any lab setting? should i give up on this diagnosis I had the first ncs done in september.

Another possibility for that distribution of sensory symptoms might be the C6 nerve root in the neck so there are a few possibilities. If it is not seriously disabling I would be inclined not to do anything too radical about it. Eventually it will either go away or else it will become apparent what it is. A second opinion from a rheumatologist would not hurt though. I don't think you can really make the case that you have CTS yourself when most of the evidence at present seems to be against it so I am afraid you are dependent on the professionals who you are actually able to consult in person to try and reach a final diagnosis. I will be interested to know what the eventual answer is - if there is one. JB

I had an MRI of my neck done in which they found osteophytes on the c5 and c6 nerves but they were very small. I am going to get the following tests done: an MRI of the hand, a ct scan of the hand, and by hand I mean wrist as well, and another nerve conduction test. I am going to see a neurologist as well, after all these tests are done I will let you know the result. The MRI of my neck had a report attached to it that said the osteophytes were very small and that they were not impinging on nerves.

It doesn't sound as though there is enough of an abnormality on that MRI to clearly explain the symptoms as a neck problem. I hope the symptoms are not being too much of a nuisance. JB

They are not but I am paranoid because the lack of diagnosis makes me fear what is coming next. Are there any tests similar to the Phalen's test that can test for radial nerve compression? The fact that the symptoms are mostly on the part of the opposite side of the palm on the hand raises some concern. there is no weakness, but about 3 times I have experienced after waking up (I did not wake up because of the symptoms but rather just woke up and then preceded to have the symptoms) super intense tingling that resulted in very slight stiffness in the fingers and a super intense almost electric like shock. I think my neurologist and gp would be interested to hear these new symptoms but I really wonder how they relate to possible cts diagnosis and what I can do on my own to prepare for my next meetings with the discussed professionals. any advice is appreciated and I thank you a lot for your expertise.

I'm not aware of anything specific for the radial nerve. We only see two radial nerve problems commonly - injuries in the upper arm from sleeping awkwardly or trauma and, less commonly, external compression of the superficial radial nerve in the forearm from things like handcuffs. There is a motor branch of the radial nerve called the posterior interosseous nerve, problems with which can cause a wrist and finger drop but I only see these very rarely. As long as symptoms remain fairly tolerable and sudden twinges like the three you describe are infrequent then, provided obvious causes have been looked for, my general advice, hard though it may seem, would be to try not to worry about them too much. JB

An Mri of my wrist revealed that my wrist was normal except for a small ganglion cyst at the posterior aspect of the scapholunate ligament. is this significant for cts like symptoms?
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Hard to tell without seeing the images I think - rather depends what they mean by 'posterior aspect' and 'small' - sorry! JB

I'm sorry to ask so many questions... I promise after the next nerve conduction study that I will be done posting unless something totally dramatic or interesting happens. to quote the report.....

"there is a slight irregularity of the scapholunate ligament. There is a small cyst located just posterior to the posterior band, This cyst is probably arising from the schapholunate ligament it measures about 9mm in cephalocaudal* 7 to 8 mm in transverse * about 3 mm in Ap diameter".

It would have been more helpful if the radiologist had said whether they thought it might be acting as a space occupying object within the carpal tunnel or not - 9x8x3 mm is a fairly large object if it is sitting in the carpal tunnel  but you really can't tell from that report - and in any case I am a little wary of wrist MRI reports, having seen a few which were totally erroneous. I really don't think there is any substitute for looking at the pictures. 

Numbers of postings and questions are no problem but there are serious limits to what I can do and say in an online forum across the Atlantic. I hope you are finding it useful to discuss it. JB

I do have the pictures. I will bring the cd to my neurologist on Monday. I have developed an interest in nerves and tendons and so has my mother who is a sleep and lung doctor. My goal is just to come to a plan of action about how much guitar I can practice and a plan of treatment. It will be very interesting to see what the ncs results are.

I got your email this morning. Thank you for your interest. So let me see. ... Where we last left off I had just gotten an M.R.I of the wrist and was about to go for a repeat nerve conduction test and then I forgot to update. So I went for the repeat N.C.S which was exactly the same as my first one and was completely normal (they tested radial nerve this time as well). When talking to my neurologist he still maintained that my injury was a soft tissue injury. I later postulated that perhaps it could thoracic outlet syndrome but to be honest I was sort of fed up with my GP and neuro to go back. My symptoms persist to a certain degree, but it's pretty good overall I would say. I am still playing guitar for many hours a day and the symptoms are very inconsistand and change a lot! hard to know if it's progressing to something but when I think about last year at this time they were much worse so I'd like to think they have gotten better. As far as the cyst goes I went to see an orthepedist and he said it was small and not in a location that would affect my nerve and that if they wanted to remove it they would have to do it with ultrasound and it would be difficult. We talked about a potential cortisone shot, but because my symptoms are so inconsistent and mild it seemed unlikely to benefit CTS or tendonitis. I began lifting weights and doing strengthening exercises for tendonosis with good success. I would say overall things are looking pretty good. So here is a bullet point summary of my current symptoms, some of which have nothing to do with CTS
- tendonosis of the wrist, so bending it intensely or stretching it can cause soreness and a small degree of pain, also induces weird sort of temporary nerve type feelings
- occasional sensation changes on the backside of the thumb(radial side)
-tingling in the median fingers if i lean on the hand intensely, which would probably happen anyway so maybe thats not important
-pain in the joints from weightlifting and guitar
- in ring and pinky finger, waking up at night with these fingers completely numb(Weird eh?)
-occasional weird tinges of like one second long tingling in any one of the fingers
I feel confident the diagnosis is not cts, I am still confused how tingling and nerve feelings could arise from a soft tissue injury but I guess these feelings are not painful or inhibit the function of my hand, and they are clearly made worse from aggressive use of the hand so its just a matter for me now of not overpracticing i suppose.

Thanks for the update. Overall that sounds like a good advert for not doing anything too aggressive when the symptoms are modest, the tests normal and the diagnosis unclear. The ring and little finger at night thing sounds like the ulnar nerve - do you sleep with the elbow bent and hand under your head/pillow? - if so it's probably nothing to worry about unless symptoms spread into the daytine. JB 

they do not persist into the daytime. i am not at all worried about that numbness. kind of strange that only those fingers would ever go numb. anyway...
I wonder do you have any practical advice for monitoring whether this will spread to some kind of serious neuropathy problem other than rest?
I feel like i keep my wrists pretty straight at night so I wonder what is the point of a splint? is it to support the muscles and tendons so they dont have to work as hard to remain straight?
also should i continue to have nerve conduction studies? and how can i go about determining whether thoracic outlet syndrome is the problem? do you recommend any more tests or MRI's or something.
I am just trying to be cautious....

I'm not a fan of too much medical testing. In general the best way to monitor your health is just to pay attention to new symptoms as they develop (I can heartily recommend the book Over-diagnosed by H Gilbert Welch, Lisa Schwartz and Steven Woloshin if you are interested in the issues raised by our increasing ability to detect changes in the body which may never matter to the patient). The reason for the particular distribution in the fingers is usually just the anatomy - the way the nerves are wired up/distributed. The only way to check your sleeping position is either get someone to watch you or to set up an all-night video recording - whatever you think you are doing is probably wrong. As far as CTS is concerned the theory of the splint is primarily to keep the wrist straight but it is possible it may also be resting the tendons and ligaments. You lose most of your muscle tone when asleep, in fact during REM sleep when you are dreaming you are actually paralysed, so there is little risk of your muscles 'working harder' quite the opposite. Thoracic outlet syndrome is contentious - I wouldn't worry about it unless you develop more symptoms. JB