diagnosis

It sounds like a mixture of arthritis of the thumb joints and carpal tunnel syndrome from that description but there are enough atypical features for both diagnoses that one would not be at all confident in that diagnosis without seeing the hand and it's one of those cases where you might need nerve conduction studies or ultrasound imaging before being confident that there was an element of CTS to it. The thumb is innervated by the C6 nerve root and radial nerve too and as your GP suggests there are forms of tenosynovitis which can cause pain in this area so there are quite a few possible diagnoses to think about. NCS and ultrasound imaging may not be reliable with only a 2-3 week history so you might have to wait a bit longer before pursuing investigation further. A trial of local steroid injection would not be a bad idea provided there is not another obvious explanation on examining the hand and taking a full history. JB

Thank you very much for this. My GP has referred me to the orthopaedic department at my local hospital, but the appointment isn't for another 2.5 weeks. My symptoms continue in the same way, with my left thumb, index and middle finger now also causing pain and stiffness about twice at night. The splint I wear at night (and all day) on my right hand doesn't appear to have done very much to reduce the pain or the tingling. I have noticed that the tingling is concentrated on the left side of my thumb (palm facing outwards). It's all very unpleasant and worrying.

Two and a half weeks for an orthopaedic out-patient appointment is fairly quick by NHS standards but if you have a painful condition of course it would be preferable to have a walk-in service. The majority of CTS presentations are not dominated by pain and patients tend to take a fairly leisurely approach to getting anything done about it in the early stages - I find that if I try to arrange routine appointments at less than 2 weeks notice the number of patients who fail to turn up rises. I hope you manage to get it sorted out. JB

Thank you for this, and for your response to my post on Dougcuk's account of his experience with C Trac. As you can imagine, I have spent many hours pondering my condition and am now almost sure that you are right and that I have carpal tunnel syndrome associated with what my x-ray report describes as degenerative changes at the left first carpometacarpal joint, with no erosions, and a small osteophyte on the trapezium at the right first carpometacarpal joint, with 'appearances otherwise unremarkable'. Of course, I am going to hang in there and wait to see the consultant in the trauma and orthopaedic department at the Whittington on the 27th, but I am writing to ask if the presence of osteoarthritis is a counter indicator for use of C Trac, should I decide to try it out. I checked on the C Trac website, but all it says is that 'C TRAC does not relieve the symptoms of osteoarthritis of the base of the thumb'; it does not warn against use of the device. Certainly it emphasises that one first needs a clear diagnosis of carpal tunnel syndrome. Once again, I cannot thank you enough for responding to all my questions and concerns.

I would not spend money on the C-trac just yet. I have seen no comments of problems with arthritic thumbs but it does apply considerable pressure to the first carpometacarpal joint. JB

I finally have the results of my nerve conduction tests, which translate as Grade 4 on your severity scale in both hands, with the right hand worse than the left hand (RH distal motor latency to APB is 5.40 compared with 6.27 in the LH). The registrar at my hospital offered me either injections or surgery at my follow-up meeting, but he clearly thought that surgery would be preferable and advised me accordingly. I'm now booked in for an operation on my right hand at the end of April, but am still wondering if I shouldn't go back and ask for the injections, even though I see from this website that the median remission rate in severe cases is just 4.5-5 months and that I might just be putting off joining the line for surgery. I am also very tempted now to order CTRAC, although, as you say in your response to DougCuk, it would be a lifetime commitment to managing the symptoms, if it works. Everyone I have spoken to knows of someone who has had the surgery and been happy with the outcome, but the accounts posted here of failed or only semi-successful operations give pause for thought. I no longer wake up at night with searing pains in my thumbs, but I do have near-constant aching and tightness in both hands, and intense tingling to the point of 'burning' in my thumbs, with brief intervals of more moderate sensations. Both my hands are ice cold nearly all the time, and red from the knuckles to the fingertips, and I have started getting painful twinges in my right wrist. I also find myself becoming clumsier and struggling with simple things like washing up, opening cans, buttoning clothes and driving the car. I'd be very grateful for any advice you might have that could help me with my decision.

I think the most striking thing about your story is that you only had 2-3 weeks of symptoms in January and you have grade 4 NCS now. If there really were no symptoms of CTS 4 months ago then this sounds like fairly aggressive CTS and I would concur with your surgeon that surgery is probably the best bet statistically. The only major exception to that would be if you happen to be diabetic - CTS in diabetes can creep up on you without causing much in the way of symptoms until it becomes quite severe so the length of symptomatic history can be misleading. You can find the post surgery subjective outcome opinions of several hundred grade 4 patients in the surgical prognosis page here to get an idea of the odds - CTS surgery is successful enough generally that most people's personal circle of acquaintances who have had it done will tend to give a fairly rosy view of the outlook.

Secondly it does sound as though you have more than just CTS (this probably explains your low symptom score on here incidentally) - the change in skin colour is not not part of the carpal tunnel syndrome and you do have some arthritic changes on the x-rays. I'm sure you are aware that carpal tunnel surgery is not going to affect those (except possibly to exacerbate the development of arthritic change in the wrist but that is a bit speculative) - did the surgeons make any comment on the x-rays or the presence of other problems?

I can't honestly recommend the C-trac I'm afraid - there just isn't enough quality evidence that it works to justify the cost and time investment (and the Pulvertaft hand centre trial should be appearing in print shortly).

Surgery at the end of April is fairly quick for the NHS - it sounds as though that was about a 6 week wait from listing. As you have the problem in both sides one might consider injection while waiting, especially for the side which is not being operated if you have significant symptoms there - if nothing else it might slow down progression in the left hand while the right is operated on. Getting someone to do it might be tricky though - it could take as long to organise as surgery.

Out of curiosity, how did you arrive at your grading in my terms? Did you have a copy of the results and work it out yourself or are they using my grading scale in your area anyway? (incidentally those DML values suggest the left is slightly worse than the right - larger numbers are worse for that one) JB

Mr Bland, I can't believe the speed with which you have replied to me. Please do not let anyone persuade you that the website and your forum should be taken down. I feel I have a virtual guardian angel somewhere out there. If there were any way I could refer myself to your clinic, I'd do it like a shot.

To answer all your questions, I am not diabetic, at least not to my knowledge. I have read somewhere that cold fingers can be a very very early symptom of CTS, but I always presumed it was due to Raynauds, something my GP confirmed, saying there was nothing I could do about it, except keep my hands warm. I found it a bit difficult completing the diagnostic questionnaire, as it distinguishes between 'pain', 'numbness' and P&N, and most of the time - except for those nights in early January when I had searing pains in my right thumb, and then again in February in my left thumb - I would describe my symptoms now as 'acute discomfort', changing progressively to more disabling sensations, such as continuous aching, tightness and cold in my hands, combined with burning and itching in the thumb, and twinges and weakening in my right wrist, which I presume is due to increasing pressure on the nerve and tendons. I have a very different sharp pain in my left CMC, which I know is due to the arthritis, but the (expensive) Push CMC brace I bought led to different aches there and I stopped using it. The splints I've been wearing, almost 24/7 on my right hand, do help to stabilise my hand, but do not appear to do anything for the symptoms. I still resort to ibuprofen, gels and ice packs, especially at night, when the tightness and deep aching become oppressive and almost approximate to what I'd call 'pain' - my threshold, incidentally, is pretty high.

The consultant I saw originally did remark on the x-ray showings of osteoarthritis in both hands, pointing out on the pictures that the left thumb was considerably worse than the right one, so much so that he might not even recognise the right one as being arthritic. The registrar who followed up at the appointment I made following my nerve conduction tests did not mention the arthritis and said that the coldness in my fingers should ease following surgery. I would say that he isn't a specialist in hand or upper limb disorders, although the consultant does specialise in shoulders, and I think the registrar, who is a member of his team, consulted with him briefly after seeing me.

What I forgot to mention in my last email was the sudden appearance of a swelling on my elbow. I saw my GP about it and she thought it was bursitis, and quite unrelated to the carpal tunnel in my hands. She prescribed antibiotics, because it looked and felt infected. I've just finished the course and while the inflammation has subsided, my elbow is still tender. Oddly, my left elbow is feeling similarly bruised and tender, but without any swelling. The registrar concurred with my GP that the flare-up on my elbow had nothing to do with my wrists. It does seem odd, though, that it should happen now - I certainly haven't bumped sharply into anything.

I have asked for an injection for the arthritis in my left CMC, which they plan to do at the same time as the surgery on my right hand. I thought that dealing with the underlying condition first might be preferable. However, if you think I'd benefit more from an injection in the carpal tunnel, I'm sure they would do that instead.

I obtained a copy of my NCS tests yesterday and tried to work out the severity grading on your scale myself. I've clearly got it wrong. The summary 'opinion' on the test report simply says: "The NCS show signs of severe bilateral CTS (R>L)." I am copying what I think are the relevant values on my report (I have ignored values for the ulnar and radial nerves), so that you can assure me that I am having the surgery done in the right order! I must say I continue to be baffled by the way CTS travels, making a nonsense of the idea that it's computer mouse related (I am right-handed).

Once again, I cannot thank you enough for all the expert advice and help you have given, and the sympathy you have extended, and all with a promptness that would be impossible to secure even as a private patient, let alone through the NHS.

Motor Summary Table

Nerve Side Stim Record Dist(mm) LatOn(ms) B-PAmp(mV) CV(m/s)
Median Right Wrist APB 5.40 2.62 n/a
Elbow 275 10.37 2.58 55.4

Left Wrist APB 6.27 6.30 n/a
Elbow 255 10.73 5.83 57.1

Sensory Summary Table
Nerve Side Stim Record Dist(mm) LatOn(ms) B-PAmp(mV) CV(m/s)
Median Right Digit II Wrist ------------------------NR---------------------------
Digit III ------------------------NR---------------------------
Mid Palm ------------------------NR------------------------------

Left Digit II Wrist ------------------------NR-----------------------------
Digit III -------------------------NR---------------------------
Mid Palm 80 2.95 5.40 27.1

You happened to catch me on a train travelling to a postgraduate meeting in Liverpool this morning - hence the fortuitously quick reply. You have actually done very well with translating the nerve conduction study results and both hands are indeed grade 4 on my scale. When it comes down to trying to decide which one is worse then it is interesting that the report describes the right side as worse. There are actually two measurements there - firstly the 'DML' or distal motor latency - the time taken for a signal starting at the wrist to reach the muscle of the thumb and make it twitch - the longer this time is the slower the nerve is conducting and the worse the CTS. By that measurement your left hand is worse at 6.27 msec compared to 5.4 on the right - but this is not a big difference.

The other measurement is the size of the electrical signal generated by the twitching thumb. For this measurement a smaller signal implies less muscle and thus thus more severe nerve damage and on this measurement it does indeed look as though the right side is worse - 2.62 mV compared to 6.3 mV. I suspect that whoever reported the test was more impressed by either the amplitude measurment, or by looking at your hand, or by the severity of symptoms and therefore described the right side as being the worse. In my own lab we feel that the amplitude measurements, for a variety of technical reasons, are a less reliable guide and when we say 'mild' or 'severe' we are referring explicitly to the neurophysiology and not to any other assessment of severity. Therefore if I had to say which side was worse I would go for the left. However it is a mild difference and these are both grade 4 so the outlook for surgical treatment of both hands is the same.

I'm sure your doctors are all right about the elbow swelling  - it is simply not a feature of CTS.

If I had to decide which hand to deal with first in this situation I would generally say whichever one is giving you the most trouble. The main concern I would have would be to manage your expectations of what to expect from surgery given the possible presence of multiple conditions. Good luck... and if you can find time afterward I will be interested to hear how it turns out. JB

Dr Bland, I go in for the op on Monday and am writing to ask your advice on having a steroid injection in the other hand at the same time. I'm lined up for an injection for the osteoarthritis in the CMC, which has been giving me increasing pain, possibly because of the carpal tunnel there. I'm wondering whether to ask for an injection for the carpal tunnel instead, or, indeed, altogether avoid having an injection in the left hand, in case the steroid affects the healing in the right, or causes problems that I'd rather not deal with while my right hand is out of action. The symptoms in both hands are now equally severe, with additional aches in my right wrist and shoulder. I could also ask for the surgery to be done on the left hand first. Decisions, decisions! I'd be most grateful for any advice.

Simple answer - I don't think there is any logical reason not to inject the hand that is not being operated on. JB

Thank you so much!

Dr Bland, I delayed writing to you about the outcome of the surgery on my right hand, in the hope that I'd be able to give you unqualified good news. However, you were right about not pitching my expectations too high. It is now almost 3 months since the operation and, while the numbness and burning sensation have gone, the painful tightness in the fingers and palm remains, especially when I bend them. The scar looks very neat, but there's a painful lumpiness on either side of it, with the pain extending to the base of my thumb. I still massage the area religiously with Vitamin E oil, and do various nerve and tendon gliding exercises I've found online, as well as the exercises I was given by the hospital after the surgery. I have no idea whether all this is normal and my hand is just taking longer than the average two months to recover or whether I should be worrying about scar adhesion. Certainly, the tightness in my hand feels very similar to the carpal tunnel symptoms I had before the op, and still have, more intensely, in the left hand, which makes me wonder whether the operated tunnel isn't simply narrowing again. At my last appointment with a member of the consultant's team I was told that the surgery had been done by the top man, who would have taken all the precautions to section the ligament fully, and that the outcome might be the best I could expect. He said I should go back to them if the pain/tightness persisted after a year. A friend who had it done said she had pain in the base of the thumb and in the hand for a considerable time, but that it cleared up. I have no idea what to think or expect or do.

I have been wondering if the surgery could have exacerbated what was very mild CMC osteoarthritis, as the pain at the base of the thumb on the operated side is very similar to the severely osteoarthritic CMC on my unoperated left hand. I am lined up for a steroid injection for this in early August and should appreciate your advice as to whether this might be unwise given the carpal tunnel symptoms I also have there, especially as it isn't likely to give longer-term relief. Oddly, these have diminished somewhat, or possibly just changed, as I no longer have the burning sensation or numbness, but certainly plenty of painful tightness as well as increasing weakness of the wrist. I must say that I'm a bit apprehensive about the injection, because of some horror stories I've heard from friends.

Another curious development two weeks after surgery was the problem that arose with my shoulder. The consultant said it wasn't frozen, but an impingement, with 'rotator cuff pathology'. He was sure that it wasn't related to the surgery, although I felt that keeping my hand elevated for 3 days after surgery must have contributed to the injury. The physio I've been having has helped, but I still don't have full range of movement.

All this has meant that I've stopped thinking about surgery for the carpal tunnel syndrome in my left hand. at least until my right hand gets slightly better (if you think I can still be optimistic), and my shoulder heals fully. However, I'd be grateful if you would advise as to whether the nerve is just likely to get more damaged the longer I leave it. The surgeon told me in the theatre that the nerve in my right hand was 'awful, blue instead of yellow and plump', and I know from the nerve conduction tests that both hands were equally severe (grade 4 on your scale). I wear a brace on my unoperated left hand most nights, and occasionally on my operated hand, too!

I see that the exchange continues about Ctrac You may like to know that I did invest in it and tried it for nearly 4 weeks before the operation on my right hand. Sadly, it did nothing for me, but I was kindly offered a nearly full refund for the machine.

Many thanks.

Quite a bit to think about there. The improvement in the symptoms in the fingers sounds as though they probably did divide the ligament successfully but in a case that started out at grade 4 and is not markedly better 3 months after surgery I would always repeat the nerve conduction studies and look at the ultrasound to check just in case. Every surgeon - no matter how senior - occasionally has bad results with this operation and sometimes these can be amendable to revision. I wouldn't leave it a year - it's quite long enough now 3 months after surgery to be concerned if it is not improving and start to try and figure out why.

I don't think anyone knows for sure whether carpal tunnel surgery has any direct consequences for the CMC joint but it is almost exactly at one end of the ligament so it is quite plausible. I would definitely go ahead and try injection, both for the left CMC and the unoperated CTS - nothing to lose basically (and ignore the horror stories). The tenderness either side of the scar is quite common and usually settles in time - but not always I'm afraid.

The shoulder will have been more or less coincidental I think. The left CTS could be deteriorating but the only real way to tell is to repeat the NCS and as they need doing again for the unsatisfactory outcome on the right they will get repeated for the left side at the same time. Surgeons all think they can judge the severity of the problem by visual inspection at operation but I think they are wrong - some day we will have to put it to the test, get them to operate without knowing the nerve conduction results and try to guess the grade.

As you will have seen, the Pulvertaft Centre trial concluded that the C-Trac was no more effective than a normal splint and possibly caused more problems (as well as being 30x the price). It would be a good idea to add a comment on your experience of it to that discussion thread here as I am sure that quite a few people looking for information on it end up reading that. JB

Many thanks again, Dr Bland, for replying so quickly. I shall try to contact the orthopaedic department at the Whittington to see if I can speak to someone there about further NC tests, and the possibility of giving me two injections in my unoperated left hand, one for the CTS and one for the CMC. I must say I am not very optimistic, and may have to do all this in stages. My CMC injection is scheduled for 6 August and I'm due to be given a follow-up appointment some time in September/October. This is turning out to be my annus horribilis!

I'll add a note about my experience of CTRAC to that thread.

Thank you, again.