Opinion on my carpal tunnel
Hello. I just wanted to get an opinion from an experienced person when it comes tothe problems ive bren having with my hand.
The main crux of the matter is that im not sure if I have carpal tunnel or some other neruological problem. This is for a few reasons, which I will list in the following exposition dump.
Firsy, im a 20 year old healthy male. Not overweight. Noone in my immediate or distant relatives has ever had carpal tunnel. I played a lot of PC games over the last couple of years, and in December of last year I started to get fatigue in my forearm. Thinking nothing of it, I continued playing games (probably about 3-4 hours a day with breaks every hour). A few days later, I had intermittent severe aches in my right hand (which uses the mouse). I had severe pain every day intermittently for a couple weeks, then I started to get prickling sensations in my fingers (I want to specify that ive never had pins and needles in the sense of when you sleep on your arm, its always been prickling sensations). The pain kept coming (mainly in my fingers now, not including the pinky) now along witht he prickling sensation, and I hadnt touched a mouse since I started feeling hand pain; it was there everyday despite the lack of hand activity.
After about a month from original onset, I started getting trigger finger in my pinky in the joint between the palm and the finger. To this day I still havr trigger finger in that pinky every morning, though its gone after about 30 seconds after waking up. Numbness was always mild, and was only ever present when there was severe pain in the associated area. After about two months, my hands started to feel normal again. I still couldnt use a mouse, but I could at least write and do general taskswithout a severe hand ache (in the first two months I couldnt even hold a spoon without my hand aching.)
I ended up getting a nerve conductoin test, though my hand was feeling much better by this point, and it came back normal. An ultrasound of the carpal tunnel came back normal. Doing phalens test or any other clinical test in attempt to irritate the carpal tunnel has never produced or worsened symptoms. The hand specialist I spoke with (an orthopedic surgeon) said that he was still quite sure that it was carpal tunnel, and I was one of the few who comes back with normal conduction results. He wanted me to get a steroid injection into the wrist, mainly as a diagnostic tool, saying that if it didnt help that we would have to look at other causes.
I ended up cancelling the steroid injection because my hand felt, for the most part, fine. I still couldnt use a mouse for extended periods of time, however, because severe fatigue and mild aching would ensue. I could write fine, however.
Now, in the last week, the pain and problems have come back (though they were always there, just incredibly mildand only present when I used a mouse). The cause I can only attribute to a climb up a large sandhill (my forearm was incredibly achy afterwards) or an increased use in a gamepad (a controller, not the mouse I used to always use for gaming). I get pain again now during the day no matter what I do, along with prickling. Im going to get a steroid injection now, as I honestly have no other options.
Given this experience ive had, and the seemingly fine test results, do you guys think this is carpel tunnel? I cant see how it could be anything else, but it just seems odd to me that id have this problem at my age given my family history and weird test results.
As an aside, a theory my specialist came up with for why my NCS results were normal was that my symptoms at that time only occured when I stressed my hand, and when activity wasnt present the nerve wasnt compressed, so it wouldnt show up in the conduction test.
Thankyou to whoever took the time to read this, and I would appreciate a second opinion on whats going on.
Thankyou for the quick reply.
I have actually tried splinting, just after my symptoms started happening. Unfortunately, and i'm not even sure how, the splinting actually made the pain worse sometimes. I definitely didn't notice any improvement during the couple week i wore the splint.
The ultrasound was done by SCAN, which is a radiology clinic in Queensland, Australia. They were looking specifically for CTS. I actually just recently (as in just today) have found out the results i had for a wrist MRI from 2 months ago. The radiologists report stated this, word for word:
"No evidence of tenosynovitis. No wrist synovitis or effusion. Mild increased T2 signal within the median nerve in the carpal tunnel. In the appropriate setting this may reflect mild median neuritis, but should be correlated clinically."
I assume this is an indicator of mild carpal tunnel?
Yes increased T2 signal in the nerve on MRI can be a sign of CTS. The most studied imaging finding is now enlargement of the nerve on ultrasound which is almost as sensitive as NCS and is sometimes abnormal when the NCS are normal - your ultrasound report should include a measurment of the cross sectional area of the median nerve at the wrist along with their local normal range (in this clinic normal nerves measure between 4 and 9 square mm). I would suggest repeating the NCS and then trying injection I think. JB
I don't have the report for my ultrasound, but looking at the scans i can see two markers placed on the sides of the median nerve.
The numbers are
Major: 0.695 cm
Minor: 0.176
Area: 0.096cm2
Going by your description, the nerve seems to be in normal range. But of course i may not even be reading the thing correctly haha.
The NCS is quite expensive, as is the steroid injection, and i dont have much money at the moment. So i may just go ahead with the steroid injection and go from there.
Thankyou very much for your time.
Sounds as though they have calculated the area of the nerve from the long and short axis diameters on the assumption that the nerve shape in cross section is an oval - not the best way to make the measurement. Most of us now do it by tracing the outline of the nerve with a freehand cursor and allowing the machine to calculate the area within the curve but however it is done there is so much variation between units/machines/users that the numbers don't mean much without being told the normal values for that unit.
I thought Australia had fairly good public healthcare? Steroid injection has real costs in the UK of well under £1 each for the steroid itself, the syringe and the needle so the real cost of injection is simply the time and expertise of the person doing it - I have seen quite high charges made here and one wonders about the economics of it sometimes. JB
In most cases it does, with a lot of medical procedures bulk billed. But for some reason the steroid injection in the wrist costs $150, and the nerve conduction study costs $250 (Though you get $100 back if you're with medicare).
Hi Jeremy.
Been dealing with the on and off pain since my last post, which has mainly mainfested as forearm pain that can sometimes be disabling. Unfortunately i've been experiencing symptoms in my left hand now. Tingling in my whole hand, pain and numbness the ring and pinky finger side of the hand specifically.
I honestly can't believe this. My left hand never ever endured the same amount of work as my right hand had, all it ever did was press a few keys on a keyboard. Do you believe this could be biological in nature? As in something systemic is causing this carpal tunnel? Because i just can't believe that i have carpal tunnel in both hands at 20 years old, especially when the workload between the two hands has always been starkly different.
Anyway, out of curiosity, assuming no permanent damage has been done to the nerve, is recurrence of carpal tunnel possible after surgery? Is it possible to go back to old habits without fear of recurrence (Such as frequent mouse use), or does a permanent change to hand habits have to take place in order to prevent another flare up?
Thankyou for your time.
If symptoms are concentrating on the little finger side of the hand now someone should give some thought to the possibility that what you have is ulnar neuropathy rather than CTS. I think we have still not conclusively shown that your problem lies in the wrist despite the MRI comment.
Recurrence of CTS is possible after surgery but pretty rare. Essentially, once the surgeons have finished with you, you then have a trench rather than a tunnel so it is pretty hard to get the nerve trapped again. Most people therefore manage to get back to their usual forms of hand use but there are some slightly worrying studies from the US regarding individuals with heavy manual occupations which suggest that a significant number of these may nerver get back to their original work. JB
Thankyou for the reply.
My right hand has always had trigger finger in the pinkyfinger since onset (But if i wear a splint at night i don't wake up with trigger finger in my pinky. Do you believe this is more evidence for it being carpal tunnel?), but at it's worst the pain and numbness is definitely the whole hand and severe pain in the forearm. Only my left hand has the numbness and pain on the pinky side, with tingling in the whole hand.
Just another question, my hand specialist told me back in January that he believes when he sees nerve conduction results like mine that it is very unlikely that the nerve damage (or lack thereof) can get any worse. He said i could come back in 10 years and still have a perfectly healthy nerve, even if i were to do taxing work with my hand. This is kind of why i have been so lax in seeking treatment, but the statement had always puzzled me. Do you agree with him in this regard, and if so, why exactly is that the case?
Thankyou.
Trigger digit is undoubtedly associated with CTS, ie the two conditions occur together more often than you would expect by chance, but that still doesn't mean that your hand problem is definitely CTS.
Did the specialist say 'unlikely that it CAN get any worse' or 'unlikely that it WILL get any worse'? We see people with extremely severe nerve conduction abnormalities and you might say the former of those patients. The second statement is a bit different - it's almost the same thing as saying that this is not really CTS. I have the view that CTS has progressed a bit beyond being just a syndrome - a collection of symptoms and signs which are seen together and which can have a variety of causes - to being a condition which, by definition, is a problem with the median nerve at the wrist. We may not have tests sensitive enough to always demonstrate that there is a problem there but I still think that most people with classic symptoms of CTS do have such a problem even if their tests are normal. I also think that, if you have normal test results, there is no pressing urgency to dive into surgery because of fear of irreversible disease. For what it's worth I have a small cohort of patients who had typical CTS symptoms when they first presented and normal NCS and who then turned up in the clinic 1-5 years later with the same symptoms and abnormal NCS - so the condition clearly progresses in some patients with normal studies.
The difficulty in your case is that you do not have 'classic' carpal tunnel syndrome so we are still somewhat uncertain of the diagnosis. I often resort to local steroid injection as a diagnostic procedure in such cases. JB
My first nerve conduction came back normal as well...same symptoms as you. One year later I had another nerve conduction and had CT in both hands. I knew something was wrong the first time. I had 3 completely sleepless nights out of town at a business meeting when I feel it could have been dealt with a year prior. A person knows when something is up with their own body...
in many cases a herniated disc in the cervical area can give similar symptoms as CTS. for example at the C5 area,
C6 is more likely to mimic CTS than C5 but investigations should usually be able to distinguish between the two. JB
So the ongoing saga continues, haha. I'd just like to say that i really appreciate your help over all this time Jeremy.
Anyway, i did another nerve conduction study on my right hand (1 year after my first) and one on my left. The Neurologist said that the results were normal again (Though unfortunately the severe symptoms i had in my left hand had died down by the time i did the test, i never seem to catch it at the right time).
I also got a steroid injection into my wrist, and that didn't really help. I had quite a bit of aching pain caused by the injection for about a day or two after, but that went and it was back to the usual moderate activity causing aching, burning and hotness in my hands and forearms.
The specialist said that he doesn't know what it is. He doesn't think it's carpal tunnel because it didn't respond to the injection + the neuro results were normal. He said i should have my rheumatoid checked due to the bilateral pain seemingly out of nowhere, and said i should go get hand therapy from a physio.
I personally believe it's carpal tunnel in both hands, but it only becomes apparent upon activity. Obviously this is my opinion, but i just don't see what else could be causing these forearm and hand problems.
So i'm kind of directionless at the moment. Would you recommend i get a second opinion? Go see a hand therapist? Take a chance and see if surgery works?
Thanks.
There's a lot of evidence against it being CTS there - your demographic to start off with, then atypical symptoms, lack of response to splinting and injection, serial normal NCS etc. At least some of your symptoms suggest trouble at the elbow rather than the hand - did they check conduction in the ulnar nerve round the elbow? It would be worth looking at ultrasound imaging at both sites (wrist and elbow) at this point. If it is not CTS then there are rheumatological possibilities (various forms of tendon inflammation etc), other neurological disorders in the neck, and contentious entities like 'compartment syndrome' in the forearm. What speciality is your current specialist? JB
Dont think they did the ulnar nerve. And my specialist is the hand surgeon that ive been with for the past year. Hes basically said he cant do anything more for me.
Im booked in for rheumatoid tests in April. Do you think hand therapy would be any use? Im kind of out of ideas on where to go now. I can go and get ultrasounds on my ulnar and median like you said, though I did get one done on my median last year that was supposedly normal.
Aside from the general pain, the thing thats really getting me at the moment is that whenever I use my left thumb (swiping on a phone, pressing buttons on a TV remote etc.) I get massive burning on the underside of my forearm about halfway up. Eventually turns into hotness and pain in my left hand. Is this characteristic of something, or just another atypical symptom?
Thanks
A rheumatological or neurological opinion would certainly be worthwhile. It's often good for someone to approach the problem with a different mindset. Ultrasound of nerve is a bit difficult - you need to find someone who is interested in peripheral nerve pathology rather than a 'musculoskeletal ultrasonographer'.
The forearm pain on using the thumb is not a usual characteristic of CTS. There is a muscle in the forearm - flexor pollicis longus - which bends the thumb. I wonder if your pain might be in that muscle in some way - there's a fairly good illustration of where it is in wikipedia and it's probably worth trying to work out exactly which movements of the thumb produce the pain. JB
Hi Jeremy, it's been a while.
I thought i'd update you on my condition because it may be of interest to you after all these years. My problem is now 90% gone, and the cause was related to the massive amount of tension i had in my arms and hands. Whenever i would do something with my hands, i would unknowingly tense up my arms and hands. As the pain got worse i would tense up even more to deal with it and on the cycle continued. There was a lot of mental gymnastics i had to do aswell, because anticipating pain would tense up my hands and pain would come. Very weird and silly issue that has plagued me for years, but i believe i can completely recover now. Pain stays at bay for as long as i can keep my mind away from my hands and keep everything relaxed.
Obviously after all of this, im now very conscious about hand and wrist health. I never want something like this to happen again.
After reading a lot of your content and realizing that the actual causes of CTS are still a bit up in the air, and not necessarily tied to computers and keyboards, i thought id ask you about what to do and avoid. From your experience, how can i give myself the best chance to avoid pathology with my hands in the future? Should normal PC use be curbed, stop using a mouse? Should i strengthen my forearms and hands? Are stretches helpful in prevention? Any recommendations would be incredibly appreciated.
Thanks Jeremy.
Thanks for coming back with a long-term update. In technical terms that sounds rather like a description of a dystonia - which can certainly cause forearm pain. I'm glad it's improving. Unfortunately I don't think it's possible to give any evidence based advice on what to either deliberately do or what to avoid. I think my best common-sense guess would be to say don't do too much of anything - try to vary the way you use your hands and arms and avoid long periods of the same repetitive activity without breaks. JB
That's a very comprehensive story, thankyou. You are right that you are, to begin with, a low risk person for CTS (no family history, young, male) but there are always exceptions and it is not impossible that this is CTS. You should run through the questionnaire here on the website but it will probably come out with a fairly low score. Your surgeon is almost right about the NCS results too, your symptoms were largely in remission at that point and, if it is CTS, it may have gone back to normal at that stage. One of the things that is not widely appreciated about CTS is that it is not always a progressive disorder but can relapse and remit, or even be a single episode which resolves and never recurs. You do not have to have symptoms exactly at the time of the test for it to be useful however and NCS abnormalities do not come and go as the symptoms wax and wane within a 24 hours period. What we measure is not the tingling but a property of the nerve physiology which happens to be fairly closely, though not perfectly, correlated with the presence of CTS - hence the fact that there are both false positive and false negative results.
Trying an injection is a good tactic, as is wearing a night splint for a few weeks - have you tried that? it would also be worth repeating the NCS while the symptoms are going through a bad period (they should be done by the same person and compared with the previous set to look for change). Finally - who did the ultrasound and were they looking specifically for CTS or for other musculoskeletal problems in the wrist? - expertise in peripheral nerve imaging is quite thinly spread at present in the UK, though getting better. JB