Ross Hauser, MD | Caring Medical Regenerative Medicine Clinics, Fort Myers, Florida
Danielle R. Steilen-Matias, MMS, PA-C | Caring Medical Regenerative Medicine Clinics, Oak Park, Illinois
Katherine L. Worsnick, MPAS, PA-C | Caring Medical Regenerative Medicine Clinics, Fort Myers, Florida
David Woznica, MD | Caring Medical Regenerative Medicine Clinics, Oak Park, Illinois
In this article we will explore various treatment options for Carpal Tunnel Syndrome. All treatments have success stories. All treatment have less than successful stories. This article will present evidence for non-surgical treatment options.
A series of new studies effecting patients with Carpal Tunnel Syndrome are questioning the success and validity of Carpal Tunnel Syndrome surgery and the how accurate recommendations to patients following surgery are as to when they can return to work. This is a question that is inspired by new research:
When your surgeon recommends you to Carpal Tunnel Syndrome surgery, ask the surgeon if they will have the surgery themselves if they were you. The likelihood is that the surgeon would say no.
We am not going to comment on this study from the Journal of Plastic Surgery Hand Surgeons, (1) we will only tell you this appeared in a medical journal written for and by hand surgeons.
- One objective of this survey were “to study if surgeons’ perceptions of the benefit of six surgical procedures differ if they consider themselves as patients instead of treating a patient.”
- “Surgeons who considered themselves as patients had less confident perception on the benefit of carpal tunnel release compared with surgeons, who considered treating patients.”
- “Hand surgeons and hand therapists had similar perception of the benefits of surgery. The expected functional result was regarded as the most important factor in directing the decision about the treatment.”(Good post-surgical function, the most important outcome of the surgery was considered a marginally successful.)
CONCLUSIONS: “Surgeons tended to be more unanimous in their opinions in cases, where there is limited evidence on treatment effect. The agreement between surgeons and therapists implies that the clinical perspectives are similar, and probably reflect the reality well.” The reality of a less than hoped for outcome.
As a second opinion, let’s present evidence from Dutch researchers who wrote in the journal Acta neurochirurgica (neurosurgery).(2)
- The effectiveness of the surgical treatment of carpal tunnel syndrome (CTS) is well known on short term. However, limited data is available about long-term outcome after carpal tunnel release (CTR).
- At long-term follow-up, 87 patients (40.3%) completed a questionnaire abouty the severity of symptoms and their functional abilities in the operated on hand.
- Mean score on Symptom Severity Scale and Functional Status Scale improved at 8 months and did not change significantly after 8 months. The patients were then followed up for 9 years.
- At 9 years favorable outcome was reported in 81.6%.
CONCLUSIONS: Carpal tunnel release is a robust treatment for carpal tunnel syndrome and its effect persists after a period of 9 years. The most important factor associated with long-term outcome is treatment outcome after about 8 months and to a lesser extent functional complaints pre-operatively.
What all this means is that at 9 years after surgery, 4 out of 5 patients reported favorable results. But if you had functional complaints before surgery, the chances are less optimistic for long-term success.
I need to get back to work, what is a realistic recovery time from Carpal Tunnel Surgery? The answer is “Paradoxical”
Maybe, the surgeons in the above study are aware of what other research is saying. No one has a good answer to the question of when people can return to work after carpal tunnel surgery. This is an editorial from the Scandinavian Journal of Work, Environment and Health. (3) It is based in part of data from American workers examined in US work environments.
The concern is aging or long-term workers at the same job where Carpal Tunnel Syndrome is a risk
- “Work participation and long work careers are becoming critical for the sustainability of aging societies. Carpal Tunnel Release is a fairly common procedure, often carried out due to difficulties or inability to perform work duties. It is rather paradoxical that we know so little about the extent to which this procedure can restore work ability and enhance return to earlier or amended duties and not even how long it typically takes to return to work after Carpal Tunnel Release.”
The problem is Carpal Tunnel Syndrome Diagnosis may not be correct and the surgery may not fix what is wrong
In 2017 surgeons at Thomas Jefferson University Hospital in Pennsylvania published guidelines calling for a much more extensive examination of patients suffering from Carpal Tunnel Syndrome. Why? Because many patients with Carpal Tunnel Syndrome may not have Carpal Tunnel Syndrome.
In this study, (4) the researchers are saying: the problem of Carpal Tunnel Syndrome is recognizing and managing other potential sites of peripheral nerve compression.
Here is what the research says:
- Is it Ulnar Tunnel Syndrome / Guyon canal syndrome? The ulnar nerve may become compressed as it travels through the outer edges of the wrist
- Is it the posterior interosseous nerve (a forearm nerve branch that travels in back of the forearm)? That nerve may become entrapped in the central region of forearm as it travels through the radial tunnel, which results in a pain without motor weakness.
- Is the nerve trapped not on the wrist but the forearm? The median nerve may become entrapped in the proximal forearm, which can result in a variety of symptoms.
- Carpal Tunnel overnight? Is it Spontaneous neuropathy of the anterior interosseous nerve (a forearm nerve branch that travels in the front of the forearm) .
The solution to understanding which of these problems may be impacting the patient? “Electrodiagnostic and imaging studies may aid surgeons in the diagnosis of these syndromes; however, a thorough physical examination is paramount to localize compressed segments of these nerves. An understanding of the anatomy of each of these nerve areas allows practitioners to appreciate a patient’s clinical findings and helps guide surgical decompression.”
So do I really have Carpal Tunnel Syndrome?
Carpal tunnel syndrome is a progressively painful hand and arm condition caused by pressure, damage, or repeated injury to the median nerve at the wrist. Since pressure on the median nerve causes carpal tunnel syndrome, then anything that crowds, irritates or compresses the nerve in the canal, can lead to the symptoms. This pressure can come from swelling or anything that would cause the tunnel to become smaller.
Wrist surgery has limited and widely varying degrees of success in treating carpal tunnel syndrome. Surgery can also make the condition worse, especially when the condition has been misdiagnosed.
Seldom do patients and athletes find relief from the “Carpal Tunnel” complaints of pain in the hand and elbow with physical therapy and surgery because the diagnosis is so often wrong. The most common reason for pain in the elbow, referring to the hand, is weakness in the annular ligament, not from Carpal Tunnel Syndrome.
Cervical ligament weakness and annular ligament laxity should always be evaluated prior to making the diagnosis of carpal tunnel syndrome.
A physician who understands the referral patterns of these ligaments should evaluate the individual with this condition before surgery is considered. Because most physicians do not know the referral pain patterns of ligaments, they do not realize that cervical vertebrae 4 and 5 and the annular ligament can refer pain to the thumb, index, and middle fingers. Ligament laxity can also cause numbness.
Telling the difference between Signs and Symptoms of “true” versus “pseudo” carpal tunnel syndrome
- Symptoms typical of Carpal Tunnel Syndrome
- Numbness in the thumb, index and middle finger
- Thumb weakness, sense of loss of strength
- Atrophy of the thenar eminence the muscles on the palm of the hand at the base of the thumb.
- Positive Tinel’s sign – a tingling or numbness when a health care provider presses on suspect nerve entrapment
- Postive Phalen’s test -tingling or numbness when the patient puts the back of the hands – back to back with fingers pointing down.
- Postive EMG/NCV – Nerve conduction studies that show clear disruption of nerve function
- Pseudo Carpal Tunnel Syndrome when it is thought to be Carpal Tunnel Syndrome but it is not
- Numbiness, a non-descript intermittent numbness
- Tenmderness over the annular ligament elbow
- Normal thumb strnegth
- Hand muscles not atrophies
- Negative Tinel’s sign
- Negative Phalen’s test
- Negative EMG/NCV
As noted earlier, the pain experienced in the wrist is often referred pain and may be due to an injured or weakened annular ligament which may lead to a misdiagnosis of carpal tunnel syndrome.
Is surgery inevitable with a carpal tunnel syndrome diagnosis? Although the standard practice is to inject steroids or to prescribe anti-inflammatory medications, the end result with a diagnosis of carpal tunnel syndrome is usually surgery.
Prolotherapy and carpal tunnel syndrome – stability and strength in wrist and elbow
Actual carpal tunnel syndromes are caused by compression of the median nerve and pseudo carpal tunnel syndromes are caused by ligament weakness. They both may present with the same or similar symptoms but have entirely different pathology.
- Comprehensive Prolotherapy treatment for pseudo carpal tunnel involves multiple injections of dextrose-based solution to the various ligament attachments around the elbow or wrist.
- Prolotherapy treatment to the injured weakens structures of the wrist and elbow stimulates a natural inflammatory response in the weakened ligament tissues.
- Prolotherapy treatment sends regenerative cells to the areas of the wrist or elbow that need healing, and collagen is laid down. This strengthens the weak wrist and elbow ligaments. They become tighter and stronger, and the original cause of pain and symptoms is eliminated.
A Case study of a 42 year of female athlete with Carpal Tunnel Syndrome
We have seen countless patients with wrist, elbow, carpal tunnel type syndromes. So have many of our Prolotherapy colleges. In Turkey, doctors reported this case history in the British Journal of Sports Medicine: (5)
- Forty-two years old recreational female athlete had Carpal Tunnel diagnosis in both wrists for 6 months.
- Treated with NSAIDs, B6 vitamin and ultrasound therapy were used.
- Symptoms eased but healing was not completed.
- Prolotherapy was used and injected at bone at the enthesis (the ligament attachment to the bone) of the transverse carpal ligament
- Injections were done 2 weeks apart and 3 injections were done.
- Patient was prescribed with a home standard exercise program.
- Patient was reminded at each contact to avoid NSAIDs and new therapies for Carpal Tunnel Syndrome to limit overuse of the wrist during the treatment period.
- Results of treatment: Pain scores improved significantly.
- Results of treatment: Nerve conduction velocity also showed an improvement. The Nerves functioned better based on speed of messages.
The use of Platelet Rich Plasma therapy for Carpal Tunnel Syndrome
Like Prolotherapy, Platelet Rich Plasma injections are regenerative in nature, providing stability, tissue repair, and pain relief. The PRP injections are often given with Prolotherapy inections to provide a whole joint treatment.
In a six month follow-up study, university researchers in Taiwan found that Platelet Rich Plasma Therapy effectively relieves pain and improves disability in the patients with carpal tunnel syndrome.(6)
In this 2017 research the Taiwanese team examined a few small reports with short follow-up periods that showed the clinical benefits of Platelet-Rich Plasma for peripheral neuropathy (see below) including one pilot study and one small, non-randomized trial in patients with carpal tunnel syndrome.
To confirm whether or not PRP was beneficial for carpal tunnel patients, they conducted a randomized, single-blind, controlled trial to assess the 6-month effect of PRP in carpal tunnel syndrome patients.
Sixty patients with single-side mild-to-moderate carpal tunnel syndrome were randomized into two groups of 30, namely the PRP and control groups.
- In the PRP group, patients were injected with one dose of 3 mL of PRP using ultrasound guidance and the control group received a night splint through the study period.
- The PRP group exhibited a significant reduction in the pain scores and improved function compared to the those of control group 6 months post-treatment.
- This study demonstrates that PRP is a safe modality that effectively relieves pain and improves disability in the patients with carpal tunnel syndrome.
1 Leppänen OV, Jokihaara J, Jämsen E, Karjalainen T. Survey of hand surgeons’ and therapists’ perceptions of the benefit of common surgical procedures of the hand. Journal of plastic surgery and hand surgery. 2018 Jan 2;52(1):1-6. [Google Scholar]
2 De Kleermaeker FG, Meulstee J, Bartels RH, Verhagen WI. Long-term outcome after carpal tunnel release and identification of prognostic factors. Acta neurochirurgica. 2019 Feb 19:1-9. [Google Scholar]
3 Viikari-Juntura E. Why do we know so little about return to work after carpal tunnel release? Scand J Work Environ Health. doi:10.5271/sjweh.3771
4 Strohl AB, Zelouf DS. Ulnar tunnel syndrome, radial tunnel syndrome, anterior interosseous nerve syndrome, and pronator syndrome. J Am Acad Orthop Surg. 2017 Jan;25(1):e1-e10. doi: 10.5435/JAAOS-D-16-00010. [Google Scholar]
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