jeremydpbland
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This one of those things that's really hard to work out from a web conversation isn't it. The bony lump on the inside of the elbow is called the medial epicondyle and is part of the humerus - the long bone of the upper arm. The 'point' of the elbow - the bit you elbow someone with - is called the olecranon and is part of one of the long bones of the forearm. The other anatomical terms we need here are 'proximal' and 'distal' - Proximal means 'nearer to the body' and distal 'nearer to the hand' in this case. If you start at the medial epicondyle the first muscle you will feel distal to that is called flexor carpi ulnaris,. This is one of the muscles that bends the wrist and you can feel it contract when you flex the wrist. If we are going the other way the first muscle you come to proximal to the medial epicondyle is a part of the triceps.

The area where the flexor carpi ulnaris and other muscles are anchored to the medial epicondyle often becomes sore.

We are not really designed to stay in one position for long periods of time and that includes during sleep. If you watch time lapse video of sleeping people you may be surprised just how much we move around at night, so fixing a limb in any one position is liable to leave it feeling somewhat stiff in the morning. I think wrist splinting only workhs for carpal tunnel syndrome because it is a fairly small part of a limb which is immobilised. JB

Curtis Stevens
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I tried to grasps most of what you said, I think I did.

I'm a dummy, what I'm feeling again is just my muscles getting a working out as it appears that was just soreness from the workout a day or so ago.

I'm going to give it some time before I jump to any conclusion going forward, once I get through the muscle workout period and that isn't the cause anymore. Sorry for bothering you with this nonsense.

Curtis

jeremydpbland
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No problem - gives me something to think about. JB

Curtis Stevens
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It appears working out was my problem at that time. Everything seems to be fine mostly for my elbows. I can't go resting my arms on arms rest. It isn't because it hurts, but my brain gets some kind of signal that there is some kind of discomfort. Other than that, seems to be fine.

CTS - I would say mostly cured right now. There are some things I can do with my hands that it doesn't like and starts to bother it, but most things are fine. I'm wondering if a 2nd shot is in order, if it would help get it to a complete cured state or a good chance it will or is just a waste of time and money. I don't know when you should consider getting a 2nd shot. If a patient is 80-90% cured by shot 1, do you say try a 2nd and see if it gets even better?

I've met my deductible for once, so I'm all for anything until the end of the yr.

Curtis

jeremydpbland
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You have hit on one of the interesting research questions there - I'm afraid no-one really knows. In a Spanish trial where they gave a second dose of steroids two weeks after the first if there were any residual CTS symptoms at all they got remarkably good overall injection results, but there were still plenty of long-term relapses. To be sure I think you would need a placebo controlled early second injection trial. Everyone gets the same initial injection and then two weeks later those with any residual symptoms randomly get either 1 ml of saline or another dose of steroids and then you follow everyone up for 2 years. My guess is that such a formal trial would cost about half a million dollars.In the absence of such a trial I would say re-inject as soon as the patient decides that the symptoms are a significant nuisance. JB

Curtis Stevens
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I've come across this doctor that has a lot of information and videos out there about a ton of topics. I think he is becoming very popular with millions of visitors. Of course, he has one about carpal tunnel. Curious to hear what you think after hearing him talk: I'm sure it is going to be a very good laugh for you... ;) Curtis

jeremydpbland
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He's not a doctor, at least not a medical one. (I'm not a PhD either - but you can have a PhD in anything and become officially a 'doctor') He seems to be qualified in "nutrition" - an area full of  practitioners selling things of unproven value, possibly chiropractic - a fringe medicine area, and maybe ayurvedic medicine - hard to tell for sure from his list of qualifications. Unless he writes and gets published a peer reviewed paper about his recommendations I would suggest simply ignoring him until he does. (So far as I can see on a quick search he has not published any scientific work). Youtube videos and popular books are not the way to set about progressing medical science I'm afraid - we try to practice evidence based medicine nowadays. JB

Curtis Stevens
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What are your thoughts about stem cell therapy for either CTS or the elbow? I searched your site and didn't find any references.

jeremydpbland
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I haaven't seen anything reputable published as yet but I could have missed something. There are several outfits selling stem cell 'treatment' for CTS but no quality evidence of efficacy so far as I know. JB

Curtis Stevens
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Would you personally spend the money to try? It would be $2500 for both my elbows and wrists, no insurance coverage of course. I don't want to piss away money, but medically speaking if this does have a shot at working.

jeremydpbland
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I certainly wouldn't spend that on a completely unproven treatment with little theoretical justification for why it should help myself. JB

Curtis Stevens
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Ok, thanks. I have had my 2nd shot almost 2 months ago. These two shots have definitely helped, but I've never been 100%. It has helped it so much that I can do a lot of things that I used to not without discomfort, but there are still somethings I can do that will really irritate it. I guess you can say it has just prolonged the inevitable. It feels like it might be slowly progressing downward, not sure. I have a hard time seeing it becoming 100% cured at this point, so I'm trying to decide if and when I do the surgery. I've met my insurance deductible, so they will pick up most of the bill until the end of the yr. I would like to do both hands at once for that reason, but I know that is also very risky! I was hoping stem cell could be my answer before I say slice her up.

Curtis

jeremydpbland
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In my own clinic I use repeated nerve conduction studies a lot to get an objective measure of whether the nerve is deteriorating or not and generally go for surgery when it is clearly getting worse but that is not likely to be an option in much of the world. I'm not a fan of bilateral simultaneous operations myself but there have been studies demonstrating that they can be done successfully and that patients appreciate only having to have one period off work for both hands - it's fine as long as they are successful but I've also come across several patients with bilaterally unsuccessful surgery that has been something of a disaster for them - a couple of such stories are here on the website. JB

Curtis Stevens
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What's the purpose of doing repeated nerve conduction studies, like for me to do one now? Isn't surgery my last option at this point, regardless of what that ncs tells us?

jeremydpbland
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If the NCS results are holding stable or improving I am more inclined to carry on treating with steroids until the patient is completely sure that they want to take on the small risk and inconvenience that goes with surgery, whereas if the NCS results are getting worse I tend to push people towards the operation - though ultimately I like all my patients to make their own choices, just informed by the best available evidence. I am thus using the NCS as a decision aid - though not the only factor in deciding how to proceed. By comparison with the rest of the world however I am somewhat eccentric in the way I run my clinic. JB

Curtis Stevens
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Interesting! I'm on my second shot though. Was there any improvement from the 2nd shot over the first? I'm not sure, I know it was starting to bother me more when I got the 2nd shot, I think. Hoping that a 2nd would finish it off. But I never got there. Not 100% that is. Assuming the NCS shows improvements, which I would be very surprised if there isn't significant improvement. Would you do a 3rd shot? It has only been 2 months since my 2nd shot. It is starting to feel like the shots are just temporary.

jeremydpbland
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I have patients in the clinic here who have between 1 and 14 injections to a hand so far. Every time you do another one some patients relapse, some decide to give up and go for surgery and some remain well for prolonged periods. In the absence of a high quality, long-term, prospective study it's very hard to put precise numbers to this but we did a retrospective study two years ago where we tried to trace all of the patients who had started out with an injection in 2007 during 2015 - 8 years later. Only 41% had had surgery by that stage and the symptoms ni the other 59% were adequately controlled by injections. The average number of injections received during the 8 years had been 2 but one patient had had 10. Similar findings have been published by a a group in Scotland and by the Mayo clinic so it's not just me. So yes, if NCS were improving and the injections were not getting too frequent (I like them to average less than one every 6 months) I would consider a third injection. Up to three are considered acceptable in European guidance on treating CTS by injection - beyond that it gets to be a bit more of a 'research' procedure. JB

Curtis Stevens
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The outfits you know that are doing stem cell treatments, does it say something knowing they are not bragging about the results? I cannot believe there's no publication of the success, unless there is none. Injections are an anti-inflammatory and if they are helping s lot, would you not have good confidence stem cells might actually work knowing an anti-inflammatory drug is helping? I do not know much about stem cells and how they really work, to know if it is similar to an anti-inflammatory.

I think I am ready to schedule the surgery, but part of me wonders if five years from now, the entire medical industry may be pushing stem cell treatments because it's a great cure. I missed out and did the surgery when I didn't have to.

You have the doctors that are doing stem cells, but I hesitate and have them do it. As you know you can cause damage injecting in the carpet tunnel if you don't know exactly what you doing, doing more harm than good.

Has your office not considered trying the stem cell? If not, may I ask why?

jeremydpbland
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There is little theoretical basis for using stem cells in CTS and so far as I can see it is something that is confined to the USA at present so not available to me in the UK anyway.  There are more promising avenues of investigation that I would pursue if I had time and money to run numerous trials. I don't believe in trying off the wall new ideas except in the context of a properly constructed, randomised, controlled, preferably double blind, clinical trial - so there are many reaosns why I would not 'experiment' with stem cell treatment. (Oh and corticosteroid injections are probably not 'anti-inflammatory' in CTS) JB

Curtis Stevens
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I thought the shots were, if they are not anti-inflammatory in CTS, then what's happening for it to have helped my symptoms?

The two shots I've had were 6/6 and 8/31. My symptoms are without any doubt, much better than they were before my first shot. But they are not 100% and I still have times where it bothers me. I think it is starting to progress downward, slowly.

I never wanted to consider surgery, thinking it would be better to find an alternative solution if at all possible. But this procedure is done tens of thousands times a year, so it must not be that bad with not too many consequences. I guess I hesitate knowing you are cutting something that was meant there for a reason. I'm trying to confidence myself surgery isn't the end of the world. I just didn't want to end up regretting it later, loss of strength as I get older or whatever the long term consequences are since I'm only 36.

Curtis

jeremydpbland
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We don't fully understand what steroids are doing in CTS but there are some biochemical abnormalities in the carpal tunnel in CTS patients which we would expect to be influenced by steroids. The operation is generally successful and one should not be too put off by the horror stories on the web, remember that patients with bad outcomes are much more likely to be 'heard' on the net complaining about it than are the majority of patients with good outcomes. Howver cynical one may be about the workings of healthcare it is safe to say that it would not be such a commonly performed operation if it did not usually produce good results and the figures in the surgical outcome section of this website are pretty representative of the odds. It's almost certainly a better bet than stem cell therapy at present. I'm working on a prognostic model which would give a much more personalised prediction of the probability of success but that's not ready for public use yet. JB

Curtis Stevens
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Again, thank you for all of your time!! I'm going under the knife next week and then 3 weeks later for the other hand. I don't recall exactly, but he said the procedure he does is your tiny incision below the palm at the wrist like everyone else, but he also makes a tiny incision around the thumb area, can't tell you exactly, been too long since he told me. For some reason, to be able to ensure he gets somewhere very well and it is harder to ensure that if you don't come from both sides. Does this make sense?

Does it make sense to wear the splints at night after the procedure, long term, in hopes it prevents it from ever coming back? I'm sure I sleep with my wrist bent, and I wasn't sure if that isn't really good, after surgery or not and need to keep my hands straight since I like to bend them all the time while sleeping.

jeremydpbland
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Sounds like the two-portal endoscopic surgery devised by Okutsu. There should be no need for long-term splinting after surgery. The aim of surgery is to retore your hands to normal for good - anything less than that is a failure in my book. JB

Curtis Stevens
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So once I'm healed up, I shouldn't live my life to try to prevent a relapse, by not or doing certain actions? In other words, if I relapse, it isn't because I did an activity that caused it to?

jeremydpbland
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As long as the operation is done correctly that is exacty right. CTS does sometimes re-occur even after surgery. It probably affects about 1 in 20 people if you wait long enough and seems to take 10-20 years or so. There is no real evidence that recurrence has anything to do with use of the hand. It seems to be gradual repair of the transverse carpal ligament by scar tissue over time so far as we can tell - but it is so uncommon to see these cases that they have not been much studied. Most CTS occurs in an older age group who do not survive long enough to get a recurrence at 20 years. JB

Curtis Stevens
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Do you have any idea what procedure he is doing? I had finally decided shots were not going to be 100% permanent, so I just called to schedule surgery. During my email exchanges with his staff, I can't seem to get the answer out of them. I thought I knew what procedure he was doing, now I have no idea. It isn't open, isn't endoscopic. "His carpal tunnel’s are minimally invasive, the incision is much smaller, it is in the palm of the hand and not the wrist."

My left hand is supposed to be tomorrow and the right on Dec 8th. I really don't have a choice to postpone it as it will go into next year and will cost me $5K more with insurance vs doing all of it this yr.

Curtis

Curtis Stevens
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Posting a more "fun" question. How are medical costs in your country? Do you know how much money the facility collects from patients? I can't believe just the facility is going to get $8K from me and the insurance company. You now still have the surgeon, etc. The medical field is so messed up here.

jeremydpbland
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There are several minor variants of carpal tunnel surgery described as 'minimally invasive'. None of them have been shown to be clearly superior to the standard open procedure and if I needed surgery I would stick with the long tried and tested operation. I would ask for the published reference to the technique and if it's not been published then I would want to know how many he had done and what evidence he had of the outcomes but such an approach is difficult for an ordinary patient I'm afraid.

Medical costs in the UK - The NHS tariff cost for a carpal tunnel operation at present is a little under £900. That is the amount received by a hospital like mine for doing the operation. None of that is paid directly by the patient. It all comes from general taxation. In primary care the operation is done more cheaply and can cost as little as about £300-£400. This doesn't seem to stop surgeons making a comfortable living. In the private sector in the UK carpal tunnel surgery costs 1-3k, usually as a package including aftercare. JB

Curtis Stevens
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Surgery - I think you could say it probably comes down to preference. Why a surgeon does it one way or another, maybe prefers it the best, thinks he is best skilled that way, has the best outcome, etc. I'm going to say it really comes down to smaller incision, faster healing, etc. From what I read, successful rates are all the same, just which one is more convenient for the patient and if the doctor fills he is most skillful doing it one way or another.

I think I know what he is doing, I'll find out tomorrow.

If I fly up there, when could you do mine? LOL US health care is so screwed up. The amounts doctors get I would say is reasonable. It's the facilities that are just becoming rich!

jeremydpbland
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At the moment I can arrange surgery for those who need it in about 6 weeks. Usually it's shorter than that but we have a Xmas break and one ill surgeon for a few weeks. Some surgery is properly evidence based - ie a particular procedure is chosen because it has demonstrably better results or lower costs or both - but a great deal of surgical practice does indeed come down to individual preference by the surgeon. JB

Curtis Stevens
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Comes to find out he does the mini open, after doing all 3 methods for a number of yrs on each. He said he does the mini open because there are a few people that (I don't recall exactly what he said), but something about their nerve around the thumb isn't where it should be and if you do endo, then there is a 100% risk of doing bad things, maybe you will hit it? I do remember him talking about something around the thumb, I'm sure it's a nerve, but beyond that, not sure. He said it is a very small chance, but for the people that have that abnormality, it's 100% risk for them. I had it last Wed. I did my nondominant hand. Other hand is in less than 2 weeks. This is going to be rough! I have to work a show later this week and I can't do what I need to with one hand... I'm not sure how long it really takes the stitches to heal. I wear my splint most of the time to make sure I don't do something that would reopen the wound, but if I do too much, not sure if the discomfort I feel is the incision or what he did and that's good. I'll find out what the therapy wants me to do in two days, but that's when I need the hand to be useful for my show, this Wed-Thur. I have a to wear a latex glove on that hand... I have a hard time seeing it getting much better in the next 48 hrs.

jeremydpbland
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He's probably referring to the recurrent motor branch of the median nerve which is sometimes injured when it lies in an unusual place. There isn't really any clear evidence that the risks to are higher with one operation rather than another but whichever operation he is happiest with is probably best. I personally wouldn't have two hands done in very quick succession like that but it's your choice. Good luck with healing. JB

Curtis Stevens
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"I personally wouldn't have two hands done in very quick succession like that but it's your choice."

Why do you say that? Due to life inconveniences? If I wait, has to be next yr and I have to pay $5500 more myself...

jeremydpbland
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First of all, two weeks is often too soon to judge whether the outcome of the first hand is what you want or not. I've seen some terrible catastrophes when both operations have turned out badly and a patient has been near totally disabled. Secondly, when you operate on the first side, the other one sometimes improves anyway, occasionally making surgery unnecessary. Thirdly, having both hands partly out of action at once is something of an inconvenience - OK if you're a really quick healer and the first one is fine by two week later but quite a few people do not recover that fast. On the other hand US healthcare is giving you a substantial financial incentive so you are a bit stuck. JB

Curtis Stevens
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If this one turned out badly, would I not already know about it?

True, I'm not 100% sure this will fix my problem. I'm pretty confident it will. I also worry that my cubital may become a bigger problem in the future. I find myself avoiding resting my elbow on my desk, resting my arms on side chairs, etc. The elbow splints definitely made most of the pain go away, but have a feeling it may not be a permanent fix. I just have to wait and see. I was hoping that removing my CTS that there might be a chance it would make my cubital issues go away too.

Inconvenience? No joke, it sucks already! I feel like I'm having to rush into the next one just so I can get it in before the end of the yr. It's only money, maybe it will be best to wait a few months. My right hand, dominant of course, is the worst of the two though.

How often does that happen, the other side naturally improves? I have a hard time seeing that, maybe if I did my right hand first.

jeremydpbland
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The other side improving after surgery on the first one has been observed by many people but no definite figure has been put to it. My guess is that it is about one in ten - but some of those then turn up 5 years later with symptoms in the un-operated side again and end up having that done. As with many things in CTS the timescale is so long that formal randomised controlled trials cannot really be long enough to capture what happens to all the patients. In CTS research circles one year is generally considered to be a really long follow up period!

In terms of judging the outcome. In many cases there is such immediate relief of symptoms that it is obvious from day 2 that the procedure has been successful as far as relieving the CTS is concerned but even some of these patients then go on to develop side effects form the operation such as persistent wrist pain, or the wound breaks down - I've seen some of these take 6-8 weeks to heal properly and end up with an uncomfortable scar. JB

Curtis Stevens
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I have had two shots and he commented after doing this hand that it was really tight in there. So I would think that is a good indication surgery is going to work, since my symptoms were about 95% gone after the shots. I just can't do somethings at the gym, like push ups without it starting to hurt, etc.

Patients developing side effects, is that common? What causes that? The surgeon doing something wrong? If so, even if that doesn't happen with the first surgery, could that not happen with the second, no matter how long you wait, meaning that chance of risk is always there with each procedure?

Uncomfortable scar? How does that happen? The incision isn't that large. You really make me hesitate, but I do know this is probably one of the most common procedures here in the US. I would like to think most of them go without a hitch.

jeremydpbland
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Most are indeed successful. I'm amused by surgeons who make comments like that after the operation - they seem to say it about EVERY CTS operation. I think the situation is that the normal carpal tunnel is pretty tight.

Side effets mostly relate to the fact that they are destroying the transverse carpal ligament - which is a functional part of the wrist. The incision may be small but it is in a site which gets a lot of everyday wear and tear so they can be uncomfortable. There are also sometimes injuries to small cutaneous nerves when they make the incision and this can occasionally lead to pain in the area later.

The chance of a bad result from the second operation is about 6x higher if you have a bad result from the first one. JB

Curtis Stevens
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Since surgeons are only operating on people with CTS symptoms, no one will know what a normal healthy tunnel looks like to compare, so yeah I agree, that comment is pretty pointless.

Side effects from destroying the ligament - this will happen no matter the method of surgery or who is performing it right? If this happens, not sure what other choice I have. Yeah, the shots got me to about 90% cured, but there were still things I couldn't do without pain and long term, that probably isn't good.

Incision discomfort - would you say this common? This doc doesn't do endo anymore... Would you say its common to injur the cutaneous nerves?

How long do you think I should realistically give it before doing the 2nd operation, to know how the first one went without possible side effects creeping up?

Not considering any financial incentive, what would you recommend if I were a friend or family? You have a good 90% of being just fine doing the other hand next week, etc?

Curtis Stevens
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Is it normal to take the stitches out 4 weeks later? That seems like a long time.

jeremydpbland
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Problems due to cutting the ligament do indeed occur regardless of the technique used - I think that is why all the many efforts to come up with a 'less invasive' method of surgery are doomed to failure. The whole point of the operation is to cut the ligament and if you devise an operation so non-invasive that it doesn't do this it's not going to alleviate the pressure on the nerve.

Painful scars for a long time after surgery are not very common but do occur - maybe 0.5% as a long-term issue but there are no reliable figures. Some injury to very small nerves in the skin is pretty much inevitable with any cut but mostly they recover OK and you don't notice.

We like to give people at least 6 weeks between operations and usually 3 months or more but there are surgeons who do both at the same time and a couple of papers claiming to demonstrate high patient satisfaction with bilateral procedures - only small series though. I think a recommendation to friends would be to play it by ear if the surgeon is flexible enough to do it at short notice and to have the second hand done when: a) the first one is fully functional again and b) the second hand is actually significantly symptomatic. In most people's situation however this will be influenced by the availability of surgery and other factors, such as your financial ones.

We usually remove stitches at 2 weeks. Some surgeons use a 'dissolvable' suture which does not need explicit removal. JB

Curtis Stevens
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I am always amazed by your dept of knowledge. If there is ever a world expert on CTS, you are the man! I wonder how much of your knowledge most surgeons know or don't know, if most would learn a lot by reading your site or all the forum posts.

It sounds like most of the bad things that can happen, are going to happen, even if your surgeon is the most skillful. You just have to cross your fingers. My guy is 52 and sounds like he has been doing this for a number of decades. So I'm pretty confident I can't get much more skillful than him.

My surgery is on the 20th now, so I'm hoping that is better. We'll see. They said they recommend removing the sutures at 3 weeks, so that's when I go in now since my next surgery is after. I get various sensations, discomfort or whatever you might call it in various places. It isn't constant though. Crossing my fingers that works out, just a short term side affect.

My dad had his cts done a long time ago, through endo and they told him after a week, go back to being a meat butcher. He said of course it hurt a lot cutting meat with that hand, but was told it wouldn't cause any damage. Would you say that is true or you should avoid anything that is causing discomfort to that now cut ligament?

Do you think therapy is a good idea? I was given basic tendon gliding exercises. Sounds like that is a good idea as that ligament heals, reduce scar tissue maybe?

Curtis

jeremydpbland
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I think you are right, most of the complications of this operation are not primarily due to poor quality surgeons - though that is not to say that surgeon generated catastrophes do not happen. I suspect the commonest surgical 'mistake' is simply operating on people who do not really need it.

Tendon gliding exercises are popular with some surgeons and physios but the evidence that they help is pretty scanty - they are hard things to study scientifically. On the other side of the balance they are unlikely to do any harm. JB

Curtis Stevens
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How long would you say you should experience some soreness/discomfort from the ligament being cut? If I press on the area below where the incision is, very base on your palm, right above where the palm meets the wrist at the wrist creases, it is sore. I can put my thumb on a table and push down and it hurts. If I rotate my thumb inward just a bit and then push down, it really hurts more. How long should this last before you start thinking it is something more? Is this something you should stretch that out, massage the area, etc or leave it alone as you are causing it to take longer to heal?

jeremydpbland
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That's not uncommon, massage is usually recommended but I don't really know how much it helps. It can last anything from a few days to being permanent, at least to a slight extent, and is pretty unpredictable from one patient to the next. JB

Curtis Stevens
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So I can't hurt it or make it worse or keep it from getting better by massaging, stretching, etc?

jeremydpbland
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I doubt it, as long as you don't 'massage' to point of causing tissue damage of course. JB 

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