Still symptoms after CTS and pronator terms surgeries


Hi, I'm turning to this forum for advice after trying everything else I could think of. I'm looking for advice about what I can do to ensure my diagnosis is correct, and if there are any other treatment options. I thought I would just list everything I've tried in anticipation of questions, but I am happy to elaborate on anything. Thanks for taking the time to wade through this post.

I started drawing and painting 7-8 hours a day in Dec 2015. After about three months, I started to notice symptoms.

I've had carpal tunnel release surgery and pronator teres release surgery (10 months ago), but still have nearly the same symptoms. My doctor has sent me back to hand therapy twice since surgeries, but it doesn't help. I don't know what else to tell my doctor other than the symptoms haven't improved. I've tried completely resting my arm (no activity) and gradually becoming more active (but not doing any drawing or painting), but symptoms return. They return from doing any gripping or wrist flexion activities.

Symptoms: After drawing for a while, I have mild pain, swelling, warmth, itching in medial forearm. In fingers (1st three digits) and thumb I have weakness and numbness. The day after doing a chore with heavy gripping I have sharp pains in my medial forearm.

Summary of medical visits:

- Feb 2016: Chiropractor: ART and ultrasound treatments.
- March 2016 saw Orthopedics doctor.
- April 2016: hand therapy for 6 weeks.
- June 2016: doctor speculates it could be CTS or pronator syndrome.
- June 2016 EMG. Results: compressed motor branch at carpal tunnel.
- July 2016: CT release right arm.
- Aug 2016: Saw doctor. Still had symptoms.
- Sept 2016 pronator teres surgery.
- Sept 2016: symptoms seem to be gone.
- Oct 2016: symptoms return
- Nov. 2016: hand therapy.
- Mar 2017: massage therapist

I have tried the following treatments:
Hand therapy: ultrasound, massage, e-stimulation, laser, nerve gliding, stretches.
At home: stretching all muscles of arm and shoulder (Ming Chew's book), self massage, trigger point therapy, self ART, light weights (1-2 kg) flexing, extending, pronating, supinating.

I tried resting it completely for months, and then gradually introducing light weight work but it always brings back symptoms. I've tried returning to the offending activities (drawing and painting) gradually, but symptoms return.


The first thing I see in that story which sounds slightly odd is the comment on the June 2016 EMG "compressed motor branch at carpal tunnel" - do we have that set of nerve conduction EMG results in full? If you could also run through the symptom questionnaire here on the website that would help me understand your symptom pattern and risk factors a bit more. I take it that symptoms do improve with rest but then recur when you try to take up the same activities again? What is the latest medical diagnosis? JB


Thanks for the reply. I will request a copy of the EMG results and post them.

I did the survey--do you have access to it or can I post it somehow?

Symptoms improve nearly completely with rest. They return within 20 min. of painting or within an hour of light drawing. Painting has more wrist flexing, so it aggravates it more.

The most recent diagnosis was Aug. 2016 pronator terms syndrome. That was based only on my verbal symptom description, since the EMG didn't show anything abnormal, I believe.


I have a paper copy of the EMG, but I can't see any way to upload a scan or picture of it.

Electrodiagnostic Report

Nerve Conduction:
Median Study
Motor Lat: 5.0 ms
N Amp: 1.1mV
Sensory NCV: 51 m/s

Ulnar Study
Motor Lat: 3.3 ms
N Amp: 7.5 mV
Sensory Lat: 3.2 ms
Normal Amp: 28 uV

Lat 2.4 ms/23 uV
Amp: 2.6 ms/7uV

Electrodiagnostic interpretation:
1) NCS: Normal right median sensory distal latency. Severly prolonged right median motor distal latency with a low amplitude and extremely broad CMAP. Difficult to obtain an accurate proximal median nerve response due to the low amplitude and broad waveform response. Right median sensory forearm conduction through the forearm was WNL. Normal right ulnar motor and sensory distal latencies; no slowing across the right elbow. Normal right distal radial sensory latency.

2) EMG: Normal monopoly needle exam of the right arm and neck.

Evidence of a severe median motor neuropathy at the wrist consistent with right carpal tunnel syndrome with denervation. As discussed with Dr --, there is no right median sensory delay.

No evidence of a right Martin-Gruber Anastamosis or AI.

No evidence of significant electrophysiologic slowing across the ulnar nerve at right elbow.

No electrophysiologic evidence of an acute right cervical radiculopathy, plexopathy, or generalized peripheral neuropathy.


Thanks. I've deleted the questionnaire copy as I can read it via the website anyway and that's a lot of personal information to put in the public forum. Basically your symptoms are not really typical of CTS and those nerve conduction studies are not at all typical of CTS. If it's not CTS then that would of course explain the lack of response to surgery. My first thought on seeing those results in someone your age would be of possible neurogenic thoracic outlet syndrome but they didn't really do the necessary further tests to follow that up as a possibility. You are right that it's not possible to post the NCS results directly on here but you've done a pretty good job of transcribing them - if you do want me to look at them in full then you can always email me a scan (address in the contacts page). I think you need an opinion from a good neurologist to get any further. Please let me know how you get on. JB

It turns out, in email conversation later, that subsequent NCS have revealed the presence of a median/ulnar anastomosis in the forearm, explaining the original NCS results. JB 16.8.17

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