New symptoms and treatment is not working

luxurytravel
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I am a 47 year old male. I felt only wrist pain initially starting in August/2019. Eventually, the palm area and area below the fingers felt swollen. Many times I would wake up in the morning with numb hands. In November of 2019, the numbness in the right hand (specifically the thumb, index and middle finger) was constant. I immediately sought medical attention where recommendation was to use ibuprofen and take a rest from physical activity (mostly boxing (3 hours a week) and light dumbbell use.

After 2 weeks of the symptoms persisting, I visited a hand/wrist specialist who recommended splinting at night daily. He thought my condition was CTS. I have been religiously splinting at night daily and have discontinued any activities that I think might be aggravating the issue. There has been no improvement in my symptoms. In fact, the left hand is intermittently going numb and I can feel a very mild trace of numbness in the left hand as well. I have been stretching, going to phyio (dry needle therapy, ultrasound) etc. I'm not taking any NSAID.

It has been approx. 45-50 days that i have been splinting at night but no improvements. My doctor believes that I came in with very early symptoms of CTS. Should I splint 24 hours a day or what is the best recommendation? Is it possibly Rheumatoid Arthritis or something else?

jeremydpbland
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According to standard anatomy the palm area should not be affected by CTS because the nerve which carries sensation from that area passes outside the carpal tunnel. With that story I would wonder whether another process in the area is producing swelling and that may be giving you a secondary CTS (the numb fingers at 3 am) so I would want to get some nerve conduction studies and ultrasound imaging done to try and clarify the diagnosis before launching into aggressive treatment. JB

luxurytravel
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The right hand numbness in the thumb, index and middle finger is constant and has been for the past 45 days. The middle of the palm area still feel tender (making a fist) and there is some wrist pain. There is quite a bit of stiffness when I wake up (after wearing night braces) and it takes approx. half an hour before the hands feel less stiff. What alternative diagnosis could there be besides CPT. Aside from the numbness in the right hand area, the symptoms are bilateral.

jeremydpbland
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That distribution of numbess is a pretty good marker of trouble with the median nerve and with the rest of your history I don't have a problem with the diagnosis of CTS. The question is just whether it is CTS occurring alone or CTS secondary to another process - it sound more like the latter to me but a combination of nerve conduction studies and ultrasound imaging should help to sort it out. Possibilities for the primary cause include a variety of forms of tendonitis and arthritis. JB

luxurytravel
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The doctor has suggested a possible culprit of the CTS and palm area issues is elevated blood sugar levels. My A1C has never exceeded 6.4 and has been in the range of 6.0 to 6.4 for the past 10 years. My latest morning fasting blood sugar levels are approx. 6.5. I realize this would place me in the prediabetic range. I am taking 1000mg of Glumetza daily at night. Have you seen any presence of CTS with people with that kind of A1C range?

As a side note, in the past 45 days, I have brought down my A1C to 6.0 and have lost approx. 5 pounds but with no improvement in symptoms.

jeremydpbland
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Established diabetes is almost certainly a risk factor, albeit only a modest one, for getting CTS, though I thik it's actually more important because it modifies the ways CTS present with symptoms than it is because it 'causes' it as such. The evidence on pre-diabetes is that it is probably not important, though fewer studies have been performed. There's also quite a bit of literature on whether diabetes is a poor prognostic factor for surgery, again the answer is probably that diabetic patients do somewhat less well with the operation but as always there are conflicting results from different studies. Being overweight is probably at least as strong a factor in causation, at least in younger patients but there are no really satisfactory studies of weight loss as a treatment for CTS. JB

luxurytravel
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I'm also getting inflamation below the A1 Pulleys (small bumps close to the middle of the palm area) and its difficult to make a fist. Dull pain in the morning is there upto half way between wrist and elbow. Is CPT the only diagnosis or could the underlying causation be something else? Also, for getting ultrasound, which area of the hand/wrist is the best to get ultrasound? Is it worthwhile to get it all the way to the neck in the event the nerve compression is further up? Also, in recent bloodwork, my ferratin storage is 10. Have you seen low iron storage as a culprit in CTS? Thank you so much for this resource. Between appointments in the public health care system (sometime taking months) its reassuring to have yourself answer questions from people around the world. God Bless

jeremydpbland
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You may well have problems with the flexor tendons as well - Dupuytren's contracture and trigger digits are both common in CTS patients and even more common in diabetic CTS patients. If you see someone who is knowledgeable about nerve imaging for ultrasound they will examine all relevant sections of the nerve anyway, guided by the clinical presentation and what is found as the examination proceeds. The problem is that there are relatively few people in the world who know a lot about nerve imaging compared to the total number of people who do ultrasound examinations, though we are working to spread the expertise. I'm not aware of any links between iron metabolism and CTS as such. JB

luxurytravel
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If the Anti-CCP test is negative, RF factor is negative and CRP levels are below allowable range, what are the chances it could be Rhuematoid Arthritis?

or

If there is presence of CTS, inflammation of flexor tendons and very slight finger triggering (middle finger when extended by itself), that elevated blood sugar levels could be the culprit.

The doctor is leaning on the side of elevated blood sugar levels, but has said that nerve conduction studies or ultrasound will not be useful.

jeremydpbland
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I'm not a rheumatologist so I'm not going to comment on the diagnostic properties of blood tests for rheumatic diseases beyond the fact that 'sero-negative RA' - ie something that looks like rheumatoid arthritis but with a negative rheumatoid factor test - is a well recognised entity!

Nerve conduction studies are always useful when someone has raised the possibility of CTS as a diagnosis (but then I would say that - I'm a neurophysiologist) :-) Whether ultrasound is useful or not depends very much on the expertise of the available ultrasonographers. My view remains firmly that every patient who is going to have CTS treated with anything more aggressive than a splint should have NCS performed before they start on treatment. JB

luxurytravel
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Is it possible to see you privately if i'm not from the UK? How would that work?

jeremydpbland
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I do a small amount of private work, mostly because I don't think patients being treated at the local private hospital (which does not have its own neurophysiology facilities) should get NHS investigations 'on the cheap' thereby subsidising the private sector, and there is no-one else in the area at present who patients can go to. Otherwise I might give up private work altogether. I try not to let commercial concerns intrude on the way the website runs, ie I do not want this site to function as advertising in an attempt to draw in patients to my private pratice so I have generally declined the few people who have asked. I have seen a couple of people from outside the UK but not charged them. There are complications to this however - I use NHS facilities for all my work, both NHS and private and for the private cases the hospital does make a charge for use of them so even if I don't charge the hospital does, and there are limits to how much I can do for non-NHS patients as I rely on being able to refer to NHS services a lot. How far away are you? It's propably not worth more than a cheap European trip to visit my clinic. If you have the resources to travel for an opinion it's usually possible to track down someone fairly locally with the necessary skills - though I did have one correspondent from Fiji who really did not have anything that remotely could be called 'local'. JB

luxurytravel
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Is it possible the trigger finger could be caused by CTS itself? Or are the underlying reasons for trigger finger a combination of CTS and diabetes or Rheumatoid Arthritis?

jeremydpbland
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I don't think trigger finger is 'caused' by CTS as such because if you look at the time relationship between them it is sometimes the trigger digit that appears first and sometimes the CTS. What seems to be going on is that patients have a common predisposition that leads to both problems. Diabetes seems to cause lots of hand problems. There is a whole page of the website here devoted to the topic. JB

luxurytravel
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After visiting the doctor yesterday, he conducted various tests for the hand and wrist. One test was the Finkelstein test which did indicate de Quervain syndrome. As I recall, my first symptom was a similar type of pain in the wrists. The pain then went to the palm area and then resulted in CTS & trigger finger.

Is it possible that the de Quervain syndrome has caused these other issues to develop or worsen?

What is the best treatment for de Quervain syndrome?

Everyone has a different opinion regarding applying heat or ice. Considering the CTS has been present for at least 2 months now, do you recommend heat or ice?

jeremydpbland
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I see quite a few people with De Quervain's as well as CTS but I'm not aware of a study checking whether they are more common together than would be expected by chance - they are both very common conditions. The tendons involved in De Quervains are well away from the carpal tunnel so I don't think it is likely to directly cause CTS but if you have one set of inflamed tendons it may be more likely that you have others.

Heat or ice? - whatever seems to work for you. It's an easy thing to experiment with and the response ot the symptoms is probably quite a good guide. Some people alternate the two. JB

emmakaile
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For other common hand conditions the BSSH website has good information to guide you to possible treatments. This includes De Quervains EK

I have been trying to copy a link in here but it is not working at the moment. You can search for BSSH - British Society for Surgery of the Hand. (link now added above. JB

luxurytravel
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Just had nerve conduction studies and the bilateral compression is definitely in the moderate range. I want to give a really fair shot to trying to fix the problem without injections or surgery. What is your opinion of the following:

splinting most of the day and all night. I am flexible in my work and can splint about 80% of the daytime.

Visiting hand therapist/phsysiotherapist every other day.

Will taking NSAID's help with the treatment or only the symptoms?

Anything else that will help reverse the compression?

At this point, I am willing to spend as much time and resources necessary to fix the problem. I can take 2 months off work if required.

jeremydpbland
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I don't have a lot to add to the information that is up here on the website already. The only evidence based treatments are splints, steroids and surgery. There is only one good trial of NSAIDs and they were no better than placebo. All forms of manipulative treatment/exercises are essentially unproven but probably harmless, with the possible exception of chiropractic which has been known to cause neck trauma when done badly. Nerve conduction results should be graded using either the UK or Italian systems - did they give you a grade rather than the vague term 'moderate'? If you are grade 3 or below and want to avoid surgery then by far the best alternative is local corticosteroid injection, though it needs to be done by someone competent - the best evidence suggests that you have a better than 50% chance of avoiding surgery for 5 years or more if treated that way and allowed repeat injections if necessary (in our study an average of two were required over an 8 year period of follow-up). Most importantly treating it with steroids requires minimal time off work - just long enough to go and have one done usually. JB

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