Post injection right hand.

clivesmall
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I finally got my injection after paying privately on Wednesday 21st march. I had pain in the lower thumb area when the doctor inserted the needle which then shot to the end of the thumb after he adjusted the needle. After another adjustment he then injected the steroid. Since this procedure, the CTS symptoms have improved greatly. I have, in fact, slept really well for the last 3 nights wearing both splints. However, I am experiencing a shooting pain down to the end of the thumb which was the same pain as during the injection and my thumb is sore if I shake my hand. I hope this will clear over time. The injection was more painful than I expected. I have rested my hand and am not planning to play tennis until next Tuesday. I hope this is not too soon.

The pain level on a 0-10 level was 9 .5 to 10. It certainly made me yelp. I think this will be worthwhile if the improvement lasts for a few months.
 

jeremydpbland
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I can only apologise on behalf of the NHS that you had to pay to get this done. Sadly, with the current government's attitude to healthcare I am afraid we can expect much more of this in the future as individual commissioning groups are left to decide what treatments they are going to offer and the private companies providing the services pressure them to define nice tidy one off interventions like this as 'optional' items which patients can reasonably be expected to pay for.

On the other hand I'm glad it feels better!

Pain on injection is interesting - over the last few weeks we have asked patients injected here to rate the pain of injection on that 0-10 scale for 57 injections - the average rating is 3.3 - but the range is from 0 to 10! I'll put a better analysis on the main site pages at some point, probably when we have about a hundred. The shooting pain down to the end of the thumb sounds like irritation of one of the branches of the median nerve - if you get this when the needle is inserted/moved then it usually suggests that that is not a good site to inject and one aims to position the needle away from all nerve branches for injection. I am still uncertain about the merits of ultrasound guidance for injecting the carpal tunnel. With luck your thumb pain will settle in a week or two.

Out of pure curiosity - what kind of doctor did you manage to find to inject it? - rheumatologist/surgeon/GP. I would also wonder what the going rate is for injecting an already diagnosed CTS but don't feel obliged to post anything in public on here. The BMA used to publish a schedule of recommended fees for medical consultations and procedures many years ago but that was declared illegal by the competiton authorities and withdrawn, so now charges for private medical care are a sort of free market - distorted by the fact that the big insurers try to impose uniform fees - a curious perversion of classical economic theory where a near monopoly purchasing cartel gets to set the price. JB

clivesmall
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I saw a consultant hand surgeon in Cardiff. His consultation fee is 100 pounds and then the cost from the hospital for steroid and venue is approximately 180 pounds extra. I rang the previous Friday and was seen and treated the Wednesday after.

jeremydpbland
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Thankyou for that - I've edited out the actual consultant name - it's not a trivial expense is it. Our local, soon to be disbanded, primary care trust prices a steroid injection performed in primary care at about £50 but that is based on very rough estimates of the time involved in administration of the appointment and the GPs time to perform the injection. The cost of the steroid itself plus needle and syringe is of course trivial. I'll find out the actual costs at some point but it is likely to be less than £10. You may have gathered that my interest in CTS extends to the economics of it as well as more obviously medical aspects. JB

clivesmall
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I also had a quote from St Joseph's hospital for a release and the full package was 1100 pounds which if I could have guaranteed to play tennis in May I would have paid because my symptoms were so bad.

jeremydpbland
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Last time I enquired the package price for surgery for one hand round here was about £1300. I guess the next relevant checkpoint for your case is Tuesday - hopefully you will feel the hand is good enough to try tennis at that point JB

clivesmall
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I played tennis last Tuesday and Thursday for about 3 hours each time. Thankfully with no repercussions. I have slept well since the injection. My thumb is fine when I wake up but then I am still getting some numbness during the day. I don't know whether to push it and do ball exercises. I am frightened that I will undo the good the injection has done. The injection has given me tremendous relief from the CTS.

jeremydpbland
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It's nice to have what I think one could fairly call a 'success story' for injection on here, at least in the short term. I'm not sure what you mean by ball exercises but I would not indulge in things which require strenuous repetitive grip over a long period for a while as it is this sort of task which is known to increase the risk of getting CTS in the first place. I still think steroid injection is under-used for CTS - far too many people considering it 'palliative' or 'always temporary'. It will be interesting to see how long the effect lasts in this case. JB

clivesmall
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I would like to update my progress since the injection in my rtght hand, which was five weeks ago today. My thumb still gets a little numbness but overall I am absolutely delighted with the 5 weeks of relief. I am playing tennis as well as ever and sleeping like a baby at night, In fact I haven't slept so well in years. I still wear my splints at night. My left hand which initially was the main problem seemed to improve after the injection is now starting to get numb more when typing or holding things. It is OK with the splint on. I hope I am not boring you but the injection before I came to this site was not an option. I am due to be seen under the NHS on May 11th for probably an injection in my left hand. I am a bit unsure what to do. I am on the waiting list for an operation on my left hand which at its worst was not as bad as my right hand. Since the injection my left hand is now the worst. So when I finally get to the top of the list which hand do I get done. My consultant said that if you have an operation on one hand the other for what reason gets better.

jeremydpbland
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Not boring me at all - the more patient records of CTS case histories - by any route - the better as far as I am concerned. it can be hard to decide which hand to operate on when symptoms have been modified by injection and your surgeon is right that when you operate on one side the other one sometimes improves as well - seems to happen in about 10% of cases to some extent at least and is sometimes seen with injection of one hand too - I think you have only had the right hand injected yes?. I did eventually get a price for the injection itself incidentally. The one we use at present (Triamcinolone) is £7.65 for 5 injections, though we may change to methylprednisolone as I am beginning to see some data which suggests that this might be more effective.

You will have gathered from the rest of the site that I always take the nerve conduction results, and sometimes the ultrasound imaging into account, as well as the clinical picture when deciding how to proceed with management and of course we do not have those results from your hands. In general however I am inclined to be conservative about surgery when symptoms are mild in any case.

It would be interesting to see how your symptom scores have changed. If you go back to the 'My CTS' bit of the site and 'My CTS Record' you will see there is an option to take a new severity score. It doesn't do the whole questionnaire again, just the last bit. That allows you to track the change in subjective symptom severity over time.

JB

clivesmall
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I have done the severity test, a lot of the questions are about sleep loss. I do wear the splints at night so these obviously help because as soon as I remove the left one my hand starts tingling.

jeremydpbland
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Those right hand scores have really improved haven't they. I guess the most obvious thing to do would be to inject the left one but it depends a lot on the opinions of whoever you end up seeing at your next appointment of course.

Incidentally, was it your GP who felt that nerve conduction studies for CTS were 'outdated'? JB

clivesmall
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The GPs said that as the consultant I saw did not mention the injection route that that was not the way to go hence the diuretics and Amitriplin treatment. There had been no mention of nerve studies. The final GP I saw was herself a tennis player and understood my reason for trying the injection which would allow me to play in Bolton May 4th-7th. Unfortunately that referral got me an appointment too late so I had to pay privately. I am keeping the May 11th NHS appointment and may end up having an injection in my left hand.

jeremydpbland
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Of course neither diuretics nor amitriptiline have been shown to be any better than placebo in treating CTS in randomised trials (so far as I know there are no trials of amitriptiline). Treatment of CTS, much of the time, is simply determined by chance - if you are referred to a surgeon, some of them believe that surgery is the only answer, some use injection. If you go to a rheumatologist with it you will almost always be offered injection. Personally I think treatment decisions in each case should be made on an individualised basis with the aid of as much information as you can get about the patients and their CTS - which of course includes the neurophysiology, but the surgeons have accused me of self interest in recommending NCS of course, and they could be right. At least you are getting a variety of opinions. JB

Tatum Kaelker
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johnn
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Hi Clive and Jeremy.

Sorry to hear about your difficulties, Clive.

I was going to post an update anyway. Fortunately for me since I had my injection my hands have recovered completely and I am about to play in the club tournament. I played last year and could hardly hold a racket.

My operation seemed to have no effect at all, it was the injections which seemed to kick things off.

I know there is no evidence for a link to the immune system for cts but my case began with other problems of swollen lower legs and a severe pain in my upper right shoulder. Since I had my major heart op 18 monthe ago I have had other problems such as gout and atrial fibrillation. Also painful arthritis.

These have now also disappeared.

Good luck !

John

jeremydpbland
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Glad to hear your has turned out OK and you are back on court - all you need now is some decent weather. JB

clivesmall
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Just an update to let you know my progress and for information for others. It's now a year since my left hand operation and I would say it is about 90 percent good although my grip is weak. My right dominant hand was operated on nine months ago. It is about 80 percent good and I am back playing tennis regularly. My grip is weak for small diameter objects, thankfully my racket grip is large enough to grip firmly. I am sleeping well and the CTS symptoms have gone. I get stiffness in both hands but perhaps this is something else due to my age. I was always aware of my hands prior to my ops. I am less aware of my left hand and hope the right hand improves with time. I am a 63 year old male.

jeremydpbland
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The grip strength thing is interesting. There have been quite a few studies in which grip strength is measured as an indicator of surgical outcome. At least some of these studies seem to to be based on the premise that grip is weaker as a result of CTS and should improve with surgery but so far as I can see CTS generally has little effect on power grip whereas the operation does. People tend to find an average loss of grip strength of about 2% after surgery but that 2% figure conceals considerable variation between individuals. JB

ct1
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I posted another thread from the Republic of Ireland regarding my mild/moderate CTS and seeing that Clive is a tennis player, just a quick question. I play at least two or three times a week and am using a very basic wristband style brace as at the moment I do feel like my wrist is a bit vulnerable to shock and vibration (I play pretty hard). Have you tried using anything to protect your wrist while playing? Is there any particular style of brace or wristband that is recommended?

clivesmall
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I have only just seen your comment about wrist straps and I have used a couple of different types which are OK and help a bit. My left hand was operated on over 2 years ago and is about 95 percent good and giving no problems except for very slight stiffness. I can make a fist with it. My right hand is now 14 months post op. It is not as good as my left and painful after playing tennis tonight. I would say about 60 percent good. I can't close my fist fully and my grip is weak. I have a lot of stiffness in the fingers especially the index finger. I would like some further tests to see what the problem is but I don't know what to ask the GP. I feel that my right hand is deteriorating by the day but am at a loss on what to do.

jeremydpbland
Online

That's your dominant hand that's causing more trouble isn't it Clive, that's probably significant. Some of the weakness of grip is probably related to the carpal tunnel surgery but there may be other problems too with the tendons and fibrous tissue in the palm of the hand (have a look at the recently added page of the site relating to trigger finger and Dupuytrens). You need to be able to examine the hand to make a start on that so it would be worth seeing your GP - who can at least refer you on to hand surgery for a more specialist opinion. Just explain the current problems using the hand - you don't need to ask anything specific at present.

Your story remains a vivid illustration of some of the issues surrounding diagnosis and treatment of CTS - not least the fact that the outcomes in the two hands can be different and that you need long-term follow-up to get a full picture. JB

clivesmall
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Yes Jeremy it is my dominant hand and I have got Dupuytrens which is worse in my right hand. Last night after playing I had a lot of tenderness in the wrist area. I am not going to rush into anymore surgery. The knuckle joints in my index and middle fingers can be sore when clenching my fist and when squeezing them, old age does not come alone.

jeremydpbland
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Very true - but some of the afflictions of age can be ameliorated without the inconvenience and risk of surgery so one should not always assume that you have to grin and bear it - there is the new injection treatment for Dupuytrens for example. JB

clivesmall
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I have not heard of an injection for Dupuytrens. What should I be saying to my GP who does not really suggest any way forward
for further investigations into my problems.

jeremydpbland
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The injection is of an enzyme - clostridial collagenase (trade name Xiapex in the UK I think) - used to break down some of the excess fibrous tissue. This is combined with deliberate stretching and so far I have seen reports of good results, tough this is of course not my field. It's fairly new so in a bit of a honeymoon period at present and problems may yet appear but it appeals to my leanings towards non-surgical treatments in general. You can see more about it and some results on Harry Belcher's website (see my links page). If your right hand has significantly impaired function again I would be inclined to push for an opinion from a hand surgery department. JB

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