Carpal Tunnel Syndrome: What If My Symptoms Are Unusual?
If you’ve made it this far in our mini-series about carpal tunnel syndrome (CTS), you’ll know that we have simplified things pretty drastically and have discussed the topic in a ‘black and white’ manner. Symptoms in three fingers. Two ways to treat it. Not a lot else to discuss.
But the reality (and some would say the best part of medicine) is the gray area that exists between our textbook doctrine and our patients’ daily experience.
Very little is simple.
So let’s briefly discuss some of the less common causes of CTS and the associated treatment options.
Carpal Tunnel Syndrome and Rheumatoid Arthritis
You’ll remember that CTS results from median nerve compression inside the carpal tunnel. The median nerve travels through the carpal tunnel with nine flexor tendons, the glistening white tubular structures that help you bend your fingers into a fist.
You may have also heard of rheumatoid arthritis, a type of inflammatory arthritis.
In severe cases, rheumatoid arthritis can actually lead to inflammation along the flexor tendons within the carpal tunnel. That means swelling and increased volume of the nine tendons themselves. And what does that do?
You guessed it.
As with other causes of carpal tunnel, this decreases the available space for the nerve…and compresses the median nerve. Voila. You now have carpal tunnel symptoms.
“But the reality (and some would say the best part of medicine) is the gray area that exists between our textbook doctrine and our patients’ daily experience.
Very little is simple.”
In contrast to the vast majority of CTS cases, the root cause with rheumatoid arthritis is inflammation. This is why this type of CTS is one of the few cases where I believe a steroid injection makes sense in search of long-term results. Steroids, such as cortisone, shrink the inflammation in the tendons, thus making more space for the nerve.
I typically don’t favor injections in run-of-the-mill CTS — why would you put even more fluid inside a space that is already too small? Especially when that fluid’s purpose (cortisone) is to shrink inflammation. In ‘regular’ carpal tunnel, there is no inflammation. So I don’t favor an anti-inflammatory injection in that case.
But in the case of rheumatoid arthritis? Absolutely, an injection makes sense as a treatment option.
Carpal Tunnel Syndrome and Pregnancy
Another similar case is pregnancy.
It is common in pregnancy to experience ‘fluid shifts.’ While the mechanisms aren’t fully understood, what this means is the fluid that normally exists in your body gets redistributed when you are pregnant. And sometimes that means increased fluid exists within your carpal tunnel or along your flexor tendons.
Yet again, you have a recipe for median nerve compression.
Unfortunately, carpal tunnel symptoms can be common during pregnancy
While I’ll admit that adding more fluid to this in the form of an injection doesn’t make a ton of sense, historically, injections have a high success rate in temporariliy easing the symptoms of pregnancy-induced CTS.
What do I think is actually going on here?
It boils down to a difference in treatment goals. In pregnancy-induced CTS, we are looking far more short-term. We just need to get these patients to delivery. Like opening the floodgates, the symptoms of CTS rapidly melt away once the baby is delivered.
In ‘standard’ CTS, we need a permanent fix. And therein lies the difference.
What About Routine Injections, PT, or Alternative Medicine?
A few closing points:
Depending on your interpretation, some scientific studies have shown the efficacy of injections in standard carpal tunnel [1, 2]. Certainly, patients often feel better temporarily, but with minimal long-term benefit. An injection isn’t solving the problem so, in general, I avoid it. But in the right person (“Doc, I can’t have surgery until the winter because of this really important training I have to do this summer for my career”), I will still occasionally give carpal tunnel injections.
Many patients wish (as do I) that physical therapy would be a viable option prior to proceeding with surgery. There is some scant evidence around a set of exercises known as nerve glides [3]. But all-in-all, the science just doesn’t support it [4]. In my experience, it is a rare patient who benefits from therapy for CTS, so we usually skip it.
Pick-your-own alternative therapy. This article could be over 1,000 words by simply listing all the alternative therapies available. Chiropractor, acupuncture, herbals, massage, etc, etc. Have any of them stood up to scientific rigor and been shown to treat carpal tunnel? No. Does that mean none of them help at all? Perhaps not.
I am all for alternative therapies if you feel that is your best option. Please just be aware of two things. (1) they can be expensive and often not covered by insurance. (2) do not do these without checking in with a hand surgeon first. The absolute worst-case scenario is that you disappear from the hand surgeon for three years while working with your alternative therapy — all the while your nerve is becoming more and more compressed. And dying. And causing irreversible damage. I’ve seen it happen and it’s devastating. Patients come back to me wondering why their hand doesn’t work. And I can’t fix it. That, in my mind, is the only true risk of alternative therapies. Otherwise, try whatever it is that resonates with you.
Wrapping Things Up
Well, that about does it.
This series of short articles should have you familiar with the basics of carpal tunnel syndrome, its diagnosis, and treatment. If you made it all the way though, I thank you for your time and I hope you learned something.
I’d love to hear from you — what resonated, what still doesn’t make sense? I would always be happy to do a follow-up article with additional specifics.
If you missed any of the previous articles, please find the links below. In the meantime, I wish you success in your journey to taking back control of your health.
References:
[1]: Atroshi I, Flondell M, Hofer M, Ranstam J. Methylprednisolone injections for the carpal tunnel syndrome: a randomized, placebo-controlled trial. Ann Intern Med. 2013 Sep 3;159(5):309-17. doi: 10.7326/0003-4819-159-5-201309030-00004. PMID: 24026316.
[2]: Ly-Pen D, Andréu JL, de Blas G, Sánchez-Olaso A, Millán I. Surgical decompression versus local steroid injection in carpal tunnel syndrome: a one-year, prospective, randomized, open, controlled clinical trial. Arthritis Rheum. 2005 Feb;52(2):612-9. doi: 10.1002/art.20767. PMID: 15692981.
[3]: Kim, Sang-Dol. "Efficacy of tendon and nerve gliding exercises for carpal tunnel syndrome: a systematic review of randomized controlled trials." Journal of physical therapy science 27.8 (2015): 2645-2648.
[4]: Piazzini DB, Aprile I, Ferrara PE, et al. A systematic review of conservative treatment of carpal tunnel syndrome. Clinical Rehabilitation. 2007;21(4):299-314. doi:10.1177/0269215507077294
