Wrist shooting pain following carpal tunnel release

[Baby_Physio_Kieran]

Hi, I have a patient with a severe intermittent shooting pain in her right (R) wrist following a carpal tunnel release, and I would appreciate some advice on where to go with her.

PC
- R anterior & posterior wrist pain (severity 5/10), which shoots up forearm to just distal to the elbow. Slowly develops ache with prolonged activity. (i.e. evening)
- Thenar eminence feels numb
- Activity dependent. (+ weather dependent)
- Aggrevating factors - turning pages of a book, writing.
- Easing factors - painkillers (occ. paracetamol or cocodamol)

HPC
- Dec '05 - Patient slipped on grease and landed on R arm and had pain in R wrist.
- 2 wks later - Saw GP, had nerve conduction tests.
- Mar '07 - Carpal tunnel release.
- 22/08/07 - Initial PT assessment - No better since release, in fact more pain now.
- No investigations
- No prev. physio/or other therapy

PMH
- Nil else.
- Overweight, but generally healthy

SH
- Full time mum (31 yrs old)
- Used to play badminton

O/E
Obs – Thenar eminence swollen (feels fibrous/consolidated.)
AROM
Wrist: R L
E 40 55
F 25 55
RD 5 15
UD 30 45

(PROM is more then AROM in all directions, but causes intense shooting pain from fingers to point just distal to elbow when surpassing AROM)

Radio-ulnar jnt:
Pro full (but shooting pain)
Sup full (but shooting pain)

Static strength
Wrist:
F 4+
E 4+

Accessory mvts
Wrist:
All directions painful causing intense shooting pain.


Palpation
Wrist:
Jnt line tender anterior + posterior

ULTT
Earlier elicitation of pain with wrist mvts when upper limb nerves are ‘wound up’ or ‘tensioned’
Tensioning nerves causes same wrist pain, without shooting to forearm.


Rx
As a treatment I performed very gentle accessory mvts of wrist and gentle massage of anterior wrist and thenar eminence. I also gave advice to the use of ice therapy at home and to perform slow, rhythmic active wrist movements within pain limits, and to perform gentle massage of the same area as long as ache is not exacerbated.

I am not sure what the best approach is with this patient. I am working on the theory that there is significant scar tissue around the wrist which is compromising the median and radial nerves, and that breaking it up will allow increase in ROM without pain. Then we can begin to begin strengthening exercises.
I am afraid of hypothesising too much, but other than this I do not know what the best course of action is, and quite frankly it makes me feel inadequate to not be able to do more.

[Baby_Physio_Kieran]

I've just read some summaries of RCT's done on the subject of complications of carpal tunnel syndrome and apparently around 5% of open releases result in painful hypertrophic scar formation... Not sure if that just adds fuel to theories or not...

[jwilso]

the problem is that physios only see those 5 % as the rest are ok. we get the ones that have not gone well and like in your case end up worse. this is a complication of surgery. it sounds to me like you are on the right track with treatment. some of the patients that i have seen like your patient appear to have one or two signs of complex regional pain syndrome( formerly known as RSD).good luck

[ginger]

The likely result of having been incorrectly diagnosed in the first place. Wrist pain may be referred from hypomobile joints between C5 and T3, with resultant irritation to nerve roots .This far more likely situation will create the same symptoms as the much more rare condition occurring with so called carpal tunnel syndrome. Mobilisation to the lower cervical and upper thoracic facet joints will free joints irritated by a protective response there, results are immediate and long term provided sufficient mobility is restored . Recommend CM.
Check for brachial dural tightness and release with ballistic stretches if required.

[alophysio]

Hi.

It does sound like scarring and tightness...I am assuming they went ahead with the operation because the NCS showed that the conduction velocity was different proximal to the carpal tunnel compared to distal...

Was the patient's C/S checked at any stage (for differential diagnosis as Ginger suggests above)?

Is palpation of the nerve trunks of the C/S tender?

I can't believe this lady didn't have a course of physiotherapy before an operation at least to try alleviate the symptoms - especially after a fall onto the arm...

Neural mobilisations ala Bob Elvey, Michael Shacklock, David Butler etc might be handy, especially to decrease the neurosensitivity of the system.

Good luck - sounds interesting!

[Baby_Physio_Kieran]

Hi, sorry, I did not think anyone had taken an interest in this case study, so I neglected to update you on the situation.

I saw the patient last thurs (now sat night) and there was very little change. She reported that she had more mvt, but this was not objectively the case.

Her wrist mvt is very much dependant on neural tension, and is therefore severely limited (10-20 degrees painless mvt) with extended fingers, but moderately more with flexed fingers.

She also reports that the Rx from the previous session (see above) seemed to cause some aggrevation for the rest of the day (as i expected, and as I warned). Unfortunately, she did not try ice therapy because "it was already too painful" and she didnt want to try anything that would make it worse. (I think she then associated physio Rx and advice with pain, unfortunately..) Further to this, she had been performing the massage at home and reported that it was painful for the rest of the day.. When asked for how she was performing the massage, she replied "about an hour".. And with further probing she reported that it became painful after approx 10 mins of massage.
Obviously I take responsibility for this as I must have neglected to prescribe set parameters for the massage...

As a note of interest it also came up that she was driving with this hand, which, considering the lack of RoM and associated pain, is quite scary. Obviously I advised against this, but there is only so much you can do...

During the session she was very reluctant to allow any massage out of fear of pain. After some discussion we agreed that a possible route may be electrotherapy (even though I am not a huge advocate), so we tried a short session of Short Wave Diathermy.

After approx 5 mins of Rx she reported that the "ache" had reduced, and had now been replaced by a tingling sensation. She reported this as a positive change.

As a home exercise I prescribed the same active mvts within painless range and just 2 mins of massage twice daily to the anterior wrist area and thenar eminence.

Thank you for your interest and advice. Ginger, from the behaviour of the symptoms I would be surprised if it were originating from the Cx/TxSp, but it maybe worth a look!

Alophysio, i have assumed the same thing (re. results of nerve conduction tests), and for the moment that is all I can do. As far as I'm aware there has been no CxSp assessment done so far, but I will make sure to do one next time. She did not report any previous physio...
Is neural mobilisation the same as "neural flushing" - i.e. smooth rythmic mvts to run the neural system through its various sleaves, (etc.)?

[ginger]

spondylitic referred events are difficult to provoke with active movement tests or other forced compressive manoevres. In most cases , use of these tests will offer little to indicate either presence or absence of referred pain from cervical joints/nerves. It will be possible however to give some hints or indicators when doing AP mobs of the cervical facet joints uilateraly. Of interest are your descriptions of hand/wrist position and tightness , all indicative of severe dural tightness. Also indicative of a central locus of irritation as previously pointed out. Use your hands. Mobilise C5 first of all. Do this in prone with a PA movement till protective tone is reduced. This may take five minutes. Be patient and persistant. Check her symptoms immediately after, you will almost certainly have releived enough in this safe and easy way to gain confidence in the approach. If you go off on a tangent and start massaging her wrist , you may as well give up. The signs are there for you to see a central problem with distal symptoms. Common as cow pats in a dairy. Avoid the temptation to get more detailed "neuro" investigations as simply time wasting. You have plenty of info already .

[alophysio]

Hi Kieran,

Yes, neural mobilisations are gentle movements of the nerves. Sometimes referred to as "slide and glide" etc. Should be pain free.

Nerves only require a very small compression before they lose their blood supply (pins and needles and altered sensation are your warning signs!). Go easy. Ipsilateral C/S LF and elbow extension then contralateral C/S LF and elbow flexion is a common exercise.

Obviously it is much more sophisticated that and careful assessment of which nerve trunks, nerves etc are involved.

Sounds like she has some pyschosocial issues as well. Fear Avoidance, no idea of pacing, etc etc.

By all means check the C/S out but don't forget the holistic assessment.

Good luck