Carpal tunnel syndrome: Non-surgical injections and nerve release treatments

Ross Hauser, MD., Danielle R. Steilen-Matias, MMS, PA-C

Carpal tunnel syndrome: Non-surgical injections and nerve release treatments

In this article, we will explore various treatment options for Carpal Tunnel Syndrome with a focus on the evidence for non-surgical treatment options.

A series of new studies affecting patients with Carpal Tunnel Syndrome are questioning the success and validity of Carpal Tunnel Syndrome surgery and how accurate recommendations to patients following surgery are as to when they can return to work. This is a question that is inspired by new research:

In many patients we see, they do not have a “single” problem but many problems causing them chronic pain. Many times they see us for the problem that is giving them the worst pain today. This is usually the case in people who see us for Carpal Tunnel Syndrome.

This would be more true for people suffering from carpal tunnel pain who already had carpal tunnel surgery in both hands and continue to have their problems. Worse for them is that these problems have no expanded to include things like De Quervain’s Tenosynovitis, Trigger Finger or Trigger Thumb, and arthritis in both hands. So they wear braces, get cortisone injections which we discuss below, and are prescribed heavier doses of anti-inflammatory medications. For these people, they seem to have nowhere to turn except pain management and possibly physical therapy and any type of help they can buy online.

Sometimes the problem is not limited to their hands. An MRI may show cervical spine stenosis impinging on the nerves and these people will be recommended for two surgeries. One to fix the stenosis and one to fix the carpal tunnel. Sometimes the patient is told to get a cervical spine fusion or anterior cervical discectomy and fusion because of continued pain and wrists after what was deemed “failed carpal tunnel surgeries.”

Surgery works for many people. Some people have great results and their wrist and carpal tunnel pain are gone forever. These are not the people we see in our office. We see the people we just described. People looking for answers. Hopefully, we can help provide them.

When your surgeon recommends you to Carpal Tunnel Syndrome surgery, ask the surgeon if they will have the surgery themselves if they were you. The likelihood is that the surgeon would say no.

We are not going to comment on this study from the Journal of Plastic Surgery Hand Surgeons, (1) we will only tell you this appeared in a medical journal written for and by hand surgeons. These are surgeons discussing the problems they encounter with carpal tunnel surgery.

Surgeons were asked: If you were the patient would you get this surgery?

CONCLUSIONS: “Surgeons tended to be more unanimous in their opinions in cases, where there is limited evidence on treatment effect. The agreement between surgeons and therapists implies that the clinical perspectives are similar, and probably reflect the reality well.” The reality of a less than the hoped-for outcome.

Is carpal tunnel syndrome surgery only a short-term treatment or does it work in the long run?

As a second opinion, let’s present evidence from Dutch surgeons/researchers who in April 2019 wrote in the journal Acta Neurochirurgica (neurosurgery). (2)

CONCLUSIONS: Carpal tunnel release is a robust treatment for carpal tunnel syndrome and its effect persists after a period of 9 years. The most important factor associated with long-term outcomes is treatment outcome after about 8 months and to a lesser extent functional complaints pre-operatively.

What all this means is that at 9 years after surgery, 4 out of 5 patients reported favorable results. But if you had functional complaints before surgery, the chances are less optimistic for long-term success.

Many people have great success with carpal tunnel surgery. Many people have less than optimal results. The people we see in our office typically have had initially good results but the continued wear and tear of their job or activities have caused the numbness to return, some pain to return, and they are proceeding down the path of repetitive stress injury and a lifetime of wrist braces as surgery the second time may not be an answer or even advisable.

I need to get back to work, what is a realistic recovery time from Carpal Tunnel Surgery? The answer is “Paradoxical”

Maybe, the surgeons in the above study are aware of what other research is saying. No one has a good answer to the question of when people can return to work after carpal tunnel surgery. This is an editorial from the Scandinavian Journal of Work, Environment, and Health. (3) It is based in part on data from American workers examined in US work environments.

The concern is aging or long-term workers at the same job where Carpal Tunnel Syndrome is a risk


When can I return to work after carpal tunnel release surgery?

Many people have successful carpal tunnel syndrome surgery and they can return to work and activities weeks after the surgery. These are people we typically do not see at our center. We see the people who had complications of delayed recovery.

An April 2019 study comes to us from hand surgeons in the United Kingdom. Writing in the Journal of Hand Surgery, European Volume (4) the authors wrote:

“There is a limited evidence base from which to derive recommendations for safe and effective return to different types of occupation after carpal tunnel release surgery. The current practice (recommendations) of members of the British Society for Surgery of the Hand and the British Association of Hand Therapists was investigated with a questionnaire. In total, 173 surgeons and 137 therapists responded. (Average) recommended return to work times was:

However, the responses were wide-ranging:

Conclusion: “Variation in the recommended timescales for return to work and other functional activities after carpal tunnel release suggests that patients are receiving different, possibly even conflicting, advice.”

The problem is Carpal Tunnel Syndrome Diagnosis may not be correct. Therefore a Carpal Tunnel surgery may not fix what is wrong


In 2017 surgeons at Thomas Jefferson University Hospital in Pennsylvania published guidelines calling for a much more extensive examination of patients suffering from Carpal Tunnel Syndrome. Why? Because many patients with Carpal Tunnel Syndrome may not have Carpal Tunnel Syndrome.


In this study, (5) the researchers are saying: the problem of Carpal Tunnel Syndrome is recognizing and managing other potential sites of peripheral nerve compression.

Here is what the research says:

The solution to understanding which of these problems may be impacting the patient? “Electrodiagnostic and imaging studies may aid surgeons in the diagnosis of these syndromes; however, a thorough physical examination is paramount to localize compressed segments of these nerves. An understanding of the anatomy of each of these nerve areas allows practitioners to appreciate a patient’s clinical findings and helps guide surgical decompression.”

So do I really have Carpal Tunnel Syndrome?

Carpal tunnel syndrome is a progressively painful hand and arm condition caused by pressure, damage, or repeated injury to the median nerve at the wrist. Since the pressure on the median nerve causes carpal tunnel syndrome, then anything that crowds, irritates, or compresses the nerve in the canal, can lead to the symptoms. This pressure can come from swelling or anything that would cause the tunnel to become smaller.

Wrist surgery has limited and widely varying degrees of success in treating carpal tunnel syndrome. Surgery can also make the condition worse, especially when the condition has been misdiagnosed.

Seldom do patients and athletes find relief from the “Carpal Tunnel” complaints of pain in the hand and elbow with physical therapy and surgery because the diagnosis is so often wrong? The most common reason for pain in the elbow, referring to the hand, is weakness in the annular ligament, not from Carpal Tunnel Syndrome. (Please see our accompanying article on Comprehensive Prolotherapy and PRP tennis elbow and elbow instability injections). Cervical ligament weakness and annular ligament laxity should always be evaluated prior to making the diagnosis of carpal tunnel syndrome.

A physician who understands the referral patterns of these ligaments should evaluate the individual with this condition before surgery is considered. Because most physicians do not know the referral pain patterns of ligaments, they do not realize that cervical vertebrae 4 and 5 and the annular ligament can refer pain to the thumb, index, and middle fingers. Ligament laxity can also cause numbness.

Telling the difference between Signs and Symptoms of “true” versus “pseudo” carpal tunnel syndrome

As noted earlier, the pain experienced in the wrist is often referred pain and may be due to an injured or weakened annular ligament which may lead to a misdiagnosis of carpal tunnel syndrome.

Is surgery inevitable with a carpal tunnel syndrome diagnosis? Although the standard practice is to inject steroids or to prescribe anti-inflammatory medications, the end result with a diagnosis of carpal tunnel syndrome is usually surgery.

Another surgical problem: Inappropriate Preoperative Gabapentinoid and post-surgical opioid problems

Many people are delaying surgery or on a list to get surgery and they may have to wait. While they are waiting or delaying they may be prescribed Gabapentin, an anti-epileptic drug, or an anticonvulsant drug. Gabapentin is prescribed in adults to treat neuropathic pain such as that found in carpal tunnel syndrome.

A May 2020 article in The Journal of Hand Surgery (6) issued these cautions on why patients were being prescribed Gabapentin when they should not be.

Patients continued to fill gabapentinoid prescriptions at 91 to 180 days after surgery

Results:

Gabapentinoids should be avoided when possible

Conclusions: Despite a lack of evidence to support the use of gabapentinoids for carpal tunnel syndrome, 6% of patients are prescribed a gabapentinoid prior to surgery, and prolonged use is common. Given the effectiveness of surgical release and the risks associated with gabapentinoids, greater attention is needed to ensure that gabapentinoids are prescribed appropriately, avoided when possible, and stopped after surgery.

Can I get by with cortisone injections or extracorporeal shock wave therapy?

As with any treatment, some patients may find benefit in the use of cortisone injections. Of course, the side effects of prolonged cortisone use are well documented. These would include tissue breakdown. Please see our article Alternative to Cortisone Injections.

Some people opting for an alternative to cortisone may explore extracorporeal shock wave therapy. It is likely that if you are reading this article and you have suffered from years of chronic wrist pain that you may have already had these treatments or they are on your list of “treatments,” not tried yet.

A November 2020 paper in the Journal of Orthopaedic Surgery and Research (7) offers a head-to-head comparison of the two treatments.

In this study, the researchers acknowledged that “many studies have demonstrated the effectiveness of extracorporeal shock wave therapy and local corticosteroid injection for the treatment of carpal tunnel syndrome, and some studies showed that the effect of extracorporeal shock wave therapy was superior to local corticosteroid injection.” Here the researchers conducted their own evaluation by investigating the results of previously published studies and combining the data.

What they found was:

This research team concluded: “In terms of pain relief and function improvement, the effects of extracorporeal shock wave therapy and local corticosteroid injection are not significantly different. In terms of electrophysiological parameters (the electric activity and ability of nerves to move and relay messages), local corticosteroid injection has a stronger effect on shortening motor distal latency (the nerve messages travel faster and there is less nerve dysfunction); extracorporeal shock wave therapy is superior to local corticosteroid injection in improving action potential amplitude (improving nerve dysfunction). Extracorporeal shock wave therapy is a non-invasive treatment with fewer complications and greater patient safety.”

Caring Medical’s approach to carpal tunnel syndrome – stability and strength in wrist and elbow

Actual carpal tunnel syndromes are caused by compression of the median nerve and pseudo carpal tunnel syndromes are caused by ligament weakness. They both may present with the same or similar symptoms but have entirely different pathology.

In our treatments we utilize:

Prolotherapy treatment demonstrated and described

In the video below, Ross Hauser MD demonstrates and describes Prolotherapy to the wrist. A summary of the video is below.

Summary:

A case study of a 42-year female athlete with Carpal Tunnel Syndrome

We have seen countless patients with wrist, elbow, carpal tunnel type syndromes. So have many of our Prolotherapy colleges. In Turkey, doctors reported this case history in the British Journal of Sports Medicine: (8)

The case for Dextrose injections in helping your carpal tunnel problems

In this next study, the researchers discuss 5% Dextrose injections. As mentioned above, Prolotherapy treatment involves multiple injections of the dextrose-based solution to the various ligament attachments around the elbow or wrist. We must next have a discussion on the dextrose percentages and what it means to you

The percentages of dextrose mean something

In 2016, our Caring Medical research team published a paper in Clinical Medicine Insights. Arthritis and Musculoskeletal Disorders.(9) Here we wrote:

“The most common Prolotherapy agent used in clinical practice is dextrose, with concentrations ranging from 12.5% to 25%. Dextrose is considered to be an ideal proliferant because it is water-soluble, a normal constituent of blood chemistry, and can be injected safely into multiple areas and in large quantity.” The reason for the increased percentage is to counteract dilution in the joints. The greater the strength of the dextrose solution the more healing. So in the paper discussed below 5% dextrose injection is 2 – 3 times weaker than a typical Prolotherapy injection. So let’s see how the 5% or less potent injection does. It does pretty well.

A March 2020 study in the medical journal Pharmaceuticals (10) reviewed the findings of a number of clinical trials which the research team suggested yielded several important findings on regenerative injections in carpal tunnel syndrome.

The researchers concluded:

The use of Platelet Rich Plasma therapy for Carpal Tunnel Syndrome

Like Prolotherapy, Platelet Rich Plasma injections are regenerative in nature, providing stability, tissue repair, and pain relief. The PRP injections are often given with Prolotherapy injections to provide a whole joint treatment.

Platelet Rich Plasma could reduce swelling of the median nerve for a mid-long-term effect

In November 2020 researchers publishing in the medical journal BioMed Research International (11) evaluated the effectiveness of platelet-rich plasma injections in patients with carpal tunnel syndrome. What they found in their research was PRP could be effective for mild to moderate carpal tunnel syndrome and superior to traditional conservative treatments in improving pain and function and reducing the swelling of the median nerve for a mid-long-term effect. To some extent, the electrophysiological indexes (nerve function) also improved after PRP injection compared with other conservative treatments.

“PRP represents a promising therapy for patients with mild to moderate carpal tunnel syndrome”

A May 2020 study from the University in Toronto published in the Archives of Physical Medicine and Rehabilitation (12) reviewed the current research comparing Platelet Rich Plasma Therapy injections, cortisone, and saline injections. They concluded that “PRP represents a promising therapy for patients with mild to moderate carpal tunnel syndrome; however, included studies were limited as follow-up was short, the studies included patients that were heterogeneous (widespread to be able to isolate on a subgroup that may have had better or lesser success than another group), and the number of included studies was low. Further investigation is necessary to determine the true efficacy and effect of PRP and to better delineate the long-term results in patients with carpal tunnel syndrome.”

 

“Platelet-rich plasma could be an effective treatment of mild to moderate idiopathic carpal tunnel syndrome and superior to corticosteroid in improving pain, function, and distal sensory latency of median nerve.”

A December 2019 study published in the journal Clinical Rheumatology (13) looked at patients suffering from mild to moderate carpal tunnel syndrome. They were randomly divided into two groups. Group 1: patients received ultrasound-guided PRP injection and group 2 patients received ultrasound-guided corticosteroid injection. The researchers in this study closely examined the impact of treatments on the median nerve.

Let’s point out here that this is a single PRP injection versus a single cortisone injection. A more comprehensive approach to PRP would likely produce superior results as we have seen in our clinical observations and outcomes.

The single PRP injection

Typically we do not find that we can help a patient achieve long-lasting healing with a single injection of PRP. Some people do achieve this result.

Doctors at Greece’s Athens University published their findings in the journal Neural Regeneration Research (14) in which they investigated whether a single injection of platelet-rich plasma can improve the clinical symptoms of carpal tunnel syndrome.

A later paper from these same researchers (15) published in 2018 in the Journal of tissue engineering and regenerative medicine found similar findings of the effectiveness of a single injection of platelet-rich plasma (PRP).

When will a single PRP injection fail?

We take great strides in our articles to give a realistic assessment of treatments based on nearly three decades of helping people with conditions related to wrist pain, elbow pain, thumb pain, and Carpal Tunnel Syndrome. We have seen people respond to one treatment of PRP, however, we do not use PRP as a stand-alone treatment. In our opinion, maximum results can be achieved if we combine PRP treatment with dextrose Prolotherapy injections and sometimes non-surgical nerve release. In our clinical experience, while one injection of PRP may help some people, it is usually not the long-term relief the people seek. This is also borne out by the number of people who contact us seeking to continue a more comprehensive PRP Carpal Tunnel Syndrome treatment following a failed healing program. However, it is not just the number or type of treatment a patient receives that may lead to treatment failure. There can be other factors.

A June 2021 study published in the International Journal of Clinical Practice (16) tried to offer guidelines to help doctors predict who would have successful PRP treatments for their Carpal Tunnel Syndrome  and those who would have less of a chance to have successful PRP treatment for their Carpal Tunnel Syndrome

What were the factors that may have caused some of the patients to have poor outcomes?

PRP, Prolotherapy and Non-surgical Nerve Release & Regeneration Injection Therapy for Neuropathy

First, we will discuss a study on PRP alone in the treatment of neuropathy in carpal tunnel syndrome, and then we will discuss non-surgical nerve release.

In a six-month follow-up study, university researchers in Taiwan found that Platelet Rich Plasma Therapy effectively relieves pain and improves disability in patients with carpal tunnel syndrome. (17) In this 2017 research, the team examined a few small reports with short follow-up periods that showed the clinical benefits of Platelet-Rich Plasma for peripheral neuropathy (see below) including one pilot study and one small, non-randomized trial in patients with carpal tunnel syndrome.

To confirm whether or not PRP was beneficial for carpal tunnel patients, they conducted a randomized, single-blind, controlled trial to assess the 6-month effect of PRP in carpal tunnel syndrome patients.

Sixty patients with single-side mild-to-moderate carpal tunnel syndrome were randomized into two groups of 30, namely the PRP and control groups.

  • In the PRP group, patients were injected with one dose of 3 mL of PRP using ultrasound guidance and the control group received a night splint through the study period.
  • The PRP group exhibited a significant reduction in the pain scores and improved function compared to the control group 6 months post-treatment.
  • This study demonstrates that PRP is a safe modality that effectively relieves pain and improves disability in patients with carpal tunnel syndrome.

Is surgery inevitable with a carpal tunnel syndrome diagnosis? Although the standard practice is to inject steroids or to prescribe anti-inflammatory medications, the end result with a diagnosis of carpal tunnel syndrome is usually surgery.

A patient’s case presentation with an unusual swelling of her wrist and then her left hand was going numb

In this video Ross Hauser, MD presents a patient’s case history. A summary transcript and explanatory notes are below the video.

Video summary:

This is a case history of a patient who came in with an unusual presentation. She had an unusual swelling of her wrist and her left hand was going numb. These are symptoms compatible with carpal tunnel syndrome. We documented her carpal tunnel syndrome by ultrasound imaging. She also had a bifid median nerve which means that the median nerve has split or bifurcated. I wanted to show that on ultrasound. This patient is a good illustration of how wrist instability causes carpal tunnel syndrome so the carpal tunnel is just a bony tunnel through which the median nerve passes.

This is an ultrasound image of a carpal tunnel patient's bifid median nerve. Bifid or "splitting" of the nerve is somewhat rare but is seen often enough in carpal tunnel syndrome patients. The splitting can occur as a result of wrist instability and may be the cause of numbness and other nerve related problems. In some patients the bifid median nerve remains asymptomatic.

This is an ultrasound image of a carpal tunnel patient’s bifid median nerve. Bifid or “splitting” of the nerve is somewhat rare but is seen often enough in carpal tunnel syndrome patients. The splitting can occur as a result of wrist instability and may be the cause of numbness and other nerve-related problems. In some patients, the bifid median nerve remains asymptomatic.

The question is why do people get carpal tunnel syndrome? What is causing the narrowing or compression of the median nerve in this tunnel?

If the bones in your wrist are hypermobile, floating around, or loose,  you have wrist instability. The bones are moving too much. When the patient then moves her wrist in certain ways, she will get tingling or numbness. So again, what is causing the carpal tunnel to narrow with those movements? In many people, it is a wrist ligament injury. It is not carpal tunnel syndrome, but rather the wrist instability causing compression of the median nerve. In some patients, this can be accompanied by a ganglion cyst or a cyst that forms on the back of the wrist.

Non-surgical Nerve Release & Regeneration Injection Therapy and Joint Stabilizing Treatments

Many syndromes involve entrapment of a certain nerve, with carpal tunnel syndrome being one of the most common conditions. In this case, the median nerve, which supplies many of the muscles and sensations in the hand, resides in the carpal tunnel of the wrist. The carpal tunnel walls are lined by bone on the sides and bottom and a tough fibrous tissue on the top called the transverse carpal ligament. The bones that comprise the walls of the carpal tunnel (as in other bony tunnels) are connected to other bones that make up the wrist. When a person sustains a wrist ligament injury, the adjacent bones can move too much, thus narrowing the carpal tunnel. In this instance, NRRIT is performed in combination with Comprehensive Prolotherapy to free the compressed median nerve, often providing instant pain relief, as well as opening the space long-term by correcting the excessive wrist-bone movement by stabilizing this joint.

A key clue that a nerve entrapment syndrome such as carpal tunnel syndrome stems from joint instability is associated with cracking, popping, or clicking in the joints near the bony tunnel. On physical examination, other clues include excessive motion or soft joint end feel compared to the non-symptomatic side, as well as tenderness when the ligaments of the nearest joint are palpated and stressed. When these signs or symptoms are not present, the cause of the nerve entrapment is most likely not joint instability. Thus, these are more likely to be appropriate for NRRIT as the primary treatment.

What are we seeing in this image?

Nerve Release & Regeneration Injection Therapy, NRRIT is a nerve hydrodissection technique that we have found very successful in releasing peripheral nerve entrapments like those found commonly in Carpal Tunnel Syndrome and related syndromes such as Ulnar Tunnel Syndrome / Guyon canal syndrome.

This image shows that one cause of Carpal Tunnel Syndrome is median nerve compression. The nerve is compressed by subluxation of the carpal bones and ligament instability.

How Many Treatments of NRRIT are Required?

Sometimes only one treatment is needed, but often, three to six visits are needed, especially in cases of severe joint instability where the nerve irritation is located. Patients suffering from nerve pain should not delay seeking medical care for these conditions. This cannot be overemphasized. Permanent nerve damage may occur.

The picture shows an ultrasound image revealing a before and after Nerve Release Injection Therapy treatment. The before image shows an entrapped nerve. In the after image the median nerve is released.

 

Summary and discussion

Unfortunately, many patients with elbow and hand pain have been misdiagnosed with carpal tunnel syndrome. Carpal tunnel syndrome refers to the entrapment of the median nerve as it travels through the wrist into the hand. The nerve supplies sensation to the skin over the thumb, index, and middle fingers. A typical carpal tunnel syndrome patient will experience pain and numbness in this distribution in the hand.

A comprehensive physical examination to look for nerve compression in the C4-C5 cervical vertebrae and the annular ligament in the elbow should be made to rule out problems of referred pain to the thumb, index, and middle fingers. Ligament laxity can also cause numbness, as already discussed. Cervical and annular ligament laxity should always be evaluated prior to making the diagnosis of carpal tunnel syndrome.

Do you have questions about your problems with carpal tunnel syndrome? Get help and information from our Caring Medical staff.

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This article was updated July 3, 2021

 

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