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.
- When your surgeon recommends you for 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.
- Is carpal tunnel syndrome surgery only a short-term treatment or does it work in the long run?
- I need to get back to work, what is a realistic recovery time from Carpal Tunnel Surgery? The answer is “Paradoxical”
- When can I return to work after carpal tunnel release surgery?
- The problem is Carpal Tunnel Syndrome Diagnosis may not be correct. Therefore a Carpal Tunnel surgery may not fix what is wrong.
- So do I really have Carpal Tunnel Syndrome?
- Telling the difference between Signs and Symptoms of “true” versus “pseudo” carpal tunnel syndrome.
- Another surgical problem: Inappropriate Preoperative Gabapentinoid and post-surgical opioid problems.
- Can I get by with cortisone injections or extracorporeal shock wave therapy?
- Pain and function scores were significantly lower in the local corticosteroid injection group compared with the other two groups.
- Caring Medical’s approach to carpal tunnel syndrome – stability and strength in wrist and elbow.
- The case for Dextrose injections in helping your carpal tunnel problems.
- The use of Platelet Rich Plasma therapy for Carpal Tunnel Syndrome.
- Platelet Rich Plasma could reduce swelling of the median nerve for a mid-long-term effect.
- “PRP represents a promising therapy for patients with mild to moderate 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.”
- The single PRP injection for carpal tunnel syndrome.
- When will a single PRP injection fail?
- PRP, Prolotherapy and Non-surgical Nerve Release & Regeneration Injection Therapy for Neuropathy
- Nerve hydrodissection.
- A patient’s case presented with an unusual swelling of her wrist and then her left hand was going numb.
- Non-surgical Nerve Release & Regeneration Injection Therapy and Joint Stabilizing Treatments
Many patients we see, 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 not 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 for 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 for 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?
- One objective of this medical review was “to study if surgeons” perceptions of the benefit of six surgical procedures differ if they consider themselves as patients instead of treating a patient.”
- “Surgeons who considered themselves as patients had less confident perception on the benefit of carpal tunnel release compared with surgeons, who considered treating patients.”
- “Hand surgeons and hand therapists had similar perceptions of the benefits of surgery. The expected functional result was regarded as the most important factor in directing the decision about the treatment.”(Good post-surgical function, the most important outcome of the surgery was considered marginally successful.)
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)
- The effectiveness of the surgical treatment of carpal tunnel syndrome (CTS) is well known in the short term. However, limited data is available about the long-term outcome after carpal tunnel release (CTR).
- At long-term follow-up, 87 patients (40.3%) completed a questionnaire about the severity of symptoms and their functional abilities in the operation on hand.
- The mean score on Symptom Severity Scale and Functional Status Scale improved at 8 months and did not change significantly after 8 months. The patients were then followed up for 9 years.
- At 9 years favorable outcome was reported in 81.6%.
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
- “Work participation and long work careers are becoming critical for the sustainability of aging societies. Carpal Tunnel Release is a fairly common procedure, often carried out due to difficulties or inability to perform work duties. It is rather paradoxical that we know so little about the extent to which this procedure can restore workability and enhance return to earlier or amended duties and not even how long it typically takes to return to work after Carpal Tunnel Release.”
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:
- 7 days for desk-based duties,
- 15 days for repetitive light manual duties and
- 30 days for heavy manual duties.”
However, the responses were wide-ranging:
- While some stressed a sooner return to work for desk-based studies at seven days, some doctors recommended that the patient wait thirty days.
- An average of 15 days for repetitive light manual duties saw some doctors recommending 8 weeks or 56 days off work.
- 30 days for heavy manual duties could extend to a 90-day recommendation by some doctors as a “routine recommendation.”
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: that the problem of Carpal Tunnel Syndrome is recognizing and managing other potential sites of peripheral nerve compression.
Here is what the research says:
- Is it Ulnar Tunnel Syndrome / Guyon canal syndrome? The ulnar nerve may become compressed as it travels through the outer edges of the wrist
- Is it the posterior interosseous nerve (a forearm nerve branch that travels in the back of the forearm)? That nerve may become entrapped in the central region of the forearm as it travels through the radial tunnel, which results in pain without motor weakness.
- Is the nerve trapped not on the wrist but on the forearm? The median nerve may become entrapped in the proximal forearm, which can result in a variety of symptoms.
- Carpal Tunnel overnight? Is it Spontaneous neuropathy of the anterior interosseous nerve (a forearm nerve branch that travels in the front of the forearm)?
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.”
True Carpal Tunnel Syndrome vs. Pseudo Carpal Tunnel Syndrome
Signs and symptoms of “true” versus “pseudo” carpal tunnel syndrome. Patients with true carpal tunnel syndrome (constriction of the median nerve) may present with different symptoms than those with “pseudo” carpal tunnel syndrome which involves pain referral from another injured area, often the elbow.
- In True Carpal Tunnel Syndrome there is constant and chronic numbness in the thumb, index, and middle finger. In Pseudo Carpal Tunnel Syndrome there is a “numbiness” that comes and goes.
- In True Carpal Tunnel Syndrome there is a sensation of weakness in the thumb and atrophy. In Pseudo Carpal Tunnel Syndrome, thumb strength appears normal.
- In True Carpal Tunnel Syndrome there is atrophy of thenar eminence, the muscle mound at the base of the thumb. In Pseudo Carpal Tunnel Syndrome, there is rarely muscle atrophy.
- In True Carpal Tunnel Syndrome pressing on the nerve causes a tingling sensation or positive Tinel’s sign. In Pseudo Carpal Tunnel Syndrome, there is a negative Tinel’s sign.
- In True Carpal Tunnel Syndrome there is a positive Phalen’s test (the symptoms of Carpal Tunnel Syndrome can be recreated by having the patient flex their wrist downward for 30 seconds). In Pseudo Carpal Tunnel Syndrome, there is a negative Phalen’s test.
- In True Carpal Tunnel Syndrome there is a positive EMG/NCV. In Pseudo Carpal Tunnel Syndrome, there is a negative EMG/NCV.
- In Pseudo Carpal Tunnel Syndrome there is tenderness over the annular ligament in the elbow
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
- Symptoms typical of Carpal Tunnel Syndrome
- Numbness in the thumb, index, and middle finger
- Thumb weakness, sense of loss of strength
- Atrophy of the thenar eminence, the muscles on the palm of the hand at the base of the thumb.
- Positive Tinel’s sign – a tingling or numbness when a health care provider presses on suspect nerve entrapment
- Positive Phalen’s test -tingling or numbness when the patient puts the back of the hands – back to back with fingers pointing down.
- Positive EMG/NCV – Nerve conduction studies that show clear disruption of nerve function
- Pseudo Carpal Tunnel Syndrome when is thought to be Carpal Tunnel Syndrome but is not
- Numbness, a non-descript intermittent numbness
- Tenderness over the annular ligament elbow
- Normal thumb strength
- Hand muscles not atrophied
- Negative Tinel’s sign
- Negative Phalen’s test
- Negative EMG/NCV
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 prescribe anti-inflammatory medications, the end result of 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 are 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.
- Gabapentinoids are commonly prescribed for the treatment of neuropathic pain but are not recommended for the primary treatment of carpal tunnel syndrome.
- The investigators examined the preoperative use of gabapentinoid for the treatment of carpal tunnel syndrome and to determine whether preoperative exposure is associated with persistent gabapentinoid and opioid use after carpal tunnel release.
Patients continued to fill gabapentinoid prescriptions at 91 to 180 days after surgery
- Of the 56,593 patients without a previous gabapentinoid or opioid prescription prior to diagnosis of carpal tunnel syndrome, 3,474 patients (6%) filled a gabapentinoid prescription before carpal tunnel release.
- Overall, 835 patients (24% of the preoperative users) continued to fill gabapentinoid prescriptions at 91 to 180 days after surgery.
- Of the preoperative gabapentinoid users, 20% (702 patients) continued to fill opioid prescriptions at 91 to 80 days after release.
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 benefits 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:
- Results showed that the two therapies were not significantly different in terms of visual analog scale (a 1-10 numerical pain scoring system), the Boston Carpal Tunnel Questionnaire (survey patients are given to assess their own pain and function. It is likely you may have taken this survey and probably more than once.) Also, there was no significant difference in nerve testing including a nerve conduction velocity test.
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.”
A June 2022 paper from researchers in Turkey and published in the journal Lasers in medical science (20) compared the effects of low-level laser therapy and corticosteroid injection in patients with moderate carpal tunnel syndrome (CTS).
- In this study, eighty-seven patients (some with one side and some with bilateral CTS, all in total, 143 wrists) with moderate CTS were divided into a corticosteroid, 40 mg of triamcinolone acetate solution was applied to the carpal tunnel of 44 patients (74 wrists), or low-level laser therapy groups. Low-level laser therapy was applied to 43 patients (70 wrists) five times a week, for a total of 15 sessions
- In both groups, carpal tunnel syndrome symptom pain and hand function improved significantly in the 1st month after treatment. There was no significant difference in the 6th month (intermediate-term).
Pain and function scores were significantly lower in the local corticosteroid injection group compared with the other two groups.
Researchers in Turkey, writing in the American Journal of Physical Medicine & Rehabilitation (20) compared the effectiveness of radial extracorporeal shock wave therapy and local corticosteroid injection on pain, function, and nerve conduction studies in the treatment of idiopathic carpal tunnel syndrome. A total of 72 patients who were diagnosed as having carpal tunnel syndrome were included in the study.
The 72 patients were divided into three groups:
- The radial extracorporeal shock wave therapy group received radial extracorporeal shock wave therapy
- The local corticosteroid injection group received local corticosteroid injection
- The control group only used a resting hand splint.
Results: Both clinical and nerve conduction study parameters improved with all three groups, and this improvement continued at the 12th-week follow-up of the patients. However, pain and function scores were significantly lower in the local corticosteroid injection group compared with the other two groups.
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:
- Comprehensive Prolotherapy treatment. This involves multiple injections of the dextrose-based solution to the various ligament attachments around the elbow or wrist. A treatment to the wrist area is demonstrated below.
- Injections are made to the injured and weakened structures of the wrist and elbow. The goal is to stimulate a natural inflammatory response in the weakened ligament tissues and initiate a repair of these tissues.
- The mechanism works by way of the Prolotherapy treatments sending regenerative cells to the areas of the wrist or elbow that need healing, and collagen is laid down. Collagen is an important building block of soft tissue. This strengthens the weak wrist and elbow ligaments. They become tighter and stronger, and the original cause of pain and symptoms is eliminated.
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.
- The patient in the video is a personal fitness trainer. She is very physically fit. She does many exercises that put a lot of pressure on her wrists – push-ups, Zumba, yoga.
- The pain in her wrist is making it very difficult for her to demonstrate the various exercises to her classes.
- We are injecting both rows of the carpal bones. The wrist is comprised of 8 bones and 27 ligaments. It is easy to see why a treatment that focuses on strengthening and repairing the wrist ligaments would be so important to someone with significant wrist pain.
- We see many people with wrist pain on the ulnar side where Triangular fibrocartilage complex injuries occur.
- The video shows treatment around the navicular bone and the scaphoid lunate and surrounding ligaments. We see a lot of injuries there.
- The average person requires 3 to 6 treatments.
- Prolotherapy injections can be very effective for wrist instability. When we treat the wrist, we treat the entire wrist not only the ulnar side.
A case study of a 42-year female athlete with Carpal Tunnel Syndrome
We have seen countless patients with wrist, elbow, and 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)
- Forty-two years old recreational female athletes had Carpal Tunnel diagnoses in both wrists for 6 months.
- Treated with NSAIDs, B6 vitamin, and ultrasound therapy was used.
- Symptoms eased but healing was not completed.
- Prolotherapy was used and injected into bone at the enthesis (the ligament attachment to the bone) of the transverse carpal ligament
- Injections were done 2 weeks apart and 3 injections were done.
- The patient was prescribed a home standard exercise program.
- The patient was reminded at each contact to avoid NSAIDs and new therapies for Carpal Tunnel Syndrome to limit the overuse of the wrist during the treatment period.
- Results of treatment: Pain scores improved significantly.
- Results of treatment: Nerve conduction velocity also showed an improvement. The nerves functioned better based on the speed of messages.
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 quantities.” 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.
- First, considering the effectiveness of symptom relief, D5W (a 5% Dextrose in water solution injection) was likely to be the best alternative for carpal tunnel syndrome, followed by PRP injection.
- Second, splinting ranked higher than PRP and 5% Dextrose injections in terms of functional recovery. (Splinting can be used in conjunction with
- Third, corticosteroid and saline injections ranked fourth and fifth, respectively, with respect to clinical effectiveness in providing symptom and function improvement.
The researchers concluded:
- First, a 5% Dextrose injection (Prolotherapy type) and PRP injections can be considered useful regimens for the treatment of carpal tunnel syndrome of mild to moderate severity because both methods yield better effectiveness in terms of symptom relief and functional improvement than corticosteroid and saline injections.
- Second, the mechanical effect of hydro-dissection (we discuss this below, the separation of the nerve from the surrounding tissue) may substantially contribute to the benefits derived from a 5% Dextrose Injection. This procedure is recommended to be performed under ultrasound guidance.
- Third, splinting provides proper positioning and adequate rest of the wrist in patients with carpal tunnel syndrome, and seems crucial for functional recovery. Post-injection splinting should be considered in combination with regenerative injections.
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.
- PRP treatment takes your blood, like going for a blood test, and re-introduces the concentrated blood platelets from your blood into areas of the carpal tunnel region.
- Your blood platelets contain growth and healing factors. When concentrated through simple centrifuging, your blood plasma becomes “rich” in healing factors, thus the name Platelet RICH plasma.
- The procedure and preparation of therapeutic doses of growth factors consist of an autologous blood collection (blood from the patient), plasma separation (blood is centrifuged), and application of the plasma rich in growth factors (injecting the plasma into the area.) In our office, patients are generally seen every 4-6 weeks. Typically three to six visits are necessary per area.
- In much of the research surrounding PRP treatments you will see, single injections given and then monitored for months. This is not the way we perform these treatments. In our 27+ years of clinical experience, we have noted that degenerative damage requires a more comprehensive approach. Even so, improvements in single-shot treatments have been noted in the medical literature.
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 of 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.
- The PRP group included 40 females and 9 males. The cortisone group included 41 females and 8 males
- PRP injection had significantly improved the clinical manifestations, the electrodiagnostic examination parameters of the median nerve, and the median nerve cross-sectional area at 1 month and 3 months post-injection evaluation in comparison to baseline recordings;
- Local steroid injection (cortisone) had significantly improved the clinical manifestations, the electrodiagnostic examination parameters of the median nerve, and the median nerve cross-sectional area at 1 month and 3 months post-injection evaluation in comparison to baseline recordings
- PRP injection was superior to the local steroid injection in the improvement of clinical manifestations as well as the median nerve motor conduction velocity along the wrist-elbow segment, the sensory latency (how long your nerves take to respond to stimulation), and the MN sensory conduction (demonstrated by nerve conduction studies), this superiority was observed in the third-month follow-up suggesting better outcomes in long-term follow-up.
- CONCLUSION: “PlateletRich 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 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 for carpal tunnel syndrome
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.
- Fourteen patients presenting with median nerve injury who had suffered from mild carpal tunnel syndrome for over 3 months were included in this study.
- Under ultrasound guidance, platelet-rich plasma was injected into the region around the median nerve
- At one month after a single injection of platelet-rich plasma, pain (as measured by a standard visual analog scale) almost disappeared in eight patients and it was obviously alleviated in three patients. At the same time, upper limb function was obviously improved.
- In addition, no ultrasonographic manifestation of carpal tunnel syndrome was found in five patients during ultrasonographic measurement of the width of the median nerve. During the 3-month follow-up, the pain was not greatly alleviated in three patients. These findings show very encouraging mid-term outcomes regarding the use of platelet-rich plasma for the treatment 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).
- In this latter study, 50 patients diagnosed with mild to moderate carpal tunnel syndrome and who had symptoms for a minimum of 3 months were randomly divided into 2 groups:
- Group A (26 patients) received an ultrasound-guided PRP injection into the carpal tunnel.
- Group B (24 patients) were injected with placebo (normal saline).
- Group A – the PRP injection patients showed a 76.9% success in treatment whereas Group B – the placebo group – patients demonstrated 33.3% success. This is considered statistically significant.
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
- In this study, the doctors followed seventy-one patients with moderate carpal tunnel syndrome who received a single PRP injection. The patient’s progress was assessed at three months and at six months post-injection using the standard 0-10 visual analog scale (VAS) score.
- Patients who showed improvement in pain scores of MORE than 50% were deemed “patients with good outcomes.”
- Patients who showed improvement in pain scores of LESS than 50% were deemed “patients with poor outcomes.”
What were the factors that may have caused some of the patients to have poor outcomes?
- Weight, patients with more bodyweight had less than good results
- Distal motor latency problems. Many of you have had Distal motor latency testing, many after the initial surgery. This is a motor nerve conduction test. The test is seen as a collaboration of nerve conduction improvement following successful carpal tunnel surgery. In the patients who did not have good PRP results, distal motor latency did not improve.
- Too much inflammation. The cross-sectional area of the median nerve was “thicker.” People who suffer from Carpal Tunnel Syndrome have significant swelling, thickening, and irritation in the tendons and surrounding wrist area. These swelled-up tendons can then compress the median nerve.
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 throughout 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 of a diagnosis of carpal tunnel syndrome is usually surgery.
A February 2o22 study in the journal BioMed Research International (18) offered these observations on nerve hydrodissection using various injectables. In this study, it was one injection treatment.
- “Nerve hydrodissection uses fluid injection under pressure to selectively separate nerves from areas of suspected entrapment; this procedure is increasingly viewed as potentially useful in treating carpal tunnel syndrome.”
In this study the researchers compared:
- Normal saline Injection,
- 5% dextrose water (Prolotherapy),
- platelet-rich plasma (PRP), and
- hyaluronic acid (HA) as primary injectates for hydrodissection without an anesthetic.
Sixty-one patients in the study:
- 61 severe carpal tunnel syndrome cases were examined one and six months after a single neural injection with saline, Prolotherapy, PRP, or hyaluronic acid.
- The results revealed that PRP, Prolotherapy, and hyaluronic acid were more efficient than saline at all measured time points, except for the cross-sectional area in the 1st month between the saline and Prolotherapy groups.
- Single injections of PRP and Prolotherapy seemed more effective than that of hyaluronic acid within 6 months postinjection for symptom and functional improvement
- For reducing cross-sectional area pain, PRP and hyaluronic acid seemed more effective than Prolotherapy
A June 2022 study in the American Journal of Physical Medicine & Rehabilitation found (21) “Hydrodissection is an ultrasound-guided technique that has received more attention recently for its role in nerve entrapment syndromes.” The researchers of this study then evaluated the safety and effectiveness of hydrodissection in carpal tunnel syndrome and suggested treatment guidelines. In their evaluation, the researchers examined previously published studies looking for adverse (side-effect, complication) outcomes and clinical effectiveness. Six randomized controlled trials involving 356 wrists were included. All studies used ultrasound guidance in their interventions.
- No safety-related adverse outcomes were found, although not all studies declared this.
- The conclusion of this research was that the “nerve hydrodissection for carpal tunnel syndrome can be safely performed under ultrasound guidance. However, it is unclear whether the hydrodissection mechanism truly causes improvements in clinical outcomes.” (This does not mean the hydrodissection did not help, it means the evidence was not conclusive in the studies they examined).
Prolotherapy versus cortisone
A July 2022 paper in the journal Pain Management (22) issued an assessment of the effectiveness of ultrasound-guided dextrose prolotherapy against corticosteroid injections for the treatment of carpal tunnel syndrome.
- A total of 54 patients with carpal tunnel syndrome were included.
- Patients who were assigned into the prolotherapy group were injected with 5cc 5% dextrose water under ultrasound guidance.
- Patients in the corticosteroid group received ultrasound-guided 1 ml triamcinolone 40 mg/ml injection.
- Results: Direct comparison analysis revealed that dextrose prolotherapy has a similar effectiveness as corticosteroid for improving pain intensity, functional limitation in daily life, electrophysiologic parameters and ultrasonographic outcomes.
- No remarkable difference was found between the two treatments until 3 months of follow-up.
- Conclusion: Dextrose 5% has similar efficacy as triamcinolone for improving pain intensity, functional limitation in daily life, electrophysiologic parameters and ultrasonographic outcomes.
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.
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.
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.
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.
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.
1 Leppänen OV, Jokihaara J, Jämsen E, Karjalainen T. Survey of hand surgeons’ and therapists’ perceptions of the benefit of common surgical procedures of the hand. Journal of plastic surgery and hand surgery. 2018 Jan 2;52(1):1-6. [Google Scholar]
2 De Kleermaeker FG, Meulstee J, Bartels RH, Verhagen WI. Long-term outcome after carpal tunnel release and identification of prognostic factors. Acta neurochirurgica. 2019 Feb 19:1-9. [Google Scholar]
3 Viikari-Juntura E. Why do we know so little about return to work after carpal tunnel release? Scand J Work Environ Health. doi:10.5271/sjweh.3771 [Google Scholar]
4 Newington L, Francis K, Ntani G, Warwick D, Adams J, Walker-Bone K. Return to work recommendations after carpal tunnel release: a survey of UK hand surgeons and hand therapists. Journal of Hand Surgery (European Volume). 2018 Oct;43(8):875-8. [Google Scholar]
5 Strohl AB, Zelouf DS. Ulnar tunnel syndrome, radial tunnel syndrome, anterior interosseous nerve syndrome, and pronator syndrome. J Am Acad Orthop Surg. 2017 Jan;25(1):e1-e10. doi: 10.5435/JAAOS-D-16-00010. [Google Scholar]
6 Billig JI, Sears ED, Gunaseelan V, et al. Inappropriate Preoperative Gabapentinoid Use Among Patients With Carpal Tunnel Syndrome [published online ahead of print, 2020 May 30]. J Hand Surg Am. 2020;S0363-5023(20)30213-6. doi:10.1016/j.jhsa.2020.04.011 [Google Scholar]
7 Li W, Dong C, Wei H, Xiong Z, Zhang L, Zhou J, Wang Y, Song J, Tan M. Extracorporeal shock wave therapy versus local corticosteroid injection for the treatment of carpal tunnel syndrome: a meta-analysis. Journal of orthopaedic surgery and research. 2020 Dec;15(1):1-2. [Google Scholar]
8 Örsçelik A, Yasar H, Köroglu O, Seven MM. P-75 Prolotherapy for carpal tunnel syndrome: a case report. [Google Scholar]
9 Hauser RA, Lackner JB, Steilen-Matias D, Harris DK. A systematic review of dextrose prolotherapy for chronic musculoskeletal pain. Clinical medicine insights: Arthritis and musculoskeletal disorders. 2016 Jan;9:CMAMD-S39160. [Google Scholar]
10 Lin CP, Chang KV, Huang YK, Wu WT, Özçakar L. Regenerative Injections Including 5% Dextrose and Platelet-Rich Plasma for the Treatment of Carpal Tunnel Syndrome: A Systematic Review and Network Meta-Analysis. Pharmaceuticals. 2020 Mar;13(3):49. [Google Scholar]
11 Dong C, Sun Y, Qi Y, Zhu Y, Wei H, Wu D, Li C. Effect of Platelet-Rich Plasma Injection on Mild or Moderate Carpal Tunnel Syndrome: An Updated Systematic Review and Meta-Analysis of Randomized Controlled Trials. BioMed Research International. 2020 Nov 14;2020.
12 Catapano M, Catapano J, Borschel G, Alavania SM, Robinson LR, Mittal N. Effectiveness of platelet rich plasma injections for non-surgical management of carpal tunnel syndrome: a systematic review and meta-analysis of randomized controlled trials. Archives of Physical Medicine and Rehabilitation. 2019 Dec 7. [Google Scholar]
13 Senna MK, Shaat RM, Ali AA. Platelet-rich plasma in treatment of patients with idiopathic carpal tunnel syndrome. Clinical rheumatology. 2019 Dec 1;38(12):3643-54. [Google Scholar]
14 Malahias MA, Johnson EO, Babis GC, Nikolaou VS. Single injection of platelet-rich plasma as a novel treatment of carpal tunnel syndrome. Neural regeneration research. 2015 Nov;10(11):1856. [Google Scholar]
15 Malahias MA, Nikolaou VS, Johnson EO, Kaseta MK, Kazas ST, Babis GC. Platelet‐rich plasma ultrasound‐guided injection in the treatment of carpal tunnel syndrome: A placebo‐controlled clinical study. Journal of tissue engineering and regenerative medicine. 2018 Mar;12(3):e1480-8. [Google Scholar]
16 Shen YP, Li TY, Chou YC, Chen LC, Wu YT. Outcome predictors of platelet‐rich plasma injection for moderate carpal tunnel syndrome. International Journal of Clinical Practice. 2021 Jun 9:e14482. [Google Scholar]
17 Wu YT, Ho TY, Chou YC, Ke MJ, Li TY, Huang GS, Chen LC. Six-month efficacy of platelet-rich plasma for carpal tunnel syndrome: A prospective randomized, single-blind controlled trial. Sci Rep. 2017 Dec;7(1):94. [Google Scholar]
18 Wu YT, Lam KH, Lai CY, Chen SR, Shen YP, Su YC, Li TY, Wu CH. Novel Motor-Sparing Ultrasound-Guided Neural Injection in Severe Carpal Tunnel Syndrome: A Comparison of Four Injectates. BioMed Research International. 2022 Feb 17;2022. [Google Scholar]
19 Durmaz HÖ, Tuncay F, Durmaz H, Erdem HR. Comparison of Radial Extracorporeal Shock Wave Therapy and Local Corticosteroid Injection Effectiveness in Patients With Carpal Tunnel Syndrome: A Randomized Controlled Study. American Journal of Physical Medicine & Rehabilitation. 2022 Jul 1;101(7):685-92. [Google Scholar]
20 Badıl Güloğlu S, Bilgilisoy Filiz M, Kılıç KK, Koldaş Doğan Ş, Toslak İE, Toraman NF. Treatment of carpal tunnel syndrome by low-level laser therapy versus corticosteroid injection: a randomized, prospective clinical study. Lasers in Medical Science. 2022 Jan 13:1-1. [Google Scholar]
21 Neo EJ, Shan NT, San Tay S. Hydrodissection for carpal tunnel syndrome: A systematic review. American Journal of Physical Medicine & Rehabilitation. 2022 Jun 1;101(6):530-9. [Google Scholar]
22 Babaei-Ghazani A, Moradnia S, Azar M, Forogh B, Ahadi T, Chaibakhsh S, Khodabandeh M, Eftekharsadat B. Ultrasound-guided 5% dextrose prolotherapy versus corticosteroid injection in carpal tunnel syndrome: a randomized, controlled clinical trial. Pain Manag. 2022 Jul 18. doi: 10.2217/pmt-2022-0018. Epub ahead of print. PMID: 35848821.
This article was updated June 23, 2022