The Great Masqueraders of Carpal Tunnel Syndrome

The top four orthopedic conditions that are often misdiagnosed as​ Carpal Tunnel Syndrome

#1  -  Cubital Tunnel Syndrome 

  • This is the 2nd most common neuropathy (nerve compression syndrome) behind carpal tunnel syndrome
  • The Ulnar nerve on the medial side of the elbow can be entrapped at the cubital tunnel +/- 8 cm each direction
  • Patients typically present with pain and/or numbness on the small finger side of the hand.  Weakness/clumsiness of the hand is often noted as well.  Nighttime pain is VERY common
  • Usually a clinical diagnosis: (+) Tinel’s and/or tenderness along the course of the ulnar nerve, (+) elbow flexion test, decreased sensation in the distribution of the ulnar nerve in the hand, and weakness/wasting of the hand intrinsic muscles
  • Diagnosis is often confirmed, and the severity quantified, with an EMG (nerve study).  However, EMG is unreliable in diagnosing ulnar nerve compression approximately 20% of the time….
  • With mild to moderate Cubital Tunnel Syndrome, conservative treatment can offer good results (oral anti-inflammatory pills, elbow pads/night-time splints, +/- a steroid injection at the site of nerve compression, ergonomic work station, etc.)
  • With severe compression, or a very clinically symptomatic patient, surgery can help relieve pain, restore feeling to the hand and fingers, and halt, but not reverse, muscle loss that causes the weakness/clumsiness in the hand 
  • ​Surgery is done to “release” the areas of compression, at the elbow, which diminishes the symptoms in the hand/forearm. Open and endoscopic techniques are described

#2 - Arthritis of the Wrist and Hand​ 

  • Arthritis in the hand and wrist is a common source of pain, despite these being non-weight bearing joints (like the hips and knees) ​
  • Patients present with pain, deformity, and limited range of motion of the fingers, thumb, or wrist. Occasionally weakness is noted​
  • Diagnosis is easily made with an X-ray series of the involved area
  • ​Initial treatment is conservative, with oral anti-inflammatory pills, braces, and possibly steroid injections, patches and pain lotions
  • Surgery reserved for patients in chronic pain, whom have failed a trial of conservative treatment.  Multiple surgeries have been described for different etiologies; the spectrum ranges from removal of bone spurs, to complete or partial arthrodesis (fusion) of the joint, to joint replacement
  • Arthritis patients are typically very happy with surgery, as they are able to resume their activities of daily living with little to no pain.  Hand function is taken for granted…..until it is lost! 

#3 - DeQuarvain’s Tenosynovitis

  • This is most often an overuse-type syndrome, it can be seen in patients with a recent increase in, and/or repetitive-type activities​​
  • Patients present with pain on the radial (thumb) side of the wrist where the thumb tendons pass beneath a sheath. Pain is aggravated with gripping and grasping activities and ulnar deviation (hand movement toward the small finger)​​
  • Easily diagnosed in the office with good physical exam (positive Finkelstein test, tenderness along the 1st dorsal compartment {thumb} tendons), no additional studies are typically indicated
  • Like most other types of tendonitis, treatment is conservative for as long as the patient can tolerate, patients almost always get better without the need for surgical intervention
  • Activity modification, a steroid injection, ​ and oral anti-inflammatory pills are the ​ best initial treatment for DeQuarvain’s ​ tenosynovitis. Treatment may also ​ include brace or cast immobilization, ​ to rest the tendons and decrease inflammation, ice ​ after activity, and stretching exercises​

#4  -  Trigger Finger

  • “Stenosing Tenosynovitis”, i.e., trigger finger is caused by swelling of the tendon, or sheath that it runs through, or both. The pathology almost always occurs at the A-1 pulley at the base of the tendon sheath, which overlies the palm side of the knuckle
  • Patients complain of a finger(s) that will catch, lock, or “stick”, this is often painful when it occurs, but not always.  Occasionally pts will present with pain in the palm, but no actual triggering….this is called ‘pre-clinical trigger finger’ and is treated the same way
  • Like carpal tunnel syndrome, the reason trigger finger develops is often idiopathic (unknown). It is more common with overuse or repetitive use, and in patients with diabetes, thyroid disease, or other inflammatory conditions​
  • Easily diagnosed in clinic without the need for further imaging studies or workup. Patients will have tenderness over the region of the A-1 pulley at the palmer flexion crease, and fullness in the flexor tendons. Look closely, a subluxating or dislocating extensor tendon dorsally can present almost exactly like a trigger finger, without the volar tenderness however​
  • Responds well to a single steroid injection, which is often curative. Occasionally a second injection is needed. NSAIDS, such as Aleve, can be helpful as well​
  • Failing steroid injections, or if the trigger digit is “locked” in flexed or extended position, the patient may require surgery to release the A-1 pulley and allow the tendon to glide freely again