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Interesting Median Nerve Compression Case
77 Plays4 hours ago
Hand Therapy Academy welcomes Allison as she shares a compelling case of median nerve compression. In this discussion, she and Miranda explore why the typical carpal tunnel release wasn’t resolving the issue — and what therapists can learn from the unexpected outcome.
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Transcript
Introduction to Hand Therapy Academy
00:00:05
Miranda Materi
Hi, I'm Miranda.
00:00:06
Allison Johnson
And I'm Allison, and we are Hand Therapy Academy.
00:00:10
Miranda Materi
All right, today we have Allison on again. She is one of our experienced CHTs in the office, and she is going to be sharing another interesting case. um And i really enjoy doing these with Allison because she always has some interesting patients and how they may present a little differently than what we would expect.
00:00:27
Miranda Materi
So go for it.
Post-Surgery Concerns: Lack of Improvement
00:00:30
Allison Johnson
Okay, so so I had a patient come in, pretty standard. He was status post carcal tunnel release. um So we treated him for a little bit, but his a lot of his symptoms weren't improving.
00:00:43
Allison Johnson
And it had been it had been a little while, maybe like a, like, six to eight weeks and he wasn't really making any progress with his symptoms.
Diagnosing Additional Nerve Issues
00:00:51
Allison Johnson
ah He like brought up his concerns to his doctor who I think kind of wrote him off a little bit and which just told him to give it more time, which is fine. So it comes to a progress note and I noticed he still has a lot of weakness specifically in tip pinch, um which isn't necessarily super common with just carpal tunnel syndrome. So I started looking more proximal.
00:01:12
Allison Johnson
um to see if maybe his nerve was also compressed proximally. So I looked at his laceritus fibrosis. I did a like biceps manual muscle test to see if that um, did any symptoms. I did a Tunnels there, nothing.
00:01:29
Allison Johnson
um I went a little bit lower into the forum and I did a Tunnels at pronator teres and that was positive. Um, that increased his paresthesia in his fingers. And, um, when I did like a resisted pronation manual muscle test that increased his pain, it was very, it was painful in his forearm.
00:01:47
Allison Johnson
So we started thinking pronator syndrome. He's maybe also having, um, his median nerve compressed there. Now, before he came to me, he did have, and before he had his carpal tunnel release, he did have, um, an EMG that showed moderate carpal tunnel syndrome.
00:02:03
Allison Johnson
So I do think he also had carpal tunnel syndrome. Um, but I think also just compression more approximately too.
00:02:11
Miranda Materi
Yeah, that's interesting.
00:02:11
Allison Johnson
So
EMG Limitations and Physical Exam Importance
00:02:13
Allison Johnson
yeah. So i was like, that was interesting. And then I was thinking, I'm like, were they just not looking for pronator syndrome or do those, does that like not typically show up on an EMG? Like, do you think? And I,
00:02:24
Allison Johnson
And I just, I guess I don't really know and if that's something that would.
00:02:26
Miranda Materi
Yeah, I think it's so it's like far less common, so they're not really looking for it as much.
00:02:27
Allison Johnson
here
00:02:32
Miranda Materi
um And so I think... doing a good physical exam. I think it's a good reminder, like even before surgery, right? Like yes, an EMG is the gold standard for diagnosing carpal tunnel syndrome, not necessarily pronatoria syndrome, but it is the gold standard for nerve compression injuries or pathology. So I think...
00:02:32
Allison Johnson
Right.
00:02:56
Miranda Materi
the important thing it would, or these things could be looked at or examined when the patient, when you have them come in and you say, oh, you do have carpal tunnel like this ah from the physician or whoever's evaluating before surgery and really doing a good manual muscle test, right?
00:03:10
Allison Johnson
Mm-hmm. Mm-hmm.
00:03:10
Miranda Materi
Because you probably would have picked up on it by doing a really good physical exam.
Understanding Double Crush Syndrome
00:03:15
Miranda Materi
But I think a lot of times in our mind, we're like, and we're so busy, right? And the providers are so busy, maybe they have five to 10 minutes and you're evaluating the patient. You're like, oh, this is definitely carpal tunnel. The nurse said it was carpal tunnel. So we're going to treat it like carpal tunnel.
00:03:27
Miranda Materi
And they're not wrong, but then there's like much, there's more to it, right?
00:03:32
Allison Johnson
Yeah, like other things too. Totally. And like, so when I get like a conservative, someone referred for carpal tunnel syndrome, I always do those, like that testing for proximal, but I don't really think to do it after when someone's coming to me, like status post the surgery.
00:03:41
Miranda Materi
mr
00:03:46
Miranda Materi
Yeah.
00:03:46
Allison Johnson
So I guess.
00:03:47
Miranda Materi
I mean, it makes sense, right? Cause you feel like that should have been done prior to, but
00:03:51
Allison Johnson
Yeah, I guess it's a good point that and I should just add that in, you know, even if they have the carpal tunnel release, still check more proximally. Cause I guess double, you know, double crush syndrome is a relatively, I don't know how common, but it it is a thing.
00:04:04
Miranda Materi
yeah, it definitely is a thing. I wonder, um, so then the patient you said went on and had surgery and had it released.
Second Opinion and Successful Surgery
00:04:11
Allison Johnson
Yep. So he ended up going to a different surgeon. I just don't think like he didn't feel like his first surgeon was listening to him, but he ended up going and having a second opinion to a new surgeon and had it released. Yep.
00:04:21
Miranda Materi
Did they do another nerve study or they just said, nope, that's what it is and.
00:04:27
Allison Johnson
I think they did do another nerve study actually. And, but i don't think it showed up on the nerve study. Now that I think about it, I think it's still, i don't think it showed up on the nerve study, but the surgeon did his own like provocative testing. I do know that because I saw his note and decided to do it based on his clinical exam.
00:04:44
Miranda Materi
Yeah. And how's the patient doing now?
00:04:46
Allison Johnson
Much better, much better.
00:04:48
Miranda Materi
Yeah.
00:04:49
Allison Johnson
So
00:04:49
Miranda Materi
That's good.
00:04:51
Allison Johnson
Yeah, I'm so happy.
Conservative Treatment Options
00:04:53
Miranda Materi
Yeah, that's the main thing, right?
00:04:55
Allison Johnson
Yes, yes. So he's doing much better. His symptoms are much less. um Yeah, i he's like, he's only about, i think he's about four weeks out from um that surgery.
00:05:06
Allison Johnson
So yeah, but he said almost immediately he felt a little bit better.
00:05:08
Miranda Materi
did you Did you try to treat it conservatively? Like, were you addressing treating the pronator to?
00:05:15
Allison Johnson
Yeah, we did address it for a little bit conservatively and it wasn't getting much better.
00:05:19
Miranda Materi
Yeah.
00:05:20
Allison Johnson
Yeah. Yeah.
00:05:20
Miranda Materi
And so what, I guess, cause our audience will probably want know what type of conservative treatment, um, things were you doing?
00:05:27
Allison Johnson
So we were doing like a lot of soft tissue mobilization to the pronator teres on like the flexor mass, the forearm. We were doing median nerve glides. tried doing some cupping and instrument assisted soft tissue mobilization tool to that musculature and that wasn't helping.
00:05:47
Allison Johnson
I know what we talked about earlier, like some of the research says like splinting for it. That's not something my patient was willing to try.
00:05:57
Miranda Materi
Yeah, and so we were chatting a little bit before we got on, and one option was to do a long arm with the elbow in 90 degrees and the forearm in neutral so they couldn't do the repetitive pronation. So you're kind of eliminating the irritation of the nerve by eliminating the pronation.
00:06:14
Miranda Materi
i wonder So I think like all the things you're doing sound great, but also um another thing I was thinking about was doing like activity modification. Like what things could we have them avoid doing to pronate, even though there's so many things we do that pronate, right.
00:06:28
Allison Johnson
Totally.
00:06:28
Miranda Materi
Even like, like typing, right. If the person types all day, they're going to be pronating. So
00:06:33
Allison Johnson
Right. Right.
00:06:36
Miranda Materi
yeah.
00:06:36
Allison Johnson
Yeah. That's a good point though. Looking at some of those activities and just seeing how they can do it differently to try to avoid that.
00:06:42
Miranda Materi
Yeah. But it sounds like the patient probably needed of the surgical release.
00:06:46
Allison Johnson
Yeah. It was, it was kind of cool to see because he, he said he felt better almost like immediately after that surgery, which was cool to see.
00:06:55
Miranda Materi
That's amazing. What about like his like paresthesias?
00:06:56
Allison Johnson
Yeah.
00:06:58
Miranda Materi
Like, did he have numbness and tingling like after the carpal tunnel surgery or how did it,
Identifying Proximal Nerve Injuries
00:07:04
Miranda Materi
how did that present?
00:07:04
Allison Johnson
he He did still have numbness. and He had numbness and tingling before and after the carpal tunnel surgery, which was, I think it was one off.
00:07:11
Miranda Materi
Was his like monofilament testing normal?
00:07:15
Allison Johnson
So I think it was three, six, one.
00:07:16
Miranda Materi
Oh, okay.
00:07:18
Allison Johnson
um And i don't know. I'd have to look. I'm not sure if it's back to normal yet or not.
00:07:24
Miranda Materi
Yeah.
00:07:25
Allison Johnson
But I know.
00:07:25
Miranda Materi
And then it sounds like um another like differentiating thing would be if they had sensation over the thenar eminence area where that palmar cutaneous branch of the median nerve comes off because it does proximal to the carpal tunnel.
00:07:34
Allison Johnson
Yes. and yeah
00:07:38
Miranda Materi
So if they have numbness and tingling there, it could indicate that there's a more proximal injury or proximal pathology.
00:07:45
Allison Johnson
And he did have a numbness and tingling that area.
00:07:48
Miranda Materi
So that'd be another indication. Yeah.
00:07:50
Allison Johnson
Thankfully. Right.
00:07:50
Miranda Materi
Well, it sounds like he got it taken care of,
00:07:51
Allison Johnson
Totally.
Final Thoughts and Contact Information
00:07:53
Miranda Materi
but it wasn't the typical path.
00:07:53
Allison Johnson
think right
00:07:55
Miranda Materi
Right.
00:07:56
Allison Johnson
right totally
00:07:57
Miranda Materi
And a lot of times, like we don't see patients after carpal tunnel surgery. Right. Like.
00:08:02
Allison Johnson
Right, yeah, I think like we kind of saw like he was sent to us because it wasn't getting better, i guess.
00:08:07
Miranda Materi
Yeah.
00:08:08
Allison Johnson
Yeah.
00:08:09
Miranda Materi
And that's not a complication I would have thought. You know, we think of like complications after carpal tunnel, you think, oh, pillar pain and scar, but you don't think, oh yeah, another compression.
00:08:20
Allison Johnson
Yeah, somewhere else. Yes, that was interesting.
00:08:21
Miranda Materi
Yeah.
00:08:22
Allison Johnson
I think we good reminder to always look proximal when it comes to Nerf stuff too.
00:08:26
Miranda Materi
Yeah. Even if it's the case is presented to you totally different, right? And you're probably, your order was probably for post-op carpal tunnel.
00:08:33
Allison Johnson
Right. It was. Yep.
00:08:34
Miranda Materi
Yeah. So I guess that's why we always do our own evaluations, right?
00:08:39
Allison Johnson
Yes. Correct.
00:08:41
Miranda Materi
Well, thank you for sharing, Allison. For more info, you can reach out to us at Hand Therapy Academy or email us info at Hand Therapy Academy.