Discussions By Condition: I cannot get a diagnosis.

Help my wife.

Posted In: I cannot get a diagnosis. 17 Replies
  • Posted By: richard wayne2b
  • January 19, 2009
  • 06:06 PM

My wife has undiagnosed wrist pain that is bilaterally symmetrical,does not radiate into her fingers,remains at a 5-7 on a 1-10 pain scale,and is constant.She has had no injuries to her wrists but did have endoscopic carpal tunnel release done 9 years ago.The pain is exactly equal in intensity and varies in intensity equally from side to side.It is not recurrent carpal tunnel syndrome,and her physical exam is unremarkable.Nothing in the way of NSAIDS helps her,and she gets a strange reaction to opiates.She can use her hands but with pain in her wrists.The pain is also circumferential.Please help!

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  • I am sorry but I can not help you with your wife's wrists, but I was wondering about her reaction to opiates. Every time I have taken them I have developed strange problems with breathing and a worst panic attac imaginable. The doctors find it very strange. But it has happaned four times by now. Can I ask what your wife's reaction is?
    Felsen 510 Replies
    • January 19, 2009
    • 09:33 PM
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  • She gets very belligerent.
    richard wayne2b 1232 Replies
    • January 19, 2009
    • 09:58 PM
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  • Too bad for you :)
    Felsen 510 Replies
    • January 19, 2009
    • 10:00 PM
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  • Would this be considered an in-house consult? The most common underlying cause for her symptoms would either be scarring of the median nerve to the divided transverse carpal ligament or pillar pain at the terminal branch of the palmar cutaneous nerve or between the TCL and the skin. Neither of these causes are related to incomplete release or in other words, recurrence. A less frequent cause is subluxation of the flexor tendons over the hook of the hamate and in such cases, the hook of the hamate is typically removed surgically. Is there demonstrated weakness aside from what patients normally complain about with respect to grip strength following division of the transverse ligament? Any actual decrease in range of motion? Also, has the scar evulsed or can you detect evidence of deeper scar tissue when firmly stroking your finger across the wrist proximal to the transerse ligament? Finally, have you also considered whether this could be Intersection Syndrome of the radial wrist extensors, a condition that can produce circumferential pain in the manner described in some patients. Best regards, J Cottle MD
    JCottleMD 580 Replies
    • January 19, 2009
    • 11:21 PM
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  • Dear Dr. Cottle:I cannot detect any deep scar tissue proximal to the TCL;nor is the scar evulsed.There appears to be no decrease in grip strength on either side nor decreased range of motion.I'm not sure what to check regarding Intersection Syndrome.She does seem to have a fairly new symptom in that last night she was,besides the circumferential pain in her wrists,hurting on the dorsum of her forearms from the wrist towards the elbows.Also,of note is that she gets temporary pain relief when I press down into the area of her median nerves.Thank you.
    richard wayne2b 1232 Replies
    • January 20, 2009
    • 08:54 PM
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  • Ah, well we know we're not dealing with entrapment features if compression relieves discomfort. One of the questions I failed to ask earlier is whether your wife is conducting any type of repetitive motions, particularly that requires wrist extension and flexion, an activity more commonly associated with Intersection syndrome. Intersection Syndrome is sort of a cousin to De Quervain's and you can use the opposing thumb test to determine whether inflammation is generally present at the distal intersection of the pollicis longus and brevis, and the radialis brevis. While not as striking to the patient as the presence of De Quervain's, pain on opposing the thumb into the palmar surface of the hand typically invokes a rapid pain response. I would think pain suppression might be likely in her case because it's actually referred pain from wrist extensors that intersect on the outer forearm distal to the median nerve compartment at the area of the transverse ligament. I actually saw a number of patients over the course of a year or two who collectively worked for a railroad company and used heavy prybars throughout the day to shift rail ties, complaining of pain at the wrist, sometimes the lower forearm, that in most cases was being diagnosed as Carpal tunnel with no supporting evidence on examination. In a couple of cases, the inflammation was severe enough to demonstrate crepitus. We diagnosed it as Intersection syndrome, treated it with a 1% lidocaine and betamethasone, immobilized the wrists with splints and sent them for some therapy. Follow-up revealed significant improvement, with relapse in only a couple of instances where adherance to treatment was intermittent at best. I would try the opposing thumb test to see if you can narrow down the location of the problem. There are certainly other causes, but I would think this to be a logical place to start. Best regards, J Cottle, MD
    JCottleMD 580 Replies
    • January 21, 2009
    • 00:33 AM
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  • I've had success with clients using a "triphase" bracelet from Nikken, typically used on the "mouse wrist" if they're on the computer a lot. If you can find a local consultant she could give it a try - if it's going to help her she'll probably notice some kind of improvement within a few minutes. They contain negative ion, far infra red, and magnetic technology. They've also got a far infra red wrist wrap. Karen freehelp99@yahoo.com
    Kinesiologist 62 Replies
    • January 21, 2009
    • 00:53 AM
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  • Please enlighten us by explaining in graphic detail precisely what occurs when the human body is exposed to the properties claimed to exist in the bracelet you propose, to include any physiological response and targeted treatment of the disorder that I've discussed with the individual making the original post here, who incidentally is also a physician as well. regards, J Cottle, MD
    JCottleMD 580 Replies
    • January 21, 2009
    • 02:08 AM
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  • Dear Dr.Cottle:My wife does nothing with her wrists that is repetitive.Also,she had no pain with opposition of her thumbs into the respective palmar spaces.Why do you think she gets instant but temporary relief when I press onto her median nerves?Also,why(and how)does she have bilaterally exact symptoms that are symmetrical?Thanks again.
    richard wayne2b 1232 Replies
    • January 21, 2009
    • 02:42 PM
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  • Dear Dr.Cottle:How do you know so much about so many things?I was valedictorian in both high school and college so that I'm no dummy,but I don't belong in the same ''room'' as you when it comes to medical things.This has been a very humbling experience,especially since I was the intern they called the ''zebra doctor.''Thank you again.
    richard wayne2b 1232 Replies
    • January 21, 2009
    • 03:10 PM
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  • Okay, Richard. Here goes: have you thought of trying acupuncture to help your wife's painful wrists? I think it would be helpful. I can help find a certified practitioner for you if you'd like. Best wishesDOM
    acuann 3080 Replies
    • January 21, 2009
    • 03:15 PM
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  • Hi. I'm new here. I'm trying to help. It seems that you may be for the all allopathic approach, but I'm a LMT and I see clients like your wife all the time with much success. After you have ruled out any systemic issues, you might think about finding her a very well qualified therapeutic massage therapist. This is not relaxation we are talking about--it's therapy (much like PT, except we relax the outer before going deeper) and it works for many. First off, have you done any bloodwork--perhaps a CBC to rule out infection of the interosseous membrane? Couldn't hurt...What type of pain does she experience--sharp, dull, achy? Please describe. You state that it's constant, but at a 5-7 all day, every day? Nothing affects the pain? What are her hobbies? You say that she does nothing repetitive with her wrists....but we all do repetitive things with our wrists. With a history of carpal tunnel features......I need to know your wife's particular use of her arms/wrist. Does she type a lot? Garden? Cook? How does she sleep (side with arms under her)? It makes a difference, even if it's not daily. The compression-- I'm not sure I understand exactly where you are applying this. The median nerve runs all the way down the arm, branching off in the forearm as I understand. Where exactly are you applying compression and with what (finger, palm, tool)? I'll assume that you are applying compression to the anterior wrist flexors and pronators? Does compression of the extensors aid her as well? As you most likely know, the compression of the tissues causes a temporary hyperemia of the area and a softening of the muscle groups involved so it may be significant from a MT perspective. Since compression works, you might try other friction techniques or petrissage. You can also try adding in a step--place her arm on a firm surface. While you compress the anterior forarm against this surface, flex the wrist. While you compress the posterior forarm, extend the wrist. Do all this very slowly and within her limits of toleration. Are the flexors or extensors hypertrophied? You haven't mentioned the tone of the musculature. I also didn't hear you mention any numbness or tingling..... Check the anterior scalenes (posterior to SCM at the insertion). Thoracic Outlet Syndrome can mimic Carpal Tunnel, as well as referred issues in the shoulder or pec minor. Not to disagree with the kind doc earlier (whom I have no doubt is more knowledgeable than I), but it's always possible that the entrapment may be occurring proximally, so the fact that the compression helps at the application site does not rule out this possibility in my mind. Also, how quick was the progression of pain up the arm? Overnight? Noticeable or did she just realize it when you asked? Is the pain past her elbow now? The progression further leads me to suspect entrapment either at the scalenes or the pectoral muscles, although with no weakness or numbness present....it's unusual. The bilateral exactness of this issue is a bit troublesome. I have seen many clients with similar issues bilaterally, but not exact. Even with thoracic outlet or carpal tunnel, it's usually not bilaterally exact, although some symmetry is common. Are you certain of this feature or is it simply similar? I wish you and your wife the best. Please don't rule out non-allopathic approaches that might provide her some relief, especially if the traditional route isn't working. A good physical therapist or MT might just be able to help.
    Harmonium 322 Replies
    • January 21, 2009
    • 05:11 PM
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  • Well, we have no evidence of De Quervain's and the likelihood of Intersection Syndrome is lessened as well. I have to tell you though, I'm still not convinced that this is not inflammatory in nature and the fact that it's bilateral, still strongly suggests that it's motion-driven such as using tools or a computer keyboard with some degree of regularity that would require manipulation with both hands. Can you tell me what the onset was related to in this instance, if anything? I really don't know much of the history from your initial posting. I suppose we could consider a three-compartment wrist arthrography, utilizing radiocarpal injection. An MRI would also afford global examination of both the osseous and soft-tissue structures, possibly revealing triangular fibrocartilage or remotely avascular neurosis but I really doubt that it's the case. Contrast would detect any errosion from an arthritic condition but no mention is made of supporting symptoms. Again, the fact that it's bilateral with no signs of the disorders already mentioned would make this a candidate for something motion-driven wherein both hands would be required. I have rarely seen cases with cervical involvement but it would be a stretch in this case at the very least. If you can share more of the history it might help provide more direction. Best regards, J Cottle, MD
    JCottleMD 580 Replies
    • January 21, 2009
    • 06:09 PM
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  • Dear Dr.Cottle:My wife was working at a computer at the onset of her pain.That was 5 years ago,and at first we thought it was a recurrence of her carpal tunnel syndromes,but it wasn't.She had an EMG that showed slight right carpal tunnel SX but not much.She uses our computer less than 5 minutes a day now and has no other repetitive motions that I know of.What really baffles me is the absolute symmetry of her Sx.Thank you.
    richard wayne2b 1232 Replies
    • January 21, 2009
    • 06:47 PM
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  • Dear Dr.Cottle:I forgot to tell you that she had an unremarkable MRI scan of her C-spine.
    richard wayne2b 1232 Replies
    • January 21, 2009
    • 06:50 PM
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  • Since her situation appears to be medically perplexing, it seems like a logical step to look outside the box for a solution. Regarding the technology in the bracelet, there was a large bio medical engineering study done at U of Virginia you could look over, printed Jan. 2 2009.http://www.virginia.edu/uvatoday/newsRelease.php?id=3573 This should shed some light on the magnetic aspect. Re. far infra red - although researchers admit it's not well understood in relation to healing, it does have a beneficial effect. Here is one study on wound healing http://www.ebmonline.org/cgi/content/full/228/6/724 and another from the Wolfe Clinic discusses studies from U of NJ medical school and Sunnybrook Hospital, Toronto on far infra red and pain. http://www.thewolfeclinic.com/articles/pain_relief_the_sauna_dome.htmlNegative ions of course are alcaline producing (as are far infra red and balanced magnetic energy). Since pain is an acidic state, it stands to reason that when the area is bombarded with negative ions and alcaline energy is absorbed into the body, it should have a beneficial effect against pain. The fact is that it ususally does work. Perhaps with your heavily scientific background you are more equipped to explain it on a cellular level. I found a link showing this particular bracelet I mentioned. Any Nikken consultant would have one she could try. What country is she in?http://www.nikken.com/product.cfm?ThemeID=3&GetGroupID=1&GetProductID=4 Also, since it seems to be medically difficult to resolve, and it's bi lateral, she could look for emotional triggers. Look at the work of Louise Hay. Most people are aware that if they "carry a huge burden" (stress) they can be prone to back or shoulder problems. In this line of thinking, the hands and wrists are related to doing things. Is there a hobby, some kind of art work, or something else she loved "doing" in the past that she doesn't do any more maybe for lack of time? Ask her. If so, this could pre-dispose her to hand/wrist related problems. She should start doing it, and allot time in the future to do it regularly.warm regards, Karen freehelp99@yahoo.com
    Kinesiologist 62 Replies
    • January 21, 2009
    • 07:14 PM
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  • I see. Thank you for a more thorough history and I didn't realize we were speaking of a symptomatic phase of five years. In the absence of repetitive strain injury, negative C-spine and the other more common disorders which at this point would be less likely, my suggestion would be to consider evaluation through arthrography and MRI with contrast. These tests would give you a pretty global indication of what's taking place and although regional pain syndrome is yet another consideration, I would reserve it for a diagnosis of exclusion. Please let me know how she progresses and thank you for posting. Best regards, J Cottle, MD
    JCottleMD 580 Replies
    • January 21, 2009
    • 09:49 PM
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