Neuropathic symptoms and musculoskeletal pain in carpal tunnel syndrome: Prognostic and therapeutic implications

Repetitive activities in the workplace can not only jeopardize the median nerve across the carpal tunnel but also the musculoskeletal structures, such as the ligaments, synovia, tendons and muscles producing pain, and local tenderness at the wrist, elbow, and shoulder. The occurrence of this latter condition can dominate the overall clinical picture and affect the outcome of treatments for this very common condition. A clinical evaluation of 30 patients who previously underwent a successful and uncomplicated carpal tunnel release surgery was conducted. These patients were referred back for another electrodiagnostic study to consider the possibility of persistent or recurrent nerve entrapment. These patients all had musculoskeletal pain and local tenderness at the wrist, elbow, and shoulder as their primary and disabling symptoms; and neuropathic symptoms as their less disabling complaints. All patients reported significant resolution of their neuropathic symptoms following surgery but their musculoskeletal symptoms persisted preventing them from returning to their original occupation. Fifty percent showed mild to moderate improvement in their electrophysiologic abnormalities but none had complete normalization of nerve conduction. Few patients developed symptoms of sympathetic nerve overactivity. Some patients suffering from carpal tunnel syndrome may present with a disabling musculoskeletal pain and local tenderness in the upper extremities that can persist following surgery despite resolution of neuropathic symptoms. These two symptom complexes, although both sequelae of repetitive activities, have fundamental clinicopathologic differences that must be recognized because of their therapeutic, prognostic, and medico-legal implications.