Is it ACTUALLY Carpal Tunnel Syndrome? How to Test and Treat for Numbness Pre- Surgery

Show Notes

In this episode of the Dr. JJ Thomas Podcast, we explore the critical issue of misdiagnosing carpal tunnel syndrome through the compelling story of a patient facing potentially unnecessary surgery for hand numbness. Dr. JJ Thomas demonstrates the importance of a thorough diagnostic process, revealing how comprehensive evaluations and treatments like dry needling can uncover and address the true sources of numbness. This must-watch episode offers physical therapists valuable insights into improving diagnostic skills and expanding treatment methods, transforming patient outcomes.

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What is The Dr. JJ Thomas Podcast?

Welcome to The Dr. JJ Thomas Podcast! Here I'll be talking all things physical therapy, raw and unplugged, giving you the unfiltered insights you've been searching for in your cash-based physical therapy business. If you're caught in the grind of the traditional model, swamped with paperwork, or feeling like you're not reaching your full potential as a physical therapist, this podcast was created just for you.

Sean: 00:00

What's up, primal physical therapy family? I wanna give a quick shout out and thank you to doctor JJ. So I've been dealing with carpal tunnel and issues with my hands for about a year and a half, almost 2 years. And in my left hand, I haven't had feeling in about a year due to neck injuries and shoulder injuries. And within one session with doctor JJ, we did some dry needling and some basic movement analysis, and I am beyond shocked with the results that I had.

Sean: 00:30

Been bounced around from doctor to doctor saying that I have arthritis and carpal tunnel and all these other nerve issues. And in one session, I've had more feeling in my hand in the past year. So I'm beyond grateful for doctor JJ and the Primal Physical Therapy Group. They do outstanding work. And if anybody is interested or has carpal tunnel, please reach out to them.

Sean: 00:53

They will give you so much relief with their treatment. Thank you again, primal therapy. Welcome to the doctor JJ Thomas podcast.

Dr. JJ Thomas: 01:05

Hey, everybody. I'm doctor JJ Thomas. Welcome to the doctor JJ Thomas podcast. Today's podcast, we're gonna do another clinical rounds. And if you haven't seen one of our clinical rounds before, what they are is I go through a real life clinical scenario that's happened with a patient of mine, and I'll take you through their story, our evaluative process, our thought process for integrating both choices in treatment, and in integrating back to return to activities.

Dr. JJ Thomas: 01:34

So today's clinical rounds is actually, I think, a really important one. One that is has a high need for the public. So if you're a clinician and you've seen anyone who's come in with reports of carpal tunnel, issues, that's what we're gonna talk about today. I'm gonna share with you the real life story. My friend Sean, who has become, he's actually a, he's my son's wrestling coach, one of my son's wrestling coaches.

Dr. JJ Thomas: 02:02

And, he told me, he said, JJ, he's gonna share his story with you as well. But he said, JJ, I get numbness in both my hands, so I'm gonna have surgery coming up here shortly in a few weeks. And I said, What do you mean? What surgery are you gonna get Sean? And he said, oh, they told me I have carpal tunnel.

Dr. JJ Thomas: 02:22

So I'm gonna get carpal tunnel surgery on both of my wrists. And I said, okay, slow down a second. Let's talk about your your symptoms here. I said, tell me about your numbness. What do you what kind of symptoms do you get in your hands?

Dr. JJ Thomas: 02:34

He said, my both whole hands go numb. Now, as a clinician, if you heard that, I know that some flags would go up. Right? Because we know that if it's truly carpal tunnel, if if it's truly an entrapment of the median nerve at the carpal tunnel, then the whole hand is not gonna be what's going numb. We know from our studies and from our research that that the carpal tunnel if the carpal tunnel is entrapping the median nerve, what that patient will show will represent with is numbness in the median distribution on the palmar side, which will be the thumb, the pointer, the middle finger, and half of the ring finger, but not the palm.

Dr. JJ Thomas: 03:16

So the numbness will be here on the palmar side, these 3 and a half fingers, the inside of the ring finger, but not the palm. And on the dorsal side, it'll only be the distal, the DIP, the dorsal DIPs of essentially this little spot here on the thumb, and then these 2 dorsal DIPs, and a little bit maybe there. But mostly, dorsal side, it won't be here. Now my friend Sean had numbness on his whole hand. So I have to this is fun for me though.

Dr. JJ Thomas: 03:46

Right? Because I love the investigation part of it. Meanwhile, there's a little bit at stake, because I'm thinking, oh, God. I hope I I hope I can convince him or help him in a way that he doesn't get a surgery that potentially he doesn't need. So both of them, I decided, you know what, we're gonna look mainly.

Dr. JJ Thomas: 04:01

I said, which one's worse, Sean? He said, the left one's worse. I said, we're gonna focus on that one today. So we looked a little further because I explained to him. I said, Sean, listen.

Dr. JJ Thomas: 04:11

The median nerve doesn't doesn't send doesn't If it's if it's damaged, it doesn't produce numbness in the whole hand. The ulnar nerve feeds over here. Right? And then we have different myotobo contributions both, all the way up the arm, but in each finger and in different muscle groups that we can test out. So I said, let me just look into this further for you, Sean.

Dr. JJ Thomas: 04:31

But before we do, I said, how about other, other histories? He said, oh yeah, I had shoulder surgery, I had a history of some neck, disc problems. I said, okay, we're gonna check it all. So I'm not gonna go into his full evaluation in in here, but what I really wanna highlight is the importance of, differentiating between carpal tunnel and other nerve entrapments that could be anywhere from the wrist, elbow, to the pec, to the scalenes, to the neck. Right?

Dr. JJ Thomas: 05:03

So the way we differentiated for Sean is I said, okay. I already know that, oh, let's just say that maybe the median nerve is entrapped at the wrist, but something else has to be also entrapped then to create the palmar distribution of numbness and the ulnar side distribution of numbness. So now I'm thinking, like, that kinda sounds like a zebra to have all those things at once. Let's start differentiating. When I did myotomal testing on Sean, the only thing that was weak was lumbar cleal grip of the of the, actually the ulnar side.

Dr. JJ Thomas: 05:37

So lumbarical grip, you can test t one by having them resist basically opening the fingers, so resisted adduction, essentially. And you do it if you do it on the radial side and the ulnar side, then that will help you differentiate between t one and median nerve, which will be the radial side, and ulnar nerve, which will be the ulnar side. So Sean, when I tested him, was actually clean as a whistle myotomely on the median nerve side, on the radial side. He could hold this strong as an ox. When I had him resist lumbrical grip on the ulnar side, however, he was weak.

Dr. JJ Thomas: 06:19

So now I'm thinking, okay. So it's pretty unlikely that he has a median nerve entrapment at the wrist that's producing numbness on this radial side, including the palm, which doesn't happen with strict carpal tunnel. Ulnar weakness somewhere else in trapping. Let's work our way up the chain and see what's happening at the neck and shoulder. When I tested out the shoulder and the neck, I will go through the whole scenario because it's important.

Dr. JJ Thomas: 06:44

When I went through the shoulder and neck, we'll start with the shoulder, the shoulder had, both tightness and motor control deficits, and like I said, he had a history of rotator cuff and labral issues on the left as well. When I look at his neck, his neck was severely limited. Standing rotation was limited bilateral, and you could see restriction as he moved. He was probably about, 40 degrees to the left and about 40 degree it was really about 40 degrees both sides. Flexion and extension were both limited as well.

Dr. JJ Thomas: 07:22

So in palpation, we found he was also very tight on the scalenes. Let's rewind a second and think about all the places he could be entrapped. He could be entrapped at the carpal tunnel here, but if he's entrapped there, he's not gonna be numb on the palmar side, and that would not explain his ulnar sided numbness either. He could be entrapped at the pronator teres median nerve. If the median nerve is entrapped between the two heads of pronator teres here, I'll show you on the anatomy app in a second, then you will have the palmar numbness.

Dr. JJ Thomas: 07:55

So if it's entrapped at the elbow, yes, we'll have palmar numbness. That explains that. Still doesn't explain the ulnar side. So now I'm thinking up the chain. It could be at pec minor, potentially, where those nerves come through, but it could also be scalene.

Dr. JJ Thomas: 08:11

I went to neck and scalene first because of his history of, he said, multiple disc issues, which, you know, essentially herniations is what he said. I don't know the severity. I know that he didn't have any any any history in terms of treatment there. He just said it's something he's just dealt with. So we went to the neck first.

Dr. JJ Thomas: 08:32

I did dry needling. After palpation, I dry needled his obliquus capitis inferior. I'm gonna show you these. So if we let's actually go let's go here first. I'm gonna zoom in to show you the areas that the median nerve can get entrapped.

Dr. JJ Thomas: 08:51

I'm gonna remove palmaris longus here because it's kind of blocking the way. So at the wrist here, you can see it's too hard to click on this single thing. You can see where the median nerve comes through here and can get entrapped at the wrist. But we know then that we're not gonna have the palmar side distribution and it's certainly not gonna be the whole hand. If we go up the chain here to the pronator teres, let me remove the aponeurosis.

Dr. JJ Thomas: 09:21

Gonna take off connective tissue actually. Thought I did. Here's pronator teres and you can see where the median nerve peaks out. Let me remove some more muscles here so we can see. So it's right there coming under the two heads of pronator teres.

Dr. JJ Thomas: 09:38

If we zoom back out and we look up the chain further and we take one layer of muscle off, here's pec minor, and you can see that there's a conglomerate of nerves that we know run right under pec minor. So it could be more like a thoracic outlet type syndrome where he's compressing multiple nerves. Now that starts to make a little bit more sense to me because he had the median numbness, the ulnar numbness, and the ulnar weakness. So it could be higher up on this brachial plexus here, or it could be higher up at the scalenes. Here's scalene posterior.

Dr. JJ Thomas: 10:18

I'm going to really zoom in for you, and you can see under scalene posterior, if I hide that now, and here's middle scalene, I'm gonna hide that, all these nerve trunks come out right there. Boom boom boom boom boom. Middle trunk, Right? So all these superior trunk, all these nerves are right under there as well. So in my mind, I'm gonna clear all these potential entrapment sites.

Dr. JJ Thomas: 10:43

I'm gonna palpate them. I'm gonna see if I think they're relevant. But first, after looking at his neck range of motion, I decided I really, knowing he has a history of neck injury anyway, I wanna access those, those multifidi, those deep muscles of the neck, to really stabilize his neck and hopefully reduce any nerve entrapments up at the neck. So if I remove semispinalis capitis we can reveal here it is, obliquus capitis inferior. This is one of the most important muscles for headaches for, cervical flexion and extension and rotation.

Dr. JJ Thomas: 11:22

I mean, it literally it goes from, from c 1 to c 2, and when you can access this, you really help with rotation of the neck. Not only did I do that one, but then I came down and I did multifidi of c 5 to t 1. Again, remembering that his t 1 or his ulnar side was weak with lumbricle grip, I really wanted to access that t 1 to give to give, positive input to those muscles and those multifidi. So we needled that, and as then I retested him, his neck range was so much better. And he's like, I think my hand might feel a little bit better, I'm not really sure.

Dr. JJ Thomas: 12:01

You know, it was his left side, but he's like processing the whole thing, you know, but he's like, wow, my neck feels so much better. I can't believe it. I I said, you know what, let's go back down on the table, let's check scalenes. Because I could just see he was still limited in that in that triangle area. I put him in side lying, I palpated his scalenes.

Dr. JJ Thomas: 12:18

Boy, were they tight. Like, banded, banded really tight. I needled the scalenes. We teach that in our in our dry needling master class. If you don't know how to do it, it's a very helpful muscle.

Dr. JJ Thomas: 12:30

They also teach it in many other certification courses that I've taught with and I have friends who teach with, so if you need to know, reach out, let me know. But we needed his scalenes and, got back up, retested his range. Again, it was so much better. But more importantly, he's like, I really think my hand is so much better. And again, I try to not put too much, you know, patients wanna be better.

Dr. JJ Thomas: 12:54

So sometimes when they say it right away I just let them sit with it. Like, I didn't I didn't push it too much. He's I forgot, I left this out in the beginning. He had numbness in his hand for, like, over a year. I think he said a year and a half, maybe even closer to 2 years.

Dr. JJ Thomas: 13:08

And so I don't want to, like, you know, I don't want to confuse him, I just want him to process this on his own. So he's like, oh my God, JJ, I think my hand feels better. I said, you know what? I think we did some really good things here. Let's see how this goes.

Dr. JJ Thomas: 13:21

And that is where I got the text message, the next day with the video that he told me, I can't believe the progress. So the cool thing is, he actually canceled his carpal tunnel surgery. I'm seeing him again, Wednesday night, coming up this week, so that'll be our second visit. We're gonna tease out the right arm as well, and see what's going on there. Maybe that is has carpal tunnel component.

Dr. JJ Thomas: 13:43

I didn't tease out the right side yet, but I do know that with this process of thought, you know, we can go through and differentiate between all different types of, symptoms and contributions of the nervous system, and really help our patients get, get what they need. Rather, I've had I learned to do this systematically, because unfortunately, I've had too many patients that came to me after carpal tunnel surgery. And they're like, oh my God, JJ, I had numbness in my hands, I didn't know about you. I had carpal tunnel surgery, I have the same numbness in my hands. That is like, the worst feeling, as a patient, as a therapist, as anyone.

Dr. JJ Thomas: 14:21

And, so to be able to help someone not get a surgery that they don't need is huge. So I hope this helps you guys. I look forward to, working through all of these clinical scenarios more with you. If there's other things you wanna hear about, please let me know, and, we can do some clinical maybe clinical live rounds one day. Looking forward to hearing from you.

Dr. JJ Thomas: 14:43

Talk soon.