Hi, I have a patient with a severe intermittent shooting pain in her right (R) wrist following a carpal tunnel release, and I would appreciate some advice on where to go with her.

PC
- R anterior & posterior wrist pain (severity 5/10), which shoots up forearm to just distal to the elbow. Slowly develops ache with prolonged activity. (i.e. evening)
- Thenar eminence feels numb
- Activity dependent. (+ weather dependent)
- Aggrevating factors - turning pages of a book, writing.
- Easing factors - painkillers (occ. paracetamol or cocodamol)

HPC
- Dec '05 - Patient slipped on grease and landed on R arm and had pain in R wrist.
- 2 wks later - Saw GP, had nerve conduction tests.
- Mar '07 - Carpal tunnel release.
- 22/08/07 - Initial PT assessment - No better since release, in fact more pain now.
- No investigations
- No prev. physio/or other therapy

PMH
- Nil else.
- Overweight, but generally healthy

SH
- Full time mum (31 yrs old)
- Used to play badminton

O/E
Obs – Thenar eminence swollen (feels fibrous/consolidated.)
AROM
Wrist: R L
E 40 55
F 25 55
RD 5 15
UD 30 45

(PROM is more then AROM in all directions, but causes intense shooting pain from fingers to point just distal to elbow when surpassing AROM)

Radio-ulnar jnt:
Pro full (but shooting pain)
Sup full (but shooting pain)

Static strength
Wrist:
F 4+
E 4+

Accessory mvts
Wrist:
All directions painful causing intense shooting pain.


Palpation
Wrist:
Jnt line tender anterior + posterior

ULTT
Earlier elicitation of pain with wrist mvts when upper limb nerves are ‘wound up’ or ‘tensioned’
Tensioning nerves causes same wrist pain, without shooting to forearm.


Rx
As a treatment I performed very gentle accessory mvts of wrist and gentle massage of anterior wrist and thenar eminence. I also gave advice to the use of ice therapy at home and to perform slow, rhythmic active wrist movements within pain limits, and to perform gentle massage of the same area as long as ache is not exacerbated.

I am not sure what the best approach is with this patient. I am working on the theory that there is significant scar tissue around the wrist which is compromising the median and radial nerves, and that breaking it up will allow increase in ROM without pain. Then we can begin to begin strengthening exercises.
I am afraid of hypothesising too much, but other than this I do not know what the best course of action is, and quite frankly it makes me feel inadequate to not be able to do more.

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