MaryAnn is a twenty five year old R.N. who had been experiencing pain in the right foot for more than two months.
She did not recall any injury to her foot that could be a cause. I did learn that she liked to walk two or three miles per day. MaryAnn had taken Advil at times if she was especially uncomfortable, but otherwise had not had any treatment. Two previous exams and one set of x-rays had been unremarkable.
What to do?
I see a lot of patients who have carpal tunnel syndrome. Carpal tunnel can present in a number of different ways.
History and physical exam give the most important information.
I often resort to a nerve and muscle test (EMG-NCT) on the affected side to gain even more information.
But sometimes the test comes back marginally positive or even negative. What to do?
If I am convinced that the person has carpal tunnel syndrome, I will go ahead and do a carpal tunnel release.
While tests are very important they don’t always confirm the diagnosis and you have to depend on your clinical skills to make the right diagnosis to help the patient.
I like to think that this is an example of the art of medicine which will remain a very important part of my practice.
Over the years I have successfully treated many carpal tunnel patients whose symptoms were very atypical.
Sandra is a 47 year old church secretary that had been having neck, shoulder and arm pain for more than a year. MRI had shown some bulging at one disc level on the same side of her pain.
Sandra was diagnosed as having a cervical disc protrusion and underwent neck surgery elsewhere. She really had not improved much when I saw her. I noted on my exam that her shoulder was somewhat stiff and painful. Further testing showed that she did not have a rotator cuff tear. I diagnosed “frozen shoulder” or adhesive capsulitis the pain from which can also be referred to the neck and the arm.
I then did an outpatient procedure I call exam under anesthesia. With Sandra asleep for a few minutes I gently moved her shoulder separating adhesions to relive stiffness and inflammation.
After a little physical therapy following the procedure the neck, shoulder and arm pain went away.
The point is there is no law against having 2 things wrong. Sandra did have “disc trouble” in her neck which the MRI showed, but that was not the cause of her symptoms.
I’m glad to say she is feeling well at this time.
In this case a careful history and an exam of her shoulder on the same side led to the correct diagnosis and treatment. The MRI showed something abnormal, but it was not the cause of her pain.