Pain and Tenderness after Carpal Tunnel Surgery

Paresthesias and scar tenderness are common in the subacute recovery phase following carpal tunnel release. A flare or aggravation of symptoms is common in the period of two to six weeks after surgery. Several different situations may contribute, including the following, listed roughly in most-to-least common:

Normal scar tenderness with anxiety / awareness.
Normal scar adhesions to the perineural tissues. This may result in a sudden, brief electrical paresthesia, typically shooting from the palm out the middle finger tip. It may occur while reaching, gripping, or at rest. It may be alarming, but does not necessarily mean that there is a technical problem with the surgery or with the healing process. Adhesions by themselves would not explain constant pain.

Pillar pain (tenderness adjacent to the actual ligament release, where the prominences of the trapezial ridge and the hook of the hamate are closest to the skin. The transverse retinacular ligament, divided during carpal tunnel release, attaches to these structures, and the inflammatory reaction of normal wound healing is most obvious at these points, often more than the central area of the actual release.

Aggravation of preexisting asymptomatic basal joint, pisotriquetral or triquetrohamate arthritis due to altered isometric stresses on these joints.
Reinnervation hypersensitivity - most often occurs if there was constant tingling, numbness or altered sensibility before surgery.
Reflex sympathetic dystrophy.
Coexisting neruritis from cervical radiculopathy, pronator syndrome, diabetic or other peripheral neuropathy.
Direct nerve irritation of one of the palmar cutaneous sensory branches to the palm or of the median nerve itself.

Clearly, treatment must be individualized, but a good start is to reassure the patient that most problems in this situation are temporary, and to continue to educate the patient about the nature of carpal tunnel syndrome. Nerve gliding exercises and patient self-help oriented desensitization exercises are appropriate for most patients. Burning pain, worsening pain, avoidance, even without objective signs of reflex sympathetic dystropy may be helped with a supervised stress loading program. Questions regarding worsening complaints of numbness, pain, stiffness or swelling should be discussed with the surgeon at the earliest opportunity.

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