Follow Dr Huang to Learn Clinical Diagnosis (19)

Palm Pain for Six Months – Why I Did Not Believe It Was Carpal Tunnel Syndrome

This was a middle-aged female patient who came to see me specifically for what she believed was carpal tunnel syndrome.

Before visiting my clinic, she had already seen a neurology specialist. Carpal tunnel syndrome was suspected, and she was waiting for an EMG study. If the findings supported the diagnosis, surgery might be considered as the next step.

On the surface, the process seemed perfectly reasonable. Hand pain, referral from a GP, specialist assessment, EMG testing, and surgery if necessary. This is a very standard clinical pathway.

However, after listening carefully to her story, I kept feeling that something did not quite fit.

The reason was simple.

The pain was not in her fingers.

It was in her palm.

A Detail That Made Me Stop and Think

Her main complaint was pain in the right palm that had been present for more than six months.

At rest, the pain was usually around 3 out of 10. However, certain activities would significantly aggravate the symptoms. Fastening or unfastening a bra behind her back, reaching behind herself after using the toilet, and making a forceful “OK” sign could increase the pain to 5, 6, or even 7 out of 10.

What I found unusual was what she did not have.

She had no obvious numbness in the thumb, index finger, or middle finger. She was not waking up at night because of hand symptoms. Almost all of her discomfort, including both pain and occasional abnormal sensations, was concentrated in the palm itself.

At that moment, I stopped and started thinking.

Palm pain is not the most typical presentation of carpal tunnel syndrome.

From an anatomical perspective, the palmar cutaneous branch of the median nerve leaves the main nerve before it enters the carpal tunnel. Classic carpal tunnel syndrome commonly causes numbness and tingling in the fingers, but isolated palm pain is not usually the dominant feature.

This became my first reason for questioning the diagnosis.

Of course, that alone was not enough to rule out carpal tunnel syndrome.

But it was enough to make me suspicious.

A Diagnostic Label Is Not a Diagnosis

The patient told me that the neurologist suspected carpal tunnel syndrome.

She also mentioned that the consultation lasted only around ten minutes and that no detailed physical examination was performed. I do not know the specialist’s full reasoning process, so I cannot comment on whether the conclusion was right or wrong.

However, in my view, a diagnosis should be supported by both history and clinical findings.

So I started my own assessment.

I examined the thenar muscles and found no obvious muscle wasting. Sensory testing revealed no clear sensory loss. Examination around the wrist did not produce a positive Tinel’s sign. Neither the carpal tunnel region nor the pronator teres region showed classic signs of nerve injury.

In other words, I could not find convincing evidence that the median nerve was significantly damaged, nor could I find the typical findings that would strongly support carpal tunnel syndrome.

For that reason, I was not ready to place a carpal tunnel label on her condition.

What Changed My Thinking Was Not the Examination

Over the years, I have come to believe that the location of pain is often only the final result. Movement patterns are often closer to the real cause.

So I changed my question.

Instead of asking where it hurt, I asked what movements made it hurt.

The patient described three activities that consistently aggravated her symptoms: reaching behind to unfasten a bra, reaching behind herself after using the toilet, and making a forceful “OK” sign.

At first glance, these activities appear unrelated.

But when I analyzed them more carefully, they shared one important feature.

All of them required forearm pronation and active thumb involvement.

At that moment, my attention shifted away from the palm and toward the forearm, particularly the pronator teres muscle.

Sometimes the problem is not located where the pain is felt. Sometimes it lies somewhere along the movement chain that produces the symptom.

Following the Trail From the Palm to the Forearm

With this new perspective, I began focusing on the pronator teres.

Further examination revealed significant tightness in the right pronator teres region, especially near its proximal attachment below the elbow.

Interestingly, pressing this area did not directly reproduce the patient’s palm pain. Many clinicians might have stopped there.

Nevertheless, I decided to treat the region.

I used acupuncture and cupping around the Quze (PC3) and Kongzui (LU6) areas.

The response was immediate.

Her resting pain dropped from approximately 3 out of 10 to around 1 out of 10. When she repeated the activities that previously aggravated her symptoms, the pain decreased from 5–7 out of 10 to approximately 3 out of 10.

That response gave me greater confidence.

If the primary problem had originated from the metacarpophalangeal joints, the thumb carpometacarpal joint, the thenar muscles, or the local soft tissues of the palm, treatment directed at the forearm should not have changed the symptoms so quickly.

Furthermore, examination of the hand, joints, and soft tissues failed to reveal any convincing local pathology.

Yet after treating the pronator teres region, the palm pain improved immediately.

This suggested that the pronator teres was not simply an incidental finding. It appeared to be an important part of the symptom chain.

Why the Diagnosis Matters

Many people think a diagnosis is simply a name.

In clinical practice, however, a diagnosis often determines the available treatment options and the potential for recovery.

If this ultimately proves to be classic carpal tunnel syndrome with significant nerve compromise, the treatment space for acupuncture may be relatively limited because the carpal tunnel is largely a structural problem involving bone and ligament.

However, if the problem is related to pronator teres tightness, increased neural tension, or nerve sensitization, the possibilities become much broader because muscles and soft tissue restrictions are often far more responsive to treatment.

In other words, changing the diagnosis from “carpal tunnel syndrome” to a pronator teres-related condition transforms the clinical landscape.

Instead of facing a narrow treatment pathway, we suddenly have a much larger therapeutic window.

Diagnosis does not merely determine the name of a condition.

It influences treatment strategy and may ultimately affect the patient’s recovery potential.

At present, I am leaning toward the possibility of a proximal median nerve irritation pattern. Because the palmar cutaneous branch leaves the median nerve before the carpal tunnel, a patient may experience palm pain without the typical finger numbness associated with classic carpal tunnel syndrome.

Of course, this remains a working diagnosis.

Future follow-up, resisted pronation testing, further hand examination, and the EMG results will help determine whether this interpretation is correct.

One Small Detail Changed the Entire Direction

This case reminded me that one detail that does not fit is often more valuable than ten details that do.

Everyone was focused on one question:

“Is this carpal tunnel syndrome?”

I was focused on a different one:

“Why does the pain stay in the palm?”

That seemingly insignificant observation led the entire diagnostic process down a different path.

In clinical practice, we are often guided by imaging findings, reports, and diagnostic labels. Yet the real breakthroughs frequently come from the details that cannot be easily explained.

Diseases do not always read the textbook before presenting themselves.

Patients rarely behave exactly the way we expect them to.

Many important discoveries begin with something that simply does not make sense.

Dr Huang’s Clinical Reflection

What I wanted to record from this case was not the possibility of pronator teres involvement.

It was the thinking process.

The patient had already been labelled as a possible carpal tunnel syndrome case. Her GP thought so. The neurologist thought so. An EMG had already been arranged.

Following that pathway would have been easy.

What stopped me was one small detail:

The pain was in the palm.

In my mind, classic carpal tunnel syndrome is most commonly associated with numbness and sensory disturbance in the thumb, index finger, and middle finger. Yet this patient’s primary complaint was palm pain.

That small inconsistency prevented me from accepting the diagnosis without further questioning.

So I listened again. I examined again. I analyzed the movements that aggravated her symptoms.

Eventually, the most important clue did not come from imaging, pressure points, or test results.

It came from the movement pattern itself.

The longer I practice, the more I believe that the most important clinical skill is not memorizing diseases.

It is maintaining healthy doubt.

When a diagnosis fails to explain the whole patient, we should keep asking questions instead of immediately looking for evidence that supports the diagnosis.

Very often, diagnostic progress comes not from the findings that fit our expectations, but from the findings that do not.

This case reminded me once again that the greatest danger in clinical practice is not making a wrong diagnosis.

It is stopping the thinking process once a familiar diagnosis appears.

For this patient, everything began with one simple question:

Why does the pain occur in the palm?