Pillar Pain After Carpal Tunnel Release
John M. Erickson, MD
Carpal tunnel release surgery is one of the most common procedures performed by hand surgeons in the United States. Over 90% of patients are pleased with the results of surgery, and they would recommend the surgery to a family member or friend. After the procedure, most patients have decreased hand numbness, no more hand tingling at night, and less "pins and needles" hand pain. Many patients say that they are finally able to sleep well because of the surgery.
However, surgical site pain known as “pillar pain” can be a temporary problem for some patients. "Pillar pain” is a frequent symptom following carpal tunnel release. The pain is located at the base of the hand in the heel of the palm. The muscles at the thumb base (thenar eminence) and the muscles at the base of the small finger (hypothenar eminence) are the usual areas of tenderness. The palm is sore when pressed in these locations, marked with red asterisks in the photo. This condition can occur with either open carpal tunnel release or endoscopic carpal tunnel release, but it is more common after open surgery.
Most patients can return to office work within a week and heavy manual labor within 3-4 weeks following carpal tunnel surgery, but pillar pain can make recovery from carpal tunnel release surgery take longer than expected. Putting pressure on the palm, such as trying to do a push-up or gripping a golf club, can increase the soreness.
Pillar pain does not last forever. The symptoms go away within three months in most patients. Occasionally, pillar pain can last six months. The vast majority of patients no longer have this type of pain 12 months after surgery.
There is not a good way to predict who will get pillar pain with surgery. No one knows exactly why pillar pain occurs. There are several theories to explain this condition:
Tender scar tissue: There are bony prominences in the palm that can aggravate inflamed scar tissue from surgery. The trapezium bone (within the thenar eminence) and the hamate bone (within the hypothenar eminence) are both close to the skin in the palm where the transverse carpal ligament is released during surgery.
Changes to muscle alignment: When the transverse carpal ligament is released, there are subtle changes to the mechanics of the carpal bones and the palmar muscles, which might contribute to pillar pain.
Joint inflammation: Inflammation within the nearby joints of the hand can cause pillar pain. The thumb carpometacarpal joint is a common site of wear and tear arthritis. If this joint had arthritis prior to the surgery, it can become inflamed and painful within the thenar eminence. This process can also occur at the hypothenar eminence within the piso-triquetral joint.
Nerve irritation: There are many skin sensory nerve branches in the hand and palm. These nerves might be irritated from the surgical dissection and healing scar tissue.
Hand therapy is sometimes recommended to treat pillar pain. Stretching, scar massage, desensitization, and other modalities can be used by hand therapists to reduce pain. Steroid injections are occasionally used to reduce scar tissue formation, as well. Revision surgery is not usually necessary for this condition. Most patients do not require oral medications for pillar pain.
I tell my patients to keep using their hands while working through the pain. After the carpal tunnel incision has healed, hand activity is not harmful to the recovery process. Doing too much with the hands after surgery can result in soreness, but it does not cause long-lasting damage. Eventually, pillar pain gets better with time.
Dr. John M. Erickson is a hand and upper extremity specialist at the Raleigh Hand Center. He trained in orthopedic surgery at the University of Michigan and completed a hand surgery fellowship at Vanderbilt University. He is an active member of the American Society for Surgery of the Hand (ASSH).