Wrist and Hand Pain: Carpal Tunnel and Arthritis

Two problems account for most of the wrist and hand pain we see: carpal tunnel syndrome, where a nerve is compressed at the wrist, and osteoarthritis at the base of the thumb. They feel entirely different and are treated differently, so distinguishing them is straightforward once you know what to ask.

Pathophysiology: carpal tunnel syndrome

The carpal tunnel is a fixed space at the wrist. Its floor and walls are formed by the carpal bones; its roof is the transverse carpal ligament. Nine flexor tendons and the median nerve pass through it. The tunnel cannot expand.

When pressure inside rises — through swelling of the tendon sheaths, fluid retention, or reduced tunnel volume — the median nerve is compressed. The nerve tolerates this poorly. Raised pressure first impairs the blood supply within the nerve, producing intermittent symptoms that are worst at night when fluid redistributes and the wrist tends to rest in a flexed position. Sustained compression then damages the myelin sheath, and with prolonged compression the nerve fibres themselves degenerate.

That progression is why timing matters. Early symptoms are fully reversible. Late changes — persistent numbness, and wasting of the thenar muscles at the base of the thumb — may not fully recover even after successful decompression.

Symptoms

• Numbness and tingling in the thumb, index, middle and half the ring finger. The little finger is typically spared, because it is supplied by a different nerve — a genuinely useful clue
• Symptoms worst at night, often waking you to shake the hand
• Dropping things; difficulty with buttons, keys and jar lids
• Visible wasting of the muscle bulk at the thumb base — a late sign and a reason to be seen promptly

Pathophysiology: thumb base arthritis

The trapeziometacarpal joint at the base of the thumb is a saddle joint, built for a wide range of motion. That mobility comes at the cost of stability, and it depends heavily on its ligaments. As those ligaments loosen with age and use, the joint surfaces subluxate slightly and load distributes unevenly across the cartilage. Cartilage wear follows, with the usual accompaniments: subchondral bone changes, osteophytes and episodic synovitis.

Because pinch grip loads this joint at many times the force applied at the fingertips, it becomes symptomatic earlier than most other hand joints.

Symptoms

Pain at the base of the thumb on gripping, pinching, turning a key or opening a jar, with aching that lingers afterwards. Later, a squaring-off appearance at the thumb base and loss of pinch strength.

First-line treatment

For carpal tunnel syndrome: a night splint holding the wrist in a neutral position, which addresses the nocturnal symptoms directly, plus modification of aggravating activity. This alone resolves a substantial proportion of milder cases.

For thumb base arthritis: a thumb spica splint, hand therapy, and adapting the way you grip and load the thumb.

Injection options

Injections are not a treatment on their own. Used well, they reduce pain enough that you can do the rehabilitation that actually changes the outcome. Used as a substitute for that work, they buy time and little else. These are the options we discuss.

Corticosteroid

A strong anti-inflammatory placed directly into the painful structure. Onset is fast — usually within days — and for someone who cannot sleep or cannot work, that speed matters.

The limitation is duration. The effect fades over weeks to months, and repeated injections into the same tendon carry a real risk of weakening the tissue. In tendon problems specifically, the evidence is uncomfortable: corticosteroid outperforms doing nothing in the short term but does worse over a year. We use it deliberately and sparingly, and we will tell you if we think it is the wrong choice for your problem.

Platelet-rich plasma (PRP)

A sample of your own blood is spun in a centrifuge to concentrate the platelets, which carry the growth factors involved in tissue repair. The concentrate is injected into the injured tissue.

PRP works in the opposite direction to corticosteroid: onset is slower, often several weeks, but the effect tends to last longer. Preparation matters — leukocyte-poor systems, which remove most white cells, have performed better than leukocyte-rich ones in comparative studies. We use a leukocyte-reduced system.

PRP is a genuinely promising option and we are honest about where the evidence sits: the trials are smaller and less consistent than we would like, and some professional bodies still recommend against it on those grounds. We think it is reasonable for selected patients, and we will say so if we do not think you are one.

How the injection is given

Accuracy matters more than most people expect. Injections placed by landmark alone miss the intended target a meaningful proportion of the time, particularly in deep joints like the hip and in the small spaces around the shoulder and wrist. Ultrasound guidance lets us see the needle reach the structure we are aiming at, which improves both accuracy and safety.

The injection itself takes a few minutes. Most people feel some soreness for a day or two afterwards. We usually ask you to avoid heavy loading of the area for a short period, then start or resume the rehabilitation programme.

Where injection fits in the hand and wrist

In carpal tunnel syndrome, corticosteroid injected into the tunnel reduces the pressure on the nerve and can give good relief. It is genuinely useful both as treatment and as information: a good response supports the diagnosis. The benefit is often temporary, and where symptoms return or where there are signs of ongoing nerve compromise, surgical decompression is highly effective and is the definitive answer.

In thumb base arthritis, injection into the joint can settle a painful flare and make splinting and therapy tolerable.

Both targets are small and lie close to structures you do not want to inject. These are injections where ultrasound guidance earns its place.

PRP has a smaller evidence base in the hand than in larger joints and tendons. We will be straightforward about that rather than offer it as an equivalent option everywhere.

When to see a doctor

See someone if you are regularly waking at night with a numb hand, if numbness is becoming constant rather than intermittent, if you are dropping things, or if you notice loss of muscle bulk at the thumb base. Constant numbness and visible wasting are the two findings that should not be watched and waited on.

Part of the other joints we treat. See also elbow pain, shoulder pain.

Written by Dr Gerard Ee. Last medically reviewed and updated: September 2026.