What causes numb and thick feeling hands and palms?

Numb and Thick Feeling Hands and Palms: Causes and Management

Most Likely Causes

The most common cause of numbness and thick feeling in hands and palms is carpal tunnel syndrome, which results from median nerve compression at the wrist and presents with burning, tingling, or numbness in the palm extending to the thumb, index, middle, and radial ring fingers. 1

Primary Diagnostic Considerations

• Carpal tunnel syndrome is the most prevalent compression neuropathy, affecting 3-6% of adults, and is more common in women, people with obesity, diabetes, and those working with keyboards, computer mice, heavy machinery, or vibrating tools 1, 2

• Diabetic peripheral neuropathy should be assessed in all patients with bilateral hand numbness, though it typically starts distally in a "stocking-and-glove" distribution and affects feet before hands 3, 4

• Cervical spinal cord pathology (central cord syndrome or cervical stenosis) can present with bilateral hand numbness and burning dysesthesias in the forearms, particularly in patients with degenerative cervical spine changes 4

• Chemotherapy-induced peripheral neuropathy occurs in 30-40% of patients treated with taxane-based or platinum-based regimens and presents with numbness, tingling, and burning pain 3

Critical Red Flags Requiring Urgent Evaluation

• Bilateral hand numbness with burning dysesthesias in forearms or any lower extremity symptoms requires urgent cervical spine MRI to rule out central cord syndrome 4, 5

• Acute onset of hemibody sensory loss, unilateral face/arm/leg involvement, or associated speech disturbance, visual changes, or coordination problems requires same-day stroke assessment 5

Diagnostic Approach

History and Symptom Characterization

• Document whether numbness is bilateral or unilateral, symmetric or asymmetric, and whether it follows a stocking-glove pattern versus isolated hand involvement 5

• Ask specifically about numbness and tingling in hands and/or feet and the characteristics of symptoms, including whether they worsen at night 3, 5

• Assess for associated symptoms including tingling, burning sensations, pain, weakness, and progression pattern (started in toes first versus fingers, progressing proximally) 5

• Screen for risk factors including diabetes duration and control, alcohol use, chemotherapy exposure, family history of neuropathy, vitamin deficiencies, thyroid disease, and occupational exposures 5, 1

Physical Examination

• For carpal tunnel syndrome: Perform the Durkan maneuver (firm digital pressure across the carpal tunnel to reproduce symptoms), which is 64% sensitive and 83% specific 1

• For peripheral neuropathy assessment: Test small-fiber function with pinprick and temperature sensation, and large-fiber function with vibration perception using a 128-Hz tuning fork and 10-g monofilament testing 3, 5

• Motor examination: Assess for distal weakness, particularly thumb opposition weakness (suggests carpal tunnel syndrome) or toe/ankle dorsiflexor weakness (suggests peripheral neuropathy) 5, 1

• Reflex testing: Check ankle and upper extremity reflexes, as reduced or absent reflexes suggest peripheral neuropathy 5

Laboratory Evaluation

• Initial testing should include glucose metabolism studies, complete blood count, vitamin B12 level, and thyroid function tests 5

• Additional testing including infectious workup and autoimmune markers should be considered when clinically indicated 5

Electrodiagnostic Studies

• Nerve conduction studies and electromyography are approximately 80% sensitive and 95% specific for carpal tunnel syndrome and should be ordered when clinical features are atypical, diagnosis remains unclear, or differentiation between axonal versus demyelinating neuropathy is needed 1, 5

• Electrodiagnostic testing is indicated for suspected proximal compression or other compressive neuropathies 1

Treatment Algorithm

For Carpal Tunnel Syndrome

• First-line conservative treatment: Wrist splinting (particularly at night) and/or corticosteroid injection may temporarily relieve symptoms 1

• Definitive treatment: Patients who do not respond to conservative therapies should undergo open or endoscopic carpal tunnel release 1

For Peripheral Neuropathy

• First-line pharmacologic treatment: Duloxetine should be offered for patients with neuropathic pain, numbness, and tingling 3, 4

• Physical activity should be offered for neuropathy symptoms 3, 4

• Adjunctive pain management: Acetaminophen, NSAIDs, and/or acupuncture can be offered for associated pain 3, 4

For Diabetic Neuropathy

• Improved glycemic control can effectively prevent diabetic peripheral neuropathy and slow progression but does not reverse neuronal loss 3, 4

• Treatment of other modifiable risk factors including lipids and blood pressure can aid in prevention of progression 3

• Up to 50% of diabetic peripheral neuropathy may be asymptomatic, making screening essential to prevent foot ulcers and amputations 3

Common Pitfalls to Avoid

• Do not assume carpal tunnel syndrome without considering mimickers: Many conditions present with similar symptoms including cervical radiculopathy, thoracic outlet syndrome, cubital tunnel syndrome, ulnar tunnel syndrome, and radial tunnel syndrome 6, 7

• Diabetic neuropathy is a diagnosis of exclusion: Nondiabetic neuropathies may be present in people with diabetes and may be treatable, including thyroid dysfunction, vitamin deficiencies, and toxic exposures 3, 4

• Do not delay imaging if central cord syndrome is suspected: Bilateral hand numbness with burning dysesthesias or lower extremity symptoms requires urgent cervical spine MRI before electrodiagnostic studies 4, 5

• Misdiagnosis can lead to unnecessary operative procedures and persistent symptoms, emphasizing the importance of thorough evaluation 6