Numbness/ Tingling/ Weakness Upper limb



Numbness, tingling sensations and weakness in upper limbs is a common issue caused by various conditions affecting the nerves in the Head & Neck, Shoulder, Elbow & Wrist. Few of the causes are:

  • Neck muscle strains
  • Worn joints (Osteoarthritis) of facet joints in neck
  • Nerve compression or irritation (Herniated disks or bone spurs)
  • Injuries (auto collisions)
  • Diseases such as rheumatoid arthritis and inflammatory neck pain.
  • CCPs (Chronic constricting points) along the course of nerves
  • Neuritis/ Radiculitis
  • Diabetic neuropathy



The doctor takes note on the previous medical record and does a physical exam to check for tenderness, numbness and muscle weakness. He may, if required also order:

  • X-rays:  To reveal bone spurs or other degenerative changes.
  • MRI scan: Uses radio waves with a strong magnetic field to create detailed images of bones and soft tissues in the neck.
  • Electromyography (EMG)/ NCV
  • Blood tests:  Provide evidence of inflammatory or infectious conditions.

The doctor might recommend:

  • Medications including Oral Steroids, Gabapentin, Methylcobalamin, etc
  • Physical therapy: A physical therapist instructs on correct posture, alignment and neck-strengthening exercises.
  • Transcutaneous electrical nerve stimulation (TENS): this technique uses electrodes to deliver tiny electrical impulses that are placed on the skin near the painful areas to relieve pain.
  • Traction: this method uses weights, pulleys or an air bladder to gently stretch the neck.
  • Immobilization for short-term:  A soft collar that gives support to the neck is used to help relieve pain by easing the pressure off the neck structures.
  • Surgery: Might be an option for relieving nerve root or spinal cord compression.


Neural & Soft Tissue Infilteration Therapy (NESTIT)

Low Dose Steroid Infilteration/ Neural & Soft Tissue Infilteration Therapy (NESTIT):  Steroid tablets and injections of the group Corticosteroids, (which are very different from Anabolic steroids misused by some athletes) have been repeatedly proven medically for the last 70 years in the successful treatment of inflammatory conditions due to its potent anti-inflammatory effect. Though corticosteroids are very effective in reducing inflammation, they carry numerous potential side effects, which are undesirable. To circumvent this problem, and in order to utilize the potent anti-inflammatory effects of steroid injections, at the same time taking appropriate measures to considerably lower its side-effects, Dr Tejaz Koshy John in 2010 while working as an Orthopaedician in his private clinic in Guyana, South America developed NESTIT. NESTIT stands for (Juxta) Neural and Soft Tissue Infilteration Therapy. It consists of injecting small amounts of diluted anti inflammatory steroid solution indirectly near (juxta) nerve CCPs- (chronic constricting points) in the lower back/ hip/ neck/ shoulder regions, in order to reduce juxtaneural and perineural inflammation, as well as in certain soft tissue sites including but not limited to trigger points (painful muscle “knots”)/ myofascial syndrome and/or enthesitis (inflammation of soft tissue-bone junctions) and/or sites of nerve inflammation (neuritis/ radiculitis) and/or bursitis (inflammation of fluid filled cushions called bursa) and/or additional sites causing pain referrals (referred pain) to distant sites; in order to obtain a reduction in inflammation and pain in the concerned joint/ region/ limb. It is preferably given for those patients who have Rheumatoid Arthritis, Inflammatory Arthritis, Synovitis, Inflammatory Low Back Pain, Spondyloarthropathy & Nerve and Nerve root irritation. It is not a substitute for DMARDS (Disease modifying anti rheumatoid drugs), however when given with low dose DMARDS, in Dr Tejaz John’s clinical experience it may result in significant reduction of local inflammation, pain and improvement of joint function in most cases, also indirectly reducing side effects of high dose DMARDS.

NESTIT involves 

  1. Administeration of low dose local steroid via infilterative type of injection technique rather than giving oral steroids (as cumulative daily dosage of oral steroids over a 6 week period could exceed the dose of local steroid injection by almost 5 to 10 times) or conventional single injection into joints directly.
  2. Reduce the dosage of Steroid given via injection and the use of a sliding scale according to patient’s body weight and height to regulate dosage. A 40 kg woman of 4 feet 9 inches should not receive the same dosage as a 100 kg male of 6 feet height.
  3. Dilute the low dose steroid injection upto 80% with sterile water and local anesthetic.
  4. Administer relatively insoluble low dose steroid via multiple infilterations locally in inflamed tissues in very small amounts indirectly near (juxta) nerve CCPs- (chronic constricting points) in the lower back/ hip/ neck/ shoulder regions as per requirement, in order to reduce juxtaneural and perineural inflammation, as well as in certain soft tissue sites including but not limited to trigger points (painful muscle “knots”)/ myofascial syndrome and/or enthesitis (inflammation of soft tissue-bone junctions) and/or sites of nerve inflammation (neuritis/ radiculitis) and/or bursitis (inflammation of fluid filled cushions called bursa) and/or additional sites causing pain referrals (referred pain) to distant sites; in order to obtain a reduction in inflammation and pain in the concerned joint/ region/ limb.
  5. Identification of high risk patients and risk stratification to reduce possibility of side effects, for eg. Patients suffering from serious heart & liver conditions tuberculosis, infections, significant osteoporosis, immuno-compromised patients, menstrual irregularities, already having Cushing’s syndrome, ongoing significant hair loss etc.
  6. Regular monitoring of body weight and physical appearance for early detection of Cushingoid features, if it occurs (rarely), to delay/ avoid further injections.
  7. Control of High Blood Pressure and Diabetes prior to giving injections.
  8. Doing skin sensitivity tests to rule out allergic reactions to the drugs.
  9. Explaining possibilities of common & rare side effects to the patient and taking precautions regarding other common side effects wherever possible.
  10. Opting for/ Shifting to regenerative treatments like Platelet Rich Plasma and Dextrose Prolotherapy wherever there is secondary degenerative disease / soft tissue damage, once the severe inflammation subsides.

In Dr Tejaz John’s clinical experience, the patient benefits of Low Dose Steroid Infilteration/ Neural & Soft Tissue Infilteration Therapy (NESTIT) treatment are:

  • Minimally invasive treatment method
  • Almost painless injection technique using very thin needles under local anesthesia
  • For those who want to avoid if not delay Neck surgery.
    Significantly reduces the neural symptoms associated with Inflammation.
  • Reduced risk of adverse events compared to oral steroid tablets which are taken daily, due lower dosage (very low steroid dosage compared to cumulative oral steroids over 6 week period).
  • Reduced risk of side effects/ adverse effects due to prior risk stratification and identification of high risk patients vs. low risk patients by doing precautionary steps and tests prior to giving injection.
  • Reduced incidence of post-injection pain due to highly diluted steroid solution.
  • Reduces pain, numbness and discomfort in most patients.
  • More effective treatment method in neural symptoms like numbness, tingling and weakness caused due to inflammatory conditions.
  • Faster recovery.
  • NESTIT treatment results in significant, effective, progressive improvement of pain, numbness, and function if given in series.
  • NESTIT may be followed by regenerative injections like Comprehensive Dextrose Prolotherapy at a later date to address the problem of neck instability which is the root cause of neural symptoms in many cases.


The root cause of most neck pain including disc prolapse is Cervical Instability. The stable cervical spine behaves like a see saw with its fulcrum at the facet joint. The disc in front is kind of balanced by ligaments and muscles at the back. If there is damage to the ligaments/muscles in the form of strain, more weight is transferred to the disc region in the front which may lead to disc prolapse. In Dr Tejaz John’s experience Platelet Rich Plasma Prolotherapy and Dextrose Prolotherapy offer the best results by stimulating the body’s immune system to repair and naturally tighten these ligaments and muscles at the back of the facet joint, thereby relieving stress in front of the facet joint namely the disc region.


Symptoms caused by Cervical Instability

  • Progressively worsening symptoms.
  • Frequent recurrence of catching/ locking neck pain & muscle spasms.
  • Feeling of dizziness, neck instability or giving way.
  • Pain on neck movements.
  • Need to crack or click the neck frequently to reduce symptoms.
  • Temporary relief with cervical collar.

Chronic Conditions caused by Cervical Instability: Radiculopathy, Cervical Canal Stenosis, Degenerative disc disease, Herniated disc, Numbness/ Weakness in upper limb & Cervical Spondylosis.

Many times a patient with neck pain; despite various treatments still has pain and now has been recommended a neck surgery because “MRI shows something”. But is it in fact the disc prolapse on MRI always the cause of the patient’s pain? Medical researchers are asking, “Maybe we should look at the spinal ligaments?”

In our practice we often see patients who are in severe neck pain. They have an MRI, X-ray and/or scan that may show an inaccurate picture of what is causing their pain. The MRI cannot show muscle spasms from a simple cervical strain which can cause excruciating pain. Neither can it detect microstructural damage at the ligament bone junctions/ enthesitis nor can it detect nerve sheath CCPs (chronic constricting points) along the course of various nerves. Conversely, a herniated disc may be seen on MRI which may be completely painless. Yet that herniated disc will send the patient to surgery. Dr Tejaz John has observed in his clinical practice that at times patients may bring MRI showing disc prolapse towards one side whereas the symptoms are experienced on the opposite side.



Here is a statement from the medical journal Childs Nerv Syst. 2015: “As important as the vertebral ligaments are in maintaining the integrity of the spinal column and protecting the contents of the spinal canal, a single detailed review of their anatomy and function is missing in the literature.” Unlike muscle tissue, ligaments and tendons have a poor supply of blood to regenerate them. This is why ligaments can remain in a weakened and irritable inflammatory state and may not heal. The chronic neck pain patient may have history of trauma or overuse to the neck that results in injury to various spinal ligaments that hold the vertebrae and spinal processes in place. Ligaments can bear a normal amount of stress that causes them to stretch up to their natural limit, returning back to their normal length once the stress is removed. If added (traumatic) stress is applied on the ligament, it is stretched beyond its natural range of extension, and subsequently fails to return to its original length but instead remains permanently overstretched resulting in plastic deformation, diminishing its integrity and attachment to the bone. This causes ligament and soft tissue loosening and subsequent cervical instability.

Comprehensive Dextrose Prolotherapy for Neck Pain/ Cervical Instability

Neck pain is one of the leading causes of disability, yet most of the people suffering from it do not know that Cervical spinal instability is most likely the real cause of the problem! We see, most patients take pain tablets and muscle relaxers to cover the pain, which only masks further degeneration and leads to an endless “pain management” cycle. This is like treating the symptoms versus correcting underlying spinal instability. Comprehensive Dextrose Prolotherapy can break this cycle by assisting the regeneration of weakened and stretched-out soft tissue structures of the cervical spine, alleviating pain and instability. Using Prolotherapy, these conditions can be treated properly and safely to give a more desirable symptomatic outcome. If you want to get off the neck pain bandwagon, try Prolotherapy; which is a natural and cost effective alternative method to surgery.

Prolotherapy is an almost painless injection technique under local anesthesia where very thin needles are used to inject high concentrations of dextrose solution (sugar similar to glucose) in to loose and damaged ligaments, tendon and muscle attachments around the osteoarthritic joint/ entheses. Prolotherapy works by increasing the glucose concentration in the fluid outside the cells. This results in movement of fluid from inside the cells to the outside of the cells thereby shrinking the cells and causing temporary cell damage (hyperosmolar damage). As the cells are temporarily damaged, they release many biosignals to the body which results in stimulation of the immune system of the body to accelerate the inflammatory process locally resulting in increased local blood circulation, fibroblast (fibrous cell) proliferation, ligament regeneration, tightening and repair. In Dr Tejaz John’s experience, Prolotherapy is an effective non surgical treatment method used successfully in cervical instability. This treatment method has the ability to strengthen the existing intact, but weakened, ligamentous and tendinous structures in the neck region. Along with the treatment technique, it is important to perform series of movement and muscle strengthening exercises to strengthen the already weakened muscles in chronic cervical Spondylosis.

Patient Benefits of Comprehensive Dextrose Prolotherapy:

  • Minimally invasive treatment method
  • Almost painless injection technique using very thin needles under local anesthesia
  • For those who wish to avoid if not delay Surgery
  • Significantly reduces the symptoms associated with Neck Instability, indirectly helping to prevent recurrence of neural symptoms like numbness, tingling and weakness secondary to cervical instability.
  • Reduced risk of adverse events
  • Repairs and tightens ligaments improving spine stability and ease of standing, sitting & walking
  • Safe and effective treatment method
  • Faster healing and recovery

At Beth Yehuwdah Arthritis Centre, Pullad and Daystar Clinic, Alappuzha we provide a variety of options for patients suffering from Neck Numbness/ Tingling/ Weakness Upper limb conditions. To know more about treatments and about costs, book an appointment now.


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Dr. Tejaz Koshy John

Consultant for Orthobiologics, Regenerative & Interventional Orthopaedics

MBBS, MS Ortho (Christian Medical College, Ludhiana), Joint Replacement Fellowship (HOSMAT Hospital, Bangalore), Orthopaedic Trauma Fellowship (Hebrew University Hospital, Jerusalem, Israel)

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