Carpal Tunnel Syndrome

By Dr. Chad M. Pens

Carpal tunnel syndrome (CTS) is a condition whereby the median nerve becomes compressed as it passes through the wrist and hand. The formal name for CTS is median nerve compressive neuropathy. The carpal tunnel is located in the base of the hand as it meets the wrist. This is a very complex region containing the median nerve as well as nine tendons, eight that act on the four fingers and one on the thumb. The tunnel is formed by the eight small bones in your wrist and hand (carpal bones) and the band that holds the tendons down, known as the transverse carpal ligament or flexor retinaculum. Since this tunnel does not have much flexibility, any swelling that develops can place pressure on the nerve, thus leading to entrapment and pain.

Carpal tunnel syndrome typically affects the dominant hand, but it can be present in both hands. It affects women more than men and has a peak incidence around 45 years of age. Individuals with CTS typically report a sensation of the hand feeling fat or swollen, as well as an incoordination of the hands that result in “fumbling” and dropping objects. CTS is more common in people that have a more rounded shape of the wrist versus those that are more oval.

Sufferers of carpal tunnel syndrome report pain and parathesias (burning, tingling, pins and needles, or numbness) in the palm of the hand particularly of the thumb, index and middle fingers. The pinky or little finger is not involved in carpal tunnel syndrome since it is supplied by the ulnar nerve, which does not pass through the carpal tunnel. The thumb is often spared from changes in sensation because a superficial nerve that goes to the skin (palmar cutaneuous branch), does not pass through the carpal tunnel. Early on, the condition presents with these symptoms at night that often wake the patient up. This is often the result of the posture that the wrist is held in while sleeping, usually bent to a 90-degree angle, which further compresses the tunnel. CTS presents with altered sensation in the hand in a distribution consistent with the median nerve, which is the palm of the hand. Chronic sufferers of carpal tunnel syndrome will present with atrophy or shrinking of the muscles of the thumb.

Carpal tunnel syndrome will often progress through three stages. Stage one is pain and parasthesias at night. Stage two is when symptoms are triggered by repetitive use of the involved hand. The symptoms of CTS are aggravated by repetitive use of the hands and fingers and gripping tasks, and are often improved by hand shaking or repositioning. Stage three is when the symptoms become constant.

Trauma to the wrist area or base of the hand can cause swelling to any one of the numerous structures passing through the carpal tunnel. Often times this trauma is in the form of micro trauma or repetitive strain. This type of trauma can be the result of writing, keyboarding, sewing, driving, power tools that vibrate, and repetitive work associated with an assembly line. Sports such as tennis, racquetball or several others can also cause swelling in the carpal tunnel.

CTS is a multifaceted condition that can be very difficult to treat which is why it is important to not self diagnose. When symptoms consistent with CTS are present, it is important to consider the source to be a cervical radiculopathy, otherwise known as a pinched nerve in the neck causing radiating pain into the arm and hand. Specific tests can be performed in a physical examination to establish a diagnosis of CTS. Diagnostic tests such as electromyography and a nerve conduction velocity may also be performed.

Carpal tunnel syndrome can be treated conservatively, meaning there are things that can be done to avoid surgery. The use of wrist splints at night is a start. The use of heat and cold can help effect swelling. Specific stretches need to be performed at home to improve flexibility of the forearm and hand muscles. Specific stretches performed by a manual physical therapist to address flexibility of the flexor retinaculum (the soft tissue part of the carpal tunnel) are essential to the success of a conservative treatment approach. Finally, the mobility of the median nerve as it passes through the carpal tunnel needs to be addressed. Without neural dynamic stretching, the nerve can lose its ability to slide, which can lead to prolonged symptoms. Preventative medicine is always the best policy. Therefore, make sure that your work environment is sound ergonomically, take frequent rest breaks, pay attention to your posture, and perform appropriate stretching.

If you are having symptoms such as pain and parasthesias in your hands, be sure and contact your physician to get a referral to start physical therapy. The sooner you have your condition diagnosed and a treatment plan established, the sooner you can be on the road to recovery.