RESOLVING CARPAL TUNNEL SYNDROME – PART 1
Updated: May 25
In the first half of this two-part article on addressing Carpal Tunnel Syndrome (CTS), we'll explore surgical and non-surgical treatments and delve into symptoms, fundamental anatomy, and methods for physical examinations. If you prefer to avoid the more technical details, feel free to skim through this piece, which is designed to cater to patients and healthcare professionals.
In the second part of our series on addressing Carpal Tunnel Syndrome (CTS), we'll discuss the advantages of manual therapy and exercise in alleviating this issue. Additionally, we'll provide video demonstrations of suggested treatment techniques and exercise recommendations commonly given to our patients.
CTS is the most prevalent type of nerve compression syndrome (compressive neuropathy) in the upper body (2,3). It's also the costliest musculoskeletal disorder, impacting businesses and healthcare systems, with annual expenses surpassing 2 billion dollars (mainly due to surgical costs) (1).
This condition involves a collection of symptoms stemming from the compression of the median nerve inside the wrist's carpal tunnel. CTS can be quite debilitating and painful. Fortunately, most CTS cases respond positively to manual therapy and exercise, often eliminating the need for surgery.
CAUSES OF CTS
Carpal Tunnel Syndrome can be caused by anything that compresses or irritates the median nerve within the carpal tunnel. While research indicates that certain activities are more frequently linked to CTS, they are not the sole contributing factors. Some of these associated factors include: (22, 23)
Work-related activities involving repetitive motions, vibrations, heightened wrist stress, and cold exposure.
Conditions with higher CTS occurrence rates, such as diabetes, thyroid disorders, rheumatoid arthritis, menopause, pregnancy, and various hormonal imbalances.
Genetic factors like wrist shape or ligament thickness in the wrist.
Any combination of these factors can result in the median nerve being "tethered," which may lead to increased friction, inflammation, heightened pressure within the carpal tunnel, and even fibrosis (36). The first question to ask when addressing CTS is, "What is the best approach?"
NON-SURGICAL APPROACHES VERSUS SURGERY
Compression of the median nerve can lead to various physiological changes, particularly if left untreated for extended periods. If CTS is not severe (no muscle atrophy or significant sensory impairment), conservative management (manual therapy + exercise) is often highly effective in addressing the condition. However, keep in mind that some CTS cases may require surgery.
Many patients prefer to avoid surgery at all costs, and their wishes should be respected. At the same time, it's crucial to ensure that these patients know the potential consequences of untreated severe nerve compression.
Before delving into the basics of CTS and the available remedies, let's discuss three reasons why addressing median nerve compression as soon as possible is essential to prevent permanent nerve damage. In other words, it's important to help patients understand that CTS is NOT a condition they can ignore, hoping it will resolve on its own.
Impact of Nerve Compression
The three main reasons to address this condition promptly are: (8)
Microvascular Ischemic Changes – Ischemia refers to a lack of oxygen due to reduced blood supply to the nerve, which can cause significant nerve damage.
Myelin Sheath Damage – Myelin is an electrically insulating layer surrounding nerves that facilitates signal transmission. Nerve compression often leads to myelin changes, resulting in decreased signal transmission and an immediate decline in hand function.
Demyelination – This involves the actual loss of the myelin covering nerve fibers. Chronic nerve compression cases can cause Wallerian Degeneration (nerve degeneration) and are often accompanied by permanent fibrotic changes that hinder re-innervation and restoration of nerve function.
Fortunately, the damage described above can often be avoided through manual therapy and exercise. Now that we've established the seriousness of CTS and reiterated that most cases do NOT require surgery, let's delve into the symptoms and explore treatment options.
Exciting Research About CTS
Since I originally wrote this blog, new groundbreaking research has been published in the 'Journal of Physical Therapy - 2020; 100: 1987-1996'. This long-term, four-year follow-up study compared the outcomes of Conservative Manual Therapy (desensitization maneuvers, cervical mobilization, and nerve gliding exercises) to those of CTS surgical procedures (38).
The study demonstrated that after four years, there was no significant difference in the effectiveness of Conservative Manual Therapy and CTS surgery, as both achieved favourable results. Notably, only 15% of Conservative Manual Therapy participants eventually needed surgery (38).
This research has entirely refuted the conclusions drawn by previous studies and the information currently available to the public. Earlier research claimed that up to 60% of patients still require surgery after undergoing Conservative Manual Therapy. However, this is not the case (38)!
This study indicates that, in many cases, the Conservative Manual Therapy approach to CTS should be the primary treatment before considering surgery (38).
A Crucial Element – Addressing the CTS Kinetic Chain
Past studies focused on CTS as a localized issue of the wrist, neglecting the broader scope of this complex disorder, which involves more than just the wrist and hand.
While further research is necessary, this study demonstrated that Conservative Manual Therapy can yield significant positive outcomes for CTS, but only if treatment extends beyond the localized region of the wrist and hand.
Addressing the more comprehensive CTS Kinetic Chain (from the neck to the hand) and incorporating essential desensitization maneuvers into treatment protocols are vital. This article will cover these aspects in more detail.
SYMPTOMS OF CTS
CTS symptoms can affect one or both wrists and hands. While bilateral (both wrists) CTS is common, and the dominant hand is typically impacted first. The most common symptoms of CTS include: (20)
Persistent or sporadic numbness.
Abnormal sensations (paresthesias).
Pain (burning, aching, shooting).
Stiffness.
Swelling (edema).
Radiating symptoms up the arm and into the neck. It's important to note that median nerve compression can occur at various locations from the neck to the hand and may also mimic CTS symptoms. Therefore, a comprehensive examination of all potential nerve entrapment sites is crucial.
Increased symptoms at night (particularly in patients performing repetitive motions like computer operators).
Inability to grasp or pinch objects (often dropping cups or other items).
ANATOMY OF CTS
The carpal tunnel is a narrow passage in the wrist, composed of several small bones and a ligament that forms its roof. To help non-medical professionals understand, picture the carpal tunnel as a narrow tunnel, with the floor made of small bones (scaphoid, trapezium, hamate, and pisiform bones) and the roof is a thick band called the transverse carpal ligament. The median nerve, which controls sensations and movement in the hand, lies just beneath this ligament.
In addition to the median nerve, the carpal tunnel also houses nine flexor tendons that enable smooth gliding through the carpal tunnel during normal motion. These tendons are essential for the proper functioning of our fingers and thumb. The nine tendons that traverse the carpal tunnel are:
Four flexor digitorum superficialis tendons, which help in bending the middle joints of the fingers.
One flexor pollicis longus tendon, which is responsible for bending the thumb.
Four flexor digitorum profundus tendons, which assist in bending the tips of the fingers.
These tendons and the median nerve must coexist in the limited space of the carpal tunnel, making it prone to potential compression and irritation.
Anatomy of the Hand and Wrist
If you want to learn more about wrist and hand anatomy, then check out our video “Anatomy of the Hand & Wrist “.
PHYSICAL EXAMINATION
In every suspected case of CTS, it's essential to conduct a thorough physical examination. This includes obtaining a comprehensive history (covering work and leisure activities) and assessing the wrist and hand for potential entrapment sites of the median nerve (from the neck to the hand). If you're interested in learning more, the videos below showcase some of the orthopedic and neurological examination techniques commonly used when evaluating a case of carpal tunnel syndrome.
Wrist & Hand Examination - Orthopaedic Testing
This video goes through inspection and observation, palpation, Active and Passive Ranges of motion, and orthopaedic examination of the wrist and hands.
Cervical Examination - Orthopaedic Testing
This video goes through inspection and observation, palpation, Active and Passive Ranges of motion, and orthopaedic examination of the cervical region.
Upper Limb Neuro Exam
The upper limb neurological examination is part of the over all neurological examination process, and is used to assess the motor and sensory neurons which supply the upper limbs. This assessment helps to detect any impairment of the nervous system. It is used both as a screening and an investigative tool.
Peripheral Vascular Examination - Key Points
A peripheral vascular examination is a valuable tool used for ruling out signs of vascular-related pathology. The detection and subsequent treatment of PVD can potentially mitigate cardiovascular and cerebrovascular complications. In this video we go over some of the common procedures we perform in daily clinical practice.
Nerve Conduction Tests vs. Ultrasound
Nerve conduction studies are frequently regarded as the gold standard for diagnosing CTS. These tests measure the speed at which electrical signals travel through a nerve, helping to identify any nerve damage. However, it's interesting to note that nerve conduction tests do not necessarily improve the accuracy of CTS diagnosis compared to a thorough physical examination (15).
Ultrasound, on the other hand, has emerged as a more reliable confirmatory diagnostic test for CTS. An ultrasound uses high-frequency sound waves to create images of the structures inside the body, including the median nerve and surrounding tendons. This method offers a lower false-positive rate, meaning it is less likely to indicate CTS when the condition is not actually present (19, 21). In addition, ultrasound is non-invasive, does not involve radiation, and can provide real-time imaging, making it a valuable tool for assessing CTS and monitoring the progress of treatments.
RECOMMENDED ORTHOPAEDIC REFERENCE BOOKS
Orthopaedic Physical Assessment – David J. Magee https://amzn.to/3zgu0za
Dutton'sOrthopaedic: Examination, Evaluation and Intervention, Fifth Edition https://amzn.to/3st1AOv
DIFFERENTIAL DIAGNOSIS
Several syndromes may mimic Carpal Tunnel Syndrome and need to be considered. CTS is a working diagnosis based on physical examination results, but it is not a definitive diagnosis. Here's a list of syndromes that should also be considered in a differential diagnosis:
Anterior interosseous syndrome - Affects the anterior interosseous nerve, causing difficulty making the OK sign or experiencing pinch weakness.
Cervical radiculopathy - Compression or irritation of nerve roots in the cervical spine, causing pain and/or neurological symptoms in the arm.
Degenerative arthritis - Inflammation of the joints due to progressive degeneration of cartilage, leading to pain and limited mobility.
Diabetic neuropathy - Nerve damage resulting from chronic hyperglycemia and microvascular complications associated with diabetes.
Multiple sclerosis - An autoimmune disease that damages the protective coverings of nerve fibers in the brain and spinal cord.
Peripheral neuropathies (ulnar or radial) - Damage to peripheral nerves, affecting the ulnar or radial nerves and causing sensory and motor symptoms in the upper extremities.
Pronator Teres Syndrome (PTS) - Also known as the great mimic of CTS, it's a compression neuropathy of the median nerve in the forearm. True CTS is more likely to present with night pain. The median nerve can be tender in both CTS and PTS. PTS has a negative Phalen’s test.
Tendonitis - Inflammation or irritation of a tendon, often causing pain and tenderness near a joint.
Tenosynovitis - Inflammation of the synovial sheath surrounding a tendon, often leading to pain and restricted movement.
Thoracic Outlet Syndrome - A group of disorders caused by compression of nerves or blood vessels between the collarbone and first rib, leading to pain, numbness, and weakness in the arm and hand.
Conclusion
In conclusion, Carpal Tunnel Syndrome (CTS) is a common and potentially debilitating condition that often responds well to manual therapy and exercises, reducing the need for surgery. This condition results from the compression of the median nerve in the wrist's carpal tunnel, with causes varying from work-related activities to certain medical conditions, genetic factors, or a combination of these.
It's important to stress the urgency of addressing CTS promptly to prevent permanent nerve damage. Conservative Manual Therapy, which extends beyond the localized region of the wrist and hand, is highly effective in managing this condition. However, this doesn't negate the need for a thorough physical examination and assessment of potential nerve entrapment sites, as CTS can mimic other conditions.
Recent research published in the 'Journal of Physical Therapy - 2020; 100: 1987-1996' suggests that Conservative Manual Therapy can be as effective as surgery for treating CTS, with only 15% of participants in the study eventually requiring surgery. This finding challenges previous research conclusions and calls for a reconsideration of the standard approach to CTS treatment.
As we delve further into the symptoms, fundamental anatomy, non-surgical approaches, and physical examination methods in this article, we emphasize the importance of understanding and addressing the broader CTS Kinetic Chain to yield positive outcomes. Keep an eye out for the second part of this series, where we'll discuss the benefits of manual therapy and exercise in managing CTS and provide video demonstrations of treatment techniques and exercise recommendations.
In the second part of "Resolving Carpal Tunnel Syndrome," I will delve into manual therapy options and potential exercises. You'll be able to access video demonstrations showcasing the suggested treatments and exercises we frequently recommend to our patients.
Please refer to the end of Part 2 for the complete list of references.
RESOLVING CARPAL TUNNEL SYNDROME - PART 1
RESOLVING CARPAL TUNNEL SYNDROME - PART 2
DR. BRIAN ABELSON DC. - The Author
DR. BRIAN ABELSON DC. - The Author
Dr. Abelson is committed to running an evidence-based practice (EBP) incorporating the most up-to-date research evidence. He combines his clinical expertise with each patient's specific values and needs to deliver effective, patient-centred personalized care.
As the Motion Specific Release (MSR) Treatment Systems developer, Dr. Abelson operates a clinical practice in Calgary, Alberta, under Kinetic Health. He has authored ten publications and continues offering online courses and his live programs to healthcare professionals seeking to expand their knowledge and skills in treating musculoskeletal conditions. By staying current with the latest research and offering innovative treatment options, Dr. Abelson is dedicated to helping his patients achieve optimal health and wellness.
Despite being in the field for over three decades, Dr. Abelson remains open to welcoming new patients at Kinetic Health, save for the periods he dedicates to teaching or enjoying travels with his cherished wife, Kamali. However, be forewarned, he will anticipate your commitment to carry out the prescribed exercises and punctuality for your appointments (smile). His dedication towards your health is absolute, particularly in ensuring that you can revel in life unimpeded. He genuinely delights in greeting both new faces and familiar ones at the clinic (403-241-3772).
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