- Dr. Brian Abelson
RESOLVING CARPAL TUNNEL SYNDROME – PART 1
Updated: Nov 2, 2022
In part one of this two-part article about Resolving Carpal Tunnel Syndrome (CTS), I will cover surgical versus non-surgical approaches that can be used, symptoms, basic anatomy, and physical examination processes. Feel free to skip the technical aspects of this article. I have written it for both patients and practitioners.
In part two of Resolving Carpal Tunnel Syndrome, I will cover the benefits of manual therapy and exercise in resolving this problem. I will also provide video demonstrations of recommended treatment methods and exercise recommendations we often offer to our patients.
Carpal Tunnel Syndrome (CTS) is the most common form of nerve compression syndrome (compressive neuropathy) in the upper body. (2,3) CTS is also the most expensive musculoskeletal disorder, affecting both business & health care systems, with costs exceeding 2 billion dollars annually (primarily from surgical expenses). (1).
CTS is a group of signs and symptoms that occur due to compression of the median nerve within the wrist's carpal tunnel. CTS is often a very depilating and painful condition. However, the good news is that most cases of CTS respond very well to manual therapy and exercise and do NOT require surgery.
CAUSES OF CTS
Anything that results in compression or aggravation of the median nerve in the carpal tunnel could lead to Carpal Tunnel Syndrome. Research shows that certain activities are more commonly associated with occurrences of CTS but are not necessarily the only causative factor. Some of these associative factors are: (22, 23)
Work-related activities involve repetitive motions, vibration, increased wrist stress, and exposure to cold.
Conditions with an increased incidence of CTS are diabetes, thyroid disorders, rheumatoid arthritis, menopause, pregnancy, and various hormonal imbalances.
Genetic predispositions such as wrist shape or the thickness of ligaments in the wrist.
All or a combination of these factors can lead to a “tethering” of the median nerve, resulting in increased friction, inflammation, increased pressure within the carpal tunnel, and even fibrosis. (36) The first question we should ask when addressing CTS is, “What is the right approach”!
NON-SURGICAL APPROACHES VERSES SURGERY
Nerve compression can cause several physiological changes to the median nerve, especially if this compression is left untreated for long periods. If the CTS is not severe (no muscle atrophy or significant sensory impairment), then conservative management (manual therapy + exercise) is often very successful at addressing this condition. (That being said, some instances of CTS do require surgery, so always keep this as an option.)
I have had numerous patients who would like to avoid surgery at all costs, and I respect their needs. On the other hand, ensuring these patients also have a clear understanding of the possible consequences of severe non-addressed nerve compression is critical.
So before getting into some of the basics of CTS and what can be done about it, let me explain three reasons why compression of the median nerve should be addressed as soon as possible to avoid permanent nerve damage. In other words, help our patients understand CTS is NOT a condition they can put aside in the hope that it will just disappear!
Impact of Nerve Compression
The three primary reasons to avoid procrastination in treating this condition are: (8)
Microvascular Ischemic Changes – Ischemia describes a lack of oxygen, which is caused by a decrease in blood supply to the nerve, which in turn can result in substantial nerve damage.
Myelin Sheath Damage – Myelin is the electrically insulating layer that surrounds nerves and aids in signal transmission. Nerve compression often causes changes in myelin, resulting in a decrease in signal transmission, followed almost immediately by a reduction of the function of the hand.
Demyelination – This is the actual loss of the myelin that covers nerve fibres. Chronic cases of nerve compression can cause Wallerian Degeneration (the degeneration of the nerve) and are often accompanied by permanent fibrotic changes that prevent re-innervation and restoration of nerve function.
Fortunately, the damage I have described can often be avoided with manual therapy and exercise. So now that I have explained why CTS should be taken seriously, and reminded you that most cases of CTS do NOT require surgery, let’s get deeper into understanding the symptoms and discuss treatment options.
Exciting New Research About CTS
Since I first wrote this blog, some up-and-coming new research has now been published in the ‘Journal of Physical Therapy - 2020; 100: 1987-1996’. This long-term, four-year, follow-up study compared the results obtained by Conservative Manual Therapy (desensitization maneuvers, cervical mobilization, and nerve gliding exercises) against those obtained by CTS Surgical procedures. (38)
This study showed that after four years, there was no significant difference between the effects attained by Conservative Manual Therapy and CTS Surgery (as they both achieved good results). Interestingly, only 15% of participants who received Conservative Manual Therapy also needed surgery. (38)
This research study has wholly overturned the conclusions provided by previous research and the information that is currently provided to the public. In the past, researchers said that up to 60% of patients will still require surgery after undergoing Conservative Manual Therapy. This is not the case! (38)
This study shows that, in a significant amount of cases, Conservative Manual Therapy approach to CTS should be the first line of treatment before considering a surgical approach. (38)
A Defining Factor – Addressing the CTS Kinetic Chain
Previous studies only considered CTS as a localized problem of the wrist. They did not consider the rest of this complex disorder - which involves a larger area than just the wrist and hand.
I do believe that more research needs to be conducted, but this study did show that Conservative Manual Therapy can achieve significant positive results for CTS, but only if more than the localized region of the wrist and hand is treated.
The more extensive CTS Kinetic Chain (from the neck to hand) must be addressed, along with integrating essential desensitization maneuvers into the treatment protocols. That is exactly what the rest of this article covers.
SYMPTOMS OF CTS
Symptoms of CTS can occur in one or both wrists and hands. Although bilateral (both wrists) CTS is common, the patient’s dominant hand is usually affected first. The most common symptoms of CTS are: (20)
Numbness (persistent or sporadic).
Abnormal sensations (paresthesias).
Pain (burning, aching, shooting).
Stiffness.
Swelling (edema).
Radiating symptoms up the arm and into the neck. It is important to note that compression of the median nerve can occur at multiple regions from the neck to the hand and can also mimic CTS symptoms. Thus, a complete examination of all possible nerve entrapment sites is critical.
Symptoms increased at night (especially in patients who perform repetitive motions like computer operators).
Inability to grasp or pinch objects (often dropping cups or other objects).
ANATOMY OF CTS
The carpal tunnel is made up of several small bones (laterally by the scaphoid and trapezium, medially by the hook of the hamate, pisiform). Bridging these bones, the roof of the carpal tunnel is formed by the transverse carpal ligament. The median nerve lies just below this ligament.
In addition to the median nerve, the carpal tunnel also contains nine flexor tendons that glide smoothly through the carpal tunnel during normal motion. The nine tendons that travel through the carpal tunnel are the:
Four flexor digitorum superficialis tendons.
One flexor pollicis longus tendon.
Four flexor digitorum tendons.
If you want to learn more about wrist and hand anatomy, then check out our video “Anatomy of the Hand & Wrist “.
PHYSICAL EXAMINATION PROCESS FOR CTS
For every suspected case of CTS, a thorough physical examination should be performed, including a comprehensive history (including work and leisure activities) and evaluation of the wrist and hand for possible entrapment sites of the median nerve (from the neck to the hand). Want to learn more? The videos below demonstrate some of the orthopedic and neurological examination procedures we often use in 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. This video is available for the public February 24th/20223
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. (Note: This video will be available for the public on July 8/2020)
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. (Note: This video is available for the public on October 7th/2022)
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. This video is available for the public on November 14/2022.
Nerve Conduction Tests vs Ultrasound
Nerve conduction studies are often considered to be the gold standard in diagnosing CTS. However it is interesting to note is that nerve conduction tests DO NOT improve the probability of correctly diagnosing CTS as compared to a complete physical examination. (15) Ultrasound for CTS is a better confirmatory diagnostic test as it provides a much lower false-positive rate. (19, 21)
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 FOR CTS
Several syndromes that could mimic Carpal Tunnel Syndrome also need to be considered. CTS is a working diagnosis based on the physical examination results, but it is not a definitive diagnosis. Here is a list of syndromes that should also be considered in a differential diagnosis.
Anterior interosseous syndrome – Patient will often not be able to make the OK sign, pinch weakness.
Peripheral neuropathies (ulnar or radial)
Pronator Teres Syndrome (PTS) - Also known as the great mimic of CTS. 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.
In part two of “Resolving Carpal Tunnel Syndrome” I will discuss manual therapy options and possible exercises. You will have access to video demonstrations of recommended treatments and exercises that we often provide to our patients.
References are located at the end of Part 2.
RESOLVING CARPAL TUNNEL SYNDROME - PART 1
RESOLVING CARPAL TUNNEL SYNDROME - PART 2
DR. BRIAN ABELSON DC.
Dr. Abelson believes in running an Evidence-Based Practice (EBP). EBPs strive to adhere to the best research evidence available while combining their clinical expertise with the specific values of each patient.
Dr. Abelson is the Motion Specific Release (MSR) Treatment Systems developer. His clinical practice is located in Calgary, Alberta (Kinetic Health). He has recently authored his 10th publication.
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