RESOLVING CARPAL TUNNEL SYNDROME – PART 1
Updated: May 19
In part one of this two part article about Resolving Carpal Tunnel Syndrome (CTS), I will cover surgical verses 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 treatments methods along with exercise recommendations we often provide 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 carpal tunnel of the wrist. 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 singular causative factor. Some of these associative factors are: (22, 23)
Work related activities involving repetitive motions, vibration, increased wrist stress, and exposure to cold.
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 of time. 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, certain cases 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 do respect their needs. On the other hand, it is critical to ensure these patients also have a clear understanding of the possible consequences of severe non-addressed nerve compression.
So before getting into some of the basics of CTS, and what can be done about it, let me explain 3 reasons why compression of the median nerve should be addressed as soon as possible in order to avoid permanent nerve damage. In other words, help our patients understand CTS is NOT a condition that they can put aside in the hope that it will just go away!
Impact of Nerve Compression
The three primary reason to avoid procrastination in treating this condition are: (8)
Microvascular Ischemic Changes – Ischemia describes a lack of oxygen, which is caused by decrease in blood supply to the nerve, which in turn can results 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 signal transmission, followed almost immediately by a decrease in 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 is often accompanied by permanent fibrotic changes that prevent re-innervation and restoration of nerve function.
Fortunately, the damage that I have described can often be avoided with the intervention of 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 very promising 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)
The results of 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 however, only 15% of participants who received Conservative Manual Therapy also ended up needing surgery.
This research study has completely overturned the conclusions provided by previous research, and the information that is currently provided to the public. In the past, researchers were saying that up to 60% of patients will still require surgery after undergoing Conservative Manual Therapy. This is simply not the case!
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.
A Defining Factor – Addressing the CTS Kinetic Chain
Previous studies only considered CTS as a localized problem of the wrist, and did not take into account the rest of this complex disorder - which actually 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.
Basically, the larger CTS Kinetic Chain (from the neck to hand) must be addressed, along with the integration of important 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 quite 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).
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 extremely important.
Symptoms increased at night (especially in patients who perform repetitive motions such as 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 which during normal motion, glide smoothly through the carpal tunnel. 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 through physical examination should be performed; on which includes 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). The physical examination process should include:
Palpation & Observation: Observe and palpate soft-tissues from the cervical region to the hand examining for possible entrapment's of the median nerve in locations including: (32, 33, 34, 35)
Pectoralis minor ( causes subclavicular brachial plexus compression)
Clinical Tip: Look for wasting and weakness of the LOAF muscles.Which are all innervated by the median nerve: (4)
L = First and second lumbricals
A = Abductor pollicis brevis (sole innervation is from median nerve)
Evaluate Range of Motion of the following:
Wrist flexion and extension forearm neutral.
Radial and ulnar deviation with forearm in pronation.
Digit extension combined with wrist motion.
Digit flexion combined with wrist motion.
Sensory Testing for abnormalities in sensation of the thumb, index finger, middle finger, inner half of the ring finger which are often seen with CTS.
Strength Testing using:
Grip Strength Test (reproduction of symptoms), dynamometer.
Nerve Compression Testing
Phalen’s Test (69% sensitivity, 73% specificity). (4)
Tinel’s Test (50% sensitivity, 77% specificity). (4)
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 really 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)
DIFFERENTIAL DIAGNOSIS FOR CTS
There are several syndromes that could mimic Carpal Tunnel Syndrome that also need to be considered. CTS is a working diagnosis based on the physical examination results, but it is not an absolute diagnosis. Here is 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.
DR. BRIAN ABELSON DC.
Dr. Abelson believes in running an Evidence Based Practice (EBP). EBP's 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 developer of Motion Specific Release (MSR) Treatment Systems. His clinical practice in is located in Calgary, Alberta (Kinetic Health). He has recently authored his 10th publication which will be available later this year.
Make an appointment with our incredible team at Kinetic Health in NW Calgary. Just scan the QR code with your phones camera and click the link, or call Kinetic Health at 403-241-3772 to make an appointment today!