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Resolving Carpal Tunnel Syndrome – PART 1

Updated: Apr 2


Woman Holding Wrist While Sitting at a Computer

In this initial instalment of our two-segment deep dive into Carpal Tunnel Syndrome (CTS), we'll journey through both surgical and non-surgical remedies, touching upon symptoms, foundational anatomy, and diagnostic procedures. For those inclined to bypass the intricate nuances, this piece is structured to accommodate both patients and medical professionals, allowing for a breezy overview.


In our subsequent segment on CTS, the spotlight will shine on the merits of hands-on therapy and exercise as pivotal alleviators. To further aid comprehension, we'll feature video demonstrations encapsulating treatment modalities and exercise regimens often prescribed to our clientele.


CTS reigns as the upper body's most frequently encountered nerve compression malady (compressive neuropathy). Its economic footprint is significant, emerging as the priciest musculoskeletal disorder. Annually, it drains over 2 billion dollars, with surgery often accounting for the lion's share of these costs (1).


Article Index:


Introduction

Diagnosis

 

Man Using a Power Saw

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?"


 

Wrist Surgery

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.


 

Woman Holding Her Wrist

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.


 


Manual Therapy of the Wrist

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 Image

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).


 

Carpal Tunnel Anatomy Image

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 Video
Click Image to Watch Video

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


 

Doctor Examining Patients Hand

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:


  1. Anterior interosseous syndrome - Affects the anterior interosseous nerve, causing difficulty making the OK sign or experiencing pinch weakness.

  2. Cervical radiculopathy - Compression or irritation of nerve roots in the cervical spine, causing pain and/or neurological symptoms in the arm.

  3. Degenerative arthritis - Inflammation of the joints due to progressive degeneration of cartilage, leading to pain and limited mobility.

  4. Diabetic neuropathy - Nerve damage resulting from chronic hyperglycemia and microvascular complications associated with diabetes.

  5. Multiple sclerosis - An autoimmune disease that damages the protective coverings of nerve fibers in the brain and spinal cord.

  6. 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.

  7. 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.

  8. Tendonitis - Inflammation or irritation of a tendon, often causing pain and tenderness near a joint.

  9. Tenosynovitis - Inflammation of the synovial sheath surrounding a tendon, often leading to pain and restricted movement.

  10. 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 - Carpal Tunnel Syndrome Part 1


In summation, Carpal Tunnel Syndrome (CTS) is a prevalent condition arising from the compression of the median nerve within the wrist. While factors range from work activities to genetics, timely intervention is crucial to avert permanent damage. Conservative Manual Therapy, targeting more than just the wrist, is a potent tool against CTS, but a comprehensive physical examination remains vital. A recent study in the 'Journal of Physical Therapy - 2020; 100: 1987-1996' indicates that this therapy might rival surgical interventions, urging a reevaluation of typical CTS treatments.


This article provides insights into CTS's symptoms, anatomy, and non-surgical strategies, emphasizing the significance of the broader CTS Kinetic Chain. Stay tuned for our sequel, where we'll spotlight manual therapy's role and exercises, accompanied by video tutorials of suggested treatments.


Please refer to the end of Part 2 for the complete list of references.




Note References located in Part 2

 

DR. BRIAN ABELSON DC. - The Author


Photo of Dr. Brian Abelson

Dr. Abelson's approach in musculoskeletal health care reflects a deep commitment to evidence-based practices and continuous learning. In his work at Kinetic Health in Calgary, Alberta, he focuses on integrating the latest research with a compassionate understanding of each patient's unique needs. As the developer of the Motion Specific Release (MSR) Treatment Systems, he views his role as both a practitioner and an educator, dedicated to sharing knowledge and techniques that can benefit the wider healthcare community. His ongoing efforts in teaching and practice aim to contribute positively to the field of musculoskeletal health, with a constant emphasis on patient-centered care and the collective advancement of treatment methods.


 


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