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Resolving Carpal Tunnel Syndrome – PART 1


Woman Holding Wrist While Sitting at a Computer

In this first installment of our two-part series on Carpal Tunnel Syndrome (CTS), we'll explore non-surgical treatments while discussing symptoms, foundational anatomy, and diagnostic procedures. Whether you're a patient or a medical professional, this article is designed to provide a clear and accessible overview.


In our next segment, we’ll focus on the benefits of hands-on therapy and exercise as key strategies for relief. To enhance your understanding, we’ll include video demonstrations showcasing treatment techniques and exercise routines that we commonly recommend.


CTS is the most prevalent nerve compression disorder in the upper body, also known as compressive neuropathy. Its economic impact is substantial, making it the costliest musculoskeletal disorder. Each year, CTS costs over 2 billion dollars, with surgical interventions often considered a last resort, accounting for a significant portion of these expenses.


Article Index:


Introduction


Diagnosis

 

Man Using a Power Saw

Causes of CTS


Carpal Tunnel Syndrome (CTS) can be triggered by anything that compresses or irritates the median nerve within the carpal tunnel. While certain activities are more frequently associated with CTS, they are not the only contributing factors. Some of the related factors include:


  • Work-related activities involving repetitive motions, vibrations, increased wrist stress, and exposure to cold.

  • Medical conditions with higher rates of CTS, such as diabetes, thyroid disorders, rheumatoid arthritis, menopause, pregnancy, and various hormonal imbalances.

  • Genetic factors, including wrist shape or ligament thickness in the wrist.


A combination of these factors can lead to the median nerve becoming "tethered," resulting in increased friction, inflammation, heightened pressure within the carpal tunnel, and even fibrosis. 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 cause various physiological changes, especially if left untreated for extended periods. For non-severe cases of CTS, where there is no muscle atrophy or significant sensory impairment, conservative management, including manual therapy and exercise, is often highly effective. However, it's important to note that some CTS cases may eventually require surgical intervention.


Many patients prefer to avoid surgery whenever possible, and their preferences should be respected. Nonetheless, it's crucial to ensure that these patients understand the potential consequences of untreated severe nerve compression.


Before we delve into the basics of CTS and the available treatment options, let's discuss three key reasons why it's essential to address median nerve compression promptly to prevent permanent nerve damage. In other words, patients need to 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 Carpal Tunnel Syndrome promptly are:


  1. Microvascular Ischemic Changes: Ischemia refers to a lack of oxygen due to reduced blood supply to the nerve, which can cause significant nerve damage.

  2. 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.

  3. Demyelination: This involves the actual loss of the myelin covering nerve fibres. Chronic nerve compression can cause Wallerian Degeneration (nerve degeneration) and is 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 wrote this blog, 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 (including desensitization maneuvers, cervical mobilization, and nerve gliding exercises) to those of CTS surgical procedures.


The study revealed that after four years, there was no significant difference in the effectiveness of Conservative Manual Therapy and CTS surgery, with both approaches achieving favourable results. Notably, only 15% of participants who underwent Conservative Manual Therapy eventually required surgery.


This research challenges the conclusions of previous studies and the information currently available to the public. Earlier studies suggested that up to 60% of patients would still need surgery after Conservative Manual Therapy, but this is not the case.


This study indicates that, in many cases, the Conservative Manual Therapy approach to CTS should be the primary treatment option before considering surgery.



A Crucial Element – Addressing the CTS Kinetic Chain


Previous studies often viewed CTS as a localized issue of the wrist, overlooking the disorder's broader complexity, which extends beyond the wrist and hand.


While further research is needed, this recent study demonstrated that Conservative Manual Therapy can yield significant positive outcomes for CTS, provided the treatment addresses more than just the localized region of the wrist and hand.


It is crucial to consider the entire CTS Kinetic Chain, from the neck to the hand, and to incorporate essential desensitization maneuvers into treatment protocols. This article will delve into these aspects in more detail, highlighting their importance in effective CTS management.


 

Symptoms of CTS Image

Symptoms of CTS


CTS symptoms can affect one or both wrists and hands. While bilateral (both wrists) CTS is common, 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, comprised of several small bones and a ligament that forms its roof. To help non-medical professionals understand, imagine the carpal tunnel as a tight tunnel where the floor consists of small bones (scaphoid, trapezium, hamate, and pisiform bones), and the roof is a thick band called the transverse carpal ligament. The median nerve, responsible for sensations and movements in the hand, lies just beneath this ligament.


In addition to the median nerve, the carpal tunnel houses nine flexor tendons that allow smooth gliding through the tunnel during normal motion. These tendons are crucial for the proper functioning of our fingers and thumb. The nine tendons that pass through the carpal tunnel are:


  • Four flexor digitorum superficialis tendons help bend the middle joints of the fingers.

  • One flexor pollicis longus tendon is responsible for bending the thumb.

  • Four flexor digitorum profundus tendons 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 susceptible to potential compression and irritation.


Anatomy of the Hand and Wrist

If you want to learn more about wrist and hand anatomy, check out our video “Anatomy of the Hand & Wrist. "









 

Physical Examination


In every suspected case of CTS, a thorough physical examination is essential. 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 orthopedic 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 orthopedic examination of the cervical region.



Upper Limb Neuro Exam


The upper limb neurological examination is part of the overall 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 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 review some common procedures we perform in daily clinical practice.



Nerve Conduction Tests vs. Ultrasound


Nerve conduction studies are often considered 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 noteworthy that nerve conduction tests may not necessarily improve the accuracy of CTS diagnosis compared to a thorough physical examination.


Ultrasound, on the other hand, has emerged as a more reliable confirmatory diagnostic test for CTS. This technique uses high-frequency sound waves to create images of the internal structures, including the median nerve and surrounding tendons. Ultrasound offers a lower false-positive rate, making it less likely to indicate CTS when the condition is absent. Additionally, ultrasound is non-invasive, does not involve radiation, and provides real-time imaging, making it a valuable tool for assessing CTS and monitoring the progress of treatments.



 

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 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 cartilage degeneration, 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 fibres 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 this first installment of our two-part series on Carpal Tunnel Syndrome (CTS), we've explored non-surgical treatments while discussing symptoms, foundational anatomy, and diagnostic procedures. This article aims to provide a clear and accessible overview, whether you're a patient or a medical professional.


In our next segment, we’ll focus on the benefits of hands-on therapy and exercise as key strategies for relief. To enhance your understanding, we’ll include video demonstrations showcasing treatment techniques and exercise routines that we commonly recommend.


CTS is the most prevalent nerve compression disorder in the upper body, also known as compressive neuropathy. Its economic impact is substantial, making it the costliest musculoskeletal disorder. Each year, CTS costs over 2 billion dollars, with surgical interventions often considered a last resort, accounting for a significant portion of these expenses.


Understanding and addressing CTS promptly is crucial. From recognizing the contributing factors and symptoms to applying effective conservative treatments, we can prevent the progression of this condition and avoid the need for surgery in many cases. By focusing on a comprehensive approach that includes manual therapy and exercise, and considering the entire CTS Kinetic Chain, we can achieve significant positive outcomes. Stay tuned for our next article, where we’ll delve deeper into hands-on therapies and exercises that can help manage and alleviate CTS effectively.


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




Note References located in Part 2


 

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DR. BRIAN ABELSON DC. - The Author


Photo of Dr. Brian Abelson

Dr. Abelson is dedicated to using evidence-based practices to improve musculoskeletal health. At Kinetic Health in Calgary, Alberta, he combines the latest research with a compassionate, patient-focused approach. As the creator of the Motion Specific Release (MSR) Treatment Systems, he aims to educate and share techniques to benefit the broader healthcare community. His work continually emphasizes patient-centred care and advancing treatment methods.



 


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