Carpal tunnel syndrome (CTS) is a common musculoskeletal condition that causes pain, weakness, tingling, and numbness in the wrist and hand. It can be extremely painful and limits your ability to perform your daily activities. The condition is caused by irritation of the median nerve as it passes through the wrist.
For many people, CTS worsens over time and becomes more intense with frequent use of the involved hand. Early diagnosis and treatment can help relieve symptoms faster and prevent long-term damage to the nerve. In the early stages, conservative interventions such as splinting, activity modification, and specific exercises may resolve the condition. However, if the pressure on the median nerve persists, surgery may be recommended to avoid permanent damage.
The carpal tunnel is a pathway on the palmar side of the wrist that is created by the carpal bones. They make up the floor and the sides of the tunnel, but the roof is a strong band of connective tissue called the flexor retinaculum. The tunnel is relatively rigid and has little ability to expand.
Nine tendons and the median nerve pass through the carpal tunnel. These tendons, known as flexor tendons, control the bending motion of the fingers and thumb. The median nerve originates from the network of nerves near the neck called the brachial plexus. It passes through the upper arm and forearm until it dives through the carpal tunnel on its way to the hand.
The median nerve is one of the three main nerves of the hand. It provides sensation to the thumb, index, middle, and ring fingers, but also controls small muscles around the base of the thumb.
Carpal tunnel syndrome happens when there is pressure on the median nerve from narrowing of the tunnel or swelling of the tissue surrounding the flexor tendons. Narrowing of the tunnel may be caused by awkward wrist positions or scar tissue from previous injuries. The tissues surrounding the flexor tendons are called the synovium. The purpose of this tissue is to lubricate the tendons allowing them to glide easily as the wrist and fingers move.
If the synovium gets irritated and swells, it takes up more space in the carpal tunnel and presses against the median nerve. The abnormal pressure on the median nerve often causes pain, tingling, numbness, and weakness in the hand.
Most cases of CTS are caused by a combination of factors, but studies indicate that it is more common in women and older people. Additional risk factors include heredity, repetitive hand motions, pregnancy, and extreme hand/wrist positions. Some medical conditions, such as rheumatoid arthritis, diabetes, and thyroid dysfunctions, are associated with the onset of carpal tunnel syndrome.
Signs and Symptoms
Carpal tunnel syndrome usually starts gradually without a specific injury and may be intermittent at first. The condition worsens over time becoming constant with continued use of the hand. People often complain of symptoms worsening at night due to sleeping with the wrist bent.
The symptoms of CTS may include pain, numbness, tingling, and weakness in the wrist and hand. Numbness and tingling are usually experienced in the thumb, index, middle, and/or ring finger. Typing on a keyboard, phone use, and gripping a steering wheel are common activities that aggravate these symptoms.
Pain and weakness can be experienced in the same areas as numbness and tingling, however, many people report that they affect the whole hand. The weakness is a result of compromise of the median nerve as it passes through the carpal tunnel. This affects the thumb muscles involved in gripping and pinching. Common complaints include frequently dropping things and difficulty lifting heavy objects such as a gallon of milk.
The first step is managing carpal tunnel syndrome is a consult with a qualified healthcare provider. Many people start with their primary care physician, but you could begin an orthopedic physical therapist or an orthopedic surgeon depending on your insurance requirements. In either case, the provider will obtain a history of your condition, perform a physical examination, and order additional testing to assist in the diagnosis.
Obtaining a history of your condition is one of the most important parts of the assessment. One of my physical therapy school professors had a saying to emphasize this point. He said, “when doing an initial evaluation, there is one person in the room with all of the answers . . . and it’s not you.” A good history helps the provider understand when your symptoms started, how they began (trauma, overuse, etc.), and the pattern of progression since the onset.
Once the history is complete, your provider will move to the physical examination. During this phase, she will test your range of motion, strength, flexibility, and sensation. She will also perform specialized tests such as Phalen’s Test and Tinel’s Sign.
To perform Phalen’s test, the provider asks you to hold your elbows at shoulder level, then place the backs of your hands together with the wrists bent to 90 degrees. This position closes down the carpal tunnel and places more pressure on the median nerve. The test is positive if it reproduces or worsens your pain and tingling in the hand.
Tinel’s sign isn’t as much of a test as it is a method to detect irritated nerves. To detect a Tinel’s sign as an indicator of carpal tunnel syndrome, the provider begins tapping lightly over the carpal tunnel where the median nerve travels to the hand. A positive sign would be the sensation of tingling or “pins and needles” in the distribution of the nerve including the pad of the thumb.
Diagnostic tests may be ordered depending on the results or the history and the physical examination. X-rays are usually the first step in diagnostic testing because they will help to rule out any structural abnormalities in the wrist or hand including fractures or arthritis. Two other types of diagnostic testing, electromyograms, and nerve conduction studies are more specific and can help to determine median nerve involvement in CTS.
Electromyograms (EMGs) measure the electrical activity present in muscles. To perform this test, the provider places a thin needle electrode into a specific muscle. When that muscle contracts, it produces electrical discharges that can be read by the needle electrode. This test can determine whether muscle damage has occurred.
Nerve Conduction Studies (NCV) are used to test the speed of electrical impulses traveling through a nerve. Two surface electrodes are taped to the skin, then a small electrical shock is passed through the median nerve. The diagnosis of carpal tunnel syndrome can be confirmed if the impulses are slowed in the carpal tunnel. This test may also be used to rule out other conditions.
Conservative management of carpal tunnel syndrome includes rest, splinting, occupational/physical therapy, medications, and injections. If your CTS symptoms are coming from repetitive activities, rest and activity modification should help to reduce the intensity. You might be prescribed a night splint that keeps your wrist in a neutral position to prevent wrist flexion and extension while you sleep.
Physical and occupational therapists, especially those who are certified hand therapists (CHTs), can help you manage carpal tunnel syndrome. They are able to make custom wrist splints if the off-the-shelf type isn’t working to manage your symptoms. You will be educated about CTS and given guidelines for activity modification to reduce irritation of the median nerve.
The therapist will instruct you in exercises to stretch the wrist flexors, finger flexors, and thumb muscles. If you’ve experienced restricted movement in the wrist or fingers, performing range of motion exercises will help you regain it. Strengthening exercises may be added to address any weakness when your symptoms have improved.
If your CTS symptoms are not responding or have limited response to splinting, rest, and exercise, your provider might recommend a trial of NSAID medications or steroid injections. Over-the-counter NSAIDs are worth trying in the early stages, but if the symptoms persist, your physician might prescribe stronger NSAIDs or a steroid dose pack for severe conditions. Steroid injections can be helpful in reducing inflammation more quickly than oral NSAID medications, but you are limited to three or fewer injections in a one year period.
For severe or persistent cases of CTS that don’t respond to conservative interventions, surgery may be performed to release the pressure on the median nerve. To release the pressure, the surgeon uses small incisions to gain access and to cut the flexor retinaculum covering the carpal tunnel.
There are two different surgical techniques to release the flexor retinaculum. The endoscopic procedure uses a telescope-like device with a small camera to cut through the tissue. This procedure generally results in less pain than open surgery during the first few days or weeks after surgery.
Open surgery requires the surgeon to make a larger incision in the palm of your hand and over the carpal tunnel. This technique gives full access to the flexor retinaculum, but it can result in a little higher pain level and greater risk for complications compared to the endoscopic approach. The healing time is slightly longer for an open procedure.
During the healing process, the sections of the flexor retinaculum grow back together, but the new tissue allows more room for the tendons and nerves to pass through the carpal tunnel. You may be advised to use a support for a short period of time, but your surgeon will usually recommend that you gradually resume normal use of your hand. You will need to avoid forceful gripping, lifting, and extreme wrist positions until cleared by the surgeon.
Carpal tunnel syndrome can be an extremely painful condition that restricts your ability to perform your usual activities of daily living. Conservative management techniques including activity modification, splinting, NSAIDs, and exercises provided by an occupational or physical therapist can resolve many cases of CTS.
For more difficult cases, injections or surgery could be required. The most important thing is to address the pressure in the carpal tunnel before it damages the median nerve. Median nerve damage can sensation impairment, chronic pain, permanent weakness, and loss of function. Carpal tunnel syndrome becomes worse over time, therefore, it is important to seek treatment in the early stages.
This article is for educational and informational purposes. It does not replace the evaluation and care by a licensed healthcare professional.
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