Carpal Tunnel Pain

Carpal Tunnel Syndrome

What is carpal tunnel syndrome?

Carpal tunnel syndrome is a compression of the median nerve in the wrist. In turn, this squeezing of the nerve can result in altered sensation commonly tingling, weakness and pain in the hand. This ailment is also termed CTS.

Our arms have 3 main peripheral nerves that help deliver strength and sensation. These are the median, radial and ulnar nerves. Peripheral nerves come out of the neck, or cervical spine, and span down the arm to the hand.

cubital tunnel nerves

There are various anatomical areas peripheral nerves can become squeezed or entrapped. However, carpal tunnel syndrome is the most common entrapment neuropathy; neuropathy meaning neuro = nerve and pathy = disease. CTS is more predominant in females vs males. The average age population CTS affects are 40-60 year olds. As of 2017, the United Kingdom has the highest number of carpal tunnel syndrome cases within the population (7-19%); whereas in the United States, prevalence is 5%.

Some things can predispose you to developing carpal tunnel syndrome. Firstly are workplace or domestic factors. Common examples include prolonged / repetitive flexing of the wrist or using vibrating hand tools. Secondly are disorders that directly affect the nerves (e.g. diabetes, underactive thyroid, overactive pituitary gland or alcoholism). Thirdly is fluid retention from pregnancy or menopause. Lastly is irregularities of bones, tendons or other structures within the carpal tunnel. These irregularities commonly stem from wrist fractures, dislocations or both.

What causes carpal tunnel syndrome?

Several factors can cause carpal tunnel syndrome including wrist anatomy, certain health problems and inflammation. Carpal tunnel syndrome develops when the tissues around the median nerve irritate or put pressure on the nerve along its course through the carpal tunnel.

The median nerve essentially is squeezed within the tunnel. This compression does not allow for adequate circulation to reach the nerve and affects its ability to function. To better understand carpal tunnel syndrome, it is important to review some simple anatomy.

Carpal Tunnel Syndrome Symptoms

Common carpal tunnel syndrome symptoms include:

  • Pain, tingling, pins and needles, burning and / or numbness to the palm side of the thumb, index, middle or ½ of the ring fingers
  • Clumsy hand (e.g. dropping objects)
  • Forearm or wrist pain

Symptoms may occur at any time. Because many people sleep with bent wrists, symptoms at night are common. Nocturnal symptoms may wake you from sleep. During the day, symptoms typically occur when holding something (e.g. steering wheel, phone, shopping bag, etc.). Moving or shaking the hand typically relieves symptoms.

What will happen if carpal tunnel syndrome is not treated?

If carpal tunnel syndrome is not treated your thumb, index, middle and / or ½ of your ring fingers may go completely numb. Numbness will make you lose the ability to feel objects. Worsening hand weakness can also develop. A weaker hand will lead to an increased tendency to drop objects. In extremely severe cases, the thumb muscle bulk (i.e. thenar muscles) waste away. This is known as thenar atrophy.

thenar muscle atrophy

Carpal tunnel syndrome will usually not go away on its own and can last indefinitely if not treated. Despite this, spontaneous disappearance of symptoms can occur post-pregnancy or post-menopause. This is because hormone levels normalise and fluid retention resolves. If treated early with Hand Therapy, CTS can improve within 6 weeks.

Getting Carpal Tunnel Relief

How can I improve CTS?

Many people can improve carpal tunnel syndrome conservatively (i.e. without surgery) with Hand Therapy guided exercise, splinting or corticosteroid injections. As a note, the 2013 European Volume of the Journal of Hand Surgery reported it has been proven that 2 or more local corticosteroid injections does not provide significant added clinical benefit compared to 1 injection.

How can I relieve carpal tunnel pain?

In many cases, a combination of splinting and exercise relieves carpal tunnel pain. These interventions can be highly effective if introduced in early CTS development. Immediate Hand Therapy intervention is key. If left to degrade, the chances of you requiring surgery for carpal tunnel syndrome increases.

Carpal Tunnel Brace / Carpal Tunnel Splint

Off-the-shelf braces and custom-made splints are usually beneficial if used nocturnally (i.e. while sleeping). In order to be effective, the brace or splint must keep the wrist positioned in neutral. In other words, not overly extended or overly flexed / bent. Above all, compliance is paramount. Your brace or splint must be worn every night for at least 6 weeks.

Exercises for CTS

As a first call, active wrist and hand tendon gliding exercises will allow for your long flexor tendons to glide gently through the carpal tunnel. This will improve circulation and flexibility. Completing these with your hand in warm water can be more comfortable and helps with pain.

Moreover, active tendon gliding exercises should be combined with median nerve glides. Dependent on your level of compression, a Hand Therapist will grade the level of your prescribed median nerve “glider” or “slider” exercises. However, these should not be attempted without the guidance of a qualified clinician.

Progressive shoulder girdle, hand or thumb strengthening exercises can be considered by a Hand Therapist alongside:

  • Ergonomic review and modifications
  • Postural education
  • Fine-motor / dexterity retraining

Testing for Carpal Tunnel

As a Hand Therapist, all of the above interventions are within my remit. In addition, I can differentially diagnose if carpal tunnel syndrome may be what ails you. This is done after comprehensive assessment including special tests. Special tests are considered “positive” if your symptoms increase during completion. The 3 special tests used to diagnose carpal tunnel syndrome are:

Phalen’s Test or Reverse Phalen’s Test

Your Hand Therapist will manually position your wrist in flexion for up to 60 seconds.

Durkan’s Test

Your Hand Therapist will apply direct pressure on the median nerve over the transverse carpal ligament for up to 30 seconds.

Tinel’s Test

Your Hand Therapist will tap on the median nerve over the transverse carpal ligament.

Outside the Hand Therapy Clinic, carpal tunnel syndrome can be diagnosed via:

  • Nerve conduction study (NCS)
  • Magnetic resonance imaging (MRI)
  • Ultrasonography (US)

Surgery Options for CTS

Surgery may be indicated for moderate-to-severe cases or for CTS unresponsive to conservative measures. This is known as carpal tunnel release (CTR) or carpal tunnel decompression (CTD). Carpal tunnel surgery may be performed as an open or endoscopic procedure. Visit The British Society for Surgery of the Hand

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