Carpal Tunnel Syndrome

What Is Carpal Tunnel Syndrome (CTS)?

Carpal tunnel syndrome, or CTS, is a condition in which one of the major nerves that controls the functioning of the hand and fingers – the median nerve – becomes compressed inside a “tunnel” in the wrist. This can cause various symptoms including pain, numbness, tingling, or a “funny feeling” in the fingers, hand, or wrist.

What Is The Carpal Tunnel?

Carpal comes from carpus, the Latin word for wrist. The carpal tunnel is a small passage inside the wrist. Several fine bones of the wrist form the floor and sides of the tunnel. A ligament called the transverse carpal ligament, which arches over the bones, forms the roof of the tunnel.

Passing through this tunnel are:

• The median nerve, which conducts impulses, sent by the brain, down the arm and to the fingers
• The tendons of the finger flexor muscles, which allow the fingers to bend
• Arteries and veins

The median nerve supplies most of the feeling in the hand, particularly to the thumb, index and middle fingers, the thumb half of the palm and the outer side of the hand. It also controls the movement of many of the tendons that bend the fingers, allowing the hand to grasp objects as well as pinch.

What Are The Symptoms of Carpal Tunnel Syndrome?

Symptoms of CTS tend to appear gradually. They include:

• Numbness, tingling, or burning sensations in the thumb and fingers, particularly the index and middle fingers, which are affected by the median nerve
• Pain in the hands or wrists
• Loss of dexterity or gripping strength
• Difficulty performing routine tasks with the hands such as holding a cup, vacuuming, washing up, or even driving; some people have difficulty holding a newspaper or a telephone
• Pain in the arm and shoulder
• Swelling of the hand, which often increases at night

A telltale sign of CTS is when symptoms are severe enough to awaken the sufferer from sleep, with tingling or pain in the hand. Symptoms may worsen at night because of the way the hand is positioned during sleep. Some may find relief by vigorously shaking their hand while held high or low, by rubbing their hands together, or even by soaking the hand in warm water.

What Causes Carpal Tunnel Syndrome?

We don’t always know what causes carpal tunnel syndrome. In fact, in most cases no obvious cause can be found.

However, any condition that lessens the amount of space in the carpal tunnel or narrows the tunnel can potentially result in compression of the median nerve within the tunnel. Such conditions usually result in swelling around the tunnel or alteration of the normal anatomy of the wrist due to injury or growth of a benign lesion.

These include:

• Various injuries, including previous fractures of the wrist (the change in anatomy may narrow the tunnel)
• Medications that may lead to fluid retention, including oral contraceptives (birth control pills)
• Hormonal changes and conditions that lead to fluid retention, such as pregnancy (CTS that occurs during pregnancy usually disappears within four to six weeks following delivery)
• Medical disorders that lead to fluid retention or are associated with inflammation, such as rheumatoid arthritis, diabetes, hypothyroidism, Lyme disease, and others.
• Benign growths within the wrist for example a ganglion (cyst)
• Medical disorders that involve constricted blood vessels, such as Raynaud’s disease

The following can increase the chance of developing carpal tunnel syndrome:

• Cigarette smoking, which constricts blood vessels
• Obesity, which can increase pressure on the nerves in the wrist

Carpal Tunnel Syndrome and Repetitive Strain Injuries (RSI):

During the 1970s it became popular to attribute many painful conditions of the upper limb joints and tendons to what became known as “Repetitive Strain Injuries” (RSI), and later as “Cumulative Trauma Disorders” (CTD). These types of injuries were said to result from prolonged overuse of the upper extremities by performing  repetitive motions of the shoulders, elbows, hand, or fingers, usually in the workplace.

Back then this was not initially accepted by all physicians, and until late 1990’s many physicians questioned the validity of the diagnosis of Repetitive Strain Injury.

Now it is universally accepted that such injuries, including Carpal Tunnel Syndrome, may result from repetitive movements of the wrist in the workplace.

• Repetitive movements and prolonged overuse inflames the tendons’ protective layer, called the synovial sheath, causing the sheath to swell.
• The swollen tendons may place pressure on the median nerve in the carpal tunnel.
• Thus, nerve impulses are disrupted and the normal functioning of the nerve is impaired.

Repetitive strain injuries:

• Have been the fastest growing category of occupational illness
• Are the leading cause of job-related illness
• Accounted for 64% and more of all reported workplace illnesses

Activities That Can Trigger Carpal Tunnel Syndrome

CTS can be triggered by long hours of poor posture (slouching, jutting the chin forward) and work that encourages the wrists to be bent up, in, or out. Activities that foster these conditions include:

• Using vibrating tools
• Cutting
• Crocheting, knitting, sewing
• Using hand tools, particularly those used for turning or twisting (screwdrivers, wrenches)
• Bicycling, house cleaning, playing a stringed instrument, and other activities that can put pressure on the wrists
• Typing at computer keyboards
• Computer mouse pointing and clicking

Who Gets CTS Most Often?

According to the U.S. Bureau of Labor Statistics, reported cases of CTS occur most often among workers in the following industries:

• Meat packing
• Knit underwear mills
• Motor vehicles and car bodies
• Household laundry equipment manufacturing
• Poultry slaughtering and processing

Conditions That May Cause Similar Symptoms

Symptoms of carpal tunnel syndrome can be mimicked by those of other medical disorders, such as:

• Arthritis of the neck, hand, or wrist
• Circulation disorders
• Nerve disorders, such as a trapped nerve at the inner elbow
• Previous injuries to the wrist
• Tendinitis (inflamed tendons) at the wrist

Carpal Tunnel Syndrome: How Is The Diagnosis Made?

A doctor will take a careful medical history, asking about:

• The symptoms and what brings them on
• How long you’ve had them
• What makes them worse or better
• Your general medical background

The doctor will examine your hands, wrists, elbows, shoulders, and neck to check for nerve compression or other problems, and may perform a more detailed examination to look for medical conditions.

Examination will include:

• Tapping your wrist over the median nerve to see if this reproduces your symptoms (the Tinel test)
• Gently holding your wrist bent forward for 30 to 60 seconds to see if this reproduces your symptoms (the Phalen test)
• Gently using pinpricks and light stroking motions with a pin to see if any part of the hand has lost sensitivity (a sign of nerve damage)

Specialized Tests

Sometimes, it is not clear whether the symptoms are due a problem with median nerve at the wrist or higher up in the arm. They could be caused by a problem with other nerves to the hand, particularly the ulnar nerve, or even from affected nerves in the neck, causing the pain and tingling to radiate into the hand.

Specialized tests will resolve this dilemma:

• Nerve conduction tests. This test determines if the transmission along the nerve has slowed down due to damage to the nerve. A doctor or certified technician will place electrodes on the hand and wrist. Small electric shocks are applied to the nerves in the fingers, wrist, and forearm to determine if the nerve messages are being conducted properly.
• Electromyography. In more serious cases, the muscles supplied by the nerve will show abnormal electrical activity. A doctor or certified technician will insert a very fine, sterile wire briefly into a muscle in the affected area, and the electrical activity will be displayed on a monitor.
• X-rays of the wrist and neck. These may be taken to rule out arthritis or previous fractures. (X-rays alone cannot reveal the presence of CTS.)
• Magnetic resonance imaging (MRI). This test can determine if structural abnormalities at the wrist are contributing to CTS.

How Is Carpal Tunnel Syndrome Treated?

Continued compression on the nerve can cause increasingly severe symptoms and can ultimately damage the nerve. This can permanently impair some of the functions of the hand. For this reason, treatment is important.

Proper treatment can control or cure CTS and prevent permanent disability. Depending on the severity of CTS, conventional treatment may involve some or all of the following measures. 

For some these non invasive treatments work. But for many a surgical solution will be needed.

The type of treatment will depend on how severe the symptoms are. They include:

• Resting the wrist for a period of time in a wrist splint
• Physical therapy
• Modifying activities and work habits, if necessary
• Modifying your work station ergonomically
• Anti-inflammatory medications
• Diuretics
• Steroid injection into the wrist
• Treating a related medical condition that may be causing CTS symptoms
• Some may try alternative treatments
• Surgery

Wrist Splints

A splint is a device that prevents a joint from bending. Wrist splints keep pressure off the median nerve by preventing the palm from bending forward. There are several types of splints:

• Neutral splints, which keeps the wrist straight.
• Cock-up splints, which holds the wrist in a slightly extended position, that is, bent slightly upwards. For many people, these splints are particularly helpful when used at night, for driving, and during other activities that would force the wrist to bend forward.
• Job-specific splints, such as custom-made splints for people in particular occupations.

A splint should not be worn all day, as this could lead to further muscle weakness and a worsening of symptoms. Remove the splint for a while every four to six hours. It is important that the splint fit properly, and that all the fingers can move freely

Physical Therapy

The doctor or a physical therapist can custom-tailor an exercise regimen for a person with carpal tunnel syndrome. Physical therapy also may involve pain-relief measures such as:

• Moist heat
• Ice packs
• Ultrasound or TENS (transcutaneous electrical nerve stimulation), which involves placing electrodes of the surface of the skin to help block pain impulses

Anti-Inflammatory Medications

Anti-inflammatory medications, known as NSAIDs (non-steroidal anti-inflammatory drugs), are commonly prescribed to manage CTS. Many are available over the counter, including ibuprofen, naproxen and others. Of the newer anti-inflammatories introduced a few years ago, known as COX-2 inhibitors, with supposedly significantly fewer side effects, Vioxx (rofecoxib) was recently withdrawn as it was unfortunately found to have previously unrecognized very significant cardiovascular side effects. Celebrex (celecoxib) remains available.

NSAIDs can cause stomach upset and prolonged use can even lead to stomach bleeding. Taking the medication with food can minimize these side effects.

Diuretics

Known also as “water pills,” diuretics reduce fluid retention in the body and may help CTS in cases where excess fluid aggravates symptoms (in some women during their menstrual cycle, for instance).

Steroid Injection Into The Wrist

A steroid solution may be injected directly into the carpal tunnel if symptoms have not improved with simple measures. This does not cause the undesirable effects commonly associated with long-term steroid use. The relief may be permanent or temporary.

Alternative Treatments

Some people may find these alternative treatments helpful in conjunction with conventional therapies. They have not been shown scientifically to be helpful.

• Cold Laser Therapy, Noninvasive, low-energy (“cold”) laser light is used to penetrate the skin and soft tissue. The process stimulates the nerve and increases circulation in the wrist without the need for cutting the skin.
• Acupuncture. This is an ancient Chinese treatment in which the acupuncturist inserts very fine needles into points on the body. Acupuncturists believe that energy flows through the body along pathways called meridians. If something interrupts the energy flow, pain or illness can result. The needles are thought to stimulate energy flow. Although there may be slight discomfort when the needles are inserted, many people find great relief when acupuncture is done by a qualified professional. Sometimes only one treatment or a very few treatments are needed.
• Vitamin B6 (pyridoxine). Some researchers claim that vitamin B6 relieves CTS. It is not advisable to take more than 200 milligrams per day (including the amount in your multivitamin). More than this amount can cause nerve damage. Vitamin supplementation should be part of an overall plan of balanced nutrition. The dose of vitamin B6 should not be increased if it is found to be unhelpful; rather it should be discontinued.
• Magnet therapy: Some people believe magnets of at least 550 to 850 gauss stimulate blood flow and offer pain relief. (Gauss is a unit of measurement of magnetic strength.) The side of the magnet with negative polarity is fastened against the skin, either with tape, or as part of a splint or wrap. Refrigerator magnets are too weak for medicinal purposes. Do not use strong magnets near computers or any other equipment that stores data electronically, as the data could be erased by the magnetic force.

Exercises To Prevent And Manage Carpal Tunnel Syndrome

Your doctor or physical therapist should approve your exercise plan before you start.

Keep in mind that:

• These exercises are not meant as a substitute for consultation and examination with a qualified specialist.
• Those with an acute injury should not do some of these exercises.
• Sets of exercises may be done several times a day as needed.
• You should not use ice immediately before exercise.

Commonly recommended exercises for prevention and management of CTS include:

1. Wrist range of motion (dorsiflexion/palmar flexion). Place forearm on a table with wrist off the edge, palm down. Bend hand downward as far as possible, then upward. Repeat 5 or 10 times.
2. Wrist range of motion (pronation/supination). Place forearm and whole hand on table, palm flat on tabletop. Turn wrist so back of hand is now flat on tabletop. Repeat 5 or 10 times.
3. Flexed forearm stretch with palm down. Without raising the shoulders, extend the affected arm straight out in front of the body and slowly, gently bend the wrist down with the free hand. Keep the fingers over the knuckles of the bent hand, not over the fingers. A stretch in the forearm muscles and the wrist should be felt. Hold 10 seconds; repeat 5 or 10 times.
4. Flexed forearm stretch with fist. Repeat the preceding exercise, but this time first make a fist, then bend the wrist down. Hold 10 seconds; repeat 5 or 10 times.
5. Forearm stretch with palm back. Another way to stretch the forearm muscles is to extend the arms straight out to the side, palms facing backward. Simply bend the wrists back. Hold 10 seconds; repeat 5 or 10 times.
6. Dorsiflexed forearm stretch with palm out. Extend the arm straight in front of you with the palm facing outward. Place your free hand on the underside of the knuckles and press back toward the body. Do not raise the shoulders. A stretch in the underside of the forearm should be felt. Hold 10 seconds; repeat 5 or 10 times.
7. Tendon glide. Start with a relaxed hand, fingers straight. Make a fist. Then slide your fingertips to the base of the palm, keeping the thumb straight. Then glide the fingers upward to make a “hook.” Repeat 5 or 10 times.
8. Neck Stretch. Sit or stand with head facing forward. Tilt the head down as far to the right as possible (right ear to right shoulder) and hold for 5 seconds. Place your right hand on the left trapezius muscle (between the neck and shoulder joint) to increase the stretch. Reverse instructions for the other side. Repeat 3 to 5 times.
9. Shoulder shrug and rotation. Stand with arms at the sides. Shrug the shoulders up toward the ears, then squeeze the shoulders back, stretch them down and then roll them forward. Do the whole rotation slowly. Repeat 3 to 5 times. If you cannot comfortably do the whole rotation, just shrug the shoulders up and down.
10. Pectoral stretch. Stand in a doorway (or an empty corner). Rest your forearms, including your elbows, on the doorframe, keeping your arms at a 90-degree angle. Lean forward till a stretch is felt in the chest muscles. Do not arch your back. Hold 20 seconds; repeat 5 times.

Surgery For Carpal Tunnel Syndrome

Surgery is reserved as a last resort if:

• Other treatments fail
• Hand function continues to deteriorate

In most people, surgery completely abolishes the symptoms of CTS. However, you should be aware that:

• In long-standing cases, if the nerve has suffered irreversible damage and is no longer able to function normally, loss of sensation and weakness in the fingers will persist. Fortunately, this is rare.
• A few people experience a return of CTS symptoms after a period of time.

Symptoms such as pain and tingling in the hand and nighttime symptoms usually disappear soon after surgery. Numbness in the palm and fingers may take longer.

The types of surgery for carpal tunnel syndrome are:

• Open Carpal Tunnel Release Surgery
• Endoscopic or Keyhole Surgery

Open Carpal Tunnel Release Surgery

The goal of this procedure is to increase the space in the carpal tunnel in order to remove pressure on the median nerve, which is compressed in the tunnel at the wrist. This operation is relatively simple and is usually done on an outpatient basis.

It may be performed with either:

• local anesthetic, with injection of a numbing substance directly into the hand where the incision is to be made
• regional anesthetic, with injection of a numbing substance into the upper arm to numb the entire arm
• general anesthesia, with the patient asleep

The procedure involves dividing the ligament that forms the roof of the tunnel. This allows the nerve to pass freely through the tunnel without being compressed.

• A tourniquet may be placed over the upper arm to limit bleeding. This will allow a clear, unobstructed view of the nerve.
• An incision, about one and a half to two inches long, is made in the palm, usually in the skin crease, extending up to the wrist.
• The ligament is exposed and then carefully divided – that is, it is opened along its length, making the median nerve entirely visible in the tunnel.
• The nerve is carefully inspected to be sure it is free along its length in the tunnel and not obstructed.
• The wound is then closed.

After the operation:

• The hand may be dressed with bandages and a splint or plaster cast, usually for up to a week or two. The arm should be elevated to reduce swelling, and a sling may be worn for comfort. Avoid leaving the hand hanging down, since this position encourages swelling to remain in the hand.
• It is best to remove the arm from the sling every few hours to move the elbow and shoulder so they don’t get stiff. Move the fingers regularly.
• Be careful not to wet the dressing. Cover the dressing with a plastic bag when washing.
• Sutures are usually removed after a week to 10 days. Some surgeons prefer to use absorbable sutures or adhesive tape.
• Once the dressings are removed, you will be encouraged to move the hand and fingers. You’ll begin with gentle gripping exercises, first with the palm empty and then with a soft sponge in the palm. Some physicians will arrange a supervised hand therapy program.
• Many physicians recommend massaging the scar with oil or cream.

More than 100,000 open release procedures are performed every year. Complications are extremely rare. Very few patients feel discomfort from the scar tissue.

Endoscopic Or “Keyhole” Surgery

A newer procedure using a very small incision at the wrist allows the surgeon to pass fiber-optic tools through an endoscope (a device consisting of a pencil-thin tube and an optical system) into the tunnel. Then, using specialized tiny instruments, the surgeon divides the ligament. The surgeon views the carpal tunnel area and the median nerve on a video monitor.

The advantages of endoscopic surgery are that recovery time is quicker and the scar is smaller. However, since this is a newer procedure, not all surgeons are experienced with it. Therefore, the success rate may be a little lower than the conventional technique and the complication rate higher.

“Keyhole” surgery for carpal tunnel syndrome has its opponents as well as proponents. It is important to select a surgeon with expertise in this procedure.

Frequently Asked Questions: Carpal Tunnel Syndrome

Here are some frequently asked questions related to Carpal Tunnel Syndrome.

Q: My doctor wants me to wear a wrist splint at night. How come? Nighttime is the one chance I get to rest my wrist – during sleep I’m certainly not straining my wrist, and the splint is annoying.

A: During the night, many people bend their wrists in awkward positions, so the symptoms of CTS can get worse. The splint will hold your wrist in a neutral position. Once you fall asleep, you won’t know the splint is there.

Q: I am a woman newly diagnosed with CTS. Of the people in my office who have CTS, all of them are women. Are women more likely to get CTS than men?

A: Studies indicate that more women than men get CTS, but the exact reason why is not known. It is suspected that hormonal changes that lead to fluid retention, such as the fluctuations that take place during PMS, pregnancy, and use of oral contraceptives, account for a lot of CTS cases in women. Among office workers, women may spend more hours typing – but, according to the U.S. Bureau of Labor Statistics, there are more reported cases of CTS in women who work on assembly lines, operate machinery, and tend retail stores, than among women who type for a living.

Q: What type of specialist should I consult if I think I have CTS?

A: There is simply no substitute for an accurate diagnosis. Besides a family practitioner or internist, sufferers may consult an orthopedist, neurologist, hand surgeon, rheumatologist, physiatrist, or a specialist in occupational medicine or sports injuries. If ultimately surgery is required, it will be done by an orthopedic surgeon or a hand surgeon.

Putting It All Together: Carpal Tunnel Syndrome

Here is a summary of the important facts and information related to Carpal Tunnel Syndrome.

• Carpal tunnel syndrome, or CTS, is a painful disorder in which the major nerve to the hands and fingers, the median nerve, is “compressed” in a tunnel at the wrist. This may cause tingling, numbness, and other symptoms in certain parts of the hand and fingers.
• In most cases, the cause is unknown. CTS can be brought on by repetitive motion and awkward positioning of the hands and wrists, or it may stem from medical conditions associated with swelling.
• CTS can occasionally cause permanent disability to the hand if not treated.
• Women are more likely to get CTS than men are.
• Professional diagnosis is important because there are other disorders that can cause symptoms similar to CTS.
• Symptoms appear gradually. They include, but are not limited to, numbness, tingling or burning sensations in the thumb and fingers, particularly the index and middle fingers.
• A telltale sign of CTS is when symptoms are severe enough to awaken the sufferer from sleep.
• There are self-help measures everyone can take after being properly diagnosed, including targeted exercises, modifying one’s work habits and workstation, wrist splints, and anti-inflammatory medication.
• Surgery should be performed only when other treatments have failed.

Glossary: Carpal Tunnel Syndrome

Here are definitions of medical terms related to Carpal Tunnel Syndrome.

Carpal tunnel: A small passage located below the wrist at the heel of the hand through which the major nerve to the hand, the median nerve, as well as tendons that bend the fingers pass

Cold laser therapy: Noninvasive procedure that uses low-energy (“cold”) laser light to penetrate the skin and soft tissue

Dexterity: Skill and ease in use of the hands

Endoscopic surgery: A procedure in which fiber-optic tools are passed through a very small incision to divide the transverse carpal ligament; also called keyhole surgery

Ergonomics: The science of fitting a job and job-related equipment to individual human physical and psychological characteristics

Fibromyalgia: A fatiguing, chronic condition of the muscles and connective tissue in which very specific trigger points on the body are painful

Ligament: A band of fibrous tissue connecting bones, cartilage, and other structures

Median nerve: Conducts impulses from the brain, down the arm and to the fingers

Musculoskeletal: Pertaining to the muscles, joints and bones

Neurologist: A specialist in disorders of the central nervous system

Noninvasive: Any procedure or treatment that does not invade the body by way of insertion or incision

NSAID: Non-steroidal anti-inflammatory drug

Occupational medicine: The practice concerned with injury and illness in the workplace

Orthopedist: A specialist in structural disorders of the skeleton, joints, muscles, fascia, and other supporting or connective tissue such as cartilage, tendons and ligaments.

Phalen test: Diagnostic test in which the wrist is bent forward for 30 to 60 seconds to see if CTS symptoms result.

Physiatrist: A specialist in physical medicine

Raynaud’s disease: Vascular condition in which the fingers become cold and pale when blood vessels are constricted upon exposure to cold

Repetitive strain injury (RSI): An injury to the upper extremities resulting from prolonged overuse, pressure, force, vibration, or awkward or constrained posture

Rheumatoid arthritis: A systemic (affecting the whole body) form of arthritis believed to stem from an abnormality in the immune system. Characterized by inflammation of the joints and other symptoms. Unlike osteoarthritis, rheumatoid arthritis is not caused by wear and tear on the joint cartilage.

Rheumatologist: A specialist in rheumatic diseases

Splint: A device that immobilizes a joint

Tendon: Fibrous tissue connecting muscles to bones and other parts

Tinel test: A diagnostic test in which the wrist is pressed or bent over the area of the median nerve to see if the tingling characteristic of CTS results

Additional Sources Of Information: Carpal Tunnel Syndrome

Here are some reliable sources that can provide more information on Carpal Tunnel Syndrome.

Cornell University Ergonomics Web (Cuergo for short), at http://ergo.human.cornell.edu. Indispensable information on how to set up an ergonomic workstation and position oneself at it. Illuminating studies on keyboard and mouse design.

Typing Injury FAQ, billed as the RSI Community’s Online Resource, at http://www.tifaq.org. Excellent links to articles and a comprehensive list of resellers of ergonomic equipment for just about every body part and need. It pays to shop around; prices for the same equipment vary widely among sellers.

CTD Resource Network, at http://www.ctdrn.org. An information clearinghouse, publishes the monthly online newsletter RSI Network. Has up-to-date information on developments in the study of RSI and ergonomic products.

Safe Computing, at http://www.safecomputing.com. A reseller of ergonomic equipment. Site also contains useful informational links and articles.

Center for Carpal Tunnel Studies, a treatment center in Arizona.http://www.centerforcarpaltunnel.com . Information on treatments and ergonomic products.

Carpal Tunnel Syndrome/RSI Association 
Phone: 707-571-0397

A clearinghouse for information about RSI and support groups.

American Chronic Pain Association 
Phone: 916-632-0922
www.theacpa.org

Best WristTreatments – Get 52 *FREE* Tips On How To Deal & Treat Wrist Pain & CTS. Discover The Best Wrist Pain Treatments Around & Find Great Deals & Info On Cures & Pain Relief Products. 
http://www.best-wrist-treatments.com/

Book: “Repetitive Strain Injury: A Computer User’s Guide,” by Emil Pascarelli, MD and Deborah Quilter (NY: John Wiley & Sons, 1994). Excellent background on RSI, including CTS; practical advice on prevention and treatment, with illustrations.