So you think you have Carpal Tunnel Syndrome?

What is the carpal tunnel?

The carpal tunnel is a space created by the carpal bones and the transverse carpal ligament.  The tunnel is about the diameter of your index finger.  Through the tunnel run the median nerve and 10 muscle tendons flexor digitorum superficialis (there are 4 of these tendons), flexor digitorum profundus (there are 4 of these tendons), flexor carpi radialis, and flexor pollicis longus.  

10 tendons and the nerve pass through the tunnel created by the carpal bones and the transverse carpal ligament. / Photo by Blausen.com staff (2014). “Medical gallery of Blausen Medical 2014” and available via CC by 3.0

What is Carpal Tunnel Syndrome?

Carpal tunnel syndrome (abbreviated CTS) is used as an umbrella diagnosis with most people attributing any wrist pain to carpal tunnel syndrome.  Actual CTS can be difficult to diagnose as there are similarities with neck injuries, nerve impairment, thoracic outlet syndrome, pronator teres syndrome, sprained wrist ligaments, and trigger point referral pain produce similar symptoms.  A doctor will use diagnostic tools such as nerve conduction tests, electromyograms.  Two other diagnostic tools are called “Tinel’s sign” and “Phalen’s test.”  While you can perform Tinel’s and Phalen’s on yourself, it is important, as with all medical conditions, that diagnosis is done by a qualified health professional.  Accurate and timely diagnosis will minimize the possibility of permanent nerve damage, long term discomfort and disability.  

Symptoms of CTS Pain

  • Numbness of the wrist or hand, specifically in the thumb, pointer, and ring finger
  • Tingling of the wrist or hand, specifically in the thumb, pointer, and ring finger
  • Nocturnal pain
  • Loss of grip strength
  • Reduced fine motor control
  • Atrophy of the thumb muscle in your palm (anatomically referred to as the thenar eminence)

Atrophy of thenar eminence / Photo available in public domain

Causes of CTS

CTS can by caused by numerous factors which ultimately result in the entrapment of the median nerve.  The tunnel is a finite space and some factors cause the tunnel to get smaller, entrapping the nerve, or the other structures in the tunnel get bigger, again entrapping the nerve.    

  • Repetitive motion which increases the pressure within the tunnel, entrapping the nerve
  • Tendinitis (swollen tendons) of the muscles that pass through the carpal tunnel
  • Hypertrophy of the muscles
  • Displaced carpal bones
  • Bony deformity
  • Scar tissue (direct trauma or previous carpal tunnel surgery is commonly implicated)
  • Tight muscles can create referral pain which mimics the numbness and tingly sensation in hands often present in carpal tunnel.
  • Pregnancy, diabetes, hyperthyroidism, rheumatoid arthritis, or gout can create changes in the tissues which can then create a higher pressure within the tunnel

Treatment

Prevention, as always, is the best treatment.  Modify repetitive hand movements to reduce wrist pain and problems.  Pain, in this case, is a very good indicator of something being wrong and it needing change.  In general, keep the wrist in a neutral position throughout activities, minimize repetition and reduce the speed and force of movement.  One common activity that often puts your wrist in a compromised position is typing and using a mouse.  Using a wrist support like this (affiliate) will be helpful by cradling your wrist in a neutral position.  There are also handy wrist supports for laptop (affiliate) users too.  The most important part of the wrist support is making sure that it is the correct height for your wrist and keyboard.  

PRICES is a handy acronym for CTS treatment.  PRICES stands for positioning, rest, ice, compression, elevation, and support.  Proper positioning during activities will reduce the severity of CTS symptoms, as will rest by reducing or ceasing exacerbating activities.  Ice will help to reduce inflammation, as will compression and elevation.  Support of the wrist through proper bracing will help to keep the wrist in a neutral position, which keeps the carpal tunnel as big as possible.  NSAIDS (nonsteroidal anti-inflammatory drugs like aspirin and ibuprofen) will also help reduce inflammation.  

 

A wrist brace to help maintain a neutral position of the wrist to help alleviate carpal tunnel symptoms. / Photo available in the public domain

A variety of healthcare professionals outside of a medical doctor can be helpful in management of CTS.  Chiropractors and osteopaths can perform boney manipulation, which is helpful if a displaced carpal is the problem.  Physical therapists can help by using ultrasound, electrical stimulation, as well as demonstrating some stretching and strengthening exercises.

Massage can be immensely helpful for CTS patients.  A therapeutic massage, within pain tolerance, for carpal tunnel syndrome with specific work on the hand, wrist, forearm and shoulder may help decompress the median nerve.   Massage that doesn’t exacerbate symptoms has been shown to contribute to improvement in strength, function, and symptoms of patients with CTS [1].  Massaging the specific muscles which pass through the carpal tunnel could help address tendinitis and reduce the symptoms of carpal tunnel.  Those muscles are:

  • Flexor carpi radialis
  • Flexor pollicis longus
  • Flexor digitorum superficialis
  • Flexor digitorum profundus

Additionally, not all CTS is actually from impingement of the median nerve.  A variety of muscles create referral pain which mimic some symptoms of CTS.  Referral pain is pain perceived in a location different than its stimulus (for example some of the symptoms of a heart attack can be pain in the jaw or arms).  Targeted massage of these muscles, all of which have referral pain patterns similar to actual CTS, could alleviate your symptoms of CTS:

  • Scalenes
  • Subclavius
  • Infraspinatus
  • Subscapularis
  • Supinator
  • Brachioradialis
  • Pronator teres
  • Palmaris longus
  • Flexor carpi radialis
  • Flexor pollicis longus
  • Flexor digitorum superficialis
  • Flexor digitorum profundus

As you can see, the flexors repeat on both lists.  Massaging the flexors can be highly beneficial to a CTS patient.  

For severe cases, surgery is sometimes offered as a solution.  A 2012 review of scientific studies shows success rates of carpal tunnel release surgery are anywhere between 75-90% and recurrence occurs 4-57% of the time (highly variable due to the individual doctor’s definitions of “recurrence” in the case of CTS), usually about 2 years post surgery.  In a CTS, the surgeon cuts the transverse carpal ligament, and then sutures the skin back together [2].  The ligament is left alone after it is cut, and forms scar tissue, which could make the tunnel smaller and worsen the symptoms.  Because of the high likelihood of recurrence, and the common complications associated with surgery, it makes sense to exhaust all other potential solutions before resorting to surgery.  

Scars from two different variations of carpal tunnel surgery / Photo By HenrykGerlach CC BY-SA 3.0 , via Wikimedia Commons

Self Massage of the Flexors

Being able to massage your own flexors can help alleviate some symptoms of CTS.  There are two main ways to massage the flexors of your arms.  The first way is general and not precise, but is a great introduction to self massage of the forearms, or as a way to warm up your arm for more specific massage.  The first technique is a “pin and stretch” technique in a crouched position.  Stand up straight, and then bend over, wrapping your forearm, with a fist and flexed wrist, into your knee pit.  Crouch down, pinning your arm between your thigh and your calf.  Now extend your wrist and open and spread your fingers.  Bounce up, relieving the pressure on your arm and flexing your wrist while making a fist, then bounce down and repeat.  This can be repeated along the length of your forearm.  

Pin and stretch your forearm in your knee pit. / Photo by Bodymybody.com

The second way to self massage your forearms is on a counter.  Place your forearm on a counter, palm up.  Use your other forearm to press down and glide along the length of your forearm.  Alternatively you can “saw” while you glide.  You can also do a pin and stretch during this move, making a flexed fist before the glide starts and unfurling as the glide progresses.  

Use your opposite forearm to massage the affected forearm. / Photo by Bodymybody.com

My Conclusions

Carpal tunnel is an often misunderstood diagnosis.  With proper knowledge of what the carpal tunnel is and other reasons your wrist can hurt, you can attempt to alleviate the symptoms appropriately.  


References

[1]   Werner, Ruth. “Chapter 3 Musculoskeletal System Conditions.” A Massage Therapist’s Guide to Pathology. 5th ed. N.p.: Lippincott Williams & Wilkins, 2013. 119-21. Print.

[2] Louie, Dexter, Brandon Earp, and Philip Blazar. “Long-term Outcomes of Carpal Tunnel Release: A Critical Review of the Literature.” Hand (N Y) 7.3 (2012): 242-46. PubMed. U.S. National Library of Medicine, 22 June 2012. Web. 07 May 2017.


 

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