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Carpal Tunnel Syndrome

 

What is carpal tunnel syndrome?

The carpal tunnel is a narrow passage inside the wrist formed by bone on the bottom and a carpal ligament on top. The median nerve and adjacent tendons run from the forearm into the palm to control the thumb and first three fingers. 

Carpal tunnel syndrome (median nerve entrapment) occurs when the median nerve is squeezed or compressed at the wrist. Swelling and inflammation develop, compressing the nerve and causing carpal tunnel symptoms. Carpal tunnel syndrome is the most common type of nerve entrapment.

What causes carpal tunnel?

Carpal tunnel pain occurs when the tendon presses on the median nerve. With inflammation, the space within the carpal tunnel shrinks, adding to the compression of the nerve.

Some people, often women, have a smaller tunnel and are more at risk of developing carpal tunnel syndrome.

Repetitive movements with the wrist in an unnatural position or overuse are seen among office workers, computer/smart phone users, carpenters, assembly line workers, musicians, and some athletes. Carpal tunnel syndrome can also develop with illness (e.g., rheumatoid arthritis, diabetes, hypothyroidism), obesity, smoking, or pregnancy. It can result from trauma, an injury to the upper arm, a dislocated wrist, or a fracture.

What are the symptoms of carpal tunnel syndrome?

 Symptoms begin slowly at first; pain comes and goes in the thumb and first three fingers. Some people “shake out” their hands to try and ease the discomfort. The most common symptoms of carpal tunnel syndrome include:

  • Numbness
  • Pins-and-needle tingling
  • Pain that occurs along the path of the median nerve.
  • Waking at night with pain
  • Shooting pain in the wrist or forearm
  • Weakened grip
  • Frequently dropping things
  • Difficulty buttoning clothes
  • Fingers that feel swollen (even when they’re not)
  • Having trouble making a fist. 

If long-standing nerve damage and a loss of muscle mass occur, this may cause the palm area under the thumb to look smaller. As the condition worsens, you may feel sharp, shooting hand pain that persists during the day. The pain may extend up to the elbow.

Not all hand pain is related to carpal tunnel. Therefore, a diagnosis is needed to rule out other problems, such as ulnar nerve entrapment at the elbow or a pinched nerve in the neck (cervical radiculopathy).

How is carpal tunnel syndrome diagnosed?

Shooting pain in the hand signals carpal tunnel syndrome. An accurate diagnosis rules out other joint or muscle problems that can mimic this syndrome. Your doctor will check the feeling, strength, and appearance of your neck, shoulders, arms, wrists, and hands. Your doctor will ask about your hand pain, including possible causes, and will perform two tests that pinpoint median nerve compression.

  • Tapping test: Tap the inside of your wrist. Does this cause pain or shock-like tingling?
  • Wrist flexion (Phalen test): Put the back of your hands together, shoulders relaxed, with fingers pointing down for 1 minute. Does this cause your symptoms? 
  • EMG (electromyography): a needle inserted into a muscle of your hand records the electrical activity of that muscle. Testing also includes a nerve conduction study; electrodes are taped to the skin to deliver several quick, split-second electrical pulses. In carpal tunnel syndrome, the speed of the median nerve impulse is slower than normal. The test is uncomfortable: as the current is applied, a split-second tingle, burning, or shock sensation is felt.

Results will confirm whether your pain is related to the median nerve and not something else. If nerve entrapment is involved, your physician will discuss possible treatments with you.

Inform your doctor about any health problems (e.g., diabetes), strains or recent injuries to your wrist, arm, or neck. Any one of these could affect the median nerve. Describe your daily routine or anything that could have strained or hurt your wrist. Your doctor might order blood tests, which can help detect a health problem that is causing your symptoms. If there are signs or symptoms of a nerve or muscle disorder, your doctor may order an electromyography with nerve conduction testing.

What are treatment options for carpal tunnel syndrome?

The severity of your symptoms will guide treatment. For mild to moderate symptoms, a number of nonsurgical strategies may help your wrist and hand feel better, including:

  • Stop or reduce repetitive activities that cause stress, numbness, and pain. Rest your wrist longer between activities. 
  • Have a good posture, especially in the neck and shoulder area.
  • Certain yoga stretches and exercises may be therapeutic. 
  • Improving wrist and forearm mobility and strengthening.
  • Ice your wrist for 10 to 15 minutes 1 to 2 times every hour. Although nonsteroidal anti-inflammatory drugs (NSAIDs) may relieve pain and reduce swelling, use these medications with caution.
  • Chiropractic adjustments in the spine and extremities may reduce wrist pain, restore joint motion, and balance musculature. Massage or physiotherapy may address painful trigger points.
  • Keep your wrist straight by wearing a wrist splint at night.
  • Try an anti-inflammatory diet and add B6 and B12 supplements if approved by your doctor.
  • An injection of cortisone, a synthetic steroid solution, into the carpal tunnel area may help to reduce the inflammatory cascade of carpal tunnel pain and swelling. Pain relief after the injection is immediate for some patients or delayed for others; some have no relief at all. Your doctor will discuss the special precautions and potential complications of these injections.

When is surgery considered for carpal tunnel syndrome?

Sometimes carpal tunnel pain persists. Even in patients who have carefully followed nonsurgical therapy, symptoms can become debilitating and make daily activities more difficult. If nerve damage is a concern or the muscles appear weak or atrophied, treatment becomes more pressing to avoid further damage.

Surgery, known as a carpal tunnel release, aims to cut and release the ligament may be option if testing confirms the median nerve is entrapped or if pain, weakness, and numbness persist. After surgery the ligament heals back together, but with enough space for the nerve.

Surgery can be performed either as an open or endoscopic technique. Both are performed as outpatient surgery, require small incisions, and take only 10 minutes. Both procedures involve cutting the carpal ligament to relieve pressure on the median nerve. Recovery varies, depending on the incision size and the patient’s overall health.

Another technique is to use an endoscope. After two small incisions are made in the wrist and palm, an endoscope equipped with a small camera is inserted. Viewing the carpal tunnel through the endoscope, the surgeon cuts the ligament from underneath to release the median nerve. If needed, the procedure can be switched to an open surgery.

What are the risks of carpal tunnel surgery?

No surgery is without risks. General complications of any surgery include bleeding, infection, blood clots, and reactions to anesthesia. Specific complications related to carpal tunnel surgery may include nerve injury and scarring.

During the healing process, the ligament gradually grows back together while allowing more room for the nerve than there was before. Some patients feel tenderness around the scar.

Most patients are helped by surgery and are able to return to their jobs. If there was nerve damage before surgery, a full recovery to a “normal hand” may not be possible. Loss of wrist strength affects 10 to 30% of patients. Residual numbness, loss of grip, or pain may be helped by physical therapy. Persistent symptoms are higher in those with diabetes.

The risk of recurrence is small. The most common reason for repeat surgery is incomplete cutting of the ligament during the first surgery or scarring.