Carpal Tunnel Syndrome
What is Carpal Tunnel Syndrome?
Carpal Tunnel syndrome is also known as median nerve entrapment or median nerve compression. It is a common condition that causes pain, numbness and weakness in the hands and wrist. It happens when there is increased pressure on the median nerve and compresses the nerve. Th median nerve provides sensation to the thumb, index and middle fingers and also to half of the ring finger (3.5 fingers). The small finger is spared. The median nerve also provides strength to some of the muscles at the base of the thumb.
The carpal tunnel is a narrow canal in the wrist. The bottom and sides of the tunnel are surrounded by the carpal bones. The transverse carpal ligament forms the top of the tunnel. The median nerve and tendons pass through this narrow space. The boundaries of the carpal tunnel are very rigid thus this canal has little capacity to "stretch" .Conditions that narrow the carpal tunnel or when the tendons swell that will cause carpal tunnel syndrome as the median nerve is compressed.
Carpal Tunnel Syndrome affects between 3-6% of adults and its more common between the ages of 45 and 64 years. The prevalence increases with age and is more common in women. It can appear in one or both wrists.
In most patients, carpal tunnel syndrome gets worse over time, so early diagnosis and treatment are important.
Carpal Tunnel syndrome is also known as median nerve entrapment or median nerve compression. It is a common condition that causes pain, numbness and weakness in the hands and wrist. It happens when there is increased pressure on the median nerve and compresses the nerve. Th median nerve provides sensation to the thumb, index and middle fingers and also to half of the ring finger (3.5 fingers). The small finger is spared. The median nerve also provides strength to some of the muscles at the base of the thumb.
The carpal tunnel is a narrow canal in the wrist. The bottom and sides of the tunnel are surrounded by the carpal bones. The transverse carpal ligament forms the top of the tunnel. The median nerve and tendons pass through this narrow space. The boundaries of the carpal tunnel are very rigid thus this canal has little capacity to "stretch" .Conditions that narrow the carpal tunnel or when the tendons swell that will cause carpal tunnel syndrome as the median nerve is compressed.
Carpal Tunnel Syndrome affects between 3-6% of adults and its more common between the ages of 45 and 64 years. The prevalence increases with age and is more common in women. It can appear in one or both wrists.
In most patients, carpal tunnel syndrome gets worse over time, so early diagnosis and treatment are important.
Risk factors for Carpal tunnel syndrome
People who are most at risk are those with jobs or activities that involve repetitive finger use, especially those associated with high force, long-term use, extreme wrist motions and vibration.
Other risk factors are:
People who are most at risk are those with jobs or activities that involve repetitive finger use, especially those associated with high force, long-term use, extreme wrist motions and vibration.
Other risk factors are:
- Heredity: Smaller carpal tunnels can run in families
- Hand and wrist position: Doing activities that involve extreme flexion or extension of the hand and wrist over a prolonged period of time increases pressure on the nerve.
- Repetitive hand use over a prolonged period of time may aggravate the tendons in the wrist. This cause swelling and puts pressure on the nerve.
- Hemo-dialysis
- Previous wrist fracture /dislocation
- Pregnancy: Hormonal changes during pregnancy can cause swelling.
- Arthritis disease: Rheumatoid Arthritis and Gout
- Thyroid disease
- Diabetes
- Alcoholism
- Older age
- Structural problems in wrist joint
- Cysts and tumors in the wrist
Symptoms of Carpal Tunnel Syndrome
Initially the symptoms come and go but as the condition worsens, the symptoms worsen and persist for a longer period of time. Night symptoms are common as people sleep with the wrists flexed and it may wake the patient up. Shaking the hands helps relieve symptoms in the early stage of the condition.In the most severe condition, the muscles at the base of the thumb visibly shrink in size. Many patients find that moving or shaking their hands helps relieve their symptoms.
- Numbness, tingling, burning and pain especially in the thumb and index, middle, and ring fingers (3.5 fingers)
- Occasional shock-like sensations in the fingers
- Pain or tingling sensation may travel up the forearm toward the shoulder
- Weakness and difficult to perform fine movements such as buttoning your clothes
- Dropping things as a result of weakness, numbness, or a loss of proprioception
Initially the symptoms come and go but as the condition worsens, the symptoms worsen and persist for a longer period of time. Night symptoms are common as people sleep with the wrists flexed and it may wake the patient up. Shaking the hands helps relieve symptoms in the early stage of the condition.In the most severe condition, the muscles at the base of the thumb visibly shrink in size. Many patients find that moving or shaking their hands helps relieve their symptoms.
Diagnostic tests for carpal tunnel syndrome
1. Tinel’s sign: Your doctor taps over the median nerve at the wrist to see if it produces a tingling sensation/numbness in the fingers.
2. Phalen test: Bend and hold your wrists in a flexed position, individuals with carpal tunnel syndrome will experience numbness and tingling in the fingers within 60 seconds. The more quickly symptoms appear implies that the carpal tunnel syndrome is more severe.
3. Examining the hand and wrist for signs of weakness and atrophy in the muscles around the thumb
4. X-rays of the wrist may be ordered if there is limited wrist motion, or evidence of arthritis or trauma.
5. Electromyography (EMG): A fine needle is inserted into the muscle. It measures the electrical activity in muscles and it can reveal whether there is any median nerve damage and if so, how severe it is.
6. Nerve conduction studies: These tests measure the signals travelling in the nerves of your hand and arm and can detect when a nerve is not conducting its signal effectively.
7. Ultrasound : using high frequency sound waves to check the structure of the median nerve.
8. MRI: These studies provide better images of the body's soft tissues to determine if there are problems with the nerve itself or due to scarring from an injury or tumor.
1. Tinel’s sign: Your doctor taps over the median nerve at the wrist to see if it produces a tingling sensation/numbness in the fingers.
2. Phalen test: Bend and hold your wrists in a flexed position, individuals with carpal tunnel syndrome will experience numbness and tingling in the fingers within 60 seconds. The more quickly symptoms appear implies that the carpal tunnel syndrome is more severe.
3. Examining the hand and wrist for signs of weakness and atrophy in the muscles around the thumb
4. X-rays of the wrist may be ordered if there is limited wrist motion, or evidence of arthritis or trauma.
5. Electromyography (EMG): A fine needle is inserted into the muscle. It measures the electrical activity in muscles and it can reveal whether there is any median nerve damage and if so, how severe it is.
6. Nerve conduction studies: These tests measure the signals travelling in the nerves of your hand and arm and can detect when a nerve is not conducting its signal effectively.
7. Ultrasound : using high frequency sound waves to check the structure of the median nerve.
8. MRI: These studies provide better images of the body's soft tissues to determine if there are problems with the nerve itself or due to scarring from an injury or tumor.
Treatment for Carpal Tunnel Syndrome
Carpal Tunnel Syndrome is a gradual process which will worsen over time without some form of treatment. Thus one should get it evaluated in the early stages as it may be possible to slow or stop the progression of the disease.
Non surgical treatment
In early stages, carpal tunnel syndrome can often be relieved without surgery.
1. Bracing or splinting: Wearing a brace or splint at night will prevent you from bending your wrist while you sleep. Or you can try to keep your wrist in a straight or neutral position, this help reduce pressure on the nerve in the carpal tunnel. It may also help to wear the splint when you are doing activities which may aggravate your symptoms.
2. Drugs : Like Nonsteroidal anti-inflammatory drugs (NSAIDs) such as ibuprofen, celebrex, arcoxia, mefenamic acid and naproxen can help relieve the pain and inflammation.
3. Modify activity : Symptoms often occur when the hand/wrist are held in the same position for too long or when there's repetitive movements of the hand/wrist. If your job or recreational activities aggravate your symptoms, then you should change or modify the activities. You can also make ergonomic changes to your work site or work station for example raising or lowering the chair or the computer keyboard to bring the patient into proper alignment. That can help slow or stop progression of the disease.
4. Steroid injections: is a powerful anti-inflammatory agent that can be injected into the carpal tunnel. It helps to relieve the pain but their effect is sometimes only temporary.
5. Exercises:
- Shake it out : Shake your hands to get relief
- Fist to stop sign : Make a fist then slide your fingers up until they point toward the ceiling (like a "stop" sign). Repeat 5-10 times.
- Fist to fan: Make a fist then fan your fingers out and stretch them as far as you can. Repeat 5-10 times.
- Thumb touches: One at a time, touch the tip of each finger to the tip of your thumb so they make an O-shape each time. Repeat a few times.
- Wrist stretches: Rest your elbow and arm on the table and let your wrist hang over the side, palm of your hand facing up. Then bend your hand toward you so your fingers point up toward the ceiling and hold for 5 seconds. Next bend your hand away from you so your fingers point down toward the floor and hold for 5 seconds. Repeat 10 times.
- Flex/extend wrist: Hold your arm straight out in front of you, flex your wrist and hold for 30 seconds. Then extend your wrist and hold for 30 seconds.
- Hand squeeze exercise: Squeeze a soft rubber ball and hold for 5 seconds. Repeat 10 times.
- Wrist stretch with weight
Carpal Tunnel Syndrome is a gradual process which will worsen over time without some form of treatment. Thus one should get it evaluated in the early stages as it may be possible to slow or stop the progression of the disease.
Non surgical treatment
In early stages, carpal tunnel syndrome can often be relieved without surgery.
1. Bracing or splinting: Wearing a brace or splint at night will prevent you from bending your wrist while you sleep. Or you can try to keep your wrist in a straight or neutral position, this help reduce pressure on the nerve in the carpal tunnel. It may also help to wear the splint when you are doing activities which may aggravate your symptoms.
2. Drugs : Like Nonsteroidal anti-inflammatory drugs (NSAIDs) such as ibuprofen, celebrex, arcoxia, mefenamic acid and naproxen can help relieve the pain and inflammation.
3. Modify activity : Symptoms often occur when the hand/wrist are held in the same position for too long or when there's repetitive movements of the hand/wrist. If your job or recreational activities aggravate your symptoms, then you should change or modify the activities. You can also make ergonomic changes to your work site or work station for example raising or lowering the chair or the computer keyboard to bring the patient into proper alignment. That can help slow or stop progression of the disease.
4. Steroid injections: is a powerful anti-inflammatory agent that can be injected into the carpal tunnel. It helps to relieve the pain but their effect is sometimes only temporary.
5. Exercises:
- Shake it out : Shake your hands to get relief
- Fist to stop sign : Make a fist then slide your fingers up until they point toward the ceiling (like a "stop" sign). Repeat 5-10 times.
- Fist to fan: Make a fist then fan your fingers out and stretch them as far as you can. Repeat 5-10 times.
- Thumb touches: One at a time, touch the tip of each finger to the tip of your thumb so they make an O-shape each time. Repeat a few times.
- Wrist stretches: Rest your elbow and arm on the table and let your wrist hang over the side, palm of your hand facing up. Then bend your hand toward you so your fingers point up toward the ceiling and hold for 5 seconds. Next bend your hand away from you so your fingers point down toward the floor and hold for 5 seconds. Repeat 10 times.
- Flex/extend wrist: Hold your arm straight out in front of you, flex your wrist and hold for 30 seconds. Then extend your wrist and hold for 30 seconds.
- Hand squeeze exercise: Squeeze a soft rubber ball and hold for 5 seconds. Repeat 10 times.
- Wrist stretch with weight
Surgical treatment
If nonsurgical treatment does not relieve your symptoms after a period of time > 6 months, then your doctor will suggest surgery especially when the symptoms are severe: constant numbness, constant pain and wasting of your thumb muscles. Then surgery may be recommended to prevent irreversible damage.The goal of surgery is to increase the size of the tunnel in order to decrease pressure on the nerves and tendons that pass through the tunnel.
The surgical procedure performed for carpal tunnel syndrome is called a "carpal tunnel release." There are two different surgical techniques to relieve pressure on your median nerve by cutting the transverse carpal ligament that forms the roof of the tunnel. This increases the size of the tunnel and decreases pressure on the median nerve. The surgery can be done under general anesthesia but more commonly it is done under local anesthesia.
Open carpal tunnel release
In open surgery, the surgeon will make a small incision in the palm of your hand and divide the transverse carpal ligament so as to increases the size of the tunnel. After surgery, the ligament may gradually grow back but there will be more space in the carpal tunnel and pressure on the median nerve will be relieved.
Endoscopic carpal tunnel release
In endoscopic surgery, the surgeon makes one or two smaller skin incision so as to insert a miniature camera and an endoscope to assess the wrist anatomy. Then a special knife is used to divide the transverse carpal ligament similar to the open carpal tunnel release procedure.
After surgery, there will be some discomfort which lasts 24 to 72 hours. However, patients often experience complete nighttime symptom relief even the night after surgery. Sutures are removed 10 to 14 days after surgery. Hand and wrist use for everyday activities are gradually restored with the guidance of an occupational therapist/physiotherapist.
Heavier activities with the affected hand are restricted for 4 to 6 weeks. You may have to wear a splint or wrist brace for several weeks. Recovery times vary depending on the patient’s age, general health and severity of carpal tunnel syndrome. Strength and sensation will gradually improve over the following year.
Many patients who undergo carpal tunnel release surgery achieve nearly complete relief of all symptoms. However in some individuals who has severe carpal tunnel syndrome, recovery may be slow and may not be complete. Carpal tunnel syndrome can reoccur but this is not common.
The most common complications from surgery include:
If nonsurgical treatment does not relieve your symptoms after a period of time > 6 months, then your doctor will suggest surgery especially when the symptoms are severe: constant numbness, constant pain and wasting of your thumb muscles. Then surgery may be recommended to prevent irreversible damage.The goal of surgery is to increase the size of the tunnel in order to decrease pressure on the nerves and tendons that pass through the tunnel.
The surgical procedure performed for carpal tunnel syndrome is called a "carpal tunnel release." There are two different surgical techniques to relieve pressure on your median nerve by cutting the transverse carpal ligament that forms the roof of the tunnel. This increases the size of the tunnel and decreases pressure on the median nerve. The surgery can be done under general anesthesia but more commonly it is done under local anesthesia.
Open carpal tunnel release
In open surgery, the surgeon will make a small incision in the palm of your hand and divide the transverse carpal ligament so as to increases the size of the tunnel. After surgery, the ligament may gradually grow back but there will be more space in the carpal tunnel and pressure on the median nerve will be relieved.
Endoscopic carpal tunnel release
In endoscopic surgery, the surgeon makes one or two smaller skin incision so as to insert a miniature camera and an endoscope to assess the wrist anatomy. Then a special knife is used to divide the transverse carpal ligament similar to the open carpal tunnel release procedure.
After surgery, there will be some discomfort which lasts 24 to 72 hours. However, patients often experience complete nighttime symptom relief even the night after surgery. Sutures are removed 10 to 14 days after surgery. Hand and wrist use for everyday activities are gradually restored with the guidance of an occupational therapist/physiotherapist.
Heavier activities with the affected hand are restricted for 4 to 6 weeks. You may have to wear a splint or wrist brace for several weeks. Recovery times vary depending on the patient’s age, general health and severity of carpal tunnel syndrome. Strength and sensation will gradually improve over the following year.
Many patients who undergo carpal tunnel release surgery achieve nearly complete relief of all symptoms. However in some individuals who has severe carpal tunnel syndrome, recovery may be slow and may not be complete. Carpal tunnel syndrome can reoccur but this is not common.
The most common complications from surgery include:
- Post-operative bleeding
- Infection
- Nerve aggravation or injury
- Scarring
Prevention of Carpal Tunnel Syndrome
- Sleeping and working with your wrists held straight.
- Avoiding excessive flexing and extending your wrists repeatedly.
- Decreasing repetitive/strong grasping with the wrist in a flexed position.
- Taking rest breaks from repetitive activities.
- Stretching exercises before and after activities.
- Maintaining correct posture to prevent strain on the wrist and hands
- Redesigning the workstation to reduce unnatural and awkward wrist positions
- Keep the hands warm in a cold environment
- Treat underlying conditions like diabetes and thyroid diseases
