Current Management of Carpal Tunnel Syndrome: Difference between revisions
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== Clinically Relevant Anatomy == | == Clinically Relevant Anatomy == | ||
Urits I, Gress K, Charipova K, Orhurhu V, Kaye AD, Viswanath O. Recent advances in the understanding and management of carpal tunnel syndrome: a comprehensive review. Current pain and headache reports. 2019 Oct;23(10):1-8. | Some clinically relevant anatomical structures include<ref name=":0">Urits I, Gress K, Charipova K, Orhurhu V, Kaye AD, Viswanath O. Recent advances in the understanding and management of carpal tunnel syndrome: a comprehensive review. Current pain and headache reports. 2019 Oct;23(10):1-8.</ref>: | ||
The carpal tunnel is a U-shaped, osteofibrous canal | * The carpal tunnel is a U-shaped, osteofibrous canal | ||
* The floor of the tunnel is formed by the carpal bones and the roof by the flexor retinaculum | |||
* The tunnel is located deep to the flexor retinaculum/ transverse carpal ligament, between the tubercles of the scaphoid and trapezoid on the lateral side and the pisiform and hook of hamate on the medial side | |||
* The four main structures passing through the tunnel are: | |||
** Four tendons of flexor digitorum superficialis | |||
** Four tendons of flexor digitorum profundus | |||
** One tendon of the flexor pollicis longus | |||
** Median nerve | |||
*** Path of the median nerve: | |||
**** Begins in the axillary region with the root of median nerves situated in the anterior rami of C5-T1 | |||
**** The median nerve is formed by fascicles of the medial and lateral cords of the brachial plexus | |||
**** Runs distally in the arm next to the brachial artery until the middle of the arm, and descends into the cubital fossa (anterior elbow) | |||
**** Principal nerve supply to the anterior compartment of the forearm | |||
**** The muscular branch in the forearm supplies all the superficial and intermediate layers of the forearm flexors, except for flexor carpi ulnaris | |||
***** Pronator teres | |||
***** Palmaris longus | |||
***** Flexor digitorum superficialis | |||
***** Flexor carpi radialis | |||
**** The terminal branch of the median nerve enters the hand through the carpal tunnel, along with the tendons of flexor digitorum profundus, flexor digitorum superficialis and flexor pollicis longus | |||
**** Distal to the carpal tunnel the nerve supplies five intrinsic muscles in the thenar part | |||
**** The median nerve supplies sensation to the skin on: | |||
***** the entire palmar surface | |||
***** the sides of the first three digits | |||
***** the lateral half of the fourth digit and | |||
***** the dorsal aspects of the distal halves of these digits | |||
**** Innervation to the thenar eminence includes flexor pollicis brevis, opponens pollicis and abductor pollicis brevis | |||
== Aetiology == | |||
Increased pressure in the carpal tunnel and compression of the median nerve is the main cause of carpal tunnel syndrome. The aetiology of carpal tunnel syndrome can be related to<ref name=":1">Osiak K, Elnazir P, Walocha JA, Pasternak A. [https://journals.viamedica.pl/folia_morphologica/article/view/FM.a2021.0121/64749 Carpal tunnel syndrome: state-of-the-art review.] Folia Morphologica. 2021 Nov 9.</ref>: | |||
* Work | |||
* Lifestyle | |||
* Injury | |||
* Genetic predisposition | |||
* History of repetitive wrist movement or exposure to vibrations or forceful angular motions such as typing, gaming, machine work | |||
* Specific conditions may also be associated with an increased risk for the development of carpal tunnel syndrome (CTS). These can include: | |||
** Diabetes | |||
** Pregnancy | |||
** Obesity | |||
** Rheumatoid arthritis | |||
** Fall on an outstretched hand (FOOSH) – this can displace the lunate bone which can cause pressure in the carpal tunnel | |||
* CTS is more commonly seen in females, and it usually occurs between the ages of 36 and 60 | |||
CTS is more commonly seen in females, and it usually occurs between the ages of 36 and 60 | |||
== Pathophysiology == | |||
Increased interstitial pressure in the carpal tunnel due to various causes such as: | Increased interstitial pressure in the carpal tunnel due to various causes such as: | ||
Mechanical overuse | * Mechanical overuse | ||
* Osteoarthritis | |||
Osteoarthritis | * Trauma | ||
* Acromegaly | |||
Trauma | |||
Acromegaly | |||
All of these place pressure on the median nerve. | |||
It is hypothesised that the compression of the median nerve leads to the development of local ischemia and this may cause demyelination of the nerve resulting in the clinical symptoms. Normal pressure in the carpal tunnel varies between 2 – 10 mmHg. Repetitive wrist motion causes fluctuations in carpal tunnel pressure. Wrist extension can result in a 10-fold increase in pressure and wrist flexion can result in an 8-fold increase in pressure.<ref name=":1" /> | |||
== Clinical Presentation == | |||
* Symptoms can develop gradually over months, years or decades<ref name=":2">Wang L. Guiding treatment for carpal tunnel syndrome. Physical Medicine and Rehabilitation Clinics. 2018 Nov 1;29(4):751-60.</ref> | |||
* Symptoms may arise spontaneously, but not commonly<ref name=":2" /> | |||
* Numbness | |||
* Tingling or pins and needles sensation in the median nerve distribution of the hand (thumb, index finger, middle finger and half of the ring finger) | |||
* Symptoms are worst at night or early morning (complaints of nocturnal burning pain) and are relieved by shaking of the hand<ref name=":2" /> | |||
* As symptoms worsen, intermittent pain and numbness may be experienced during daytime activities such as driving, lifting, working on the computer | |||
* Increased symptoms with static gripping of objects such as a phone or steering wheel | |||
* As symptoms progress, increased tingling and numbness and burning pain in the hand may be reported<ref name=":0" /> | |||
* If symptoms are left untreated, patients can complain of constant pain, swelling of the hand, difficulties with motor control and finally weakness and visible atrophy of the thenar eminence.<ref name=":0" /> | |||
* Sensory deprivation may also be present, resulting in clumsiness, weakness, loss of grip and pinch strength<ref name=":2" /> | |||
== Differential Diagnosis == | |||
The process of differential diagnosis should consider all conditions which could potentially cause dysfunction of the median nerve, the brachial plexus, C5 to C8 nerve root systems and the central nervous system. <nowiki>https://www.physio-pedia.com/Carpal_Tunnel_Syndrome</nowiki> | The process of differential diagnosis should consider all conditions which could potentially cause dysfunction of the median nerve, the brachial plexus, C5 to C8 nerve root systems and the central nervous system. <nowiki>https://www.physio-pedia.com/Carpal_Tunnel_Syndrome</nowiki> | ||
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What is Carpal Tunnel Syndrome[edit | edit source]
Carpal tunnel syndrome is an entrapment or compression of the median nerve at the wrist as it passes through the carpal tunnel.[1] It is the most common compressive neuropathy and is more common in females.[2] The location of symptoms is in the thumb, index finger, middle finger and the radial half of the ring finger. Early symptoms include:
- Pain
- Numbness and tingling
- Paresthesia
- Can also lead to burning symptoms
Clinically Relevant Anatomy[edit | edit source]
Some clinically relevant anatomical structures include[3]:
- The carpal tunnel is a U-shaped, osteofibrous canal
- The floor of the tunnel is formed by the carpal bones and the roof by the flexor retinaculum
- The tunnel is located deep to the flexor retinaculum/ transverse carpal ligament, between the tubercles of the scaphoid and trapezoid on the lateral side and the pisiform and hook of hamate on the medial side
- The four main structures passing through the tunnel are:
- Four tendons of flexor digitorum superficialis
- Four tendons of flexor digitorum profundus
- One tendon of the flexor pollicis longus
- Median nerve
- Path of the median nerve:
- Begins in the axillary region with the root of median nerves situated in the anterior rami of C5-T1
- The median nerve is formed by fascicles of the medial and lateral cords of the brachial plexus
- Runs distally in the arm next to the brachial artery until the middle of the arm, and descends into the cubital fossa (anterior elbow)
- Principal nerve supply to the anterior compartment of the forearm
- The muscular branch in the forearm supplies all the superficial and intermediate layers of the forearm flexors, except for flexor carpi ulnaris
- Pronator teres
- Palmaris longus
- Flexor digitorum superficialis
- Flexor carpi radialis
- The terminal branch of the median nerve enters the hand through the carpal tunnel, along with the tendons of flexor digitorum profundus, flexor digitorum superficialis and flexor pollicis longus
- Distal to the carpal tunnel the nerve supplies five intrinsic muscles in the thenar part
- The median nerve supplies sensation to the skin on:
- the entire palmar surface
- the sides of the first three digits
- the lateral half of the fourth digit and
- the dorsal aspects of the distal halves of these digits
- Innervation to the thenar eminence includes flexor pollicis brevis, opponens pollicis and abductor pollicis brevis
- Path of the median nerve:
Aetiology[edit | edit source]
Increased pressure in the carpal tunnel and compression of the median nerve is the main cause of carpal tunnel syndrome. The aetiology of carpal tunnel syndrome can be related to[4]:
- Work
- Lifestyle
- Injury
- Genetic predisposition
- History of repetitive wrist movement or exposure to vibrations or forceful angular motions such as typing, gaming, machine work
- Specific conditions may also be associated with an increased risk for the development of carpal tunnel syndrome (CTS). These can include:
- Diabetes
- Pregnancy
- Obesity
- Rheumatoid arthritis
- Fall on an outstretched hand (FOOSH) – this can displace the lunate bone which can cause pressure in the carpal tunnel
- CTS is more commonly seen in females, and it usually occurs between the ages of 36 and 60
Pathophysiology[edit | edit source]
Increased interstitial pressure in the carpal tunnel due to various causes such as:
- Mechanical overuse
- Osteoarthritis
- Trauma
- Acromegaly
All of these place pressure on the median nerve.
It is hypothesised that the compression of the median nerve leads to the development of local ischemia and this may cause demyelination of the nerve resulting in the clinical symptoms. Normal pressure in the carpal tunnel varies between 2 – 10 mmHg. Repetitive wrist motion causes fluctuations in carpal tunnel pressure. Wrist extension can result in a 10-fold increase in pressure and wrist flexion can result in an 8-fold increase in pressure.[4]
Clinical Presentation[edit | edit source]
- Symptoms can develop gradually over months, years or decades[5]
- Symptoms may arise spontaneously, but not commonly[5]
- Numbness
- Tingling or pins and needles sensation in the median nerve distribution of the hand (thumb, index finger, middle finger and half of the ring finger)
- Symptoms are worst at night or early morning (complaints of nocturnal burning pain) and are relieved by shaking of the hand[5]
- As symptoms worsen, intermittent pain and numbness may be experienced during daytime activities such as driving, lifting, working on the computer
- Increased symptoms with static gripping of objects such as a phone or steering wheel
- As symptoms progress, increased tingling and numbness and burning pain in the hand may be reported[3]
- If symptoms are left untreated, patients can complain of constant pain, swelling of the hand, difficulties with motor control and finally weakness and visible atrophy of the thenar eminence.[3]
- Sensory deprivation may also be present, resulting in clumsiness, weakness, loss of grip and pinch strength[5]
Differential Diagnosis[edit | edit source]
The process of differential diagnosis should consider all conditions which could potentially cause dysfunction of the median nerve, the brachial plexus, C5 to C8 nerve root systems and the central nervous system. https://www.physio-pedia.com/Carpal_Tunnel_Syndrome
Pronator teres syndrome
Anterior interosseus nerve syndrome
Cervicobrachial syndromes
Injury to the digital nerves at the palm of the hand
Carpometacarpal arthritis of the thumb
Cervical radiculopathy
De Quervain’s tenosynovitis
Peripheral neuropathy
Raynaud syndrome
Ulnar compressive neuropathy Wipperman J, Goerl K. Carpal tunnel syndrome: diagnosis and management. American family physician. 2016 Dec 15;94(12):993-9.
Diagnosis of Carpal Tunnel Syndrome
Electrophysical assessment (i.e., nerve conduction studies) can measure and examine median nerve dysfunction. This is useful when diagnosing carpal tunnel syndrome to assess nerve function and quantify damage to the nerve. Padua et al 2016
There is a debate in recent literature with traditionalists arguing that nerve conduction studies are the gold standard for confirmation of a carpal tunnel syndrome diagnosis, and contemporary thinkers argue that a diagnosis is possible based on clinical symptoms. Furthermore, even amongst traditionalists in favour of nerve conduction tests, there seems to be no consensus on the single best technique to be used. Recent advances.
Neuromuscular ultrasound is a valuable tool to investigate carpal tunnel syndrome as it provides information on median nerve morphology and the surrounding structures (Walker et al 2018)
Recent research highlights that based on expert consensus combining electrodiagnosis and ultrasound is more effective than using either modality on its own. In cases where electrodiagnostic studies are normal or unable to localise suspected carpal tunnel syndrome, ultrasound can add value. Pelosi L, Arányi Z, Beekman R, Bland J, Coraci D, Hobson-Webb LD, Padua L, Podnar S, Simon N, van Alfen N, Verhamme C. Expert consensus on the combined investigation of carpal tunnel syndrome with electrodiagnostic tests and neuromuscular ultrasound. Clinical Neurophysiology. 2022 Jan 6.
Magnetic Resonance Imaging (MRI) is becoming more popular as a diagnostic tool for carpal tunnel syndrome. It can define the deeper and lateral limits of the carpal tunnel in more detail than ultrasound. It has also been shown to provide objective and accurate information about the anatomy and pathologies of the carpal tunnel. Vo NQ, Nguyen DD, Hoang NT, Ngo DH, Nguyen TH, Trong BL, Le NT, Thanh TN. Magnetic resonance imaging as a first-choice imaging modality in carpal tunnel syndrome: new evidence. Acta Radiologica. 2022 Apr 18:02841851221094227. Available from https://www.researchgate.net/profile/Thao-Nguyen-Thanh/publication/360041860_Magnetic_resonance_imaging_as_a_first-choice_imaging_modality_in_carpal_tunnel_syndrome_new_evidence/links/625fbbff9be52845a911d504/Magnetic-resonance-imaging-as-a-first-choice-imaging-modality-in-carpal-tunnel-syndrome-new-evidence.pdf
X-ray is recommended to exclude other causes of wrist pain or bony pathology Chammas M, Boretto J, Burmann LM, Ramos RM, Neto FCS, Silva JB. Carpal tunnel syndrome – part 1 (anatomy, physiology, etiology and diagnosis). Revista brasileira de Ortopedia (English edition) 2014 September-October; 49 (5):429-436.
Physical Examination
The location of the symptoms is key for diagnosis (course ref)
Carpal compression test
Apply firm pressure directly over the carpal tunnel for 30 seconds.
The test is positive when paraesthesia, pain or other symptoms are reproduced
Add link to PP page: https://www.physio-pedia.com/Carpal_Compression_Test
Add video?
Phalen’s test
Add link to PP page: https://www.physio-pedia.com/Phalen%E2%80%99s_Test
Have the patient fully flex their wrists by placing the dorsal surfaces of both hands together for 30 – 60 seconds
A positive test is when symptoms (numbness, tingling, pain) are reproduced
Reverse Phalen’s test
Add link to PP page: https://www.physio-pedia.com/Phalen%E2%80%99s_Test
Have the patient fully extend their wrists by placing the palms of both hands together for 30 – 60 seconds
Positive test is when symptoms are reproduced
Tinel’s sign
Add link to PP page: https://www.physio-pedia.com/Tinel%E2%80%99s_Test
Test is performed by lightly tapping over the median nerve for 30 seconds to reproduce symptoms
Read more on other physical examination tests here: https://www.physio-pedia.com/Carpal_Tunnel_Syndrome#Physical_Examination
Management of Carpal Tunnel Syndrome
Conservative management:
Wrist control orthosis – blocks wrist extension and flexion motion which decreases compression of the carpal tunnel
Patients wear it mostly at night
Activity modification – educate patients on how to modify daily activities and avoid positions that cause increased compression of the nerve
Ergonomics education
Desk and keyboard height
Elbow wrist and finger alignment
Medication
Non-steroidal anti-inflammatory medication
Oral steroids
Corticosteroid injections
At the treating physician’s discretion
Surgical Management
Open surgery of endoscopic surgery where transverse ligament is cut and this creates space in the carpal tunnel and reduces pressures on the median nerve
Post-surgical rehabilitation
Exercises are aimed at reducing stiffness and therapy is short term as recovery time is quick after surgery. (course instructor)
Finger abduction and adduction
Gets intrinsic muscles working
Tendon glides
Promotes excursion of the flexor digitorum profundus and flexor digitorum superficialis
Hand straight
Hook fist
Full fist
Straight fist with fingers touching the palm of the hand
Tabletop position
Back to straight hand
Add images of these hand positions
Dosage
Patient repeats tendon glides three to five times
Stiffness will determine how many times a day patients should perform tendon glides
Very stiff after surgery – perform tendon glides six to eight times a day
Minimal stiffness – perform tendon glides one to three times a day
Digit blocking
If patient experiences stiffness after surgery, digit blocking may help to increase motion
For example if patient is stiff in PIP or DIP
Patient blocks th joint below with other hand and performs movement
This forces motion to go through the stiff joint
Patient repeats this 5 times, holding it for 5 seconds
Can be done with individual digits or all at once, depending on which joints are lacking motion
Thumb opposition
Allows for movement of flexor pollicis longus
Patient touching their thumb to fifth finger – thumb opposition
Prolonged duration of symptoms without treatment leads to irreversible changes and thenar muscle atrophy
Speedy and correct treatment is there for crucial
Outcome Measures Link to a few
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References[edit | edit source]
- ↑ Padua L, Coraci D, Erra C, Pazzaglia C, Paolasso I, Loreti C, Caliandro P, Hobson-Webb LD. Carpal tunnel syndrome: clinical features, diagnosis, and management. The Lancet Neurology. 2016 Nov 1;15(12):1273-84.
- ↑ Ostergaard PJ, Meyer MA, Earp BE. Non-operative treatment of carpal tunnel syndrome. Current reviews in musculoskeletal medicine. 2020 Apr;13(2):141-7.
- ↑ 3.0 3.1 3.2 Urits I, Gress K, Charipova K, Orhurhu V, Kaye AD, Viswanath O. Recent advances in the understanding and management of carpal tunnel syndrome: a comprehensive review. Current pain and headache reports. 2019 Oct;23(10):1-8.
- ↑ 4.0 4.1 Osiak K, Elnazir P, Walocha JA, Pasternak A. Carpal tunnel syndrome: state-of-the-art review. Folia Morphologica. 2021 Nov 9.
- ↑ 5.0 5.1 5.2 5.3 Wang L. Guiding treatment for carpal tunnel syndrome. Physical Medicine and Rehabilitation Clinics. 2018 Nov 1;29(4):751-60.