Current Management of Carpal Tunnel Syndrome

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Introduction

What is Carpal Tunnel Syndrome

Carpal tunnel syndrome is an entrapment or compression of the median nerve at the wrist as it passes through the carpal tunnel. 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. It is the most common compressive neuropathy and is more common in females. Ostergaard PJ, Meyer MA, Earp BE. Non-operative treatment of carpal tunnel syndrome. Current reviews in musculoskeletal medicine. 2020 Apr;13(2):141-7. 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

Parasthesia

Can also lead to burning symptoms

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.

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

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:

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 carp 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

Etiology

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: Osiak K, Elnazir P, Walocha JA, Pasternak A. Carpal tunnel syndrome: state-of-the-art review. Folia Morphologica. 2021 Nov 9.

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 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

Increased interstitial pressure in the carpal tunnel due to various causes such as:

Mechanical overuse

Osteoarthritis

Trauma

Acromegaly,

Places pressure on the median nerve

It is hypothesised that the compression of the median nerves 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.  : Osiak K, Elnazir P, Walocha JA, Pasternak A. Carpal tunnel syndrome: state-of-the-art review. Folia Morphologica. 2021 Nov 9.

Clinical presentation

Symptoms can develop gradually over months, years or decades Wang L. Guiding treatment for carpal tunnel syndrome. Physical Medicine and Rehabilitation Clinics. 2018 Nov 1;29(4):751-60.

Symptoms may arise spontaneously, but not commonly Wang L. Guiding treatment for carpal tunnel syndrome. Physical Medicine and Rehabilitation Clinics. 2018 Nov 1;29(4):751-60.

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 Wang L. Guiding treatment for carpal tunnel syndrome. Physical Medicine and Rehabilitation Clinics. 2018 Nov 1;29(4):751-60.

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 reportedRecent Advances in the Understanding and Management of Carpal

Tunnel Syndrome: a Comprehensive Review

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. Recent Advances in the Understanding and Management of Carpal

Tunnel Syndrome: a Comprehensive Review

Sensory deprivation may also be present, resulting in clumsiness, weakness, loss of grip and pinch strength.Wang et al

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.  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

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Phalen’s test

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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

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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

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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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