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Carpal Tunnel Syndrome

Carpal Tunnel Syndromes

Carpal tunnel syndrome is a median entrapment neuropathy. Common symptoms include numbness, paresthesias and pain in the median nerve distribution.


Presentation

The median nerve passes along the base of the palm and the sensory distribution continues to the thumb, to first two fingers and the lateral half of the ring finger. Thus, when this nerve is pressurized, it undergoes dysfunction and the symptoms due to this are mainly tingling sensation along the respective fingers.

Patients also experience numbness and burning sensation which is aggravated during the night [5]. The tingling sensation is noticed more while doing activities such as holding objects or activities involving repeated flexion movements such as type writings etc.

When the condition worsens the patients develop insensitivity, thus they develop inability to differentiate between temperatures over the hand. This is when there is a complete axonal loss leading to absent sensory or motor reflexes. The symptoms in general are activity related and are non-continuous with phases of remission intermittently. Pain is usually associated with numbness. Patients complain of aching sensation along the palm extending to forearm. Loss of muscle power suggests wasting of the muscle leading to clumsiness, loss of grip. Patients complain of objects slipping from the hand [6].

Pain
  • DISCUSSION: Vitamin D deficiency increases the pain intensity in patients with CTS. Treatment of vitamin D deficiency in these patients may play a role in pain relief.[ncbi.nlm.nih.gov]
  • Altered pain inhibition through CPM was investigated through cold water immersion of the foot as the conditioning stimulus and pressure pain threshold over the thenar and hypothenar eminence bilaterally as the test stimulus.[ncbi.nlm.nih.gov]
  • Risk factors before surgery that predicted worse NP after surgery were found to be a younger age, weaker pain, and the absence of night pain.[ncbi.nlm.nih.gov]
  • Besides, we have also analyzed whether the functionality and pain intensity levels amongst female hairdressers with CTS are different from the ones of unemployed women with CTS or not.[ncbi.nlm.nih.gov]
  • Carpal tunnel syndrome (CTS) is a cause of pain, numbness, and tingling in the hands and is an important cause of work disability.[ncbi.nlm.nih.gov]
Weakness
  • Such symptoms, induced by a specific wrist position, may be help to diagnose a latent weakness in the intrinsic muscles of the thumb, present in patients with CTS.[ncbi.nlm.nih.gov]
  • If untreated, the nerve can be damaged, causing permanent weakness, numbness, and tingling.[nlm.nih.gov]
  • Some residual numbness or weakness is common. Most people may need to modify work activity for several weeks following surgery.[ninds.nih.gov]
  • If significant pain and weakness continue for more than 2 months, your physician may instruct you to work with a hand therapist.[web.archive.org]
Hand Pain
  • A 30-weekspregnant diabetic female attending US evaluation due to intermittent hand pain, numbness, and weakness bilaterally.[ncbi.nlm.nih.gov]
  • There are several conditions that may cause hand pain and numbness.[spine-health.com]
  • Understanding Hand Pain and Numbness Learn the symptoms and underlying causes of persistent hand pain and numbness.[spine-health.com]
  • Conditions Related to Inflammatory Arthritis Both arthritis and CTS are potential culprits for hand pain and numbness. Arthritis raises the risk for carpal tunnel syndrome.[arthritis-health.com]
  • However, it does have a set of symptoms that are different from many other sources of hand pain. Even so, there are several other hand pain conditions similar to, or associated with, carpal tunnel syndrome. One of these is de Quervain’s tendinosis .[my.clevelandclinic.org]
Arm Pain
  • METHOD: A total of 198 cashiers, belonging to a cohort investigated in 2011-2012 for arm pain, were screened for re-assessment in 2015 (at least 40 months from the first examination), and 156 women had complete demographic, personal and working data allowing[ncbi.nlm.nih.gov]
  • Davis , Arm pain and work , Medicolegal Reporting in Orthopaedic Trauma , 10.1016/B978-0-443-06833-1.00026-1 , (485-500) , (2010) . Alyssa B. Schultz and Dee W.[doi.org]
  • Pain Neck Headache Overuse Injuries Pinched Nerve Rheumatoid Arthritis RSI - Repetitive Strain Injury Tennis Elbow Thoracic Outlet Syndrome Thumb Sprain[physioworks.com.au]
  • Things that help cause carpal tunnel syndrome include: Conditions or illnesses that can cause or contribute to arm pain or swelling in the joints and soft tissues in the arm, or to reduced blood flow to the hands.[northshore.org]
Forearm Pain
  • Obesity Diabetes and metabolic syndrome Menopause, pregnancy and female hormones, as the age of peak incidence is 40‒60 years old Symptoms of CTS Pain, numbness, and tingling in the wrist and first three fingers of the affected hand Forearm pain may occur[lifeextension.com]
  • This pain can radiate distally to the palm and fingers or, more commonly, extend proximally along the ventral forearm.[web.archive.org]
  • pain [ 38 ], or numbness in the third finger only [ 27 ].[doi.org]
Dry Eyes
  • MATERIALS AND METHODS: A 78 year-old woman with vitreous opacities, her daughter with dry eye syndrome, and brother with carpal tunnel syndrome were tested for a mutation in the TTR gene.[ncbi.nlm.nih.gov]
Cutaneous Manifestation
  • A review of literature on cutaneous manifestations associated with the syndrome is also presented. Copyright 2016 Elsevier Ireland Ltd. All rights reserved. KEYWORDS: Carpal tunne syndrome; Type 2 diabetes; Ulcero-osteolytic lesions[ncbi.nlm.nih.gov]
Tinel's Sign
  • Clinical outcome measures were taken by Boston Questionnaire score, the presence or absence of Tinel's sign, and Phalen's test findings. Median nerve conduction studies were also undertaken and interpreted according to Dumitru's reference values.[ncbi.nlm.nih.gov]
  • Tinels sign and Phalens test were positive with no obvious thenar muscle wasting on examination.[ncbi.nlm.nih.gov]
  • RESULTS: Neuromuscular ultrasound of the median nerve on the symptomatic side revealed penetration of the nerve by a persistent median artery and vein in the mid-forearm, with a positive sonographic Tinel sign over this spot.[ncbi.nlm.nih.gov]
  • Tinel's sign is the induction of paresthesias by tapping over the site of the median nerve at the wrist. In Phalen's sign, symptoms are reproduced by maximum flexion of the wrist for 60 s. The classically described patients are middle-aged women.[ncbi.nlm.nih.gov]
  • The sensitivity and specificity of the ONG study i.e. 95.18% and 98.31%, respectively, were compared with standard clinical tests: Tinel sign (61.45% and 14.69%), Phalen test (34.94% and 45.20%), reverse Phalen test (81.93% and 34.46%) and carpal compression[ncbi.nlm.nih.gov]
Wrist Pain
  • He gave history of bilateral wrist pain associated with numbness over the median nerve distribution of the hand. Tinels sign and Phalens test were positive with no obvious thenar muscle wasting on examination.[ncbi.nlm.nih.gov]
  • Try these exercises to relieve the wrist pain of carpal tunnel syndrome. Finding relief from the wrist pain of carpal tunnel syndrome isn't just a personal matter; it's an economic issue.[arthritis.org]
  • Bharadvaja's Twist Bharadvajasana I Salutation Seal Anjali Mudra Warrior II Pose Virabhadrasana II 6 Yoga Warm-Ups for Wrist Pain and Carpal Tunnel Syndrome Yoga teacher Mark Stephens shares methods for warming up and massaging the wrists to reduce pain[yogajournal.com]
  • And that’s correct, but a newly released patent hints at some future improvements for the function that could also spare you some wrist pain and warn you about stress.[cultofmac.com]
  • Other symptoms include: numbness , tingling, and pain in your thumb and the first three fingers of your hand pain and burning that travels up your arm wrist pain at night that interferes with sleep weakness in the muscles of the hand Doctors can diagnose[healthline.com]
Phalen's Sign
  • In Phalen's sign, symptoms are reproduced by maximum flexion of the wrist for 60 s. The classically described patients are middle-aged women.[ncbi.nlm.nih.gov]
  • The patient presented with a 3-year history of CTS, consisting of progressive pain and paresthesias in his right hand, positive Tinel and Phalen signs, and an electrodiagnostic study demonstrating median nerve compression at the wrist.[ncbi.nlm.nih.gov]
  • Reproduction of tingling with wrist flexion (Phalen sign) or with direct pressure on the nerve at the wrist in a neutral position (median nerve compression test) is also suggestive.[merckmanuals.com]
  • Phalen sign: The wrist is allowed to fully flex, this induces severe tingling along the nerve distribution area. In carpal tunnel compression test, a firm pressure is applied over the carpal tunnel directly for about 40 seconds.[symptoma.com]
  • Phalen's sign. Hold your hands back-to-back as shown with your wrist bent at 90 degrees. If you develop pain, numbness, or tingling within 60 seconds, you may have carpal tunnel syndrome.[emedicinehealth.com]
Thenar Muscle Atrophy
  • At the six-month follow-up examination, the patient experienced relief from numbness and improvement in thenar muscle atrophy was noted.[ncbi.nlm.nih.gov]
  • muscle atrophy may occur Applies To Median nerve entrapment Partial thenar atrophy ICD-9-CM Volume 2 Index entries containing back-references to 354.0 :[icd9data.com]
  • Impairment of sensation in the distribution of the median nerve and thenar muscle atrophy may occur.[fpnotebook.com]
  • Severe cases, especially those with thenar muscle atrophy, are more likely to require surgical release of the carpal tunnel. Shi & MacDermid (2011).[physioworks.com.au]
Flexion Contracture
  • A 69-year-old man presented with digital flexion contracture and severe carpal tunnel syndrome of his right hand and was treated surgically.[ncbi.nlm.nih.gov]
Tingling
  • Carpal tunnel syndrome (CTS) is a cause of pain, numbness, and tingling in the hands and is an important cause of work disability.[ncbi.nlm.nih.gov]
  • If untreated, the nerve can be damaged, causing permanent weakness, numbness, and tingling.[nlm.nih.gov]
  • The three main symptoms are: tingling numbness pain These symptoms occur in: the thumb the index finger the middle finger half of the ring finger However, the tingling, numbness and pain can sometimes extend outside this area.[web.archive.org]
  • Hoffmann-Tinel test: In this test, gentle tapping is done on the median nerve area, this causes tingling sensation on the palm where the nerve innervates.[symptoma.com]
Paresthesia
  • Patients characteristically complain of nocturnal paresthesias or burning pain. Motor complaints relate to thenar muscular weakness and atrophy.[ncbi.nlm.nih.gov]
  • PURPOSE: Distribution of paresthesia throughout the skin area without median nerve innervation is frequently seen in carpal tunnel syndrome (CTS). However, its pathophysiologic mechanisms are still unclear.[ncbi.nlm.nih.gov]
  • This article describes a 35-year-old man who presented to the ED with complaints of discomfort and paresthesias in his right wrist after a fall, and was subsequently diagnosed with acute carpal tunnel syndrome.[ncbi.nlm.nih.gov]
  • The patient presented with a 3-year history of CTS, consisting of progressive pain and paresthesias in his right hand, positive Tinel and Phalen signs, and an electrodiagnostic study demonstrating median nerve compression at the wrist.[ncbi.nlm.nih.gov]
  • It was associated with paresthesia and hypoesthesia predominantly of the thumb, index finger and middle finger. Clinical examination and electrodiagnosis led to diagnosis of carpal tunnel syndrome.[ncbi.nlm.nih.gov]
Numbness of the Hand
  • Abstract Carpal tunnel syndrome (CTS) occurs when the median nerve becomes compressed as it passes through the wrist within the carpal tunnel, resulting in pain, tingling, weakness, or numbness in the hand or the wrist.[ncbi.nlm.nih.gov]
  • Carpal Tunnel Overview Carpal tunnel syndrome causes pain, tingling, and numbness in your hand from pressure on the median nerve in your wrist. Illnesses, pregnancy, and obesity can cause carpal tunnel syndrome.[webmd.com]
  • Often, a person with CTS will wake up in the middle of the night with pain and numbness in the hand and will need to shake or massage the whole hand and wrist to restore normal feeling.[irishhealth.com]
  • Symptoms of Carpal Tunnel Syndrome Numbness Tingling Pain Hand weakness Night time hand pain and numbness These symptoms are most commonly experienced in the fingers and hand; however, some people feel pain in the arm and elbow.[fox13now.com]
  • He may also check to see if tapping on your wrist, having you hold your hands in a certain way, or pressing on the inside part of the wrist causes tingling, pain, or numbness in your hands.[aapmr.org]
Peripheral Neuropathy
  • KEYWORDS: ART; Carpal Tunnel Syndrome; Extrahepatic disorders; HAART; HCV; HI; Hepatitis; Hepatitis C virus; Mixed cryoglobulinemia; Peripheral Neuropathy, Autoimmunity; Peripheral Neuropathy. [Indexed for MEDLINE] Free full text[ncbi.nlm.nih.gov]
  • A comprehensive clinical approach is discussed, considering the natural history of the disease and its potential complications, as well as the lack of consensus regarding standard therapeutic options for the compressive peripheral neuropathies in the[ncbi.nlm.nih.gov]
  • BACKGROUND: Carpal tunnel syndrome is the most common focal peripheral neuropathy seen in most electrophysiological laboratories.[ncbi.nlm.nih.gov]
  • Sometimes, peripheral neuropathy is one of the first symptoms of systemic vasculitis. Although the classic form of peripheral nervous system vasculitis is mononeuritis multiplex, it can also present as a mononeuritis.[ncbi.nlm.nih.gov]
  • Abstract In patients with symptoms of a peripheral neuropathy especially during pregnancy, use of imaging techniques such as Ultrasound (US) and Magnetic Resonance Imaging (MRI) may be essential for the diagnostic accomplishment.[ncbi.nlm.nih.gov]
Dropping Things
  • Other symptoms can be the tendency to drop things, difficulty manipulating small objects, and a burning sensation.[aanem.org]
  • Symptoms of carpal tunnel syndrome Typical symptoms affecting the hand and fingers in carpal tunnel syndrome include: Pain Numbness Tingling A combination of the above three Weakness of grip and tendency to drop things held in the hand In long term sufferers[news-medical.net]
  • In hand and fingers: Numbness Loss of movement Swelling Prickling Mild-to-severe pain (may experience pain at night) Decreased sensation Decreased strength Other symptoms may include: Tendency to drop things Difficulty manipulating small objects Evaluation[foundationforpn.org]
  • Patients may sometimes notice a weaker grip, occasional clumsiness, and a tendency to drop things.[handsurgeonsnewyork.com]

Workup

Carpel tunnel syndrome is mainly diagnosed through the presentation and the confirmatory signs that are elicited on the subjects. Sensory examination involves pin prick test that checks bilateral sensation.

  • Hoffmann-Tinel test: In this test, gentle tapping is done on the median nerve area, this causes tingling sensation on the palm where the nerve innervates.
  • Phalen sign: The wrist is allowed to fully flex, this induces severe tingling along the nerve distribution area.
  • In carpal tunnel compression test, a firm pressure is applied over the carpal tunnel directly for about 40 seconds. This results in relapse of all symptoms [7].

However, an MRI scan can be useful to rule out a mass or a lesion occupying the space that compresses the nerve. Ultrasound techniques are now being used along with the nerve conduction studies. These confirm the nerve abnormalities.

Electr physiologic studies enable accurate estimation of the degree of nerve damage thus provides guidance for the prognosis. Certain tests are useful that provide confirmation of CTS.

Staphylococcus Aureus
  • KEYWORDS: Staphylococcus aureus; carpal tunnel syndrome; necrotizing fasciitis; pyogenic flexor tenosynovitis[ncbi.nlm.nih.gov]

Treatment

Symptomatic relief can be achieved through the conservative mode of treatment. This consists of the use of splints on the wrist to be worn at night for a period of at least 3 weeks. Non-steroidal anti-inflammatory drugs for a course of 1-2 weeks help a lot of patients especially with flexor tendinitis or rheumatic arthritis.

Steroidal injections provide a huge amount of symptomatic relief. Surgery is considered when the conservative approach fails [8]. It involves release of the edematous ligament.

A rehabilitation program is highly essential for recovery and strengthening of the affected muscles and ligaments. Aerobic exercise and loosing weight is given prime importance [9].

Prognosis

Carpal tunnel syndrome may lead to lifelong nerve dysfunction. Some cases resolve completely. Surgical treatment prevents recurrence up to 5 years. Conservative treatment may lead to arrest of the further nerve damage.

Patients with obesity or diabetes have poorer prognosis as compared to other healthy subjects. This condition disables the person from doing his daily activities; he is not able to perform simple tasks like carrying objects, or cooking, cleaning etc. Thus it leads to psychological distress [4].

If left untreated, it can lead to progressive wasting of the muscles of hand and ultimately loss of sensation with numbness. It was reported that due to carpal tunnel syndrome, many people were away from their jobs for as long as 27 days in a month.

Etiology

Although the exact etiology remains unknown, there are many factors that link to the possibility of this syndrome. Systemic illnesses such as hypothyroidism, rheumatoid arthritis, diabetes mellitus are known to trigger carpal tunnel syndrome.

The nerve can also be pressurized due to a local lipoma, a ganglion or a vascular abnormality. Inflammation around the flexor tendons such as tenosynovitis, also compress the nerve and contributes to the carpal tunnel syndrome [2].

People involved in physical labor comprising of continuous and constant hand movements, or having repetitive wrist flexion activities tend to increase pressure at the base of the wrist increasing the risk for carpal tunnel syndrome.

Epidemiology

According to the studies conducted in the population of the North American citizens, it was found that the incidence of carpal tunnel syndrome is 1-4:1000. The incidence is common amongst the population involved in manual labor work especially those involved with footwear and clothing industries.

Women are far more affected than males. The incidence increases as age increases. Common age group at risk is between 29-45 years. Individuals with high BMI are commonly affected and the incidence also rises with diseases such as diabetes mellitus, endocrinal and hormonal disorders. It commonly affects women who are pregnant [1].

Sex distribution
Age distribution

Pathophysiology

In carpal tunnel syndrome, symptoms occur due to median nerve dysfunction. This happens as a result of series of changes occurring due to the mechanical pressure on the nerve. It begins with ischemia of the nerve. This is because of the impeded blood flow resulting into blocking of the venous flow, leading to back pressure, and edema [3].

The nerve undergoes demyelination progressing to axonal loss. The amount of pressure that leads to an obstructed blood flow accounts to as low as 20 mm hg. This pressures leads to capillary breakage, edema in and around the nerve and persistent rise in the pressure on the nerve.

Prevention

Preventive measures involve maintaining a healthy weight which helps in preventing diabetes, arthritis and other diseases. Exercising regularly and avoiding smoking are important. People involved in cash collecting jobs should avoid forceful wrist movements while opening the drawers with keys. People who are involved in type writing work should change the set up of their desks and computers according to convenience. The level of the wrist should be at the level of the elbow or slightly higher.

Breaks from continuous activities are advised to relax and stretch the tensed muscles. Stiffness and pain is more if the environment is cold and hence the temperature should be adjusted or if that is not possible, woolen gloves are to be worn to keep the wrist and palms warm. For writers, a large pen with a soft grip is advised so as to relieve the pressure of the fingers due to tight grip [10].

Summary

The carpal tunnel is a narrow tunnel or a canal on the distal area of the wrist at its base. It connects the forearm to the wrist and in this tunnel several muscular tendons along with median nerve pass through.

The compression or the entrapment of this median nerve is called as the carpal tunnel syndrome (CTS). The inflammation of the tissues surrounding the tendons increases the pressure within the canal thus pressing the nerve. Carpal tunnel syndrome comprises of symptoms following this compression [1].

Patient Information

Carpal tunnel syndrome is a syndrome consisting of multiple symptoms due to pressure on the medial nerve in the wrist. The medial nerve passes along the carpel tunnel at the base of the wrist joint. Many muscles, ligaments along with the median nerve pass through the canal.

When this nerve is compressed it results in sensory loss, tingling, numbness, pain, stiffness and aching of the affected hand. The causes are local and systemic. The local causes include compression of the nerve due to excessive and forceful wrist movements commonly seen in those involved in repeated hand movements like typewriting, food packers, foot making laborers etc. local tumors or tendinitis also increase the pressure in the canal leading to pinching of the nerve. Systemic causes are diseases such as diabetes or arthritis.

Treatment consists of pain killers and anti-inflammatory drugs. Surgery is done if pain is severe and not responding to medications. Prevention is done by regular exercise, weight loss, stretching and taking breaks from constant activity [11].

References

Article

  1. Atroshi I, Gummesson C, Johnsson R, Ornstein E et al. Prevalence of carpal tunnel syndrome in a general population. JAMA. 1999 Jul 14;282(2):153-8.
  2. Werner RA, Andary M. Carpal tunnel syndrome: pathophysiology and clinical neurophysiology. Clin Neurophysiol. 2002 Sep;113(9):1373-81.
  3. Cellocco P, Rossi C, Boustany SE, di Tanna GL, Costanzo G. Minimally invasive carpal tunnel release. Orhtop Clin North Am. 2009 Oct;40(4):441-448.
  4. Middelkoop M, Koes BW. Carpal tunnel syndrome. Part I: Effectiveness of nonsurgical treatments -- a systematic review. Arch Phys Med Rehabil. 2010 Jul;91(7):981-1004.
  5. Huisstede BM, Randsdorp MS, Coert JH, Glerum S, et al. Carpal tunnel syndrome. Part II: effectiveness of surgical treatments -- a systematic review. Arch Phys Med Rehabil. 2010 Jul;91(7):1005-1024
  6. Jarvik JG, Comstock BA, Kliot M, Turner JA, et al. Surgery versus non-surgical therapy for carpal tunnel syndrome: a randomized parallel-group trial. Lancet. 2009 Sep 26;374(9695):1074-1081.
  7. LaStayo P, Mills A, Bramlet D. Prospective analysis of splinting the first carpometacarpal joint: an objective, subjective, and radiographic assessment. J Hand Ther. 2000 Jul- Sep;13(3):218-226
  8. Wilson KM. Double incision open technique for carpal tunnel release: an alternative to endoscopic release. J Hand Surg Am. 1994 Nov;19(6):907-912.
  9. Wilson J. Median mixed nerve conduction studies in the forearm: evidence against retrograde demyelination in carpal tunnel syndrome. J Clin Neurophysiol. 1998 Nov; 15(6):541-46.
  10. Wong SM, Griffith JF, Hui AC, Tang A,et al. Discriminatory sonographic criteria for the diagnosis of carpal tunnel syndrome. Arthritis Rheum. 2002 Jul; 46(7): 1914-21.
  11. Wiederien R, Feldman TD, herusel LD, Loro WA et al. The effect of the median nerve compression test on median nerve conduction across the carpal tunnel. Electromyogr Clin Neurophysiol. 2002 Oct-Nov; 42(7): 413-21

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Last updated: 2018-06-22 00:03