Carpal Tunnel Syndrome
Carpal tunnel syndrome (CTS) is a disorder affecting the median nerve at the wrist as it passes beneath the flexor retinaculum and adjacent to the flexor tendons of the fingers and wrist. Pain, tingling, burning and numbness occur in the palmar aspect of the hand typically affecting the index and middle fingers and part of the 4th finger. Symptoms are often most noticeable at night, and a loss of pinch grip strength often results. It is slightly more common in men than women, and is more prevalent in older individuals, diabetics and those who are overweight or obese. It is also relatively common during pregnancy, following trauma to the hand or wrist, and in those suffering from systemic/endocrine disorders. Contrary to what may seem ‘common sense’, there remains no clear relationship between repetitive labour and the development of Carpal Tunnel Syndrome.
How Do We Differentiate Carpal Tunnel Syndrome?
Diagnosis of CTS in the clinical setting can often be made from a number of different tests coupled with a good verbal history of the problem. Still, there are a number of other issues to assess and/or rule out:
Guyon’s Canal Syndrome affects the ulnar nerve as it passes under the ligament between the pisiform and the hamate. It presents as a pain and paraesthesia in the ulnar distribution of the hand, and is most commonly seen in cyclists as a result of prolonged weight bearing through the handlebars. Other typical patients may include those involved with martial arts and repetitive ball catching sports4 .
Cervical Radiculopathy Nerve pain coming from your neck is perhaps the most obvious differential diagnosis to consider, with involvement of the C7 nerve root particularly able to replicate symptoms in the index and 3rd fingers. Sensitisation of the median nerve at the carpal tunnel may induce symptoms higher up the arm, just as cervical nerve root irritation can refer symptoms down.
Statistically, 82% of patients with Carpal Tunnel Syndrome will respond to non-operative management. There are a variety of options for its treatment and Physiotherapists will employ a number of evidenced based strategies to help settle the condition.
- Splinting has been proven to reduce the severity of symptoms and improve the functional ability of the affected arm. Night splinting particularly has a positive affect, but more continuous day time splinting does not necessarily result in further improvement. More continuous splinting may help the CTS but raises questions over total arm function and may create issues elsewhere. Numerous types of wrist braces and aids are available, and we can source and fit the most appropriate type for each patient.
- Electrotherapy includes ultrasound, interferential and laser therapy. Ultrasound has been shown to reduce sensory loss and pain, and improve median nerve conduction.
- Manual Therapy: Mobilisation of the carpus and stretching of the flexor retinaculum helps relieve pain and improves the range of available wrist extension.
- Exercise: Neural and tendon ‘gliding’ exercises have been shown to positively affect the dysfunction of the median nerve more than splinting alone.
- Anti-inflammatory medications & Corticosteroid injections: Both of these may be useful in the early phase of CTS. Medium and long term benefits are doubtful.
As with any other condition, conservative treatments will sometimes fail in the management of CTS. Successful treatment depends on lifestyle factors that are often beyond a health practitioner’s control so for some, surgical release of the carpal tunnel may be warranted.
Fortunately, surgical correction of CTS has a >90% success rate, with the speed of return to work governed by the degree of repetition entailed in the work and whether the patient’s dominant hand is involved. Physiotherapy will help accelerate recovery.