by Brittany Galski
Description
Carpal tunnel syndrome (CTS) is a condition which leads to compression of the median nerve at the wrist.1 This compression often causes pain, numbness, tingling, and sometimes weakness affecting the use of the affected hand. If left untreated, this condition can progress and greatly affect one's quality of life.1 An early and accurate diagnosis followed by an appropriate treatment plan may decrease healthcare costs related to surgery and lost time from work. This page will summarize the following subject areas related to CTS: relevant anatomy, incidence rates, patient presentation, etiologies, classifications, evaluation and diagnostic tests, special orthopedic tests, treatment, splints, and surgery.
Anatomy
CTS occurs when the median nerve becomes compressed by the flexor tendons within the carpal tunnel.1
This nerve compression causes symptoms in the median nerve pattern (highlighted in the image below in blue).
Incidence/Prevalence
- Prevalence rates: 9.2% in women and 6% in men.2
- Incidence rates: 1-3/1,000 people per year.3
- CTS is most common in individuals aged 30 to 60 years old.2
- It is more common in women than men because women tend to have smaller carpal tunnels.3
Clinical Presentation
Individuals presenting with CTS typically complain of pain, numbness, and tingling in the hand which may have been getting progressively worse over time.4,5 Upon questioning, one may find that the patient has an occupation which requires repetitive work, such as typing. The patient may also report that they have a hard time making a fist or holding items due to hand stiffness and/or weakness.4 The patient may also have pain which radiates from the hand up the arm into the shoulder. The patient may walk into the clinic guarding the affected arm if the pain is severe.
Potential Etiologies
CTS is caused by repetitive motions of the hand and wrist such as working on a computer or an assembly line, sewing, painting, or writing.4 This repetitive motion can cause swelling which decreases the space available for the median nerve to travel under the transverse ligament in the wrist.5 CTS is often genetic in nature.4,5
Classifications
- CTS is classified by symptom severity:2
- Stage 1: Patients with stage 1 CTS usually experience symptoms at night. Common symptoms include: numbness and/or tingling in the hand, pain that radiates from the wrist to the shoulder, a sensation that the hand feels swollen or stiff. Patients may be woken up at night from these symptoms. Shaking the hand may bring symptom relief to some individuals.
- Stage 2: Symptoms at night are also present during the day especially with repetitive activities of the hand and/or wrist. Patients may develop motor problems from weakened hand muscles such as decreased grip strength, affecting their ability to hold objects in their hands.
- Stage 3: Visible atrophy of the thenar eminence muscles is present. Grip strength is diminished making functional tasks very difficult. Symptoms typically increase in severity and duration; although, some patients may experience diminished sensory symptoms with increased motor symptoms.
- CTS can also be classified as an acute or chronic condition:5
- Acute- caused by wrist trauma, infection, or hemorrhage; this type of CTS involves a rapid onset of symptoms7
- Chronic- most common type of CTS; progressive condition that gets worse over time:
-
- Idiopathic- age and gender play a role (women are more susceptible and risk for CTS increases with age)
- Anatomic- anything that occupies the space within the carpal tunnel that shouldn’t (ie. tumor or cyst) increases the pressure on the median nerve
- Systemic-associated medical conditions such as the following: ((bibcite 4,5,7))
- bone fractures of the wrist and/or carpal bones
- diabetes
- alcoholism
- hypothyroidism
- kidney failure and dialysis
- menopause, premenstrual syndrome (PMS), and pregnancy
- infections
- obesity
- rheumatoid arthritis, systemic lupus erythematosus (SLE), and scleroderma
- drug toxicity
-
Evaluation and Diagnostic tests
Diagnosis is confirmed after a subjective examination provides history of hand injuries or patterns of functional loss of the hands as described by the patient.7 During the objective exam, grip strength and finger dexterity are assessed.8 Any atrophy of muscles in the hand are noted. In addition to muscle strength, dermatomes are tested to assess sensation loss. X-rays may be used to rule out potential fractures. Electrodiagnostic studies such as nerve conduction velocity and EMG (electromyogram) are often performed to verify the diagnosis.8
Special orthopedic tests
- Phalen test (wrist flexion test)9
- Sensitivity=34%-93%
- Specificity=48%-93%
- Procedure: patient places dorsal surfaces of hands together with wrists flexed for 1 min
- Positive Sign: numbness or tingling in the thumb, index finger, middle finger, and/or lateral half of ring finger
- Reverse Phalen’s test9
- Sensitivity=88%
- Specificity=93%
- Procedure: patient places elbows on table with hands up and wrists flexed for 1 min
- Positive Sign: numbness or tingling in the thumb, index finger, middle finger, and/or lateral half of ring finger
- Tinel’s Sign9
- Sensitivity=27%-79%
- Specificity=65%-98%
- Procedure: PT taps volar surface of wrist (over carpal tunnel)
- Positive Sign: tapping causes paresthesia in the thumb, index finger, middle finger, and/or lateral half of ring finger; tingling is distal to tapping location
- Wrist flexion & median nerve compression test
- Sensitivity=61%
- Specificity=83%
- Procedure: PT extends the patient’s elbow, supinates forearm, flexes wrist to 60⁰ then applies pressure with thumb over the median nerve at the wrist, holding for 20 seconds.
- Positive Sign: pain and paresthesia in the thumb, index finger, middle finger, and/or lateral half of ring finger
- Flick Maneuver9
- Sensitivity=37%
- Specificity=74%
- Procedure: with hands relaxed, patient shakes hands vigorously repeatedly
- Positive Sign: numbness or tingling in the thumb, index finger, middle finger, and/or lateral half of ring finger
Conservative treatment
Treatment varies depending on if the condition is acute or chronic. Also, the patient’s age, occupation, overall health, current functional level, and stage of the condition is taken into account when formulating the most appropriate treatment plan.5 Typically, conservative treatment consists of ergonomic education, splinting or bracing the wrist, and anti-inflammatory medications to decrease swelling.5 Ergonomic education may help alleviate symptoms and help prevent reoccurrence in the future. Ergonomically designed keyboards are an investment worth purchasing if one’s occupation requires hours of typing. The Cochrane review of non-surgical treatment for carpal tunnel syndrome reported evidence which suggests that ergonomic keyboards are a better choice over standard keyboards for decreasing pain and improving hand function.5 Several recent research studies have found local steroid injections and splinting to be effective in reducing symptoms and improving hand function.3,((bibcite 10-14)) Splinting appears to be most beneficial when providing support to the wrist and MCP joints in a neutral wrist position.12 This neutral support may be more effective than cock-up splint. Additionally, ultrasound may be effective at relieving pain when compared to a placebo following seven weeks of treatment although the evidence supporting this is limited.
Splints
Neutral Splint[12]
Cock up Splint[12]
Surgery and post-op treatment
Surgery for CTS is indicated when conservative treatment is not effective or if the symptoms are severe.5 Surgically releasing the flexor retinaculum provides reduces the compression on the median nerve. This procedure has been shown to be very effective in cases of reversible mechanical compression at reducing symptoms..15 However, if the patient presents with nerve damage they are considered to have irreversible microscopic damage thus a poorer prognosis.14,15
Surgical options include: open carpal tunnel release, endoscopic carpal tunnel release, and minimal incision carpal tunnel release.16,17 CTS surgeries total approximately 500,000 a year which equates to about $2 billion a year.5 For this reason, prevention is key to avoid contributing to these high healthcare costs and unnecessary surgeries.
Post-op treatment may include: modalities such as ice, heat, ultrasound, or electrical stimulation to decrease pain and inflammation, nerve gliding exercises to restore mobility of the median nerve through the carpal tunnel, and strengthening exercises within the pain-free range.4 The following is an example of a workman’s comp protocol outlining typical rehab guidelines following open or endoscopic surgery:Bibliography item 18 not found.
Phase 1: (Week 1)
- Remove the suture in approximately 7-10 days
- Patient Education- recovery & self-management
- Splint should be worn at night
- RICE to ↓pain and edema
- HEP (3x/day):
- Full Active/Passive ROM Exercises:
- shoulder & elbow (if limited ROM is present)
- forearm, fingers, & thumb
- Active/Passive ROM & nerve gliding exercises
Phase 2: (Weeks 2-3)
- Controlled movements
- Patient will be instructed on how to safely use the hand & UE to life < 20 lbs., grip/pinch, & perform household functional activities
- Deep transverse friction massage to break up scar adhesions
- HEP:
- Active wrist ROM
- Light resistance work focusing on ↑ grip and pinching strength
- Progressive resisted isometric within pain free ROM with wrist in neutral position
- Modalities for pain and swelling control
Phase 3: (Weeks 4-8)
- Splinting during the day stopped & only used at night if needed for persistent pain
- Hand & UE should now be pain free when lifting up to 40 lbs., gripping /pinching & carrying out household functional activities
Clinical Goals:
- 75% pre-op wrist ROM
- 50 - 75% pre-op grip/pinch strength
- Progressive resisted isotonic & eccentric wrist strengthening exercises by adding occupation specific tasks such as lifting or carrying objects
Physical Therapy Management of Carpal Tunnel Syndrome
Additional web-based sources:
http://www.aoec.org/ceem/methods/umass3.html
http://www.assh.org/Public/HandConditions/Pages/CarpalTunnelSyndrome.aspx
http://www.ampainsoc.org/press/2010/carpal_tunnel.htm
http://www.iasp-pain.org/AM/AMTemplate.cfm?Section=Home&CONTENTID=7637&SECTION=Home&TEMPLATE=/CM/ContentDisplay.cfm
http://patients.aan.com/disorders/index.cfm?event=print&disorder_id=872
http://www.ninds.nih.gov/disorders/carpal_tunnel/detail_carpal_tunnel.htm
http://www.ncbi.nlm.nih.gov/pubmedhealth/PMH0001469/
http://orthoinfo.aaos.org/topic.cfm?topic=a00005
http://www.livestrong.com/article/136642-carpal-tunnel-physical-therapy-exercises/
http://www.neurology.org/content/58/11/1589.full.pdf
http://www.orthogate.org/patient-education/hand/open-carpal-tunnel-release.html
http://www.cdc.gov/niosh/topics/ergonomics/
http://www.rheumatology.org/practice/clinical/patients/diseases_and_conditions/carpaltunnel.asp
http://my.clevelandclinic.org/disorders/carpal_tunnel_syndrome/hic_carpal_tunnel_syndrome.aspx
http://medicalcenter.osu.edu/patientcare/healthcare_services/orthopaedics/hand/carpal_tunnel_syndrome/Pages/index.aspx
