Carpal Tunnel Relief Is Just a Shock Wave Away!

Carpal tunnel syndrome (CTS) is a very frequent nerve compression condition among working adults. It leads to numbness, pain and weakness in the hands, wrists and arms, which can significantly affect the ability to perform daily activities, but is often overlooked, under-treated, or delayed until surgical intervention is considered.

This article will tell you what CTS actually is, who it affects, how it is properly diagnosed and what treatments such as shock wave therapy and ultrasound guided hydrodissection can do for you.

The carpal tunnel is a narrow space in the wrist, created by a small bone called a carpal and protected by the transverse carpal ligament. The median nerve is one of the primary nerves that supplies the hand, and runs through this tunnel with nine flexor tendons. As pressure increases in the tunnel, the nerve becomes inflamed, causing pain, numbness, tingling and weakness in the thumb, index, middle and ring fingers.

Symptoms are slow to appear and progressively get worse. The symptoms are more likely to occur at night when the wrist is flexed during sleep, which puts more pressure on the nerve.

The early warning sign of CTS is a numb or “asleep” hand in the morning that requires shaking to wake up. Don’t ignore it.

The pressure in the carpal tunnel may come from several sources other than the wrist. To decide on the appropriate therapy, it is crucial to grasp the entire situation.

Anatomical Factors

• Variation of median nerve that divides inside tunnel, making it more vulnerable to compression (bifid median nerve)
• Persistent median artery, a vessel that fails to disappear and occupies the tunnel space, embryonic vessel
• Some people just have a smaller tunnel, and some small tunnel dimensions
• Permanent narrowing of the tunnel by fractures or dislocations of the wrist, or by bony changes

Functional and Fascial Factors

The median nerve is formed in the neck and passes through the shoulder, arm, elbow and forearm and into the hand. Any blockage on this pathway can cause the nerve to become compressed or stretched, resulting in symptoms that are similar to those of classic CTS. This is a blind spot in the standard orthopedic exam, as the diagnostic process is likely to end at the wrist when a person has carpal tunnel surgery. Studies of nerve mechanics always find that there are multiple levels of compression in many patients, and just treating the wrist doesn’t address these problems.

The main functional contributors are: scapular dysfunction, which is a poor control of the shoulder blade that causes an increase in mechanical load on the median nerve before it reaches the wrist; lacertus fibrosus entrapment, a fibrous band at the elbow that compresses the median nerve proximal to the wrist, and is often overlooked in the standard evaluation; and retinaculum stiffness, characterized by reduced movement of the transverse carpal ligament, which decreases the capacity of the tunnel to accommodate nerve movements. Another recent study by Carla Stecco and Carmelo Pirri also shed light on another important factor that can cause restriction of the median nerve in its course: thickening of the antebrachial fascia, a measurable increase in the density and stiffness of the deep forearm fascia, which is a diagnosable condition and can be specifically targeted for treatment with high-resolution diagnostic ultrasound. Last but not least, entrapment of the median nerve between the two heads of the pronator teres muscle in the forearm is a common and often overlooked cause of symptoms, either as an isolated process mimicking carpal tunnel syndrome or as an important upstream cause of double crush syndrome when wrist-level compression is also involved.

Double crush syndrome is when the median nerve is compressed at two or more points at the same time. A patient might experience mild cervical compression at their neck, tightness in their lacertus fibrosus at their elbow, and a narrowed carpal tunnel at their wrist, each of which is minor, but collectively cause significant symptoms that are debilitating.

This pattern is not detected by standard work-ups, which only assess the wrist. The tunnel is opened during surgery, the nerve is released, and symptoms continue to occur because the nerve was also compressed upstream at a location that was not evaluated.

Persistent symptoms following carpal tunnel surgery sometimes aren’t a surgical failure, it’s a diagnostic one. The best way to avoid this is to have a full nerve pathway evaluation prior to treatment.

• Computer users and programmers, prolonged typing and pointing with hands, wrists and/or arms
• Dentists and dental hygienists, repetitive precision work in sustained awkward positions
• Professionals in the health care field, surgeons, physical therapists, massage therapists
• Mechanic and tradespeople, vibrating tools and sustained grip loading
• Musicians, highly repetitive fine motor movements for hours a day
• Hairdressers, extended scissor and styling tool use
• High frequency, low variation hand tasks and assembly-line workers
• Women who are pregnant, especially in the last few weeks of their pregnancy

Women are diagnosed with CTS about three times more often than men, in part because hormones and the smaller size of the tunnel.

When symptoms are more advanced, many patients do not seek help. At this stage, nerve damage may have already started. The earlier the intervention, the better the results.

Early signs, take action on these now:

• Fingers occasionally tingle when driving, reading or holding a phone
• Having a numb hand that wakes up 1-2 times a week
• Swelling sensation in hand without swelling
• Some clumsiness with small objects, but not serious or frequent

Severe symptoms, urgent assessment:

• Persistent numbness that persists for the majority of the day
• Weak grip or trouble with jars, buttons or keys
• Dropping objects unexpectedly
• This is a sign of severe nerve damage and is seen as muscle wasting at the base of the thumb (thenar atrophy), which is irreversible

When symptoms are more advanced, many patients do not seek help. At this stage, nerve damage may have already started. The earlier the intervention, the better the results.

1. Clinical Examination

• Phalen’s test, this is when the wrist is bent for 60 seconds to see if it causes the fingers to go numb or tingle.
• Tinel’s sign, tapping over the carpal tunnel to elicit radiating tingling into the hand

2. Nerve Conduction Studies (NCS/EMG)

NCS/EMG is the gold standard for measuring the efficiency of the median nerve and is important for grading the severity and determining surgical indications. When applied alone, however, it has its limits: it only assesses electrical function, and may return normal results in early CTS, and it does not detect double crush syndrome or proximal compression sites.

3. High-Resolution Diagnostic Ultrasound

Ultrasound is a must-have addition to NCS/EMG. Nerve conduction studies provide information about the electrical activity of the nerve, but ultrasound provides information about the problem, by directly imaging the nerve and surrounding tissue in real time.

Consider them a power pair for diagnosis: NCS/EMG is the physiological power couple, while ultrasound is the structural power couple.

What ultrasound adds:

• The cross sectional area measurement is directly observable and highly measurable, with nerve swelling
• Dynamic imaging, reveals mobility restrictions and adhesions invisible on static testing
• Sonoelastography identifies a change in stiffness of nerve tissue prior to any major electrical changes
• Superb Microvascular Imaging (SMI), assesses blood flow within and around the nerve
• Full pathway evaluation, identifies proximal compression sites from neck to wrist

Treatment will vary based on the severity, length and structural findings of the symptoms. This staged framework is a representation of the progression of evidence based CTS care:

Stage 1: Initial Conservative Management

Indications: mild or early symptoms of the disease

Wrist splinting at night to keep the wrist in neutral position, along with ergonomic change of work station and anti-inflammatory measures. In truly early CTS, this phase may be the only one that yields significant improvement.

Stage 2: Advanced Non-Invasive Intervention

For: symptoms persisting despite splinting and ergonomic changes

Extracorporeal Shockwave Therapy (ESWT) to stimulate tissue repair, reduce synovial inflammation and improve nerve circulation with radial shockwave applied specifically to the antebrachial fascia and myofascial densification points where fascial thickening has been identified as a contributing factor. Structured physical therapy, such as neurodynamic nerve mobilization, forearm strengthening and scapular rehabilitation, addresses the mechanical contributors that splinting cannot reach, and manual fascial manipulation using the Fascial Manipulation methodology is used to systematically release densified fascial points along the pathway of the median nerve.

Stage 3: Image-Guided Mechanical Release

If: structural nerve adhesions, fascial entrapment or multi-level compression

Hydrodissection is a procedure that uses ultrasound to separate the median nerve from the surrounding constricting connective tissue, allowing the nerve to glide freely again. FLUSH (Fascial Liquid Ultrasound-guided Hydrodissection) is a specialized technique that utilizes ultrasound-guided fluid injection to release the fascial layers along the nerve’s path, which goes beyond the reach of a typical surgical release.

Stage 4: Surgical Decompression

For: severe CTS with progressive muscle wasting, profound axonal loss, or failure of well-executed conservative care

Surgical release of the transverse carpal ligament is still indicated in patients with thenar atrophy, significant axonal loss on NCS/EMG, and failure of conservative treatment for a prolonged period. Surgery should not be the first step if compression is severe and progressive.

ESWT is a technique that sends concentrated pulses of acoustic energy into the targeted tissue, from the outside. It is non-invasive, does not involve anaesthetic and is done in an outpatient environment.

How it works:

• Increases the repair of chronically inflamed and fibrotic tissue
• Increases blood flow to the pinched nerve and surrounding areas
• Regulates inflammatory response in the carpal tunnel area
• Gradually decreases overactive pain receptors
• Emerging evidence suggests support for peripheral nerve regeneration

The findings of the research:

This is now more strongly supported by more recent evidence:

There are limitations in that there was some variability in the protocol across the studies and that there was a need for longer-term follow-up data. ESWT works best when used along with a complete, personalized treatment program.

• Nerve root compression at C6 or C7, which causes similar hand and arm symptoms, and cervical radiculopathy
• Pronator syndrome (also known as median nerve compression in the forearm), often mistaken for CTS
• Lacertus fibrosus entrapment is an always underdiagnosed compression point in the elbow
• Diffuse nerve dysfunction, often caused by diabetes (peripheral neuropathy)
• Tendon disorders, de Quervain’s tenosynovitis and trigger finger
• Arthritis, inflammatory or degenerative joint disease with overlapping pain patterns

Before treatment, a complete nerve pathway ultrasound is necessary, which is dynamic.

• Keep wrists in a neutral position while typing and do not hold wrists extended or flexed for long periods of time
• Elbows are at 90° and forearms are parallel to the floor
• Use an ergonomic mouse; try a split keyboard if you type for long periods of time
• Monitor height should be such that the neck remains in a straight line

Movement habits:

• Make short hand and wrist rests every 30-45 minutes
• Relax tension by making gentle movements with fingers and wrists, and arms overhead
• Try not to have prolonged tight grip, if possible

Targeted exercises:

• Median nerve gliding promotes the nerve’s ability to glide, thus minimizing the risk of adhesion
• Forearm flexor stretching, decreases cumulative tension of the flexor tendons in the tunnel
• Scapular stabilization, decreases mechanical stress on the proximal pathway of the median nerve

At NYDNRehab, we will assess the entire trajectory of the median nerve from the neck to the fingertips, and determine all the factors involved before creating a treatment plan. The aim is not just to ease the symptoms of the wrist, but to get the nerve to work and glide along its entire course

1. Diagnostic Ultrasound:

High resolution imaging to measure nerve swelling, evaluate tissue stiffness, assess blood flow and map compression sites along the entire nerve pathway. Complementary to NCS/EMG when clinically indicated for a full picture of structure and function.

2. Shockwave Therapy (ESWT):

Shockwaves are applied to the carpal tunnel area to decrease inflammation, encourage healing and enhance blood flow. Usually 3-5 sessions, 1 session every week, and improvement is seen after the second or third session.

3. Hydrodissection:

Procedure in which sterile saline is injected around the nerve with ultrasound guidance, to physically separate the nerve from the adherent tissue and restore gliding mobility. It is unlike a steroid injection which is chemically acting, not structurally. It is effective at addressing the mechanical source of nerve gliding problems, rather than just reducing inflammation, making its effects more lasting, especially if the main clinical finding is adhesions.

4. FLUSH (Fascial Liquid Ultrasound-guided Hydrodissection):

A specialized hydrodissection technique that focuses on fascial restrictions throughout the entire nerve pathway, not just at the wrist. The fluid is injected under ultrasound guidance directly into the layers of the tethers to unblock them at several points at once. Very useful for patients who have had carpal tunnel surgery but have not completely resolved their symptoms, or who have been found to have multiple levels of nerve involvement on imaging.

5. Neurodynamic Nerve Mobilization:

A progressive movement technique to restore the ability of the nerve to glide through surrounding tissues. The median nerve is meant to move freely and adjust with each arm and hand movement, and if it becomes compressed or “stuck” because it cannot move, tension builds up along the nerve, even after the structure is treated. The active rehabilitation (neurodynamic mobilization) component of treatment is designed to consolidate and maintain structural changes resulting from other interventions.

6. Myofascial Release:

Manual therapy to the forearm, elbow and shoulder to relieve restrictions in the fascia that create an upstream tension on the median nerve at the wrist. The removal of these restrictions decreases the combined mechanical load on the nerve and helps make more specific treatments more effective.

7. Joint Mobilization:

Applied when limited mechanics of the wrist or forearm joints are a factor in loading the carpal tunnel. Combined with soft tissue and nerve-directed treatments in a coordinated, individualized treatment plan instead of used separately.

8. Acupuncture:

As a complimentary modality to modulate pain and regulate the nervous system, especially in those patients with increased pain sensitivity, marked night time symptoms, and/or a prominent central sensitization component to their presentation.

Carpal tunnel syndrome is not simply a wrist problem. It is a problem with the mechanics of the nerves, the health of the fascia, the system and frequently multiple areas of compression along the median nerve from neck to fingertips. Taking one wrist procedure as the sole measure is only looking at a part of a much larger picture.

The good news is that most patients, especially those who come in for evaluation before they’ve developed significant nerve damage in the structure, have a real chance of a full recovery without surgery. The reasons it may or may not be realized are simple: a proper and complete diagnosis, which goes beyond the wrist, and a treatment plan that treats the structural and functional causes of the individual patient’s symptoms.

Early diagnosis means you have options for treatment. After the appearance of thenar atrophy or substantial axonal loss on NCS/EMG, the opportunity for complete recovery diminishes. The warning signs listed in this article are there for a reason: to give you time to take action before it closes.

Your nerve is protected in comprehensive treatment. A single ligament release at the wrist will relieve tunnel pressure at one point along a nerve that runs the entire length of the arm. A durable recovery will demand that the nerve’s ability to move, circulate and function freely along its entire course be restored, not just decompressed at the obvious site.

If you have any of the early signs mentioned in this article, including numbness, wrist pain, tingling fingers, the best thing you can do now is a comprehensive exam that is structurally complete, before symptoms worsen and options are limited.

NYDNRehab provides specialized non-surgical evaluation and treatment for carpal tunnel syndrome, nerve entrapment disorders and musculoskeletal conditions in NYC.