CTS are considered a mononeuropathy (single involvement of the nerve) disorder. That is when the median nerve ( M.nerve) gets compressed and/or losses its glide ability in the osteo-ligamentous tunnel (a bony tunnel consisting of carpal bones and the palmar ligament) in the wrist. CTS are considered a continuing overuse syndrome, which fits the criteria of the cumulative trauma disorder category.
The tendons of forearm muscles, ligaments around wrist bones and carpal bones themselves make up the tunnel in which median nerve passes from the forearm to the wrist providing innervation to the first three fingers and half of the ring finger. The innervation supplied by the M.nerve provides motor and sensory function to the wrist and fingers.
Carpal Tunnel Syndrome appears unexpectedly regardless of physical action. Typically pain appears at night or in the early morning. The patient could feel a sensation of burning, numbness and tingling. The ache could be anywhere within palmar aspect of the arm, but most frequently it is felt around the base of the wrist and tips of third and/or fourth digits. In chronic CTS patient occasionally experience slight loss of movement control of his/ her fingers.
Most common neuropathy (nerve compression) in the upper extremity is. In the U.S. alone there are close to half of million surgeries annually to release the median nerve (M.nerve) inside the carpal tunnel (CT).
CT is an osteo-ligamentous opening (tunnel) of the wrist, which serves as a passageway to tendons, nerves and blood vessels traveling from forearm to the wrist.
Fifty percent of all CTS diagnosis is due to overuse. CTS are a common cumulative trauma disorder. It’s considered a multifactorial condition in which movement dysfunction within whole upper extremity leads to indication of symptoms in the wrist and fingers. Originally it was thought that the tunnel within wrist is the sole culprit.
After years of surgical exploration combined with research established that in most of the cases the tunnel width isn’t a causative factor. Nowadays science believes the disturbance of median nerve gliding along the distance of the whole arm is the cause.
Upper Chest Outlet (space where the parts of the brachial plexus are in direct contact with a portion of the pectoralis muscle)
Pronator teres space. As the median nerve enters the forearm it must pass under the pronator teres muscle. Frequent overuse of these muscles due to occasional demand can either disturb gliding of the medial nerve and predispose to further damage in the CT due to decrease gliding or create its own compression mimicking symptoms of CTS
Down at the carpal tunnel the overuse of the wrist may create hypermobility of the tendons composing the carpal tunnel, which in turn causes displacement and traction on the median nerve. Another scenario is movement restriction of carpal bones which make up the tunnel, this inflexibility of the joints increase the pressure within the canal which commonly combined with restricted gliding of the median nerve produces alteration in the nerve function.
Cervical disco genic pain
Pronator teres syndrome
Thoracic outlet syndrome
Anatomical alteration of space in the tunnel
Developmental anomaly of wrist tendons
Osteoarthritis of the joints within the wrist
Typically, Carpal Tunnel Syndrome responds well to treatment, with a high number of patients making a complete recovery. To elude work-related conditions of CTS, people perform on the job conditioning, such as muscle and soft tissue lengthening exercises, take many rests and breaks, wear a wrist brace to ensure the wrist is straight, and make sure the wrist posture and ergonomic position is precise. Fingerless gloves can keep hands flexible and warm. Warming up the wrist and fingers prior to manual work is very beneficial.
CTS research data shows that 40 percent of patients who were operated for a carpal tunnel release procedure have side effect or don’t return to their pre CTS level of activity due to pain.
Carpal tunnel release is a very common procedure.
Conventional carpal tunnel physical therapy such as applications of heat, ultrasound, iontophoresis, has very limited success. Bracing can reduce symptoms temporarily but has no long-term effect and should only be utilized in an acute stage and with combination with additional effective modalities. Best effects of CTS treatment can be achieved by a combination of methods that is utilized to restore gliding of median nerve and resolve muscle/tendon conflicts. These methods only work in combination with one another.
At NYDNRehab we use a combination of t methods affecting the glide ability of the nerve. These methods address gliding of the median nerve in the arm and the neck. These methods consist of: joint mobilization, ligament strengthening, ESWT (Extracorporeal Shock Wave Therapy) or acupuncture, myofascial release and neurodynamic nerve mobilization technique. Often times we combine this approach with hydro-dissection of the median nerve under ultrasound guidance.
The initial symptoms of carpal tunnel syndrome are hand numbness, tingling, and burning. Initially the symptoms occur intermittently and worst at nighttime while the patient is sleeping. The tingling often wakes up the patient, and they have to shake their hands to get rid of it. As the disease progresses the frequency and the intensity of the tingling and burning increases, eventually the symptoms become constant and severe. As the carpal tunnel syndrome gets worst the patient can develop symptoms of weakness and paralysis of the fingers and the hands.
Tingling is usually a sign of nerve injury. Nerves generally have two major functions. There are sensory nerves which sense information in the skin, and there are motor nerves that are used to move the muscles. Several symptoms occur when there is nerve injury, there could be numbness, tingling, or burning and there could also be associated weakness and paralysis of the muscles. One of the nerves that supply the hand is called the Median nerve. This nerve travels across the wrist to supply the fingers. With repetitive bending and straightening of the wrist this nerve gets injured; Injury of the Median nerve at the wrist causes carpal tunnel syndrome. It tends to occur in people that use the computer frequently, use the cash register, or are involved in activities that involve repetitive motion at the wrist. There is greater frequency of carpal tunnel syndrome among post-menopausal women.
The diagnosis of carpal tunnel syndrome is made using a nerve test called EMG/Nerve conduction study. Since there are multiple other causes of hand tingling, nerve testing is crucial to know if the Median nerve is injured at the wrist, which would confirm the diagnosis of carpal tunnel syndrome, or is there another cause. It also gives us crucial information about how severe the injury is, which determines the type of treatment. Another very helpful diagnostic procedure is musculoskeletal ultrasound. It further helps us to identify the cause, location and size of damaged nerve. Rapid diagnosis of carpal tunnel syndrome is important since if the problem is ignored the injury could continue and the symptoms could progress and become permanent.
Once the diagnosis of carpal tunnel syndrome is made we will determine the best possible treatment for the patient trying to prevent further nerve damage and trying to reverse the process. The different treatment options include bracing, injections, special physical therapy release and exercise methods, extracorporeal shockwave therapy. The treatment of carpal tunnel syndrome that is chosen depends on the severity of nerve damage shown on the nerve conduction study and diagnostic ultrasound, making this test very crucial. The earlier in the disease process that we see the patient the better chances of recovery. The later in the course the patient comes to our attention the chances of recovery are less, the patient could develop permanent paralysis, and surgical procedures might be required even though they could have been avoided early in the disease course. Patients with carpal tunnel syndrome could have full recovery with minimal intervention if they seek medical attention and treatment early.
Research at NYDNRehab