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Carpal Tunnel Syndrome

Carpal tunnel syndrome is a progressive and increasingly painful condition that can result from compression of a nerve that supplies the wrist and hand.

The median nerve runs from the forearm into the palm of the hand, and innervates the palm from the thumb to the third finger. It does not reach as far as the little finger. The nerve controls sensations and also supplies some of the muscles that move the fingers and thumb. As it travels to the hand it, along with nine tendons, passes through a structure in the wrist called the carpal tunnel. Carpal (wrist) bones form the sides and bottom of the narrow channel, and the transverse carpal ligament covers the top. A ligament is a band of strong connective tissue that attaches bone to bone. Surrounding the tendons is tissue called the synovium that serves to lubricate the movement of the tendons. If for some reason the synovium swells and narrows the tunnel, the median nerve is compressed and produces the painful symptoms of carpal tunnel syndrome.

Most cases of carpal tunnel syndrome are caused by a combination of factors. It is often caused by a naturally smaller than normal carpel tunnel. Any additional factor that narrows the tunnel further may trigger symptoms. Swelling from an injury to the wrist, fluid retention, a tumor or cyst, biomechanical abnormality, work-related stress on the hand, or underlying disease such as diabetes, rheumatoid arthritis, or hypothyroidism are some known contributing factors. Occasionally no cause can be found.

Women develop carpal tunnel syndrome three times as often as men, possibly because their carpal tunnels are naturally narrower. Hormonal changes and fluid retention due to pregnancy can predispose certain women to the condition. People who work on assembly lines tend to be prone to carpal tunnel syndrome although, interestingly, not people whose work requires a lot of data entry or computer work. Anyone with a medical condition that affects the nerves, for example, diabetes or alcoholism, is at increased risk.

  • Symptoms typically start as an ache in the wrist that may extend into the hand or forearm. Symptoms progress to tingling, itching or a burning numbness in the palm and fingers, excluding the little finger.
  • Fingers may feel swollen, but without visible signs of swelling.
  • Symptoms usually affect the dominant hand first and are more severe.
  • Symptoms may first appear during the night, resulting in a desire to ‘shake out’ the hand. As the condition worsens symptoms become more apparent during the day.
  • Symptoms may be noticeable when holding a steering wheel or phone.
  • Muscle weakness may make it difficult to grip or make a fist.
  • Decreased ability for the hand to sense heat and cold.
  • Pain, similar to an electric shock, may shoot up the arm or down into the fingers.
Symptoms should be diagnosed as soon as possible to avoid permanent damage to the median nerve and associated muscles.

Your doctor will ask you about your symptoms, their first appearance, duration, and severity. Your lifestyle and occupation will be discussed as these may have a direct bearing on the cause of your symptoms.

Your entire arm, shoulder, and neck will be physically examined to help with the diagnosis and rule out other conditions that can produce similar symptoms. There are specific tests for carpal tunnel syndrome: the Tinel test is performed by pressing or tapping on the wrist where the median nerve lies. If this causes tingling or pain you probably have carpal tunnel syndrome. The Phalen test attempts to produce symptoms by having you position the backs of your hands together with the fingers pointing down.

Other diagnostic tests are nerve conduction studies, electromyography, and ultrasound. Your doctor may wish to have X-rays taken to rule out bone fractures or arthritis.

If your case of carpal tunnel syndrome has been caused by an underlying condition such as diabetes or rheumatoid arthritis, those diseases will be treated first.

If other factors are responsible, treatment will consist of initial rest, immobilization, and ice. You should avoid any activity that causes your symptoms to worsen. Your wrist may be placed in a splint to prevent further movement. The splint may be particularly effective if worn at night to prevent the wrist flexing while you sleep. Crushed ice, placed in a bag and wrapped in a towel, can be applied to the wrist to reduce any swelling. NSAIDs (non-steroidal anti-inflammatory drugs) can be taken to help reduce swelling and relieve pain. Your doctor may inject your wrist with a corticosteroid, which can provide immediate pain relief. Such injections are not recommended for everyone, however, and the effects are only temporary.

Other treatments that may help with carpal tunnel syndrome symptoms are vitamin B6 supplements, yoga, and stretching and strengthening exercises. Exercises should be done under the supervision of a physical therapist, and should only start once your symptoms have lessened.

If symptoms have not improved after about six months of conservative treatment, surgery may be considered. The goal of surgery would be to relieve pressure on the median nerve by releasing (surgically cutting) the band of ligamentous tissue that forms the carpal tunnel. Surgery can be traditional open release surgery that requires an incision about 2 inches long in the wrist, or endoscopic surgery where narrow instruments are inserted through one or two small incisions. Endoscopic surgery is less invasive and tends to produce less scarring and post-operative pain, so recovery is usually faster. The severed ligament tissues grow back together after the surgery but the space for the nerve and tendons is larger so carpal tunnel syndrome rarely reoccurs.

After either surgical technique, rehabilitation of the wrist would be necessary to relieve stiffness and build up strength. You may need to wear a brace on your wrist for three weeks. It will probably take from several weeks up to six months before all weakness and pain has gone and, if you had a severe case of carpal tunnel syndrome, your symptoms may not disappear entirely.

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