CARPAL TUNNEL SYNDROME

Carpal tunnel syndrome (CTS) is a symptomatic compression neuropathy of the median nerve at the level of the wrist and is characterized by pain and paresthesias in the palmar radial aspect of the hand. Symptoms are often worse at night and exacerbated by repetitive and forceful use of the hand. As the syndrome represents a collection of signs and symptoms, no one test absolutely confirms a diagnosis. CTS is the most common compression neuropathy of the upper extremity.

Related Anatomy*

• Scaphoid tubercle, trapezium
• Hook of the hamate, pisiform
• Transverse carpal ligament
• Flexor pollicis longus (FPL) tendons
• Flexor digitorum sublimis (FDS) tendons
• Flexor digitorum profundus (FDP) tendons

Pathogenic Factors

• Anatomical: decreased size of carpal tunnel or increased contents of canal
• Physiological: neuropathies, inflammatory conditions, fluid imbalances, congenital anomalies
• Microbiology: fibrous tissue and variable edema with scattered lymphocytes; Schwann cell response, macrophage recruitment, axonal loss/degeneration, myelin stabilization
• Position and use of the wrist: repetitive flexion/extension, squeeze/release, torsion, vibration exposure, weight-bearing with wrist extended, immobilization with wrist flexed

Incidence and Related Conditions

• ~1 million adults in the United States are diagnosed with CTS each year
• Women are affected 3 times more than men; pregnancy is associated with an increased risk for CTS
• Up to 50% of patients with thumb carpometacarpal (CMC) joint osteoarthritis also have CTS

Differential Diagnosis

• Double crush syndrome
• Isolated pathology at the cervical spine, brachial plexus, median nerve of forearm
• Intrinsic nerve pathology
• Multiple sclerosis (MS)
• Amyotrophic lateral sclerosis (ALS)
• Charcot-Marie-Tooth disease
• Syringomyelia
• Spinal muscular atrophy (SMA)

Patients will present with symptoms that first appeared in one or both hands at night and then gradually increased to other times of the day. Patients report symptoms such as numbness and tingling in the palm and fingers, especially the thumb, index and middle fingers, which are intermittent and associated with specific activities such as driving, typing, knitting, etc. Patients will report difficulty grasping small objects or performing other manual tasks. In chronic, untreated cases the muscles at the base of the thumb may have atrophied; some patients are unable to discriminate between hot and cold by touch.

RECOMMENDED HAND SURGEON THERAPY ORDERS

• Dressing management as needed
• Edema control
• Patient education
• Progressive active range of motion exercises
• Wound management after sutures out - massage
• Tendon gliding
• Begin strengthening exercises at 3-4 weeks
• Scar conformer splinting if scar hypertrophic
• Work hardening if needed

Hand Therapy after CARPAL TUNNEL RELEASE

Early hand therapist assistance and intervention (first week post-op):

• Dressing assessment and changing
• Edema control – encourage elevation, encourage early gentle finger ROM, watch for RSD/CRPS signs
• Patient education – teach signs of infection, avoid maceration of surgical site, encourage smoke free recovery, avoid excessive exercise to minimize scarring

Intervention at suture removal (10-14 days post-op)*

• Steri-strips to approximate the surgical site to prevent excessive tension on the new scar.  Instruct patient to keep dry for 24 hours after suture removal
• Scar management, scar massage with vitamin E oil / thick vitamin E cream in light circular motions with moderate pressure, 3-4 minutes twice daily
• Finger tendon glides and thumb glides should be reviewed for controlled AROM of fingers and thumb (avoid power flexion with wrist palmar flexed)
• Wrist AROM in all planes within a pain free range (flexion/extension and UD/RD)
• Educate patient in desensitization techniques to minimize post-operative hypersensitivity
• Educate the patient to limit strengthening tasks, lifting and heavy use until 4-6 weeks post-op
• Rarely encourage nighttime use of CTS splint only if painful and very swollen
• Encourage finger food tasks, in-hand manipulation and coin stacking to optimize AROM and function

*Wound healing may be prolonged in diabetic patients and smokers

Intervention after post-op week 2-3:

• Progress to full unrestricted AROM of fingers, thumb and wrist while encouraging opposition to all fingers as well
• Continue scar management and introduce a scar conformer such as silicone based products. (See image below)
• Introduce a kid-friendly preloaded battery power toothbrush to encourage desensitization as necessary, 3-5 minute sessions several times per day   
• Initiate light strengthening at 6 weeks post-op as tolerated with no pain above a reported 2-3/10 as they progress (gripper, putty, clips)

Intervention at 8 weeks post-op:

• Reintegrate full use of the hand into life
• Progress strengthening and work hardening/work simulation as needed

• OCTR/mini OCTR: median nerve injury, palmar branch injury, failure to relieve symptoms, infection, persistent atrophy, pillar pain
• ECTR: ulnar nerve injury, digital nerve injury, tendon injury, superficial palmar arch injury, median nerve injury, palmar branch injury, infection, failure to relieve symptoms, persistent atrophy, pillar pain
• Recurrence occurs in up to 19% of patients after carpal tunnel release

• Conservative: effective for providing short-term relief of symptoms
• ECTR vs OCTR is associated with faster recovery times (return to work, muscle strength) but also associated with more complications owing to reduced visibility during the procedure
• OCTR leads to symptomatic relief, patient satisfaction and return to work in the majority of patients

• The carpal bones and the transverse carpal ligament are the components of the carpal tunnel. The bony attachments of the transverse carpal ligament are the ridge of the trapezium, the tuberosity of the scaphoid, the hook of the hamate and the pisiform.
• The most common cause of numbness and tingling in the upper extremity is carpal tunnel syndrome.
• Carpal tunnel syndrome is more common in women and often associated with thumb CMC joint arthritis, trigger fingers and DeQuervain's tenosynovitis.
• The carpal tunnel compression test (Durkan's test) is the most sensitive and specific physical exam test for diagnosing carpal tunnel syndrome.
• Carpal tunnel syndrome can accurately be diagnosed by history and physical exam but the diagnosis is usually confirmed by EMG/NCV testing. EMG/NCV testing also helps categorize the entrapment as mild, moderate or severe. In mild CTS there is a prolonged sensory latency with normal muscle latency and NO axon loss. In moderate CTS, both the sensory and motor latencies are prolonged with NO axon loss. In severe CTS both sensory and motor latencies are prolonged with AXON LOSS.⁵

New Articles

1. Cagle PJ Jr, Reams M, Agel J, Bohn D. An Outcomes Protocol for Carpal Tunnel Release: A Comparison of Outcomes in Patients With and Without Medical Comorbidities. J Hand Surg Am 2014 ePub. PMID: 25218142
2. Lane LB, Starecki M, Olson A, Kohn N. Carpal Tunnel Syndrome Diagnosis and Treatment: A Survey of Members of the American Society for Surgery of the Hand. J Hand Surg Am 2014 ePub. PMID: 25227597
3. Pacek CA et al. The morphology of the carpal tunnel. Hand (NY). 2010 Jan: 5(2): 135-140. PMCID: PMC2880678
4. Szabo RM, Slater RR, Farver TB, et al. The Value of Diagnostic Testing in Carpal Tunnel Syndrome. J Hand Surg 1999: 24A:704-714. PMID: 10447161
5. Werner RA, Andary M. Electrodiagnostic Evaluation of Carpal Tunnel syndrome. Muscle Nerve 44: 597-607, 2011. PMID: 21922474

Reviews

1. Ghasemi-Rad M, Nosair E, Vegh A, et al. A handy review of carpal tunnel syndrome: From anatomy to diagnosis and treatment. World J Radiol 2014;6(6):284-300. PMID: 24976931
2. Kim PT, Lee HJ, Kim TG, Jeon IH. Current Approaches for Carpal Tunnel Syndrome. Clin Orthop Surg 2014;6(3):253-257. PMID: 25177448 

Classics

1. Brain WR, Wright AD, Wilkinson M. Spontaneous compression of both median nerves in the carpal tunnel; six cases treated surgically. Lancet 1947;1(6443-6445):277-82. PMID: 20287146 
2. Phalen GS, Gardner WJ, La Londe AA. Neuropathy of the median nerve due to compression beneath the transverse carpal ligament. J Bone Joint Surg Am 1950;32(1):109-12. PMID: 15401727

HAND THERAPY REFERENCES

1. Cannon, et al. (2001).  Diagnosis and Treatment Manual for Physicians and Therapists, Upper Extremity Rehabilitation (4^th ed).  The Hand Rehabilitation Center of Indiana.
2. Mackin, Callahan, Skirven, Schneider, and Osterman, (2002). Rehabilitation of the Hand and Upper Extremity, 1, (5^th ed). St Louis, MO: Mosby Year Book, Inc.
3. Cooper, (2014). Fundamentals of Hand Therapy; Clinical Reasoning and Treatment Guidelines for Common Diagnoses of the Upper Extremity, (2^nd ed). Mosby, imprint of Elsevier Inc. Stanley and Tribuzi. (1992).  Concepts in Hand Rehabilitation.  F. A. Davis Company