Question: I am developing increasing pain in my wrist and thumb, especially when I try to open large, jars, (i.e., pickles or mayonnaise). Am I getting carpal tunnel syndrome?

Answer: It is more likely that you are in the early stages of osteoarthritis affecting the base of your thumb. Wearing a thumb spica splint at night may greatly decrease your daytime pains. Over the counter analgesics, such as naproxen or ibuprofen may help in addition to the splint use.

James B. Slattery, M.D.

Board Certified – Orthopaedic Surgery

Written By Rodger Powell, M.D.

Since first being reported in the early 20th century, Carpal Tunnel Syndrome (CTS) has become the most common nerve compression problem in this country today, affecting 1percent of the population. It is not surprising then that it is the most common ailment reported to workman’s compensation carriers. While diagnosis, pathology and treatment have become more firmly established, the search for the causes of this problem continues to evolve.

A short refresher on the anatomy of the carpal tunnel will help provide an understanding of the reason for the complaints from a patient with this syndrome. The median nerve travels from the wrist into the hand through the carpal canal, which is basically a tunnel with a bony floor and walls and a very strong ligament as its ceiling. In addition to the nerve, the thumb tendons and eight finger tendons fit through the same tight passageway. There is very little room for play or stretching in this canal, therefore, anything that causes swelling in the tendons or decreases the space in the canal will push the median nerve against the ligament and compress the soft nerve. As a result, nerve signals cannot get through the nerve, leading to the loss of sensation and function. It is analogous to parking your car on the garden hose while watering the garden. The hose will function, but you won’t water much of anything until you move the car off the hose. Carpal Tunnel Syndrome (CTS) reflects the same situation. Something must be done to relieve the pressure on the nerve so that the nerve can once again transmit the sense of touch, heat, cold and other sensations.

Patients with CTS typically complain of numbness and tingling at night, while driving, working or doing repetitive activities. Diagnosis is generally made by history, physical and exam testing. There are other causes for numbness and these can often be differentiated with electrical studies. EMG and Nerve Conduction Studies can help separate hand problems from neck compression and can often detect other problems such as diabetic nerve damage.

Several techniques and treatments for CTS have been suggested over the years, but three basic approaches are:

• Splints for night wear, non-steroidal anti-inflammatory medicines and exercises
• Cortisone injections into the carpal tunnel
• Surgical release

Of course, all the various techniques and their critiques are subjects for other articles.

In addition to articles on advances in treatment, an increasing number of articles continue to address causes of CTS, particularly as it relates to the work environment.  There are several factors that predispose an individual to CTS. These include, but are not limited to:

• Female
• Increasing age
• Obesity
• Smoking
• Diabetes
• Thyroid problems
• Arthritis
• Pregnancy

The most difficult factor to analyze when determining the cause of CTS has been that of repetitive motion. It should be noted that studies related to work activity and CTS are needed to more precisely define and understand this relationship. Certainly, vibratory tool use is clearly seen as a cause of work related CTS. Further, heavy repetitive lifting can also contribute to CTS. However, the repetitive use of a keyboard is less clear. Although, the position of one’s monitor and keyboard and the height of the chair and desk may all contribute to the problem; we must remember that CTS is caused by an increase in pressure inside the tunnel located in the person’s wrist. There is a very good study that demonstrates an increase in pressure when keyboarding and a decrease in pressure in the carpal tunnel after cessation of keying. Recently, a large Swedish study seemed to indicate a protective effect of any long-term keyboarding. Until more tightly controlled studies are completed, physicians should continue to render treatment to the injured worker in a setting that promotes rapid recovery and an early return to work.

Image provided by FreeDigitalPhotos.net.

“Surgical treatment” refers to the release of the transverse carpal ligament. The surgery itself is called a “carpal tunnel release.” Structurally, this allows for an expansion in the area of the carpal tunnel, thus decreasing the pressure on the median nerve. It is a relatively short, surgical procedure that is performed by a qualified surgeon. Common symptoms after surgery are pain, swelling, stiffness, and weakness. To manage these symptoms and guide your recovery, the physician will often send you for therapy.

Here at The Orthopaedic Institute, we have a specialized hand therapy center that currently staffs 5 occupational therapists that specialize in rehabilitation of the hand and upper extremity. No matter which course of treatment is chosen by you and your physician, our goal is to assist you through your recovery in a caring and professional manner. It is our mission to help you achieve the best possible outcome and resume your appropriate role in your normal daily activities.

Written by Rodger D. Powell, M.D.

Carpal Tunnel Syndrome represents one of a group of disorders in the body collectively known as compressive neuropathies. It is the most common nerve compression in the upper extremity and one of the most common problems seen today by hand surgeons. Compression neuropathy as its name implies is a pressure applied to a nerve from any of a variety of reasons. According to the Bureau of Labor statistics, approximately 0.1% of the population in the United States has carpal tunnel syndrome in any given year. Even more common is the perception by patients that any hand pain or disorder is carpal tunnel syndrome.

The term carpal tunnel relates to a region in the wrist that is bounded on three sides by the carpal bones or wrist bones. The roof of this semi-circular shaped bone canal is covered by a very thick ligament called the transverse carpal ligament. Through the tunnel formed by this strong ligament and bones courses the tendons that flex the fingers and the thumb, as well as the median nerve that gives sensation to the thumb, index finger, middle finger and half of the ring finger. In addition, the median nerve supplies the nerve that allows the thumb to pull across your palm to the small finger by innervating the abductor pollicis brevis muscle. For a number of reasons, the space in the carpal canal may become filled, either with fluid, a mass such as a ganglion, or a swelling of the flexor tendon sheath. Any of these situations begins to crowd the tendons and the nerve within this canal. Obviously, the bones will not yield to give any increased space nor will the transverse carpal ligament. The result is increased pressure in the carpal canal. As this pressure increases, the tendons, which are solid structures, can usually tolerate the pressure very well. But, the nerve, which has the consistency of spaghetti, reacts to the pressure by flattening and losing the ability to transmit nerve impulses. This leads to tingling in the fingers and in extreme cases, loss of motion in the thumb. It would be the equivalent of parking your car on the garden hose. Obviously, you cannot water the garden until you take the pressure off the hose. And, in most cases you will not regain sensation until the pressure is removed from the nerve.

The signs and symptoms of carpal tunnel can be varied, but the most common and classic findings are complaints of numbness and tingling at night that often wakes you from sleep. Patients also describe getting up and shaking their hands or “shaking them down by the bedside to restore circulation”. Other complaints include parasthesia or numbness while driving, doing your hair, applying makeup, reading, writing, typing or any other repetitive motion. Many times vibratory instruments such as chainsaws, weed eaters or motorcycle riding make it worse. Pain on the back of the hand, thumb or back of the forearm, usually does not come from carpal tunnel syndrome. However, carpal tunnel symptoms can cause pain radiating into the forearm and occasionally all the way to the shoulder, mimicking shoulder problems.

Diagnosis can be made by physical examination and/or neurological studies such as nerve conduction studies. Underlying diseases such as diabetes and thyroid problems need to be excluded as well. Non-surgical treatments include splints, nonsteriodal anti-inflammatory medications such as Advil, carpal tunnel exercises and in some cases Vitamin B6 (although the usefulness of this vitamin is controversial).

If the patient does not respond to non-surgical treatment, it is recommended that a surgical release of the transverse carpal ligament be performed to prevent permanent changes in the nerve. This is done as an outpatient procedure, and the procedure itself usually takes fifteen to twenty minutes. Most patients, through internet information, know of the endoscopic release which is done using a small scope and a blade placed adjacent to the scope through a very small puncture mark in the skin. The more common approach is called a mini open incision which involves making a slightly larger incision in the palm but not crossing the wrist crease. The decision to undergo this procedure, either endoscopically or open, is best made after discussion between the patient and the surgeon. The patient can expect fairly rapid resolution of the symptoms; although, literature has indicated that recovery can occur for up to 14 months following the surgery. It is felt that complete relief of symptoms and return to normal activities can be expected in greater than 90% of the patients.