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Carpal Tunnel Syndrome
Wikipedia
Carpal Tunnel Syndrome (CTS) or median neuropathy at the wrist is a medical condition in which the
median nerve is compressed at the wrist, leading to pain, paresthesias, and muscle weakness in the forearm
and hand. A form of compressive neuropathy, CTS is more common in women than it is in men and has a
peak incidence around age 42, though it can occur at any age. The lifetime risk for CTS is around 10% of
the adult population.
Most cases of CTS are idiopathic (without known cause). Repetitive activities are often blamed for the
development of CTS along with several other possible causes. However, the correlation is often unclear.
It is a multi-faceted problem and can therefore be challenging to treat. Still, there are a multitude of possible
treatments: treating any possible underlying disease or condition, immobilizing braces, prioritizing hand
activities, and ergonomics. Recent studies have shown that medications have not been able to modify the
extent of the disease. Ultimately, carpal tunnel release surgery may be required in which outcomes are
generally good.
The condition was first noted in medical literature in the early 20th century.
History
Although the condition was first noted in medical literature in the early 20th century, the first use of the term
“carpal tunnel syndrome” was in 1938. The pathology was identified by physician Dr. George S. Phalen of
the Cleveland Clinic after working with a group of patients in the 1950s and 1960s. CTS became widely
known among the general public in the 1990s because of the rapid expansion of office jobs.
Anatomy
Main article: Carpal tunnel
The median nerve passes through the carpal tunnel, a canal in the wrist that is surrounded by bone on three
sides, and a transverse carpal ligament on the fourth. Nine tendons—the flexor tendons of the hand—pass
through this canal. The median nerve can be compressed by a decrease in the size of the canal, an increase
in the size of the contents (such as the swelling of lubrication tissue around the flexor tendons), or both.
Simply bending the wrist at 90 degrees will decrease the size of the canal. Although this condition is often
painful, it can improve over time with repeated, daily, self-managed physical therapy.
Symptoms
Many people that have carpal tunnel syndrome have gradually increasing symptoms over time. The first
symptoms of CTS may appear when sleeping and typically include numbness and paresthesia (a burning
and tingling sensation) in the fingers, especially the thumb, index, and middle fingers. These symptoms
appear at night because many people sleep with bent wrists which further compresses the carpal tunnel. If
the median nerve is already under stress, the increased compression of the bent wrist results in numbness
and tingling. Difficulty gripping and making a fist, dropping objects, and weakness are symptoms of
progression. In early stages of CTS individuals often mistakenly blame the tingling and numbness on
restricted blood circulation and they believe their hands are simply “falling asleep”. In chronic cases, there
may be wasting of the thenar muscles (the body of muscles which are connected to the thumb)
Unless numbness or paresthesia are among the predominant symptoms, it is unlikely the symptoms are
primarily caused by carpal tunnel syndrome. In effect, pain of any type, location, or severity with the absence
of significant numbness or paresthesia is not likely to fall under this diagnosis.
Causes
Most cases of CTS are idiopathic: without a known cause.[5] A common factor in developing carpal tunnel
symptoms is increased hand use or activity. While repetitive activities are often blamed for the development
of CTS, the correlation is often unclear. Physiology and family history may have a significant role in
individual's susceptibility. Furthermore, stress, trauma and several other diseases are also possible causes
of CTS.
Work related
The international debate regarding the relationship between CTS and repetitive motion and work is ongoing.
The Occupational Safety and Health Administration (OSHA) has adopted rules and regulations regarding
cumulative trauma disorders. Occupational risk factors of repetitive tasks, force, posture, and vibration have
been cited. However, the American Society for Surgery of the Hand (ASSH) has issued a statement that the
current literature does not support a causal relationship between specific work activities and the development
of diseases such as CTS.
The relationship between work and CTS is controversial; in many locations workers injured at work are
entitled to time off and compensation. Many cases of carpal tunnel syndrome are provoked by repetitive
grasping and manipulating activities, and the exposure can be cumulative. Symptoms are commonly
exacerbated by forceful and repetitive use of the hand and wrists in industrial occupations. Carpal tunnel
syndrome results in billions of dollars of workers compensation claims every year.[citation needed]
Studies done by the National Institute for Occupational Safety and Health (NIOSH), indicated that job tasks
involving highly repetitive manual acts or necessitating wrist bending or other stressful wrist postures were
connected with incidents of CTS or related problems. However, it appears that the 30+ studies reviewed were
concerned with the occupations of assembly line workers, meat packers, food processors, and the like, not
general office work.
In addition, a 2005 study found that people who have discomfort at the base of the neck or in the shoulder or
work with their shoulder in elevation (indicators of poor working postures) are more likely to develop a
repetitive overuse injury. These factors can affect the biomechanics of the upper limb or tissue tolerance to
repetitive tasks resulting in injury, or both. Postural and spinal assessment along with ergonomic
assessments should be included in the overall determination of the condition. Addressing these factors has
been found to improve the status of work related upper limb injuries.
Hypothyroidism, osteoarthritis and diabetes were most often associated with CTS-like symptoms, as were
variables such as age, obesity and wrist dimension. In a 1998 study, only 35 of 297 subjects were aware of
the underlying health condition which could account for their CTS-like symptoms. Hence, these causes
would be missed by doctors if they were relying on a patient's health history to rule out other causative
factors. It is important that a doctor rule out other causes of CTS-like symptoms. If a patient does not have
CTS, corrective surgery is destined to fail.
Stress related
Studies have also related carpal tunnel and other upper extremity complaints with psychological and social
factors. A large amount of psychological distress showed doubled risk of the report of pain, while job
demands, poor support from colleagues, and work dissatisfaction also showed an increase in the report of
pain, even after short term exposure. A minority viewpoint holds that stress is the main cause, rather than a
contributing factor, of a large fraction of pain symptoms usually attributed to carpal tunnel syndrome.
Trauma related
Fractures of one of the arm bones, particularly a Colles' fracture.
Dislocation of one of the carpal bones of the wrist.
Strong blunt trauma to the wrist or lower forearm, incurred for example by using arm extremity to cushion a
fall or protecting oneself from falling heavy objects.
Hematoma forming inside the wrist, because of internal hemorrhaging.
Deformities from abnormal healing of old bone fractures.
Non-traumatic
Non-traumatic causes generally happen over a period of time, and are not triggered by one certain event.
Many of these factors are manifestations of physiologic aging. Examples include:
Inflammation of the thin mucinous membrane around the tendons. Part of the process of inflammation is
swelling, and this compresses the nerve. Swelling of this membrane is the final common pathway for most
cases of carpal tunnel, whether caused idiopathically, through exposure, or medically.
With pregnancy and hypothyroidism, fluid is retained in tissues, which swells the tenosynovium.
Acromegaly, a disorder of growth hormones, compresses the nerve by the abnormal growth of bones around
the hand and wrist.
Tumors (usually benign), such as a ganglion or a lipoma, can protrude into the carpal tunnel, reducing the
amount of space. This is exceedingly rare (less than 1%).
Double crush syndrome, where there is compression or irritation of nerve branches contributing to the
median nerve in the neck or anywhere above the wrist. This then increases the sensitivity of the nerve to
compression in the wrist. This, while a possible factor, is also a rare contributor in most cases.
Idiopathic causes are common.
Common activities that have been identified as contributing to repetitive stress induced carpal tunnel
syndrome include:
Use of power tools
Typing on a computer keyboard or typewriter
Construction work such as handling many bricks, stone and/or lumber
Excessive play of percussion instruments (especially piano) and stringed instruments
Often people suffering from carpal tunnel syndrome can have multiple contributing factors which are
aggravated by vigorous hand activities and repetitive stress trauma to the hand.
Proper attention to ergonomic considerations can reduce or eliminate these kinds of exposures.
While carpal tunnel syndrome is often called a "repetitive strain injury" (RSI) or "cumulative trauma disorder"
(CTD), these labels are discouraged by physicians, particularly hand specialists. Carpal tunnel is a specific
condition with specific symptoms that responds fairly reliably. Most of the time, carpal tunnel is not caused by
a "strain" or "trauma" of any type. RSI and CTD are relatively non-specific terms with non-specific symptoms
that respond variably to treatment.[citation needed]
Diagnosis
Clinical assessment by history taking and physical examination can frequently diagnose CTS.
Phalen's maneuver is performed by flexing the wrist gently as far as possible, then holding this position and
awaiting symptoms. A positive test is one that results in numbness in the median nerve distribution when
holding the wrist in acute flexion position within 60 seconds. The quicker the numbness starts, the more
advanced the condition.
Tinel's sign, a classic, though less specific test, is a way to detect irritated nerves. Tinel's is performed by
lightly tapping (percussing) the area over the nerve to elicit a sensation of tingling or "pins and needles" in
the nerve distribution.
Durkan test, carpal compression test, or applying firm pressure of the palm over the nerve for up to 30
seconds to elicit symptoms has also been proposed.
Other conditions may also be misdiagnosed as carpal tunnel syndrome. Thus, if, based on history and
physical examination, a CTS diagnosis is suspected but not clear, patients will likely be tested
electrodiagnostically with nerve conduction studies and electromyography; MRI or ultrasound imaging are
also used.
Prevention
The most effective way to prevent carpal tunnel syndrome is to take frequent breaks from repetitive
movement such as computer keyboard usage or use of browser based games that encourage the user for
excessive finger movement . Free software programs such as Workrave and Xwrits are available to remind
users to take breaks and stretch their wrists. There are also other ways to prevent Carpal Tunnel Syndrome
such as reduce your force and relax your grip. Most people use more force than needed to perform many
tasks involving the hands. If your work involves a cash register, for instance, hit the keys softly. For
prolonged handwriting, use a big pen with an oversized, soft grip adapter and free-flowing ink. This way you
won't have to grip the pen tightly or press as hard on the paper. Take frequent breaks. Every 15 to 20
minutes give your hands and wrists a break by gently stretching and bending them. Alternate tasks when
possible. If you use equipment that vibrates or that requires you to exert a great amount of force, taking
breaks is even more important. Watch your form. Avoid bending your wrist all the way up or down. A relaxed
middle position is best. If you use a keyboard, keep it at elbow height or slightly lower. Improve your posture.
Incorrect posture can cause your shoulders to roll forward. When your shoulders are in this position, your
neck and shoulder muscles are shortened, compressing nerves in your neck. This can affect your wrists,
fingers and hands. Keep your hands warm. You're more likely to develop hand pain and stiffness if you work
in a cold environment. If you can't control the temperature at work, put on fingerless gloves that keep your
hands and wrists warm.
Wikipedia
Carpal Tunnel Syndrome (CTS) or median neuropathy at the wrist is a medical condition in which the
median nerve is compressed at the wrist, leading to pain, paresthesias, and muscle weakness in the forearm
and hand. A form of compressive neuropathy, CTS is more common in women than it is in men and has a
peak incidence around age 42, though it can occur at any age. The lifetime risk for CTS is around 10% of
the adult population.
Most cases of CTS are idiopathic (without known cause). Repetitive activities are often blamed for the
development of CTS along with several other possible causes. However, the correlation is often unclear.
It is a multi-faceted problem and can therefore be challenging to treat. Still, there are a multitude of possible
treatments: treating any possible underlying disease or condition, immobilizing braces, prioritizing hand
activities, and ergonomics. Recent studies have shown that medications have not been able to modify the
extent of the disease. Ultimately, carpal tunnel release surgery may be required in which outcomes are
generally good.
The condition was first noted in medical literature in the early 20th century.
History
Although the condition was first noted in medical literature in the early 20th century, the first use of the term
“carpal tunnel syndrome” was in 1938. The pathology was identified by physician Dr. George S. Phalen of
the Cleveland Clinic after working with a group of patients in the 1950s and 1960s. CTS became widely
known among the general public in the 1990s because of the rapid expansion of office jobs.
Anatomy
Main article: Carpal tunnel
The median nerve passes through the carpal tunnel, a canal in the wrist that is surrounded by bone on three
sides, and a transverse carpal ligament on the fourth. Nine tendons—the flexor tendons of the hand—pass
through this canal. The median nerve can be compressed by a decrease in the size of the canal, an increase
in the size of the contents (such as the swelling of lubrication tissue around the flexor tendons), or both.
Simply bending the wrist at 90 degrees will decrease the size of the canal. Although this condition is often
painful, it can improve over time with repeated, daily, self-managed physical therapy.
Symptoms
Many people that have carpal tunnel syndrome have gradually increasing symptoms over time. The first
symptoms of CTS may appear when sleeping and typically include numbness and paresthesia (a burning
and tingling sensation) in the fingers, especially the thumb, index, and middle fingers. These symptoms
appear at night because many people sleep with bent wrists which further compresses the carpal tunnel. If
the median nerve is already under stress, the increased compression of the bent wrist results in numbness
and tingling. Difficulty gripping and making a fist, dropping objects, and weakness are symptoms of
progression. In early stages of CTS individuals often mistakenly blame the tingling and numbness on
restricted blood circulation and they believe their hands are simply “falling asleep”. In chronic cases, there
may be wasting of the thenar muscles (the body of muscles which are connected to the thumb)
Unless numbness or paresthesia are among the predominant symptoms, it is unlikely the symptoms are
primarily caused by carpal tunnel syndrome. In effect, pain of any type, location, or severity with the absence
of significant numbness or paresthesia is not likely to fall under this diagnosis.
Causes
Most cases of CTS are idiopathic: without a known cause.[5] A common factor in developing carpal tunnel
symptoms is increased hand use or activity. While repetitive activities are often blamed for the development
of CTS, the correlation is often unclear. Physiology and family history may have a significant role in
individual's susceptibility. Furthermore, stress, trauma and several other diseases are also possible causes
of CTS.
Work related
The international debate regarding the relationship between CTS and repetitive motion and work is ongoing.
The Occupational Safety and Health Administration (OSHA) has adopted rules and regulations regarding
cumulative trauma disorders. Occupational risk factors of repetitive tasks, force, posture, and vibration have
been cited. However, the American Society for Surgery of the Hand (ASSH) has issued a statement that the
current literature does not support a causal relationship between specific work activities and the development
of diseases such as CTS.
The relationship between work and CTS is controversial; in many locations workers injured at work are
entitled to time off and compensation. Many cases of carpal tunnel syndrome are provoked by repetitive
grasping and manipulating activities, and the exposure can be cumulative. Symptoms are commonly
exacerbated by forceful and repetitive use of the hand and wrists in industrial occupations. Carpal tunnel
syndrome results in billions of dollars of workers compensation claims every year.[citation needed]
Studies done by the National Institute for Occupational Safety and Health (NIOSH), indicated that job tasks
involving highly repetitive manual acts or necessitating wrist bending or other stressful wrist postures were
connected with incidents of CTS or related problems. However, it appears that the 30+ studies reviewed were
concerned with the occupations of assembly line workers, meat packers, food processors, and the like, not
general office work.
In addition, a 2005 study found that people who have discomfort at the base of the neck or in the shoulder or
work with their shoulder in elevation (indicators of poor working postures) are more likely to develop a
repetitive overuse injury. These factors can affect the biomechanics of the upper limb or tissue tolerance to
repetitive tasks resulting in injury, or both. Postural and spinal assessment along with ergonomic
assessments should be included in the overall determination of the condition. Addressing these factors has
been found to improve the status of work related upper limb injuries.
Hypothyroidism, osteoarthritis and diabetes were most often associated with CTS-like symptoms, as were
variables such as age, obesity and wrist dimension. In a 1998 study, only 35 of 297 subjects were aware of
the underlying health condition which could account for their CTS-like symptoms. Hence, these causes
would be missed by doctors if they were relying on a patient's health history to rule out other causative
factors. It is important that a doctor rule out other causes of CTS-like symptoms. If a patient does not have
CTS, corrective surgery is destined to fail.
Stress related
Studies have also related carpal tunnel and other upper extremity complaints with psychological and social
factors. A large amount of psychological distress showed doubled risk of the report of pain, while job
demands, poor support from colleagues, and work dissatisfaction also showed an increase in the report of
pain, even after short term exposure. A minority viewpoint holds that stress is the main cause, rather than a
contributing factor, of a large fraction of pain symptoms usually attributed to carpal tunnel syndrome.
Trauma related
Fractures of one of the arm bones, particularly a Colles' fracture.
Dislocation of one of the carpal bones of the wrist.
Strong blunt trauma to the wrist or lower forearm, incurred for example by using arm extremity to cushion a
fall or protecting oneself from falling heavy objects.
Hematoma forming inside the wrist, because of internal hemorrhaging.
Deformities from abnormal healing of old bone fractures.
Non-traumatic
Non-traumatic causes generally happen over a period of time, and are not triggered by one certain event.
Many of these factors are manifestations of physiologic aging. Examples include:
Inflammation of the thin mucinous membrane around the tendons. Part of the process of inflammation is
swelling, and this compresses the nerve. Swelling of this membrane is the final common pathway for most
cases of carpal tunnel, whether caused idiopathically, through exposure, or medically.
With pregnancy and hypothyroidism, fluid is retained in tissues, which swells the tenosynovium.
Acromegaly, a disorder of growth hormones, compresses the nerve by the abnormal growth of bones around
the hand and wrist.
Tumors (usually benign), such as a ganglion or a lipoma, can protrude into the carpal tunnel, reducing the
amount of space. This is exceedingly rare (less than 1%).
Double crush syndrome, where there is compression or irritation of nerve branches contributing to the
median nerve in the neck or anywhere above the wrist. This then increases the sensitivity of the nerve to
compression in the wrist. This, while a possible factor, is also a rare contributor in most cases.
Idiopathic causes are common.
Common activities that have been identified as contributing to repetitive stress induced carpal tunnel
syndrome include:
Use of power tools
Typing on a computer keyboard or typewriter
Construction work such as handling many bricks, stone and/or lumber
Excessive play of percussion instruments (especially piano) and stringed instruments
Often people suffering from carpal tunnel syndrome can have multiple contributing factors which are
aggravated by vigorous hand activities and repetitive stress trauma to the hand.
Proper attention to ergonomic considerations can reduce or eliminate these kinds of exposures.
While carpal tunnel syndrome is often called a "repetitive strain injury" (RSI) or "cumulative trauma disorder"
(CTD), these labels are discouraged by physicians, particularly hand specialists. Carpal tunnel is a specific
condition with specific symptoms that responds fairly reliably. Most of the time, carpal tunnel is not caused by
a "strain" or "trauma" of any type. RSI and CTD are relatively non-specific terms with non-specific symptoms
that respond variably to treatment.[citation needed]
Diagnosis
Clinical assessment by history taking and physical examination can frequently diagnose CTS.
Phalen's maneuver is performed by flexing the wrist gently as far as possible, then holding this position and
awaiting symptoms. A positive test is one that results in numbness in the median nerve distribution when
holding the wrist in acute flexion position within 60 seconds. The quicker the numbness starts, the more
advanced the condition.
Tinel's sign, a classic, though less specific test, is a way to detect irritated nerves. Tinel's is performed by
lightly tapping (percussing) the area over the nerve to elicit a sensation of tingling or "pins and needles" in
the nerve distribution.
Durkan test, carpal compression test, or applying firm pressure of the palm over the nerve for up to 30
seconds to elicit symptoms has also been proposed.
Other conditions may also be misdiagnosed as carpal tunnel syndrome. Thus, if, based on history and
physical examination, a CTS diagnosis is suspected but not clear, patients will likely be tested
electrodiagnostically with nerve conduction studies and electromyography; MRI or ultrasound imaging are
also used.
Prevention
The most effective way to prevent carpal tunnel syndrome is to take frequent breaks from repetitive
movement such as computer keyboard usage or use of browser based games that encourage the user for
excessive finger movement . Free software programs such as Workrave and Xwrits are available to remind
users to take breaks and stretch their wrists. There are also other ways to prevent Carpal Tunnel Syndrome
such as reduce your force and relax your grip. Most people use more force than needed to perform many
tasks involving the hands. If your work involves a cash register, for instance, hit the keys softly. For
prolonged handwriting, use a big pen with an oversized, soft grip adapter and free-flowing ink. This way you
won't have to grip the pen tightly or press as hard on the paper. Take frequent breaks. Every 15 to 20
minutes give your hands and wrists a break by gently stretching and bending them. Alternate tasks when
possible. If you use equipment that vibrates or that requires you to exert a great amount of force, taking
breaks is even more important. Watch your form. Avoid bending your wrist all the way up or down. A relaxed
middle position is best. If you use a keyboard, keep it at elbow height or slightly lower. Improve your posture.
Incorrect posture can cause your shoulders to roll forward. When your shoulders are in this position, your
neck and shoulder muscles are shortened, compressing nerves in your neck. This can affect your wrists,
fingers and hands. Keep your hands warm. You're more likely to develop hand pain and stiffness if you work
in a cold environment. If you can't control the temperature at work, put on fingerless gloves that keep your
hands and wrists warm.
Call 512-219-8999
Texas Spine And Sports Therapy Center PLLC
1500 West 38th Street, Suite 38
Austin, Texas 78731
Texas Spine And Sports Therapy Center PLLC
1500 West 38th Street, Suite 38
Austin, Texas 78731
Texas Spine And Sports Therapy Center PLLC
Dr. B. Atencio D.C
1500 West 38th Street, Suite 38 (Shoal Creek Professional Building)
Austin, Texas 78731
512-219-8999
Dr. B. Atencio D.C
1500 West 38th Street, Suite 38 (Shoal Creek Professional Building)
Austin, Texas 78731
512-219-8999
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