CONDITIONS

What Is Carpal Tunnel Syndrome

Carpal tunnel syndrome, often referred to as just carpal tunnel, is a condition that most typically results in numbness and tingling in the hands. It can range from being a minor inconvenience to a disabling condition, depending on its cause, persistence, and the particular manifestation of the condition in a particular individual.

The carpal tunnel is a narrow passageway bound by ligaments and bones at the base of the hand, which houses the median nerve and tendons that control movement of the fingers. When this tunnel swells due to inflammation or some other factor, the median nerve, which runs from the forearm into the palm of the hand, can become compressed, causing numbness, tingling, pain, and eventually hand weakness. These are the hallmark symptoms of carpal tunnel. The dominant hand is usually affected first and produces the most severe pain.

Various factors can contribute to carpal tunnel, including anatomy of your wrist, underlying conditions or disease, and possibly personal patterns of hand use.

The good news is that, for most people who develop carpal tunnel, proper treatment can very often relieve the tingling and numbness and restore wrist and hand function back to normal.

What Causes Carpal Tunnel Syndrome

Carpal tunnel syndrome typically results from a number of factors that increase pressure on the median nerve and tendons in the carpal tunnel.  Usually, genetic predisposition is a factor in the development of carpal tunnel, but there are a number of contributing factors:

  • Hormonal imbalances—such as hypothyroidism or over activity of the pituitary gland
  • Pregnancy—fluid retention during pregnancy can cause compression of the median nerve
  • Menopause—hormonal shifts can cause fluid retention that can give rise to carpal tunnel
  • Work stress—repeated use of certain tools, especially those that vibrate, along with repeated movements, such as from typing, can impact onset of carpal tunnel
  • Mechanical problems in wrist joint or hand
  • Rheumatoid arthritis—can lead to carpal tunnel
  • Cyst or tumor in carpal tunnel
  • Research is still being done on whether repetitive hand or wrist movements cause carpal tunnel, other disorders like bursitis and tendonitis have been linked to repetitive movements performed, but it’s always a smart idea to stop and stretch periodically throughout the day to alleviate any possible strain.

Risk Factors For Carpal Tunnel Syndrome

A number of factors are associated with the development of carpal tunnel syndrome—while each factor does not cause carpal tunnel, there is increased risk of carpal tunnel associated with each. Among them:

  • Age. Carpal tunnel usually only occurs in adults
  • Sex. Women are three times more likely than men to develop carpal tunnel syndrome, perhaps because the carpal tunnel itself may be smaller in women than in men.
  • Pregnancy. Fluid retention, common during pregnancy, can cause compression of the median nerve. Carpal tunnel brought on by pregnancy usually resolves on its own after birth of baby.
  • Menopause. Hormonal shifts can cause fluid retention that can give rise to carpal tunnel
  • Inflammatory conditions. Illnesses that are characterized by inflammation, such as rheumatoid arthritis, can affect the tendons in your wrist, exerting pressure on your median nerve.
  • Nerve-damaging and/or metabolic disorders. Some chronic illnesses, such as diabetes, increase your risk of nerve damage, including damage to your median nerve.
  • Anatomic factors. A wrist fracture or dislocation that alters the space within the carpal tunnel can create extraneous pressure on the median nerve. As well, those with smaller carpal tunnels are at greater risk.
  • Workplace factors. It’s possible that working with vibrating tools or on an assembly line that requires prolonged or repetitive flexing of the wrist may create harmful pressure on the median nerve or worsen existing nerve damage. As well, carpal is very common among those in the following industries:
    • Manufacturing
    • Sewing
    • Cleaning
    • Assembly-line work
    • Meat, poultry, or fish packing
  • Other medical conditions. Certain conditions, such as obesity, thyroid disorders, and kidney failure may increase your chances of carpal tunnel syndrome.

The jury is still out whether extensive computer use and carpal tunnel have a connection—there is, as of yet, not enough quality and consistent evidence to state that this is a definitive risk factor.

Diagnosing Carpal Tunnel Syndrome

Early diagnosis and treatment is key to avoiding permanent damage to the median nerve. The first step is likely a careful review of the history of your symptoms. Your doctor will ask about the pattern of your symptoms. For instance, the median nerve does not provide sensation to the pinky finger, so any symptoms in that finger likely indicate a problem other than carpal tunnel. You will also be asked about the timing of your symptoms, do you feel numbness or tingling at night, or when you grip the handlebar of your bike? This will help your doctor assess the genesis of your symptoms.

Next is a physical exam of the hands, wrists, arms, shoulders, and neck to see if the symptoms are indeed being caused by carpal tunnel or by some other condition that can mimic the effects of carpal tunnel, like thoracic outlet syndrome. Your doctor will look at your medical history, and will work to rule out other possible underlying causes. Your wrist will be looked at for:

  • Tenderness
  • Swelling or edema
  • Warmth
  • Freedom of movement

Your doctor will likely perform a Tinel test—where he or she presses or taps the median nerve to see if they can cause tingling in the fingers. If tingling or shock-like sensations do occur, the test is considered to be positive. Another test—called the Phalen or wrist-flexion test—works by putting pressure on your median nerve to see if symptoms of carpal tunnel syndrome arise. This test is performed by having you hold your forearms upright—fingers pointing down—and with the backs of your hands pressed together. Carpal tunnel syndrome is suggested if one of more of the following symptoms occur within one minute:

  • Tingline
  • Increased numbness
  • Pain

Diagnosis of carpal tunnel syndrome is often confirmed via use of electro-diagnostic test, the most common used to confirm carpal tunnel are:

  • Nerve conduction.  Electrodes are placed on the hand and wrist. Small electric shocks are applied and the speed with which nerves transmit impulses is measured to see if impulses are slowed in the carpal tunnel.
  • Electromyography. Your doctor will insert a fine needle into specific muscles; electrical activity viewed on a screen can determine if muscle damage has occurred as well as possible severity of damage to the median nerve.

Other tests that may be used to confirm carpal tunnel include:

  • Ultrasound imaging. An ultrasound can show abnormal size of the median nerve.
  • X-ray. Your doctor may take x-rays of your hands to check for arthritis, fractures or other possible conditions outside of carpal tunnel syndrome that could be causing symptoms.

Magnetic resonance imaging or MRI is not useful in diagnosis of carpal tunnel syndrome, but scans can show the anatomy of the wrist, which may be useful to rule out other possible causes for the symptoms.

If carpal tunnel syndrome is confirmed, then you will likely be referred to a hand specialist or hand surgeon, or a neurologist that deals specifically with this type of condition.

Symptoms of Carpal Tunnel Syndrome

The symptoms of carpal tunnel syndrome usually begin gradually, and tend to get worse with time.

  • Tingling
  • Numbness in palm of hand and the fingers—specifically the thumb, index and middle fingers
  • A feeling of swelling in the aforementioned parts, even if none is visible
  • Decreased grip strength
  • Difficulty handwriting

Symptoms often manifest in one or both hands during the night, since so many people sleep with flexed wrists, a position that can aggravate the median nerve. A person with carpal tunnel may wake repeatedly throughout the night, feeling like they need to “shake out” their wrists or hands. As symptoms worsen, tingling and increased numbness may be felt throughout the day, and when carpal tunnel syndrome becomes more severe, decreased grip strength may make grasping small objects or even making a fist difficult. In chronic, untreated cases, there can be muscular atrophy and loss of sensation to the fingers.

Prognosis

The prognosis for carpal tunnel syndrome is very good—milder cases often respond to non-surgical care, like bracing, stretching, and steroid injections. More advanced cases of carpal tunnel syndrome can be treated very effectively with surgery.

Living With Carpal Tunnel Syndrome

If you have carpal tunnel syndrome, consider the following tips:

  • Perform stretching exercises
  • Take frequent rest breaks
  • Wear splints at night to keep wrists straight
  • Use correct posture and wrist position when typing
  • Wearing fingerless gloves can help keep hands warm and flexible.
  • Use workstations, tools and tool handles, that encourage the wrist to maintain a natural position during work

Screening

Screening for carpal tunnel syndrome is not regularly done, per se, if symptoms arise, then a physical examination with your doctor, along with possible confirmation via electrodiagnostic tests, and additional confirmation by imaging will be done to see if you have carpal tunnel syndrome.

Prevention

While there are no proven ways to prevent carpal tunnel syndrome, there are ways to minimize stress on your hands and wrists. Here are some of the top precautions you can take:

  • Improve your posture. Poor or incorrect posture can cause shoulders to roll forward, which in turn shortens neck and shoulder muscles, compressing nerves in the neck that feed to your wrists, hands, and fingers.
  •  Be mindful of your form. Keep your wrist in a relaxed middle position—avoid extreme bends either up or down. If using a keyboard, consider an ergonomic one, and keep at elbow height or lower.
  • Take breaks. Often. Gently stretch and bend your hands and fingers throughout the day. If you use equipment that vibrates or requires you to use a lot of force, taking breaks is even more important.
  • Keep your hands warm. Hand pain and stiffness are often exacerbated by the cold—if you need to keep warm try wearing fingerless gloves!
  • Relax your grip. Less really is more—if you have to do prolonged drawing or handwriting, grip your pen or pencil more softly, try using a big pen with a gel soft-grip, and take breaks.
  • Reduce force of motion. We often do things with more force than necessary—if you’re typing, for instance, don’t hit the keys as hard.

Medication And Treatment

Carpal tunnel syndrome should be treated as early as possible to help avoid long-term damage. If underlying causes are causing the carpal tunnel symptoms, they should be treated first.


Initial treatment typically involves:

  • Resting the affected hand and wrist for two weeks or more
  • Avoiding activities that can exacerbate or worsen symptoms
  • Wrist splinting to help avoid further irritation and damage to the median nerve
  • Using ice or cool packs to reduce inflammation and swelling

The next step in treatment is to try non-surgical treatment for symptom alleviation.


Non-surgical treatments

Drugs – Certain medications can ease the pain, swelling, and discomfort associated with carpal tunnel syndrome.

  • Non-steroidal anti-inflammatory drugs. OTC medications like aspirin, ibuprofen, and other nonprescription pain relievers may ease symptoms that have been present for a short time or have been exacerbated by strenuous activity
  • Cortiscosteriods (such as prednisone) can be injected directly into the wrist (by a hand specialist only) or can be taken via pill (like prednisone) to relieve pressure on the median nerve. Corticosteroids decrease inflammation and swelling, which relieves pressure on the median nerve. Oral corticosteroids aren’t considered as effective as corticosteroid injections for treating carpal tunnel syndrome.
  • Lidocaine can also be injected directly into the wrist, and helps relieve pain associated with carpal tunnel syndrome. It also provides immediate, but temporary, relief.
  • Orally administered diuretics (also known as “water pills”) can decrease swelling.
  • Vitamin B6 (pyridoxine) supplements may ease the symptoms of carpal tunnel syndrome.

Wrist splinting – A splint that holds your wrist still while you sleep can help relieve nighttime symptoms of tingling and numbness. Nocturnal splinting may be a good option if you’re pregnant and have carpal tunnel syndrome.

Exercise – Stretching and strengthening exercises can be helpful for those whose symptoms have abated. A physical or occupational therapist, who is trained to use exercises and therapeutic massage to treat physical impairments, can help show you how to do the exercises for maximum benefit.

Yoga has been shown to reduce pain and improve grip strength among patients with carpal tunnel syndrome.


Surgery

Carpal tunnel release is one of the most common surgical procedures in the United States—every year, more than 500,000 people in the United States undergo surgeries for carpal tunnel syndrome. Studies show that 70 – 90% of patients who undergo surgery for carpal tunnel syndrome were free of nighttime pain afterward.

Surgery for carpal tunnel is generally recommended if symptoms persist for 6 months or more. The procedure involves cutting through the ligament that presses down on the carpal tunnel, essentially turning the carpal tunnel into the carpal trench. This reduces pressure on the median nerve. Surgery is done under local anesthesia and does not require an overnight hospital stay. Many patients require bilateral surgery on both hands. The following are types of carpal tunnel release surgery:

Open release surgery. This is the traditional surgical procedure used to correct carpal tunnel syndrome. It consists of making an incision up to 2 inches in the wrist, then cutting the carpal ligament to enlarge the carpal tunnel. The procedure is generally done under local anesthesia on an outpatient basis.

Endoscopic surgery. This is a newer sort of carpal tunnel syndrome surgery, and may allow faster functional recovery and less postoperative discomfort than traditional open release surgery. The surgeon makes two incisions (about ½ inch each)—one in the wrist and one in the palm. The surgeon then inserts a camera attached to a tube that allows him or her to observe the tissue on a screen, and to cut the carpal ligament in a precise manner. Endoscopic surgery, done under local anesthesia like open-release, is effective and minimizes scarring and scar tenderness. Patients report less pain with the endoscopic surgery—likely due to the incision not involving the palm, which is rich in nerve endings. Endoscopic surgery generally allows individuals to resume some normal activities in a short period of time. It may take longer to do the operation, however, and may be more expensive.

While carpal tunnel syndrome symptoms may be relieved immediately after surgery, however full recovery from the surgery may take months. During the healing process after the surgery, the ligament tissues gradually grow back together while allowing more room for the nerve than existed before.

All surgeries carry risks. Risk factors for carpal tunnel syndrome surgeries include infection, nerve damage, stiffness, and pain at the scar. Occasionally the wrist loses strength and other complications from surgery may arise. Patients should undergo physical therapy after surgery to restore wrist strength. Some patients may need to adjust job duties or even change jobs after recovery from surgery.

Recurrence of carpal tunnel syndrome following surgical treatment is rare—with the majority of those undergoing the procedure recovering completely.

Complementary and Alternative Treatment

These treatment modalities have been shown to be very effective for those that suffer from carpal tunnel syndrome:

  • Yoga. Yoga has been shown to both help reduce the pain and improve grip strength of those that have with carpal tunnel syndrome.
  • Hand therapy. Certain physical and occupational hand therapy techniques have been shown to improve symptoms of carpal tunnel syndrome.
  • Chiropractic care. Joint manipulation and movement of wrist and hand, along with stretching and strengthening exercises, along with soft tissue mobilization have been shown to help carpal tunnel symptoms.
  • Ultrasound therapy. High-intensity ultrasound can be used to help alleviate symptoms of carpal tunnel syndrome. It can raise the temperature of a targeted area of body tissue, both reducing pain and promoting healing. A course of ultrasound therapy over several weeks may help symptoms of carpal tunnel syndrome abate

Care Guide

A few simple things can help you get some temporary relief from carpal tunnel syndrome symptoms:

  • Take quick breaks from repetitive activities involving the use of your hands—if riding a bike, take turns shaking or stretching your wrist if you start to feel tingles or numbness.
  • Regularly rotate your wrists and stretch your palms and fingers throughout the day
  • Take a pain reliever, such as aspirin, ibuprofen (Advil, Motrin IB, others) or naproxen (Aleve) if you are feeling discomfort.
  • A very effective treatment can be to wear wrist splints when you sleep—easily available at most drug stores, wrist splints keep your wrists from flexing, an action that can aggravate the median nerve. The splint should be snug but not tight.
  • Avoid sleeping on your hands as this can cause pain or numbness in your wrists and hands—if you find your symptoms are worst at night when you sleep, then try wrist splinting!

If numbness, tingling, or weakness persists, please see your doctor.

When To Contact A Doctor

If you have persistent signs and symptoms that suggest carpal tunnel syndrome, especially if the symptoms interfere with your sleep and/or normal, please go see your doctor. Don’t leave the condition untreated—chronic untreated carpal tunnel syndrome can lead to permanent nerve and muscle damage.