Carpal Tunnel Syndrome (CTS) occurs when the median nerve that supplies feeling to most of the hand becomes compressed or entrapped as it passes through the carpal tunnel of the wrist. The carpal tunnel consists of eight carpal bones in the wrist, which form a concave arch, and a carpal ligament attached to either side of the arch. Through the arch pass tendons (flexor tendons of the forearm), the median nerve, and other neural and vascular structures of the wrist.

The pressure in the tunnel occurs when one performs fast repetitive motions for a long time, or from constant pressure on the wrist in an unnatural position, such as in extensive bicycling. The injury may also result from a fall on the extended wrist such as can occur in football or other sports.

CTS is one of the most common nerve injuries. Due to increased media attention and resultant public awareness, many new cases are being reported. If CTS is recognized early and treated appropriately, excellent results generally may be expected, but if left untreated CTS can cause irreversible damage.

The most common symptoms of CTS are numbness and tingling in the hand, thumb, index finger, middle finger, and lower portion of the ring finger. In the early stages, it occurs in only one finger. The individual commonly awakens with a feeling of tingling numbness and a sensation of the hand being swollen. In order to rid oneself of the strange feeling one will have the desire to shake and massage the wrist or exercise the hand. Sometimes after only a short period of persistent compression, the thumb and index finger can weaken and simple tasks such as buttoning clothes and winding a watch may become difficult. The hands become less coordinated.

CTS is more common in: people over the age of forty, people who perform a lot of manual labor; pregnant women (due to the fluid imbalance); women using birth control pills (estrogen and progestin-steroidal); diabetics and alcoholics; women than in men (by a two-to-one ratio).

CTS is relatively easy to diagnose with one or more of the following tests.

Provocative Tests:

Phalen's Maneuver—The sports medicine specialist will place your elbow on a tabletop with your arm and hand in an upright position. You will be asked to flex your hand at the wrist and hold it in that position for about one minute. If this test causes your symptoms to appear, it indicates CTS.

Tinel' s Test—The doctor may tap lightly on your wrist with a percussion hammer over the median nerve. If the tapping makes your fingers tingle, carpal tunnel syndrome could be the diagnosis.

Motor Testing—If the condition is severe the specialist will investigate the degree of atrophy and strength. The healthy athlete should be able to resist the muscle-testing maneuvers used to determine the strength of the intrinsic muscles of the hand. The specialist will then grade their strength through a grip indicator.

Electrophysiological tests—This is a set of tests that determine the velocity of nerve transition. Decreased nerve velocity points towards sensory nerve damage.

Nerve Conduction Velocity Tests—These measure the nerve's ability to send electrical impulses. They can be uncomfortable, but are used, due to a 90 percent accuracy rate.

Diabetes and alcoholism resulting in a deficiency of B-6 can aggravate CTS. Many daily activities or motions will also aggravate the symptoms of CTS, including:

1. Repetitive wrist flexing and extension: manual labor or poor sports techniques in tennis, ping-pong, frisbee, weight-lifting, etc.

2. Forceful squeezing and releasing of work tool, strength training apparatus, or sports equipment.

3. Weight-bearing with the wrist flexed for long duration, such as stationary bicycle workouts, tennis or gymnastics; improper techniques used when lifting such as not keeping wrists straight.

4. You should examine all your equipment to ensure that it does not put the wrist and hand in an awkward position.

Treatment

Conservative Methods

Chiropractors look to the carpal arch for the cause of the new root compression. They contend that abnormal biomechanics and the partial dislocation of one or more of the carpal bones can lead to the swelling and compression of the carpal arch. Motion palpitation of the carpal joints, and the radial and ulnar articulations is necessary to determine and correct any abnormal joint motion or partial dislocation. Either of these joints would have to have its biomechanics restored through peripheral manipulative techniques that would realign the carpal arch. Chiropractors typically will also use a series of therapeutic techniques described below.

The American Physical Therapy Association published some helpful stretching exercises to help reduce the chances of developing CTS. These can be supplemented by individual exercises, depending on the particular case.

According to a survey of the American Society for Surgery of the Hand, a majority of patients with CTS are treated conservatively before having surgery. Other methods of treating CTS include:

• eliminating, decreasing, or interrupting with frequent breaks, the activity that causes the problem

• pyridoxine or vitamin B-6 supplementation;

• splinting with a brace in a neutral position or at fifteen degrees of extension. (Extended use of the brace can cause atrophy of the supportive muscles of the area);

• cortisone injections (these are not considered effective in the long run by themselves and can cause side effects);

• anti-inflammatory agents (aspirin, ibuprofen);

• ice, ultrasound, or other methods.

Surgical Methods

Traditional surgical techniques involve making a 4-centimeter incision in the wrist to locate the transverse carpal ligament. After locating the ligament, the surgeon will divide it to release the pressure on the tunnel. Compression dressings and a splint are applied at the surgeon's discretion. It can take from a few weeks to several months for the incision to heal fully enough that normal activities can be resumed. Disadvantages of this procedure are a long recovery time and scarring. Advantages include a high percentage of successful cases.

Endoscopic Release

The newest technique of surgery of the carpal tunnel is endoscopic surgical release. The surgeon creates small incisions in the forearm where two tiny scopes (video cameras) are inserted. The important structures are located and marked, including the transverse carpal ligament, which must be divided. A small hook-knife is inserted into the opening and is drawn under and past the ligament, then drawn towards the ligament to divide it. The patient usually can return to normal activities within days, leaving only small incisions to heal. The rehabilitative exercises can begin quickly, with the full range of motion, and complications and scarring are limited.

Prevention of carpal tunnel syndrome lies in correct biomechanical motion of the wrist and hand. If you feel you or someone you know may have CTS, remember that treatment is more successful with early detection and intervention.

About the Author

Ms. Novak is a certified swim coach and athletic trainer for various South Chicago teams. She is aquatics coordinator for the Oak Lawn Park District and Illinois Park and Recreation Association.