What is Carpal Tunnel Syndrome?
About the width of your thumb, the carpal tunnel is a narrow channel on the palm side of your wrist. The tunnel protects the median nerve and the tendons that bend your fingers. Pressure on the nerve can cause pain and weakness in your wrist and hand and numbness or tingling in some of your fingers. This pressure is caused by crowding or irritation of the median nerve in the carpal tunnel and can lead to CTS.
Extreme wrist positions, as well as a lot of finger use, especially with a lot of force or vibration (such as holding the steering wheel when driving heavy machinery), can all contribute to CTS.
CTS is common in professions such as assembly-line work, particularly meat packing; and jobs requiring the use of hand tools, especially tools that vibrate. Although excessive keyboard and computer use is often associated with CTS, those performing assembly line work are 3 times more likely to develop CTS than those who perform data entry work. Some leisure activities can also create CTS, such as sewing, sports such as racquetball and handball, and playing string instruments such as the violin.
The following health conditions can also lead to CTS in some individuals:
- Inflammation and swelling of the tendons of the wrist
- Injuries to the wrist (strain, sprain, dislocation, fracture)
- Hormone or metabolic changes (pregnancy, menopause, thyroid imbalance)
- Fluid retention (eg, during pregnancy)
- Certain medicine use (eg, steroids)
- Degenerative and rheumatoid arthritis
How Can Physical Therapy Help?
After the evaluation, your physical therapist will prescribe your treatment plan based on your specific case.
If your evaluation confirms early-stage CTS, conservative care will be recommended as a first step. Physical therapy treatment can be effective in reducing your symptoms and getting you back to performing normal activities. During your first visit with the physical therapist, be prepared to describe your symptoms in as much detail as possible, and say what makes your symptoms worse.
Depending upon the causes of your CTS, your therapy program may include:
- Education regarding:
- changing wrist positions (ie, avoiding prolonged bent wrist positions)
- proper neck and upper back posture (ie, avoiding forward head or slouching)
- safe use of sharp utensils, tools, or other implements, if sensory changes are identified
- “stretch breaks” during your work or daily routine
- Exercises to increase the strength of the muscles in your hand, fingers, and forearm—and in some cases, the trunk and postural back muscles
- Stretching exercises to improve the flexibility of the wrist, hand, and fingers
- Use of heat/cold treatments to relieve pain
- Use of a night splint to reduce discomfort
- A worksite visit to assess your work area. For example, if you sit at a desk and work on a computer, it’s important for the keyboard to be in proper alignment to help avoid working in a bent wrist position.
- Increasing the size of tool and utensil handles by adding extra material for a more comfortable grip
- Anti-vibration gloves or anti-vibration wraps around tool handles, if vibration is a factor at your workplace
Your physical therapist will also consider your home and leisure activities, with recommendations such as wearing gloves to keep the wrist/hands warm and limiting sports that aggravate the condition, such as racquet sports, until symptoms resolve.
The goals of physical therapy are to reduce your symptoms without the need for surgery, to enable you to be as active and functional as possible, and to help you resume your normal work, home, and leisure activities.
Signs and Symptoms
CTS usually starts gradually, with symptoms such as burning, tingling, “pins and needles,” or numbness in the palm of the hand and fingers. Often the symptoms are more noticeable during the night, and individuals often report being wakened with symptoms. Many people feel the need to “shake out” their hands to try to relieve the symptoms.
As the condition progresses, the symptoms are noticed during the daytime and are often worse when holding items such as a heavy book or a hairbrush. Weakness of the hand and more constant numbness may occur if the pressure on the nerve continues. You may find that you drop objects unexpectedly or have a weakness in your grip.
How Is It Diagnosed?
Physical therapists work closely with other health care professionals to accurately diagnose and treat CTS. Symptoms of CTS are typical, and it is often possible to diagnose it without extensive testing. Physical therapists are experts in the movement and function of the body and will conduct an evaluation to determine all of the factors that may be contributing to your condition.
These are several tests that may be used to help diagnose CTS:
- Examination of your neck and entire upper extremity to rule out other conditions. Many patients have been told they have CTS, only to find out that the pain is coming from another body area.
- Grip strength of fingers and thumb
- Sensory tests
- Wrist and hand range-of-motion
- Wrist flexion (Phalen) test: Your physical therapist will have you push the backs of your hands together for 1 minute. Tingling or numbness in your fingers that occurs within 60 seconds may be an indication of CTS.
- Tinel’s Sign: Your physical therapist will use a reflex hammer or finger to tap over the median nerve at your wrist. Tingling in the thumb and index and middle fingers may indicate CTS.
- Electrical studies (electromyogram/EMG) and nerve conduction velocity (NCV): These tests determine the transmission of the nerve and the severity of the CTS.
- X-rays: When trauma has occurred or if there is reason to suspect anatomical abnormality, x-rays may be ordered.
In some cases, your physical therapist may refer you to a physician or other health care professional for additional testing or treatment.
Can this Injury or Condition be Prevented?
There are no proven strategies for preventing CTS, but there are ways to minimize stress to your hands and wrists. Since there are contributing factors to developing CTS, one single solution may not be effective.
The following strategies are effective ways to minimize stress to your hands and wrists:
- Reduce force. Most people use more force than needed when performing work with their hands. Relax your grip to avoid muscle fatigue and strain. For prolonged handwriting, use a larger-handle pen or soft gel grip.
- Take frequent breaks. When doing repeated activities, give your hands a break by performing stretching exercises once in a while. If possible, alternate your hands when completing some tasks.
- Neutral wrist position. Avoid bending your wrists by keeping them in a straight or “neutral” position. This means your wrist should not be bent up (extended) or down (flexed).
- Work area adjustment. Have a physical therapist examine your work area to make sure it fits your height, posture, and the tasks required. Simple adjustments can help avoid unnecessary strain.
- Improve your posture. Make sure your posture is appropriate to the task you are performing. Believe it or not, proper alignment of your trunk, neck, and shoulders can prevent excessive strain and improper positioning of the wrists and hands.
- Keep your hands warm. You are more likely to develop hand pain and stiffness if you work in a cold environment. If you can’t control the temperature, be sure to wear gloves to keep your hands and wrists warm.
- Maintain good health. Paying attention to your general health is an important step in preventing CTS. Staying physically fit and maintaining a healthy weight may help control diseases and conditions that may contribute to the onset of CTS.
Patients with CTS experience numbness, tingling, or burning sensations in the thumb and fingers, in particular the index, middle fingers, and radial half of the ring fingers, which are innervated by the median nerve. Less-specific symptoms may include pain in the wrists or hands and loss of grip strength (both of which are more characteristic of painful conditions such as arthritis).
Some posit that median nerve symptoms can arise from compression at the level of the thoracic outlet or the area where the median nerve passes between the two heads of the pronator teres in the forearm., but this is highly debatable. This line of thinking is an attempt to explain pain and other symptoms not characteristic of carpal tunnel syndrome.Carpal tunnel syndrome is a common diagnosis with an objective, reliable, verifiable pathophysiology, whereas thoracic outlet syndrome and pronator syndrome are defined by a lack of verifiable pathophysiology and are usually applied in the context of nonspecific upper extremity pain.
Numbness and paresthesias in the median nerve distribution are the hallmark neuropathic symptoms (NS) of carpal tunnel entrapment syndrome. Weakness and atrophy of the thenar muscles may occur if the condition remains untreated.
Most cases of CTS are of unknown causes, or idiopathic. Carpal Tunnel Syndrome can be associated with any condition that causes pressure on the median nerve at the wrist. Some common conditions that can lead to CTS include obesity, oral contraceptives, hypothyroidism, arthritis, diabetes, and trauma. Carpal tunnel is also a feature of a form of Charcot-Marie-Tooth syndrome type 1 called hereditary neuropathy with liability to pressure palsies.
Other causes of this condition include intrinsic factors that exert pressure within the tunnel, and extrinsic factors (pressure exerted from outside the tunnel), which include benign tumors such as lipomas, ganglion, and vascular malformation.Carpal tunnel syndrome often is a symptom of transthyretin amyloidosis-associated polyneuropathy and prior carpal tunnel syndrome surgery is very common in individuals who later present with transthyretin amyloid-associated cardiomyopathy, suggesting that transthyretin amyloid deposition may cause carpal tunnel syndrome.
Physical Therapy Following Surgery
If the evaluation reveals that your CTS is more severe, or if your symptoms persist, your physical therapist may refer you to a physician for a surgical consultation. If necessary, surgery will be performed to release the band of tissue that is causing pressure on the median nerve. Physical therapy treatment is important after surgery to help restore strength to the wrist and to learn to modify habits that may have led to symptoms in the first place. Your physical therapy treatment may include:
- Exercises to improve the strength of the wrist/hand muscles and improve function
- Stretching to improve mobility of the wrist/fingers and improve function
- Scar management to keep the skin supple and flexible
- Education regarding appropriate posture and wrist position to avoid carpal tunnel compression in home/leisure activities
- A worksite visit or simulation to optimize postures and positions
Carpal tunnel syndrome (CTS) is a common condition of the wrist and hand that can affect the use of the whole arm. It is caused by pressure on the nerve at the base of the palm (median nerve). Because of the demands that people place on their hands and wrists, CTS is a common condition affecting 1 out of 20 Americans. Surgery for this condition is commonly performed on the wrist and hand. Fortunately for most people who develop CTS, physical therapy treatment can often relieve pain and numbness and restore normal use of the hand, wrist, and arm without the need for surgery.