Carpel tunnel syndrome; treatment, causes, symptoms and physiotherapy managment

  In this article you will learn what is carpal tunnel syndromecauses of carpel tunnel syndromesymptoms of carpal tunnel syndrometreatment of carpal tunnel syndrome and its physiotherapy managment. This problem is most common in younger adults who are mostly office workers.


The carpal tunnel is a confined space between the carpal bones dorsally and the transverse carpal ligament (flexor retinaculum) volarly. In this region the median nerve is susceptible to pressure as it courses through the tunnel with the extrinsic finger flexor tendons on their way into the hand. Carpal tunnel syndrome (CTS) is characterized by the sensory loss and motor weakness that occur when the median nerve is compromised in the carpal tunnel. Anything that decreases the space in the carpal tunnel or causes the contents of the tunnel to enlarge could compress or restrict the mobility of the median nerve, causing a compression or traction injury and neurological symptoms distal to the wrist.


Etiology of Symptoms

Etiologic factors include synovial thickness and scarring in the tendon sheaths (tendinosis) or irritation, inflammation, and swelling (tendinitis) as a result of repetitive or sustained wrist flexion, extension, or gripping activities or sustained pressure. Because of this CTS is frequently classified as a cumulative trauma or overuse syndrome. Swelling of the wrist joint due to trauma to the carpals (e.g., a fall or blow to the wrist), a fracture of the carpals, pregnancy (hormonal changes and water retention), rheumatoid arthritis, or osteoarthritis could decrease the carpal tunnel space. Awkward wrist postures (flexion or extension), compressive forces from sustained equipment usage, and vibration against the carpal tunnel could also lead to median nerve compression and trauma.


Tests of Provocation


In a recent review on the sensitivity and specificity of the various tests used when screening for CTS, MacDermid and Doherty,
36 summarized the key signs and symptoms that increase the probability of diagnosing CTS.

History. Sensory changes in the median nerve distribution of the hand (excluding the palm, which is innervated by the palmar cutaneous branch of the median nerve arising proximal to the carpal tunnel); nocturnal numbness and pain relieved by flicking the wrists.

Observation and provocation test

 Thenar atrophy and/or weakness, positive Phalen’s test (sustained wrist flexion),loss of two-point discrimination, and positive Tinel’s sign(tapping the median nerve).Because there can be other causes of median nerve symptoms, such as tension, compression, or restricted mobility of the nerve roots in the cervical intervertebral foramen, of the brachial plexus in the thoracic outlet, or of the median nerve as it courses through tissues in the forearm region (pronator syndrome and anterior interosseous nerve syndrome),32 each of these sites must be examined to rule them out or determine if any is the cause of the median nerve symptoms. With nerve irritability it is possible to develop what is known as a double crush injur so the nerve develops symptoms at other areas along its course as well as at the primary site. Wood and Biondi73 reported that 41 of 165 patients with TOS also had carpal tunnel syndrome, which they attributed to the lessened ability of the nerves to withstand distal compression when irritated proximally. In contrast, Seror52,53 reported a lack of evidence supporting a relationship between unambiguous CTS in true neurogenic TOS (1/100), although disputed neurogenic TOS was frequently found (mild to moderate clinical symptoms and signs) even when there was no significant findings on electrodiagnostic tests.



Common Impairments

§  Increasing pain in the hand with repetitive use

§  Progressive weakness or atrophy in the thenar muscles

§  and first two lumbricales (ape hand deformity)

§  Tightness in the adductor pollicis and extrinsic extensors

of the thumb and digits 2 and 3

§  Irritability or sensory loss in the median nerve distribution

§  Possible decreased joint mobility in the wrist and metacarpophalangeal

joints of the thumb and digits 2 and 3

§  May develop sympathetic changes

Common Functional Limitations/Disabilities

Decreased prehension in tip-to-tip, tip-to-pad, and padto-pad activities requiring fine neuromuscular control of thumb opposition May not use the area of the hand where there is decreased sensation

Inability to perform provoking sustained or repetitive wrist motion, such as cashier checkout scanning, assembly line work, fine tool manipulation, typing, or manipulation of a computer mouse

Nonoperative Management of CTS

In patients with mild to moderate symptoms, conservative intervention is directed toward minimizing or eliminating the causative factor. Considerations include:

Nerve protection

 Initially, the wrist may have to be splinted to provide rest from the provoking activity. Splint the wrist in the neutral position so there is minimal pressure in the tunnel.

Activity modification and patient education

 Identify faulty wrist or upper extremity postures and activities. Modify activities to keep the wrist in neutral and to reduce forceful prehension. Teach the patient about the mechanisms of compression and their effect on the circulation and nerve pressure as well as how to modify or eliminate provoking postures and activities. Teach the patient safe exercises for a home exercise program. Emphasize the importance of compliance to reduce stresses on the nerve and tendinous structures. Also, instruct the patient to observe areas with decreased sensitivity to avoid tissue injury.


• Joint mobilization

 If there is restricted joint mobility, mobilize the carpals for increased carpal tunnel space.

• Tendon-gliding exercises.

 Teach the patient tendon gliding exercises for mobility in the extrinsic tendons; they should be performed gently to prevent increased swelling.

• Median nerve mobilization

There are six positions for median nerve mobilization in the wrist and hand. Continue to progress  each succeeding position until the median nerve symptoms just begin to be provoked (tingling). That is the maximum position to use. Sustain that position for 5 to 30 seconds without making the symptoms worse. Then alternate between that position and the preceding position. When the patient can be moved into that position without symptoms, progress to the next stretch position and repeat the mobilizing routine. The mobilization exercise should be done three or four times per day so long as symptoms are not exacerbated.


Muscle performance

• Gentle multiple-angle muscle-setting exercises

 Initially, gentle muscle-setting exercises are the only resistance exercises done. It is important that they

do not provoke symptoms.

• Strengthening and endurance exercises

 Add dynamic strengthening and endurance exercises when symptoms are not increased with isometric exercises and there is full tendon- and nerve-gliding without symptoms or edema. Utilize exercises that prepare the patient for a return to functional activities.

• Speed, coordination, endurance, and fine finger dexterity

Emphasize these activities when the symptoms are no longer provoked. Utilize activities that develop tipto-tip and tip-to-pad prehension in order to improve use of the thenar muscles as well as areas of the skin that may have decreased sensation.

Functional independence

 Teach the patient how to monitor his or her hand for recurrence of symptoms and the provoking factors and how to modify activities to decrease nerve injury. Usually, sustained wrist flexion, ulnar deviation, and repetitive wrist flexion and extension combined with gripping and pinching are the most aggravating motions.


Surgical Intervention and

Postoperative Management

If conservative measures do not relieve the nerve symptoms or the neurological symptoms are severe (persistent, numbness, weakness, pain, decreased functional use of the hand),
36 surgical decompression involving the transaction of the transverse carpal ligament is performed to increase the volume of the carpal tunnel and relieve the compressive forces on the median nerve. Also, any scar tissue is excised.

Surgery may be an open carpal tunnel release or endoscopically assisted carpal tunnel release. Therapy may be initiated after surgery if there are restrictions or muscle weakness. Use exercise and mobilization techniques that deal with the impairments and functional loss. Pain in the thenar and hypothenar eminences may result from the release and flattening of the palmar arch (pillar pain). Immediately after surgery there is loss of the wrist pulley in the long finger flexor system due to release of the flexor retinaculum. Therefore, time must be allowed for healing to prevent bowstringing of the flexor tendons at the wrist. The wrist may be immobilized 7 to 10 days postoperatively in slight extension with the fingers free to move.

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