This article is about carpal tunnel syndrome. Its main aim to is to provide information and advice about the condition with an emphasis on self-help. The article is written on the assumption that the reader has been diagnosed with carpal tunnel syndrome by a healthcare professional. If you haven't been diagnosed but you think you might have the condition then its best to get checked out first as there are many other conditions that can cause similar symptoms.
You can see my 20 minute video all about carpal tunnel syndrome below
The article address carpal tunnel syndrome by answering the 3 most common questions that people ask after they have been diagnosed.
1) What is Carpal Tunnel Syndrome ?
Carpal Tunnel Syndrome is classed as a compression neuropathy. Neuropathy is a term used to describe any nerve disorder or nerve disease. 'neuro' means 'nerve' and 'pathy' is a greek term meaning 'suffering or disease'. So neuropathy is a catch-all term meaning one or more nerves aren't functioning properly and are causing symptoms. The compression part simply describes what the cause of the neuropathy is, and essentially means that the nerve is being compressed somewhere along its length.
Any nerve could potentially be compressed but some nerves are more vulnerable than others. The nerves most commonly affected by compression neuropathy are those that pass through narrow areas or are exposed to pressure or friction on their way through the body. The nerve affected in carpal tunnel syndrome is called the median nerve, and it has to travel through a tunnel, the carpal tunnel, in order to get into your hand.
We have 3 nerves that supply the hand with sensation and muscle power but of the 3, it is the median nerve as it travels through the carpal tunnel that is most vulnerable to compression and as such, carpal tunnel syndrome is by far the most common compression neuropathy in the upper limb.
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| Diagram showing the course of median nerve traveling through the carpal tunnel |
The carpal tunnel is located on the palm side of the wrist. The floor and sides of the tunnel are formed by the wrist (carpal) bones which adopt a curved shape. The roof of the tunnel is formed by a ligament which connects the 2 ends of the boney curve. The carpal tunnel contains 9 tendons as well as the median nerve. The tendons don't seem to mind when things get a bit tight within the carpal tunnel and they can usually carry on functioning normally, but the nerve really doesn't like being squashed.
The symptoms of a squashed nerve can be pain but more commonly are tingling, pins and needles and numbness. And because the median nerve supplies sensation to the palm and the thumb, index finger, middle finger and just half of the ring finger, that is the area where symptoms are felt. We call this area the 'sensory territory' of the median nerve.
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| The sensory territory of the median nerve |
But as simple test, the next time your hand feels numb and tingly, try testing the sensation in your fingers using a piece of tissue. Look at diagram above. If you notice that your little finger feels more normal when compared to your index finger or thumb, and especially if you notice a difference between each side of the ring finger, well that is typical of carpal tunnel syndrome.
Diagnosis
Having symptoms of numbness or tingling in the median nerve territory is a good diagnostic test for carpal tunnel syndrome. Another test which is sometimes done to help diagnose the condition is a test that your health care professional may do called the Tinel's Test. Tapping over the carpal tunnel area will sometimes cause a shooting sensation into the palm and fingers caused by inflammation and irritation of the median nerve.
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| The Tinel's Test |
Research has shown that the Tinel's test is positive in about 3/4 of people with carpal tunnel syndrome but this depends on the population that is tested because it is often negative in the elderly or those who have had symptoms for a long time. In the population that I see, the test is positive in less than half of people with the condition.
Another good diagnostic tool is the Kamath and Stothard's Questionnaire. Click the link to see the questionnaire which you can complete yourself in less than a minute. A score of 5 of more is strongly suggestive of carpal tunnel syndrome.
Nerve Conduction Tests
If the diagnosis isn't obvious, or your clinician thinks there might be other causes of your symptoms then you might be sent for something called Nerve Conduction Tests. This can assess the function of the nerves in your arm in more detail and help to provide the clinician with further information from which to help make the diagnosis, or to determine the severity of the condition which can help when planning treatment.
Behaviour of Symptoms
OK so now we know what carpal tunnel syndrome is, let's discuss the behaviour of symptoms because like most MSK conditions, symptoms can vary between mild and severe. When carpal tunnel syndrome first starts, it's often mild and intermittent. In fact usually the first symptoms are a tingling sensation in the hand that occur either at night, first thing in the morning or when doing certain activities during the day, classically reading or holding a phone.
The reason for this is that the carpal tunnel varies in size depending on your wrist position. In a neutral position the carpal tunnel is at its widest but in positions of wrist flexion or extension, the carpal tunnel narrows. And these are the typical positions our wrist adopt when we are asleep, either bent as we curl up, or extended if we use our hand as a pillow, and the same gos for activities like holding a phone or typing.
So usually, the symptoms of hand tingling can be relieved by changing wrist position or shaking the hand to restore blood flow to the nerve. If the condition worsens then the the tingling and numbness can become continual throughout the day and night and this can give you a feeling of clumbsyness and a loss of dexterity. You might find yourself dropping things, not because your grip strength is any weaker but because that lack of sensory feedback can make it difficult for you to work out how hard to grasp something.
In the later stages of the condition, the hand may become continually numb and the deeper nerve fibres involved in muscle control can be affected causing weakness and muscle wastage. The main hand muscle supplied by the median nerve is called abductor policies brevis and it located in the thumb web space. A visible wasting of this muscle as seen below is an indication of more advanced or later stage carpal tunnel syndrome.
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| Muscle wastage due to advanced carpal tunnel syndrome |
2) Why Have I Got It ?
Well the first thing to say is that carpal tunnel syndrome is fairly common condition. Studies vary in their results but typically report a prevalence of between 5 and 10% in the general population and this can rise to over 10% in people with jobs involving repetitive hand activities. We know that the most common age group is the 40-60 range but it can occur at any age. We know that Women are more commonly affected than men but this levels out in the over 70's.
So thats the statistics but interesting as they are, they don't really provide the full explanation as to why you might have carpal tunnel syndrome and not your friend who is the same age and does the same job. And to answer this, the most compelling evidence we have suggests that genetic factors play the main roll as to why some people are prone to this condition and other aren't. And that make sense really. The carpal tunnel, like most parts of the body varies in size from person to person. And some people will have just inherited smaller carpal tunnels than other people.
So as you can see, a combination of genetic factors plus environmental factors like jobs and hobbies are the main reason why people develop this condition. It should also be noted however that certain other medical conditions can affect nerve function and make someone more vulnerable to neuropathies like carpal tunnel syndrome. This is a long list and beyond the scope of this article but includes things like diabetes, thyroid disease, alcoholism and some vitamin and mineral deficiencies.
Carpal Tunnel Syndrome is also commonly seen in pregnancy due to fluid retention around the wrists. Symptoms will usually resolve within 6 weeks of the birth but using some of the treatments described below can help until then.
3) What Can I Do About It ?
Carpal tunnel syndrome can be a really uncomfortable condition. Anything that disturbs sleep can affect your general well-being, mood and quality of life. So the first thing that will usually help, particularly if symptoms are intermittent and mainly at night, is controlling your wrist position. If you can avoid those positions that narrow the carpal tunnel then that usually helps with symptoms. And the easiest way of doing that is by wearing a wrist splint at night. This will help keep your wrist in a neutral position and prevent the nerve becoming squashed. The right type of splint should have thin metal bar sewn in which helps keep your wrist in the right position.
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| Amazon link to a suitable wrist splint |
If the splint doesn't immediately help then try bending the metal bar to a more neutral position and if that still doesn't help then remove the bar completely. Even without the bar, the splint will limit wrist movement enough to be effective in most cases, and without the bar it is often more comfortable for some people.
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| Removing the metal bar |
If you have mild intermittent symptoms then there is a good chance that using a splint like this every night for at least 6 weeks, will allow the nerve to go through it's normal healing process, which in carpal tunnel syndrome, is getting disturbed every night when the nerve gets squashed. So wearing a splint is not just about helping relieve symptoms, it's also about trying to cure the condition by encouraging the nerve to recover naturally.
Night time splints can also be very effective during pregnancy but they do need too be worn every night. If they feel too uncomfortable or hot/sweaty then try removing the bar and use some tubigrip underneath.
If you get daytime symptoms then you can wear the splint during the day and it will help, but its main use is at night. You see during the day, if you hold a phone and get tingling then because you are conscious and aware of the tingly sensation you will automatically change your wrist position, put the phone down, change hands etc in order to relieve the symptoms.
At night though, the nerve could be squashed for a few hours before the symptoms become intense enough to wake you. And when the nerve is squashed every night for hours on end, that is what interferes with nerve healing and can cause nerve degeneration and worsening of the condition. So you can see that using the splint at night is far more important that using it during the day.
Of course, if you have a job or hobby that involves repetitive wrist activities then you will also need to think about ways of reducing the strain on your wrist. You might be able to wear the splint during these activities and that should help. If you have a desk job and your symptoms are being aggravated by prolonged use of the mouse or keyboard then consider getting an ergonomic assessment of your work space.
Poor workplace posture can be a major aggravating factor for carpal tunnel syndrome and can usually be improved fairly easily with simple changes and better equipment, such as an ergonomic keyboard and ergonomic mouse.
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| Poor workplace posture - picture from https://www.rxwellness.net/ |
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| Standing desks have many health benefits |
Other treatments that can be considered if symptoms still persist, are injections and surgery. An injection of cortisone into the carpal tunnel can relieve symptoms in most cases but the effects can sometimes be only temporary. In my experience, if symptoms are intermittent (meaning you have no symptoms for at least some part of the day), then an injection is more likely to be effective in the long term. If your symptoms are continual then the injection is less likely to cure you, and symptoms typically return after a few months.
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| Carpal tunnel injection. Picture from http://www.neurosurg.org |
If you have visible muscle wastage around the thumb, then an injection is unlikely to help and you probably need surgery. The operation for CTS is quick and simple, usually done under local anaesthesia and often takes the surgeon less than 10 minutes. The procedure involves a small cut in the palm, usually a few cm long. The surgeon then moves some fat out of the way and they can then see the ligament that forms the roof of the carpal tunnel. This ligament in then cut to relieve the carpal tunnel pressure.
You usually have a few stitches and a then a large bandage to keep your wrist still and supported until the stitches come out in about 10 days. In my experience it is best to plan for about 6 weeks off work, especially if you have a manual job as the wrist can be sore for a while afterwards. Of course, your hand surgeon will advice you more specifically about this.
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| Carpal tunnel decompression surgery. Picture from https://www.gponline.com |
The very latest surgical technique involve 2 tiny needle point incisions where a thin wire is inserted under ultrasound guidance. This is used to cut through the ligament like a cheese wire. These new procedures have a much shorter recovery time and although only offered at specialist centres at the moment, will become more widely available in the future.
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| Minimally invasive surgery using ultrasound guidance |
Interestingly, the ligament that is cut in surgery will heal over again within a few weeks of the operation but it tends to heal with less tension than before and therefore with an overall reduction in carpal tunnel pressure.
Exercises
I also get asked about exercises that might help. Unfortunately the evidence to support exercises for carpal tunnel syndrome is limited but that is mainly because there aren't many good studies out there that have looked into their use. There are some small studies that have found that nerve gliding exercises can be helpful and in my experience they can sometimes be helpful but usually in the early stages of the condition and when used alongside some of the other treatments that we have already discussed. Exercises can however be helpful after surgery in helping to prevent scar tissue formation and therefore to help to get the best post operative results. You can see a video that describes these exercises below.
Hopefully this article has provided some useful information about carpal tunnel syndrome and what you can do to help. Please remember, it is for general information only and does not replace a consultation with a health care professional. It is important to be aware that carpal tunnel syndrome is only one of many different conditions that can cause symptoms of hand pain and tingling and so you should always seek professional advice first.
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This article provides general information related to various medical conditions and their treatment. It is intended for informational purposes only and not a substitute for professional advice, diagnosis or treatment provided by a doctor or other qualified health care professional. The information provided does not constitute personal advice or guarantee of outcome and should not be used to diagnose yourself or others. You should never ignore advice provided by a health care professional because of something you have seen or read on this website. You should always consult a doctor or other qualified health care professional for personal medical advice.