Carpal Tunnel Syndrome
1. Introduction
Carpal tunnel syndrome (CTS) is the most common compression neuropathy (nerve irritation) of the arm (9). Nerves conduct electric type signals to allow us to ‘move muscles and joints and ‘feel sensation’. When a nerve is irritated it can disrupt its ability to send signals effectively. This can result in altered sensations of touch, pins and needles, numbness and sometimes muscle weakness.
In carpal tunnel syndrome, a nerve (median nerve) is compressed as it travels through a small passage in the palm side of the wrist called the carpal tunnel. This tunnel is about an inch wide and is formed by small wrist bones called carpal bones. A strong piece of connective tissue known as a ligament (transverse ligament) forms the roof of the tunnel. In this small space, there also exist several strong tendons (attach muscle to bone) that allow us to bend our fingers.
Because all these structures are in such a small space there is little room to allow any swelling or enlargement of the tendons. If any narrowing does occur within the carpal tunnel, through something like swelling, the median nerve can become irritated and cause symptoms.
Frequently Asked Questions
- Carpal tunnel syndrome is caused by increased pressure on one of the nerves in the wrist which can cause pain, loss of strength, tingling in your hand and fingers.
- Carpal tunnel syndrome affects approximately 1%-7% of the population (1).
- In manual workers this is higher, ranging from 5%-15% (2,3).
- No.
- With correct diagnosis and appropriate rehabilitation, symptoms generally recover well.
- Carpal tunnel syndrome can resolve spontaneously (4).
- This condition is not related to any other serious conditions.
- Those aged 45–64 years (7).
- It is 3 times more common in women (7).
- Overweight individuals.
- Pregnant women.
- Those with diabetes.
- Altered sensation in the thumb, index, middle, and inner half of the ring finger.
- Loss of grip and pinch strength.
- Clumsiness and reduced dexterity e.g. when doing up buttons (8).
- Activity modification – avoid tasks that exacerbate symptoms.
- Occupational health – advice around potential workplace adaptations.
- Physiotherapy can significantly improve symptoms (6).
- Carpal tunnel syndrome wrist splints: easily purchased at little cost.
- If you are overweight, losing weight may help.
- Quicker recovery is associated with a shorter duration of symptoms, young age and carpal tunnel syndrome due to pregnancy (4).
- Symptoms may completely resolve without treatment within 6 months (5).
- Some cases require further medical management.
We recommend consulting a musculoskeletal physiotherapist to ensure exercises are best suited to your recovery. If you are carrying out an exercise regime without consulting a healthcare professional, you do so at your own risk. Book online with us today to get a programme tailored to your specific needs.
2. Signs and Symptoms
- Location of symptoms – symptoms vary and can be mild to severe; normally carpal tunnel syndrome affects one hand but can be present in both. Typically, it causes intermittent tingling, numbness or altered sensation and burning or pain in the areas supplied by the median nerve (thumb, index finger, middle finger, and the inner half of the ring finger). There are occasional situations where some patients with carpal tunnel syndrome report symptoms in a glove-like distribution, as well as a spread higher up the arm (8).
- Night-time – symptoms can be more noticeable at night and sleep can be affected. Sufferers often find they subconsciously hang their arm out of bed at night, or wake and shake their hand in an attempt to ease symptoms.
- Aggravating movements – activities of daily living that require repetitive wrist movements and strength, particularly those that require forward or backwards bending (press-ups, inclined keyboard working, etc) cause the tunnel to narrow and might contribute towards further compression and symptom exacerbation.
- Loss of strength – grip and pinch strength are the most reported strength deficits (9). These deficits are more apparent the longer someone has symptoms and can be associated with visible wasting of the muscles at the base of the thumb.
3. Causes
Carpal tunnel syndrome can be caused by various factors, all of which have the same effect of causing increased compression to the median nerve, or in extreme cases, ischemia (inadequate blood supply). The sheath that contains the tendons within the carpal tunnel can become irritated and inflamed, causing swelling and compression.
Trauma or injury to the affected arm can cause swelling and subsequent compression. Those with diabetes and other disorders such as overactivity of the pituitary gland and hypothyroidism are more susceptible to compression. Work stress, repeated use of vibrating hand tools could also lead to nerve irritation. Rheumatoid arthritis can cause bony deformity of the carpal bones and the development of a cyst or tumour in the carpal tunnel could also lead to compression (although these are much rarer causes). Fluid retention during pregnancy or menopause can also be a potential source of compression. There is a possibility of other conditions mimicking carpal tunnel syndrome, so it is advised to seek advice from a health professional to ensure you receive a correct diagnosis.
4. Risk Factors
This is not an exhaustive list. These factors could increase the likelihood of someone developing carpal tunnel syndrome, but it does not mean everyone with these risk factors will develop symptoms.
- 3 times more common in women – women have naturally smaller carpal tunnels (7).
- Those aged 45–64 years – likely due to age-related narrowing of the carpal tunnel (7).
- Being clinically overweight – increased fluid retention causes increased pressure with the carpal tunnel.
- Pregnancy – increase fluid retention causes increased pressure with the carpal tunnel.
- Diabetes – high blood glucose affects the tendons within the carpal tunnel causing increased pressure within the carpal tunnel.
- Thyroid disorders – hormonal impact on nerve function causing fluid retention.
- Menopause – hormonal impact on nerve function causing fluid retention.
- Rheumatoid arthritis – reduced space in the carpal tunnel causing increased pressure.
- Previous wrist injury – reduced space in the carpal tunnel causing increased pressure.
- Repetitive manual working. – thickening of the tendons causing narrowing of the carpal.
5. Prevalence
In non-manual workers, carpal tunnel syndrome affects approximately 1%-7% of the population (1), in manual workers (builders, machine workers, etc) this is higher, ranging from 5%-15% (2,3).
6. Assessment & Diagnosis
Musculoskeletal physiotherapists and other appropriately qualified health professionals can provide you with a diagnosis by obtaining a detailed history of your symptoms. A series of physical tests might be required as part of your assessment to rule out other potentially involved structures and gain a greater understanding of your physical abilities. A good assessment will help facilitate an accurate working diagnosis.
Your treating clinician will want to know how your condition affects you day-to-day life so that treatment can be tailored to your needs and personalised goals can be established. Intermittent reassessment will ensure you are making progress towards your goals and will allow appropriate adjustments to your treatment to be made.
With mild symptoms, particularly in those with more recent onset, further investigations are not normally required as symptoms of carpal tunnel syndrome are easily identifiable and can be rectified with relatively simple management. Unusual or persistent cases that have not responded to appropriate physiotherapy input may require further investigation such as nerve conduction studies and ultrasound imaging.
7. Self-Management
If carpal tunnel syndrome is identified early, outcomes are generally very good (4). Self-management strategies that your healthcare professional might advise include the following:
- Activity modification (avoiding or modifying activities of daily living, inclusive of work, that aggravates symptoms).
- If you work for an organisation that has an occupational health department and your symptoms are aggravated by work, it would be advisable to seek their input. They will be well placed to suggest work placed adaptations to facilitate continued working, whilst best managing symptoms.
- Utilising a carpal tunnel specific splint has been shown to produce positive outcomes (10); they are low cost and easily purchased.
- If you are overweight, losing weight might have a positive impact on both carpal tunnel related symptoms and your overall health.
8. Rehabilitation
Good outcomes can be expected with appropriate physiotherapy treatment (6). Condition-specific exercise forms a key element of the treatment plan to ensure the best recovery. Rehabilitation often includes tendon and nerve gliding exercises, of which 93% of patients involved in one study reported a good or excellent outcome (6,11).
Alongside exercise and appropriate advice, your physiotherapist might utilise various forms of hands-on treatment techniques in the form of joint mobilisations, nerve mobilisations and soft tissue techniques. These techniques can be useful to restore function and alleviate symptoms whilst you continue to strengthen and mobilise the limb.
Detailed below is a condition-specific rehabilitation programme for carpal tunnel syndrome. In some instances, a one-to-one assessment is required to individually tailor targeted rehabilitation. However, this programme provides an excellent starting point.
9. Carpal Tunnel Syndrome
Rehabilitation Plans
Our team of expert musculoskeletal physiotherapist have created rehabilitation plans to enable people to manage their condition. If you have any questions or concerns about a condition, we recommend you book an consultation with one of our clinicians.
What Is the Pain Scale?
The pain scale or what some physios would call the Visual Analogue Scale (VAS), is a scale that is used to try and understand the level of pain that someone is in. The scale is intended as something that you would rate yourself on a scale of 0-10 with 0 = no pain, 10 = worst pain imaginable. You can learn more about what is pain and the pain scale here.
Nerve gliding exercises aim to positively affect the area of contact between structures within the carpal tunnel with the end goal of reducing compression (11). More discomfort does not equal a better recovery, this is especially true for nerve-related injuries. Pain is to be expected but we suggest this remains at an acceptable level, reaching no more than 4/10 on your self-perceived pain scale.
- 0
- 1
- 2
- 3
- 4
- 5
- 6
- 7
- 8
- 910
10. Return to Sport / Normal life
For patients wanting to achieve a high level of function or return to sport we would encourage a consultation with a physiotherapist as you will likely require further progression beyond the advanced rehabilitation stage.
As part of a comprehensive treatment approach, your musculoskeletal physiotherapist may also use a variety of other pain reliving treatments to support symptom relief and recovery. Whilst recovering you might benefit from further assessment to ensure you are making progress and establish appropriate progression of treatment. Ongoing support and advice will allow you to self-manage and prevent future re-occurrence.
11. Other Treatment Options
Physiotherapy alone can significantly improve symptoms (7). However, in persistent and irritable cases more invasive treatment such as those detailed below might be required.
Injection – local corticosteroids can provide an improvement in related symptoms. However, some research reports that significant relief beyond one month is not always demonstrated (12). Given these reports, some clinicians view the option of injection as a ‘window of opportunity’ in which pain can be reduced facilitating improved adherence to rehabilitation.
Surgery – should be reserved for those who have attempted and failed appropriate conservative management. During carpal tunnel release surgery, the transverse ligament is cut to ease the pressure on the carpal tunnel. Whilst surgery is largely successful in appropriate cases, it is worth highlighting that recurrence rates following surgery vary between 0.3 and 12% (13).
12. Links for Further Reading
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References
- Marshall, S.C., Tardif, G. and Ashworth, N.L.(2007). Local corticosteroid injection for carpal tunnel syndrome. Cochrane Database of Systematic Reviews.
- Franzblau, A., Werner, R., Valle, J. and Johnston, E. (1993). Workplace surveillance for carpal tunnel syndrome: a comparison of methods. Journal of Occupational Rehabilitation. 3, 1-14.
- Homan, M.M., Franzblau, A., Werner, R.A., Albers, J.W., Armstrong, T.J. and Bromberg, M.B. (1999). Agreement between symptom surveys, physical examination procedures and electrodiagnostic findings for the carpal tunnel syndrome. Scandinavian journal of work, environment & health. 115-124.
- NICE. (2020). Carpal tunnel syndrome: What is the prognosis?. Available: https://cks.nice.org.uk/topics/carpal-tunnel-syndrome/background-information/prognosis/.
- Futami, T., Kobayashi, A., Ukita, T., Endoh, T. and Fujita, T. (1997). Carpal tunnel syndrome; its natural history. Hand Surgery, 2, 129-130.
- Bobowik, P.Ż. (2019). Effectiveness of physiotherapy in carpal tunnel syndrome (CTS). Advances in Rehabilitation, 33, 47-58.
- Bongers, F.J., Schellevis, F.G., van den Bosch, W.J. and van der Zee, J. (2007). Carpal tunnel syndrome in general practice (1987 and 2001): incidence and the role of occupational and non-occupational factors. British Journal of General Practice, 57, 36-39.
- Nora, D.B., Becker, J., Ehlers, J.A. and Gomes, I. (2004). Clinical features of 1039 patients with neurophysiological diagnosis of carpal tunnel syndrome. Clinical neurology and neurosurgery, 107, 64-69.
- Baker, N.A., Moehling, K.K., Desai, A.R. and Gustafson, N.P. (2013). Effect of carpal tunnel syndrome on grip and pinch strength compared with sex‐and age‐matched normative data. Arthritis care & research, 65, 2041-2045.
- Graham, B., Peljovich, A.E., Afra, R., Cho, M.S., Gray, R., Stephenson, J., … Rempel, D. (2016). The American Academy of Orthopaedic Surgeons evidence-based clinical practice guideline on: management of carpal tunnel syndrome. 98,1750-1754.
- Seradge, H., Jia, Y.C. and Owens, W. (1995). In vivo measurement of carpal tunnel pressure in the functioning hand. The Journal of hand surgery, 20, 855-859.
- Marshall, S.C., Tardif, G. and Ashworth, N.L.(2007). Local corticosteroid injection for carpal tunnel syndrome. Cochrane Database of Systematic Reviews.
- British Orthopaedic Association. (2020). British Society for Surgery of the Hand, Royal College of Surgeons. Commissioning guide: treatment of painful tingling fingers: BOA, BSSH, RCS.
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