Overview

Pressure on the median nerve, which is inside a narrow passage in the wrist called the carpal tunnel, causes the nerve to malfunction. This nerve provides feeling to the thumb, index and middle fingers, and half of the ring finger. It also controls several muscles in the hand, the most important of which allows the thumb to touch the little finger. Pinching occurs when the tissues in the carpal tunnel swell up.

Carpal tunnel syndrome is a repetitive strain injury. Although there are many causes for carpal tunnel syndrome, by far the most common is doing repetitive motions as part of your job. Fragmentation of work to the point that one person does one task over and over has been blamed for the increase in cases of carpal tunnel syndrome in recent years. There are approximately 1 million new cases every year.

Risk Factors

It is possible to develop carpal tunnel syndrome with or without the risk factors listed below. However, the more risk factors you have, the greater your likelihood of developing carpal tunnel syndrome. If you have a number of risk factors, ask your health care provider what you can do to reduce your risk. Risk factors of carpal tunnel syndrome include:

Occupation

The vast majority of carpal tunnel syndrome cases are work-related. People whose occupations involve repetitive work with the hands, such as keyboard operators, factory workers, typists, barbers, musicians, and vehicle drivers, are at increased risk. In addition, people who use vibrating tools, such as jack hammers, chain saws, chippers, grinders, drills, and sanders, for long periods every day may be at increased risk.

Injuries

Wrist injuries, such as burns, broken bones, compression or crush injuries, may increase your risk of developing carpal tunnel syndrome.

Medical Conditions

Having the following medical conditions may increase your risk of developing carpal tunnel syndrome:

• arthritis
• diabetes
• Raynaud's disease, which impairs blood flow in the hands
• water retention from heart failure or kidney problems
• hormone-related conditions and medications such as:
  • pregnancy
  • breastfeeding
  • menopause
  • hypothyroidism
  • Cushing's disease
  • excess growth hormone
  • birth control pills
  • cortisone pills or shots
  • some high blood pressure drugs
• tumours and cysts in the carpal tunnel

Age

Carpal tunnel syndrome is most often diagnosed between the ages of 40 and 60.

Gender

Women are diagnosed with carpal tunnel syndrome three times more often than men.

Genetic Factors

Inheriting a narrowed carpal tunnel increases your chances of developing carpal tunnel syndrome.

Diagnosis

Carpal tunnel syndrome causes symptoms in one or both hands that may also extend up the arm. Symptoms are caused by pinching of the median nerve in the carpal tunnel. This nerve supplies feeling to the thumb, index, middle, and half of the ring finger, as well as to the muscles that move the thumb toward the little finger and move the index finger around in a circle.

Symptoms include:

• tingling, burning, or numbness, especially in your thumb and index or middle fingers
• pain or numbness that worsens with:
  • wrist, hand, or finger movement
  • sleep (symptoms may wake you)
• hand stiffness or cramping that gets better after:
  • shaking the hand
  • waking up in the morning
• weakness or clumsiness of your hand
  • loss of grip strength
  • difficulty touching your little finger with your thumb
  • frequently dropping things
• pain extending up your arm
  The doctor will ask about your symptoms and medical history. He will examine your neck, arms, wrists, and hands. The physical examination will include tests of strength, sensation, and signs of nerve irritation or damage.

Tests

Simple tests for carpal tunnel syndrome include:

• Tinel's sign
  The doctor will tap firmly on your wrist right over the carpal tunnel to see if it sends an electric shock feeling into your hand. You can actually do this test yourself, as well. Tap right over the creases on the inner side of your wrist between the two bones on either side of the base of your palm.
• compression test
  The doctor will bend your wrist down so that your thumb comes as close to your forearm as it will go, and then hold it there for a minute or two to see if it causes tingling and numbness in your hand.

Other tests may include:

• nerve conduction study
  The speed at which your nerves carry signals can be determined by impaling them with tiny electrodes attached to special machines. If conduction is slowed through the carpal tunnel, you probably have a problem in the carpal tunnel.
• electromyogram (EMG)
  In a similar fashion, tiny currents can be used to stimulate muscles. The muscles respond with electrical activity that can be measured. When the nerves connecting to muscles are damaged, the muscles give off abnormal signals.
• x-rays, computed tomography (CT) scan and magnetic resonance imaging (MRI) scan
  These imaging tests may identify other causes of carpal tunnel syndrome or give more extensive information as to your particular problem.
• arthroscopy
  This procedure is useful in both diagnosing and treating carpal tunnel syndrome. This is a minor surgical procedure during which a thin, lighted tube (arthroscope) is inserted into your wrist. The surgeon can then look through the tube to see exactly what is wrong. The same tube can be used to repair the problem, using tiny tools inserted through the arthroscope into the wrist.

What Questions Should I Ask my Health Care Provider?

You have a unique medical history. Therefore, it is essential to talk with your doctor or health care provider about your personal risk factors and/or experience with carpal tunnel syndrome. By talking openly and regularly with your health care provider, you can take an active role in your care. Here are some tips that will make it easier for you to talk to your health care provider:

• Bring someone else with you. It helps to have another person hear what is said and think of questions to ask.
• Write out your questions ahead of time, so you don't forget them.
• Write down the answers you get, and make sure you understand what you are hearing. Ask for clarification, if necessary.
• Don't be afraid to ask your questions or ask where you can find more information about what you are discussing. You have a right to know.

Specific Questions to Ask Your Health Care Provider

About symptoms:

• What else could account for these symptoms?
• Given my work or lifestyle, how concerned should I be about developing carpal tunnel syndrome?
• What can I do to reduce my risk of carpal tunnel syndrome? (if you must do repetitive hand motions at work)

About treatment options:

• I've learned there are several ways to treat this condition. Which treatment will be the most effective and long lasting for me?

About lifestyle changes:

• I can't seem to make all the lifestyle changes at once. Which are the most important to attempt first?

About your outlook:

• Should I explore a change of occupation, either permanent or temporary?
• Among my other job possibilities, which are the best options for my condition?
• Can this cause permanent disability?

Treatment Options

The treatment and management of carpal tunnel syndrome requires that pressure in the carpal tunnel be reduced. There are several ways to do this. As with all health problems, the safest and simplest treatments are tried first. If your carpal tunnel syndrome is due to another treatable condition, such as diabetes or a hormone disorder, that condition may be treated first to see if the carpal tunnel syndrome resolves.

Treatment Options - Lifestyle Changes

If your carpal tunnel syndrome is caused by repetitive strain, then lifestyle has everything to do with your symptoms, and you’ll need to make some changes. Contact your health care provider when your symptoms begin to interfere with your activities.

• Check your sleeping position
• Check the ergonomics of your workplace
• Check the tools you use at work
• Warm up before and during work
• Avoid caffeine and tobacco
• Check your sleeping position

A simple change in how your wrists are positioned during sleep may solve early symptoms. Sleep with your wrists cocked upward instead of bent downward to minimize pressure in the carpal tunnel.

Check the ergonomics of your workplace

The more comfortable your workplace, and the closer your work activity conforms to the way your body works, the less chance of discomfort or reduced performance.

• Minimize repetitive hand movements when possible.
• Alternate between activities or tasks to reduce the strain on your body.
• When using your wrists, keep them straight and let your arms and shoulders share the stress.
• Use your whole hand or both hands to pick up an item.
• Avoid holding an object the same way for a long time.
• If you work in an office, adjust your desk, chair and keyboard so you are in the best possible position:
  • back straight
  • feet flat on the floor or resting on a footrest
  • knees level with or slightly lower than your hips
  • shoulders in a neutral position, not forward or back
  • elbows bent at a 90-degree angle
  • forearms parallel to the floor and wrists straight
• Take breaks at least once an hour to:
  • rest or shake your hands
  • massage the palms and backs of your hands
  • do a few stretches and loosening movements of the shoulders and arms before settling in to work, and frequently during the day
• Keep hands warm, with gloves if necessary .
• Get regular aerobic exercise such as walking or swimming.
• Cut down on caffeine and smoking, which may reduce blood flow to your hands.

Check the tools you use at work

• Avoid holding an object or tool the same way for a long time.
• Minimize time using vibrating tools. If not possible, stop frequently and follow the warm-up program below.

Warm up before and during work

According to a report published by the American Academy of Orthopaedic Surgeons, a simple warm-up routine may greatly reduce the incidence of carpal tunnel syndrome. This routine, combined with medication and rest, may prove to be better at treating symptoms than simple rest and medication.

The warm-up routine is as follows:

• Hold your hands in front of you as if pushing on a wall. Count to five.
• Relax your wrists and fingers.
• Make tight fists with both hands.
• Bend both fists downward. Count to five.
• Repeat each step 10 times.
• Then shake arms loosely while hanging at your side.

Avoid caffeine and tobacco

Both caffeine and tobacco reduce blood flow to your hands. Nerve tissue is the most sensitive to reduced blood flow. Avoid caffeine and tobacco so that you don’t decrease blood flow to these areas any further.

Treatment Options - Medications

The information provided here is meant to give you a general idea about each of the medications listed below. Only the most general side effects are included, so ask your health care provider if you need to take any special precautions. Use each of these medications as recommended by your health care provider, or according to the instructions provided. If you have further questions about usage or side effects, contact your health care provider.

Medications for carpal tunnel syndrome are prescribed to reduce swelling in the carpal tunnel. Two different kinds of medicine may be effective, but both are aimed at reducing inflammation, a primary cause of swelling in this area.

Prescription medications

• glucocorticoids (cortisone-like drugs, steroids)
  These cortisone-like drugs are given in short, sometimes tapering, bursts lasting a week or two. Glucocorticoids can produce a number of negative side effects, particularly when taken for prolonged periods. For this reason, your health care provider will prescribe them only for a short time and monitor you while taking them. These medications are often quite effective in reducing inflammation.
• Common names include:
  • Prednisone
  • Prednisolone
  • Dexamethasone (Decadron)
  • Triamcinolone (Aristocort, Kenacort)
• non-steroidal anti-inflammatory drugs (NSAIDs)
  

  There are currently 20 prescription NSAIDs on the market, each having a slightly different chemistry and side effect profile. NSAIDs can be as effective as cortisone and are safer over the long run, although they do have side effects. The newer and more expensive selective NSAIDs (celecoxib and rofecoxib) are expected to produce fewer stomach and intestinal problems.

  Common names include:

  • Indomethacin (Indocin)
  • Naproxen (Naprosyn, Anaprox)
  • Celecoxib (Celebrex)
  • Rofecoxib (Vioxx)

  Take special care with NSAIDs if you have had an ulcer or gastritis, as they can irritate these conditions. Tell your doctor if you have a stomach condition before you start taking any of these medications.

• cortisone injection

  An injection of cortisone directly into the carpal tunnel may be used to treat carpal tunnel syndrome if rest, medications, and lifestyle changes are not working. This is a simple office procedure that is quite safe if done infrequently. Cortisone reduces inflammation, thereby reducing the swelling and pressure inside the carpal tunnel.

  Injections very rarely cause excessive bleeding and even more rarely cause infection. If there is excessive pain or swelling, contact your health care provider.

• over-the-counter medications

  Lower doses of non-steroidal anti-inflammatory drugs (NSAIDs) are sold over the counter and include:

  • aspirin
  • ibuprofen (Motrin, Advil)
  • naproxen (Aleve)
  • piroxicam (Feldene)

  Take special care with NSAIDs if you have had an ulcer or gastritis. They can irritate these conditions. Tell your doctor if you have a stomach condition before you start taking any of these medications.

Special Considerations

Whenever you are taking a presription medication, take the following precautions:

• Take them as directed, not more, not less, not at a different time.
• Do not stop taking them without consulting your health care provider.
• Don’t share them with anyone else.
• Know what effects and side effects to expect, and report them to your health care provider.
• If you are taking more than one drug, even if it is over-the-counter, be sure to check with a physician or pharmacist about drug interactions.
• Plan ahead for refills so you don’t run out.

How can I prevent carpal tunnel syndrome?

You may reduce your chances of getting carpal tunnel syndrome by taking these steps:

• Minimize repetitive hand movements when possible.
• Alternate between activities or tasks to reduce the strain on your body.
• When using your wrists, keep them straight and let your arms and shoulders share the stress.
• Use your whole hand or both hands to pick up an item. Avoid holding an object the same way for a long time.

If you work in an office, adjust your desk, chair and keyboard so you are in the best possible position:

• Back straight
• Feet flat on the floor or resting on a footrest
• Knees level with or slightly lower than your hips
• Shoulders in a neutral position, not forward or back
• Elbows bent at a 90 degree angle
• Forearms parallel to the floor and wrists straight

Take breaks at least once an hour to:

• Rest or shake your hands
• Massage the palms and backs of your hands

Get regular aerobic exercise such as walking or swimming.

Cut down on caffeine and smoking, which may reduce blood flow to your hands.

Keep in mind that the rehabilitation exercises should be continued to ensure protective strength, range of motion, and stability.

Improving Sports Performance

The key to improving sports performance after recovering from carpal tunnel syndrome is a proper a rehabilitation program, and adhering to some of those same principles after the injury is gone.

The single most important aspect of improving performance is performing proper stretching exercises before and after you step onto the field, court, ice or golf course. Benefits derived from stretching include:

• increased physical efficiency and performance
• decreased risk of injury
• increased blood supply and nutrients to joint structures
• increased coordination
• improved muscular balance and postural awareness
• decreased risk of lower-back pain
• reduced stress
• enhanced enjoyment

Rehabilitation

As an athlete, your number one concern is getting back to full strength as soon as possible so that you can return to training and competition. That is why appropriate rehabilitation is extremely important.

The most common rehabilitation for carpal tunnel syndrome often includes the following:

• Rest
  Resting the wrist by keeping it straight and decreasing activities that worsen pain.
• Ice
  Gently applying ice packs to the area.
• Elevation
  Elevating the hand above the heart to reduce swelling.
• Exercise
  Exercises as directed by your health care provider.
• Wrist splint
  A splint will prevent extreme movements of the wrist. It's most effective when worn at night and can help avoid waking up with symptoms.
• Medications
  Take ibuprofen to reduce pain. An injection of cortisone into the carpal tunnel may also be prescribed.
• Surgery
  Surgery may be needed if symptoms are severe or continue after trying other treatments. The most common procedure is the carpal tunnel release.

The major objectives of rehabilitation from carpal tunnel syndrome are to improve the elasticity of the carpal tunnel and to gradually increase pain-free range of motion of the hand, wrist, thumb, and fingers. The exercises below may help achieve this. These exercises should be performed once or twice daily.

Exercises

• Extend and stretch both wrists and fingers acutely as if they are in a hand-stand position. Hold for a count of 5.
• Straighten both wrists and relax fingers.
• Make a tight fist with both hands. Then bend both wrists down while keeping the fist. Hold for a count of 5.
• Straighten both wrists and relax fingers, for a count of 5.
• Repeat exercise 10 times, then hang arms loosely at side and shake them for a couple of seconds. Total exercise time: 5 to 10 minutes.

Alternative exercises

During the period when normal training should be avoided, alternative exercises may be used. These activities should not require any actions that create or intensify pain at the site of injury. They include:

• swimming
• jogging
• stationary bicycle

Rehabilitation after surgery

Keep in mind that if your carpal tunnel syndrome requires surgery, the soft tissue needs time to heal before exercise can begin.

A physical therapy program usually begins with range-of-motion and resistive exercises, then incorporates power, aerobic and muscular endurance, flexibility, and coordination drills.

Finally, patients develop speed and agility through sport-specific exercise routines.

The ultimate goal of carpal tunnel surgery is to provide dynamic stability while maintaining full range of motion, so that athletes can return to competitive or recreational sports. Progress is assessed by the patient's perception of how stable the hand/wrist feels and by comparing the strength and stability of the injured and uninjured hands.

When can I return to my sport or activity?

Some may be ready for participation in a week, others not for two or more weeks. Of course, time for return-to-activity is much longer if surgery is necessary. Keep in mind that carpal tunnel syndrome may recur if the causative activity is continued. Just be sure to continue the exercises and prevention techniques to reduce risk of a recurrence.

Remember: The goal of rehabilitation is to return you to your sport or activity as soon as is safely possible. If you return too soon you may worsen your injury, which could lead to permanent damage. Everyone recovers from injury at a different rate. Return to your activity is determined by how soon your carpal tunnel syndrome recovers, not by how many days or weeks it has been since your injury occurred