Identifying and treating pain from Carpal Tunnel Syndrome (CTS)

Introduction and Causes

Carpal Tunnel Syndrome (CTS) commonly develops over time with wrist, hand and upper extremity repetitive use that results in excessive pressure to the median nerve at the carpal tunnel space where it gets compressed underneath the transverse carpal ligament. Repetitive activities like typing on a keyboard or operating equipment with certain hand and arm positions can be predisposing factors associated with CTS symptoms. CTS can also less frequently be the result from an acute injury with a direct blow to the wrist (Multanen et al., 2021).

The repetitive movements which develop CTS over time can eventually lead to the carpal bones shifting into positions where they can become dislodged, compressed, rotated or adversely affect the joint space. The carpal bones can have alignment abnormalities related to poor joint mechanics and positional defaults from previous injuries or from chronic overuse. CTS can have a number of factors that need to be considered as possible contributors to the encroachment on the median nerve and carpal tunnel space.

In many cases of CTS, the structural changes and poor biomechanics within the wrist also involve the forearm, elbow, neck, shoulder and scapular joint positional stability. Each joint of the arm above the wrist assists to stabilize forces moving down the arm with a chain of muscles, nerves and joints connected to the wrist and hand. Excessive force and load displaced into the wrist from abnormal upper arm movement mechanics can eventually cause encroachment of the median nerve resulting in CTS symptoms.

Diagnosis

One important component with the diagnosis of carpal tunnel syndrome is to distinguish between the source of neurological symptoms originating from either the wrist, elbow, shoulder or neck. CTS symptoms originating in the hand can have a similar presentation to neurological impingement of the nerves traveling from the brachial plexus and into the shoulder, elbow, forearm and hand. 2 common clinical special tests to identify CTS are Phalen’s test and Tinel’s sign.

Another source of neurological impingement is the neck, where the nerves exiting the spine can be compromised and cause CTS symptoms. The importance of ruling out neurological issues involving the neck or a repetitive mechanical positional change needs to be identified because one or the other could be interrelated or a major factor with the severity of CTS.

Initial Management 

The initial injury management for Carpal Tunnel Syndrome (CTS) begins by having a thorough physical assessment to the side affected and the cervical spine. Assess range of motion to the cervical spine, shoulder, elbow and wrist with observation of the scapular movement mechanics and stability/control of lower trapezius/scapular depressors. Identify overactive, weak or poorly coordinated muscle movement patterns to begin outlining the plan of care for an ongoing therapeutic exercise and home exercise program. This allows the individual to begin the HEP with good understanding to the dysfunction and physiological changes that contribute to CTS.

Start by addressing the CTS symptoms at or near the area of potential nerve entrapment with manual therapy and …

Reference

Multanen, J., Uimonen, M. M., Repo, J. P., Häkkinen, A., & Ylinen, J. (2021). Use of conservative therapy before and after surgery for carpal tunnel syndrome. BMC Musculoskeletal Disorders, 22(1), 484. https://doi.org/10.1186/s12891-021-04378-3