Carpal Tunnel Syndrome: Signs and Symptoms

Carpal Tunnel Syndrome (CTS) is a condition in which the median nerve, which runs through a bone and fibrous tunnel in the wrist called the carpal tunnel, is compressed.

This leads to pain, numbness and tingling in the hand that sometimes extends into the forearm. In advanced stages, some people with CTS have weakness and muscle loss in the hand. Complex movements and tactile sensation of the hand are essential for completing everyday tasks. Consequently, situations that affect these qualities have a significant impact on activities of daily living.

What causes its onset?

The causes of CTS can be local (cysts), regional (rheumatoid arthritis) or systemic (diabetes).  Pregnancy, menopause, obesity, hypothyroidism, oral contraceptive use and congestive heart failure may increase the risk of CTS by increasing the volume of the synovial sheath within the tunnel. Intrinsic factors within the nerve that increase the volume occupied within the tunnel include tumors and tumor lesions. Neuropathic factors (directly affecting the nerve) such as diabetes, alcoholism, vitamin toxicity or deficiency, and exposure to toxins may play a role in inducing symptoms of CTS. Diabetic patients have a higher tendency to develop CTS with a prevalence rate of 14% without and 30% with diabetic neuropathy.

It is also common in people who perform repetitive hand and wrist movements and are subjected to vibration; which may be associated with work-related factors, prolonged periods with the wrist flexed or extended, high manual force requirements, high repetitiveness and high levels of vibration.

This condition occurs more frequently in people between 30 and 60 years of age and is more common in women (5.8%) than in men (0.6%). Of people with chronic non-traumatic disease, approximately 29% complain of the wrist and hand area, with CTS being the most prevalent non-traumatic hand disorder.

What symptoms can I feel?

It can affect one or both hands feeling:

1. Clumsiness of the hand when grasping objects.

2. Numbness or tingling in the thumb and the next two or three fingers.

3. Numbness or tingling in the palm of the hand.

4. Pain that extends to the elbow.

5. Pain in the hand or wrist.

6. Problems with fine finger movements (coordination).

7. Atrophy of the muscle below the thumb (in advanced or prolonged cases).

8. Weak grip or difficulty carrying bags (a common complaint).

9. Weakness in one or both hands.

In general, we can say that clinically it manifests with pain, numbness of the fingers, tingling, weakness, burning in hands and fingers with a sensation of tingling, more frequently at night, which is able to wake the patient and is relieved by shaking the hands; but it can also appear in daytime activities such as driving or reading the newspaper.

What complementary tests can be ordered?

• X-rays of the wrist to rule out other problems such as wrist arthritis.

• Electromyography (EMG, a test to check the muscles and the nerves that control them).

• Nerve conduction velocity (a test to see how fast electrical signals move through a nerve).

• Diagnostic soft tissue ultrasound.

Is there any treatment that can improve the symptomatology?

Yes, for this condition we have conservative and surgical treatment.

It is important to treat it as soon as possible after symptoms begin. In the early stages, simple things you can do for yourself can make the problem go away. For example:

• To rest your hands take breaks that are more frequent.

• Avoid activities that make symptoms worse.

• Apply cold compresses to reduce swelling.

• Reducing the intensity of manual tasks when feasible may prevent progression and promote recovery. Limit wrist flexion/extension, reduce heavy work activities and avoid repetitive motions.

Splinting and other minimally invasive conservative treatments are more likely to help if you have had only mild to moderate symptoms that come and go with less than 10 months of progression.

Conservative treatment

Medication:

• Nonsteroidal anti-inflammatory drugs (NSAIDs). Nonsteroidal anti-inflammatory drugs (Ibuprofen, naproxen, diclofenac, piroxicam) may help relieve the pain of carpal tunnel syndrome in the short term.

• However, there is not enough evidence that these medications improve carpal tunnel syndrome.

• Corticosteroid injection (Methylprednisolone, Triamcinolone) can be injected into the carpal tunnel to relieve pain with up to three doses. With very good results.

• Corticosteroids decrease inflammation and swelling, which relieves pressure on the median nerve. For treating carpal tunnel syndrome, oral corticosteroids are not as effective as corticosteroid injections.

• Analgesics.

• B complex vitamins. With little scientific evidence.

Physiotherapeutic Treatment

• Splinting with the wrist in neutral position (so the pressure on the CT is the lowest) and the fingers free is preferable. In addition, the splint should be worn for 4 to 12 weeks and should be used only at night or when occupation permits at night and during the day in severe cases. Night splinting may be a good option if you are pregnant, as it does not require the use of any medication to be effective.

• Cryotherapy to reduce local inflammation: Place ice packs on the affected region for 15 minutes every 2 hours (if the use of ice increases the symptoms, limit its use to 5 minutes with circular movements over the area).

• Massage and self-massage of the soft tissue that can be extended to the entire forearm up to the elbow.

• Neurodynamic exercises.

• Flexibility, stretching and self-stretching exercises.

• Electrotherapy, magnetic therapy, laser therapy, therapeutic ultrasound, etc.

Surgical Treatment 

The following criteria must be accomplished for surgical carpal tunnel release (CT):

1. The clinical presentation is consistent with CTS.

2. Electrodiagnostic criteria for CTS have been accomplished.

3. The patient has not responded to conservative treatment that included wrist orthoses and/or corticosteroid injection.

The goal of carpal tunnel surgery is to relieve pressure by cutting the ligament pressing on the median nerve which can be open or endoscopic, the latter is usually less painful the first few days or weeks after surgery.

Recurrent CTS is rare. The results of revision surgery are unpredictable. In general, it is useful to wait at least 6 months from the time of the initial surgery before revision surgery, unless there are signs of surgical complications. This waiting period allows adequate time for healing, maturation and clinical improvement.

What care should I take after surgery?

After surgery, physiotherapeutic intervention will be necessary, where the necessary guidance and care will be given to achieve adequate rehabilitation of the functions. In some cases, there may be incomplete recovery if the symptoms before surgery were very severe and had a long evolution.

Conclusions

The pathology of Carpal Tunnel Sydrome is observed with relative frequency, and although its causes are not completely determined, the anatomical conditions of being a narrow passageway favors its installation. The frequency is higher in adults and women. The work activity seems to have a strong influence in its etiology, taking into account the latter it is possible to carry out actions for its prevention. In the end, if it is not treated in time, the process can become chronic, degenerative and disabling, affecting the patient's quality of life. The main objective of treatment is to achieve decompression of the median nerve and thus achieve clinical improvement and functional recovery of the hand.