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Carpal Tunnel Syndrome: Chronic Overuse and Clinical Management

Although CTS is still largely considered to be an idiopathic syndrome, there are numerous factors that have been associated with its development. Inside differential diagnoses and pain management.

This overview is part of a Chronic Overuse Injuries Primer. View the introduction.
 

History/Pathogenesis

Carpal tunnel syndrome (CTS) is a common symptomatic compression neuropathy of the median nerve at the wrist. CTS is frequently responsible for pain, paresthesia, and weakness of the hand-wrist region. Symptoms typically present at the palmar aspect of the first to third phalanges, as well as the radial side of the fourth phalange.

CTS usually occurs when there is an increase in interstitial pressure within the carpal tunnel, decreasing the diameter of the tunnel, increasing the pressure of the carpal bones and transverse carpal ligament on the median nerve, and producing the symptoms associated with CTS. Associated symptoms are likely exacerbated by tasks that require the wrist remain in a fixed, non-neutral position for an extended period, such as holding a telephone or driving. CTS is becoming more common with the ubiquitous presence of technology and computers in the workplace.1-7

Prevalence/Epidemiology

CTS is the most common upper extremity entrapment neuropathy, accounting for 90% of all entrapment neuropathies. It is estimated that CTS affects approximately 3.8% of the general population, with a prevalence rate of up to 9.2% in women and 6% in men. The peak age range of those affected is 40 to 60 years.5,8-11

Image: iStock (ruizluquepaz)Neuropathic factors, as well as related conditions, need to be considered when diagnosing carpal tunnel syndrome.

Signs/Symptoms

Paresthesias and weakness in the radial three and half digits of the hand. Increased symptoms with repetitive movements. Nocturnal symptomatology is very common. Pain may radiate proximally.

High Risk Activities for Carpal Tunnel Syndrome

  • Activities involving repetitive and/or forceful use of the hands. Sports activities include gymnastics, weightlifting (especially Olympic style), racquet sports, cycling, rowing, baseball, and golf.
  • People in occupations such as working on an assembly line or operating a keyboard are at risk of CTS. CTS is also commonly seen in occupations that frequently utilize vibrating hand tools.3,12

Related Conditions or Risk Factors

Although CTS is still largely considered to be an idiopathic syndrome, there are numerous factors that have been associated with the development of CTS.

Factors that increase the risk of developing CTS through increasing the occupied volume of the carpal tunnel inside or outside of the nerve through means of fluid, obstruction:

  • Pregnancy
  • Menopause
  • Obesity
  • Renal failure/hemodialysis
  • Hypothyroidism
  • Use of oral contraceptives
  • Congestive heart failure
  • Tumors
  • Autoimmune disease (eg, rheumatoid arthritis)
  • Wrist fracture/dislocation/deformity

Neuropathic factors, which affect the actual median nerve without necessarily increasing the pressure within the tunnel include:

  • Diabetes
  • Alcoholism
  • Toxin exposure
  • Vitamin deficiency/toxicity

Other risk factors associated with an increased risk of developing CTS:

  • Age–increased age associated with increased risk
  • Heredity—smaller carpal tunnels can be genetic
  • Gender—Women are 3 times more likely to develop CTS.5,13-14

Physical Exam

The clinician should look for positive Tinel’s sign—tingling in the thumb, index, middle finger and the radial half of the fourth digit after tapping over the median nerve at the wrist/midpalmar segments; and positive Phalen’s sign—wrist flexion for 45 to 60 seconds will reproduce paresthesias in the classic median nerve distribution. Two-point sensory discrimination should be evaluated in the neurological examination. Advanced cases of CTS will show thenar muscular loss or wasting.

Diagnostic Tests

If indicated by the Signs/Symptoms listed above or any progressive weakness, unremitting numbness/tingling, or persistent paresthesias noted in the physical exam, evaluate with baseline x-rays, MRI, musculoskeletal diagnostic U/S testing, or bone scan testing, or EMG/NCS testing (especially with relative sensory latency differences).

Differential Diagnosis

Several conditions can be considered for differential diagnosis. The diagnosis will vary depending on the patient’s symptomology. Possible candidates include those with:

  • Cervical radiculopathy
  • Thoracic outlet syndrome
  • Pronator teres syndrome
  • Anterior interosseous syndrome
  • Ulnar neuropathy
  • Radial neuropathy

Prevention

Clinicians can advise patients to take breaks from extended periods of hand use and to stretch their wrists. To help patients avoid constant or repeated flexion and extension, suggest aids to maintain neutral wrist position. Sleeping with straight wrists can help prevent CTS. Advise patients on use of a wrist splint or brace to help maintain desired neutral position.

Acute Treatment

Conservative treatments include wrist splinting in neutral positioning—especially nocturnal splinting—relative rest, work modifications, physical/occupational therapy, and NSAIDs. Clinicians may consider localized carpal tunnel steroid injections for some patients.

Long-Term Treatment/Rehab

CTS can be treated with both nonsurgical and surgical approaches. The treatment method is often directed by the severity of the case, with surgical intervention reserved for severe cases and those who are unresponsive to approximately 6 weeks of conservative treatment.

Conservative treatment methods for CTS should consist of splinting, local corticosteroid injections, physical therapy, carpal bone mobilization, therapeutic ultrasound, and yoga. Local corticosteroid injections can be used for temporary relief or to prolong the need for surgery. When surgical intervention is indicated, outcomes are very good. Surgical median nerve decompression has proven to have excellent, long-lasting outcomes in 70% to 90% of cases.5,14-17

Practical Takeaways

  • Carpal tunnel syndrome is a common symptomatic compression neuropathy of the median nerve at the wrist. CTS is frequently responsible for pain, paresthesia, and weakness of the hand-wrist region.
  • CTS is the most common upper extremity entrapment neuropathy, accounting for 90% of all entrapment neuropathies. It is estimated that CTS affects approximately 3.8% of the general population, with a prevalence rate of up to 9.2% in women and 6% in men. The peak age range of those affected is 40 to 60 years.
  • The physical exam for CTS should include Tinel’s sign (tapping over the median nerve at the wrist/midpalmar segments reproducing symptoms); Phalen’s sign (wrist flexion for greater than 45 to 60 seconds reproducing paresthesias in the classic median nerve distribution).
  • Conservative treatments with wrist splinting in neutral positioning, especially nocturnal splinting, relative rest, work modifications, physical/occupational therapy, and NSAIDs. May consider localized carpal tunnel steroid injections.
  • For severe cases, surgical median nerve decompression has proved excellent, with long-lasting outcomes in the vast majority of cases.
Additional chronic overuse injuries in this primer:
Last updated on: May 29, 2020
Continue Reading:
Plantar Fasciitis as an Overuse Injury
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