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Everybody has a carpal tunnel. The question is: do they have enough compression to cause problems? It is very common. If you ask around to your friends, most of them will have said that at some time in their life they’ve had trouble with a numb hand that then extends up the arm. So it comes, it goes, and it’s present in many of us, but when it becomes bothersome – that’s the time to think about “what should I do about it?”
There’s been a lot of talk as to what causes carpal tunnel. Well, clearly it’s higher in women than it is in men. Probably same size nerves and tendons, but in a smaller canal. But also there were a lot of what we now call Òwives talesÓ about that if you were clerical, i.e. on a typewriter or keyboard, or if you worked as a checker in a grocery store. But now we have much better data that suggests that those aren’t the causes. Interestingly enough, probably the one common thread is that people who have repeated blunt trauma – hammers, drills, things like that – that probably increases your carpal tunnel risk. But also don’t forget bicyclists who lean on those grips on the handlebars and push on those nerves day in, day out in their training.
If you’re thinking “I’m not sleeping so well during the night because I wake up and I have to shake my hands or lean them off the bed.” Or: “Gee, when I drive for long periods of time, my hands seem to go numb.” Or “Gosh, my hand when it’s on the cell phone and I’m talking for awhile, it just doesn’t feel right.” You probably have carpal tunnel. An easy thing to do is to buy yourself a set of what are called rollerblade wrist guards and they bring the wrist up like this *Demonstrates*. They’re nylon and they’re plastic. They can be found online and they can be found in sporting goods stores. You’ll think: “I should wear them during the day.” But in reality you should wear them at night and the reason is that by resting the nerves, tendons, and the inflammation at night, you’ll improve the daytime symptoms too.
So you have carpal tunnel. What’s the first line of treatment? Generally wearing the splints at night. Different practitioners have different thoughts about the positioning of the splints, but generally wearing them at night is a good thing to start with. It’s conservative, it’s safe, it’s hard to get into trouble, and probably 40-70% of people will be made better with that.
Most physicians who see patients with carpal tunnel will order a very special test. We call it the Electrical Pins and Needles Test, but its real name is an EMG – an Electro Myogram with nerve conductions. It’s sort of like looking at an intersection and seeing how long it takes for a car to get across the intersection. The EMG looks and it sees: how long does it take for the nerve impulses to go underneath the ligament, from the wrist and into the palm? If that time is prolonged (and it can be variably prolonged – meaning some people may have it a little long, some people may have it a lot long) – that determines a degree of carpal tunnel – mild, moderate or severe. If that same test (the EMG) also shows that there are muscle cells dying, something definitely needs to be done.
Sometimes people wait too long to see the doctor for their carpal tunnel. You definitely should not wait until your hand is weak. You should not wait until the muscle mass (particularly in the thumb) is going away. If it’s keeping you up at night, don’t be afraid. See your physician and at least get started on the medical treatment with the roller blade wrist guards (the so-called carpal tunnel cockup splits.
Since carpal tunnel is a medical problem, it generally is covered by one’s insurance plan. It is medical, but different people do have different coverages with their plans. Generally a portion of it or all of it is covered.
If you are a motorcyclist and you have carpal tunnel, there are some things that you can do that will help you. Number one, make sure you’re moving those hands on those bars. That will also get good blood flow to the nerve and keep you from getting the carpal tunnel. But if you’re having troubles, you may want to wear an extra pair of fingerless gloves inside your regular riding gloves. You may want to get rid of that vibration, which seems to make the carpal tunnel worse. Get some bar ends or now there are some new snakes of metal that can be put in the handlebars that decrease the vibration. Also, with carpal tunnel and on motorcycles, you want to make sure that you’re really not leaning right where that median nerve is. That’s that crease between the base of the thumb and moving over to where you have your little finger – sort of right there in the middle. Stay off of that. Move your hands frequently.
95% of people who have a positive EMG, have a good history and come to surgery having been treated medically will do well with surgery. The recurrence risk is generally pretty low and you need to know that you need to protect your hands postoperatively. You need to wear bicycle gloves when you do things. Stay off of that incision. Don’t make that carpal tunnel come back and that way – keep it gone. Typically with many open procedures, the recurrence risks should be much less than 1%. With scope procedures, it may be as high as even 25%, but generally is much lower.
If you are pregnant and have carpal tunnel, generally your carpal tunnel it will go away after you deliver. It’s caused by the excess fluid that occurs with pregnancy. The excess fluid goes away with the delivery, the carpal tunnel goes away. Every once in a while, though, we will have to operate on a pregnant individual because the carpal tunnel is just either so painful or someone starts to have weakness.
How can you keep from getting carpal tunnel? For some people, you just can’t. You’re already predisposed. Your bony canal is small, the nerves and the tendons have a fixed size. But you can avoid making things worse. Protect your hands. If you are a laborer or you do lots of things with your hands in your time at work or your time off and your past times, get some fingerless gloves, bicycle gloves – wear them inside your regular gloves. Also try to keep whatever it is that’s pushing on that central part – just where the risk becomes the palm. You don’t want to use an awl or a work implement right there, day in, day out.
Don’t be afraid of carpal tunnel surgery. The outcomes are excellent. Generally from reputable surgeons, 95% of patients should have a successful outcome. There are a couple different ways of doing the surgery and sometimes there are new fads that come along, but generally it falls into two categories. One is what’s called mini-open. That’s a small incision (less than an inch generally) where you go down, cut the ligament, sew the skin only back together, and then the ligament regrows a lot floppier down the line. The other mechanism is to do it through a scope. The good side is that it is usually a slightly smaller incision and you’re doing the same procedure. You’re cutting the ligament, you have a small incision then to close. The downside to scopes is that the recurrence risk is higher with a scope surgery than it is with a mini-open.
The symptoms of carpal tunnel can be as varied as the patient, but clearly it must involve something in the hand and the wrist. Sometimes it can actually be painful. Sometimes it can just be numbness. Sometimes it can be a sense of clumsiness. “Can’t write those numbers in the checkbook like I used to.” “My handwriting isn’t the same.” My hand doesn’t it feel right.” Typically patients present with those symptoms at night because they’re not moving their hand well and the median nerve – that special nerve that’s in there with the tendons – isn’t getting enough blood flow and so it starts acting out.
Recovery from surgery is much quicker now with our modern techniques. I had a friend who I did his surgery, he wondered why he even took the afternoon off and wasn’t back at his auto body shop. But you can’t be out there doing the wrenches straight away. People can be back in clerical things generally within the next day, maybe a couple of days. Maybe you’ll have your surgery on a Friday and get back to work on a Monday. However, if you do landscaping and you’re the pick and shovel guy, you’re not going to want to be on the pick and shovel for really probably 6 or 8 weeks. The danger being that you’re cutting that ligament. You don’t want the tendons in the nerve to come through that ligament. So generally you best take good care if you are a physical person in your work for probably 6 to 8 weeks.
The risk of carpal tunnel after surgery should be low that it will come back. Once you’ve been operated on, it should be gone. Occasionally patients do get it back, but they do well with repeat surgery and even conservative measures.
Carpal tunnel is a common problem in the population. Many people have it. Some people need to have it addressed and seen by health professionals, but not everyone. You should not be afraid to see a health professional. There are conservative treatments as we’ve outlined, and for those for whom the conservative treatments don’t work, surgery is a very effective option.
Generally (in my experience) carpal tunnel syndrome does not improve with over the counter medications such as Ibuprofen. Generally, my suggestion for first line of treatment for carpal tunnel syndrome would be splint immobilization, activity modification, and perhaps a cortisone injection.
An electromyography (EMG) or NCV (nerve conduction velocity) – those are the two tests that are commonly used to assess for carpal tunnel syndrome. The nerve conduction velocity is simpler, it’s less painful. An EMG actually involves some electrical shocks, so it tends to be more painful, but it’s very helpful information. The EMG (electromyography) will show the function of the muscle and whether the muscles are functioning correctly. If they’re not, that can be indicative of the nerve not functioning correctly. The nerve conduction velocity itself is a different test and that actually tests the conduction of the nerve in the region where you’re concerned that it may not be flowing. It’s like a telephone cable and if for some reason the telephone cable isn’t conducting its signal, then you’re not going to get your telephone signal. Same thing with carpal tunnel. If the nerve is being compressed right here in the palm, then the signal is not going to get out to the fingers and that’s why patients present with numbness in their fingers.
Carpal tunnel is compression of the median nerve at the carpal tunnel, which is a ligament that overlies nine tendons and the median nerve in the palm. What happens is that the median nerve gets compressed by this ligament called the transverse carpal ligament, which is a ligament overlying the tendons and the nerve. With certain activities – for instance, someone working with a jackhammer or even someone just working at a desk – if their nerve gets irritated, the transverse carpal ligament can compress the nerve and cause numbness and tingling in the thumb, index finger, middle finger, and ring finger.
Carpal tunnel is most common in diabetics and women. It’s more common in pregnancy. It’s also more common in patients with thyroid disease.
The typical presentation of carpal tunnel is numbness and tingling in the thumb, index finger, middle finger, and ring finger. It generally does not present with pain. In fact, oftentimes I see patients who present complaining of hand pain and they think that they have carpal tunnel syndrome. Carpal tunnel syndrome typically does not present with pain (although it can) but classically the presentation of carpal tunnel is numbness and tingling in the thumb, index, middle, and ring fingers. The numbness and tingling can be in any of those fingers. Typically it is all of the fingers, but sometimes patients will present with isolated numbness in the middle finger or index finger, but generally it’s the thumb, index, middle, and ring finger.
Typically, carpal tunnel presents with nocturnal symptoms – meaning symptoms at night. Oftentimes patients wake up in the middle of the night and have to shake their hands out because they’re numb. Other times when the symptoms can be bothersome is working at a computer, driving, anything where your risks are flexed or extended. Because risk flexion diminishes the space available for the median nerve in the palm. And so anything like this *Demonstrates* or like this *Demonstrates*, sleeping like this *Demonstrates*, for instance, can irritate the media nerve and causes numbness and tingling in the fingers. Carpal tunnel symptoms can come and go but generally, even if they do come and go, patients present because it’s bothersome to them and it affects their quality of life and their ability to work. If you’re feeling numbness and tingling in the thumb, index finger, middle finger, and ring finger, particularly at night or when performing activities of daily living, such as driving or working at your computer, then that would be a time to consider going in to see a hand specialist to assess for carpal tunnel syndrome.
Recurrent carpal tunnel syndrome is fortunately rare. Usually after a transverse carpal ligament release, after a carpal tunnel release, patients get better and they never have a recurrence. In the rare circumstances when they do, generally I try to avoid surgery because the fact of the matter is that the data shows that in a revision carpal tunnel release the outcomes are not as good as with a primary carpal tunnel release. So generally if we can avoid going back in and having to operate a second time, that’s optimal. Generally the treatment would be: perhaps some hand therapy, perhaps a cortisone injection, maybe splinting for a period of time. If I’m concerned, I’d get a new nerve study to assess to see if there is still slowing of the median nerve at the carpal tunnel because it is possible that there could be an incomplete release of the transverse carpal ligament. That would be the most common cause of persistent symptoms after carpal tunnel release.
Carpal tunnel cannot necessarily be prevented because some people just have an anatomy that puts them at risk of developing it, even if they’re not particularly active with their hands, even if they’re not laborers or working at a computer or driving all day. Some people just (for whatever reason) their anatomy is such that they’re inclined to develop carpal tunnel syndrome. For instance, avoiding excessive risk flexion, excessive wrist extension. (*Demonstrates* This would be flexion and this would be extension.) Those are the things that would actually aggravate the median nerve at the carpal tunnel. So if you can avoid excessive risk flexion and extension, that can help prevent the symptoms from occurring.
Carpal tunnel syndrome can improve both with conservative and surgical treatment options. When a patient presents with carpal tunnel initially (depending on the severity of their symptoms) generally I would start with a period of immobilization with a wrist splint because by keeping the wrist in neutral position, that diminishes the pressure on the nerve because oftentimes patients will sleep with their wrists like this *Demonstrates* or like this *Demonstrates* or when they’re at work, their wrists will be like this *Demonstrates* or like this *Demonstrates*which aggravates the nerve. So by giving a patient a splint, that keeps them in neutral position and that can help with the symptoms. Another possible treatment option that I oftentimes do would be a cortisone injection. A cortisone is an anti-inflammatory, which you can inject into the carpal tunnel region, and that can be remarkably helpful for patients long-term. If that doesn’t help, then generally my treatment would be to get a nerve study to assess the severity of the carpal tunnel syndrome.
Generally, once a patient presents with carpal tunnel syndrome, they’re going to need some sort of treatment, whether it be conservative or surgical. Generally, I would start with a period of immobilization and oftentimes that’s all patients need is activity modification to prevent the nerve from being irritated by risk flexion and extension.
If a patient does not improve with splinting or depending on the severity of their symptoms in the carpal tunnel, one option would be to give them a cortisone injection. The cortisone injection is given into the region of the carpal tunnel. The cortisone is an anti-inflammatory and it can help settle down the inflammation in the carpal tunnel. It can be actually quite helpful for carpal tunnel syndrome. I’ve had many patients who had complete resolution of their symptoms with one cortisone injection.
Non-operative pain management options for carpal tunnel syndrome would include an anti-inflammatory, such as Ibuprofen. In my experience, it’s not particularly helpful but it certainly would be worth a try. That along with splint immobilization and perhaps a cortisone injection. In my experience, heat or ice aren’t going to help with carpal tunnel syndrome either.
Generally, if we tried conservative measures (such as splinting and a cortisone injection and maybe some anti-inflammatories) I see the patient back a month later to see how they’re doing. Usually within a month you’ll know if the symptoms are going to improve with activity modification, splint immobilization, and a cortisone injection. Generally if after a month the patient’s symptoms are the same or worse, then I would order a nerve study to assess the severity of the carpal tunnel syndrome and if it’s moderate or severe, I would suggest surgery. If it’s mild, if they wanted to try a course of additional non-operative management, then I think that would be very reasonable.
As far as home remedies for carpal tunnel syndrome, the first and foremost thing I would suggest would be activity modification. Generally, if you can avoid excessive wrist flexion and wrist extension, that alone can solve the problem – at least temporarily. A couple times in my life I’ve slept awkwardly and I’ve woken up and my fingers have been numb. I think it’s pretty common. I think it happens to probably just about everyone once in awhile and that’s the point. The point is that if you can avoid the excessive flexion or extension of the wrist, that alone can be very helpful. Another option would be just to stop by the pharmacy and pick up a splint, which will keep your wrist in neutral position and in so doing that can help with the symptoms. Those would be some things you can try before coming in to see a hand specialist.
The indications for surgery for carpal tunnel would be: thenar atrophy – meaning if a patient comes in with atrophy of these muscles here *Demonstrates* – the thenar muscles (the intrinsic, small muscles of the thumb.) If these muscles are atrophied, that’s a classic sign of severe carpal tunnel syndrome along with numbness and tingling in the thumb, index, middle, and this half of the ring finger. If a patient presents that way, that would be an indication for surgery. The problem is that once you get to that level of severe carpal tunnel syndrome, the changes to the nerve and the effects to the nerve can be permanent. Even if we do the surgery, there’s no guarantee that the symptoms will improve. Generally, when a patient presents with thenar atrophy, I tell the patient that my goal is to hopefully help with the numbness and tingling and maybe the thenar atrophy can improve, but in my experience it generally does not get better but the numbness and tingling can get better. I also tell them that it’s possible that the symptoms that they have might just not get worse – meaning that the surgery is to help it from progressing rather than actually making it better. Although obviously I’m always hopeful that it’s going to make it better, but that’s in cases of severe carpal tunnel syndrome. Moderate carpal tunnel syndrome, which would be the most common where patients don’t have thenar atrophy, they just have numbness and tingling – generally the surgical indication for that would be failure of conservative management. I would start with a splint, activity modification, and a cortisone injection. If it’s not helpful, then I would offer surgery for their carpal tunnel syndrome.
The surgery for carpal tunnel syndrome involves decompressing the median nerve at the carpal tunnel. The way I do that is that I do an open carpal tunnel release, which involves making an incision in the palm – it’s about an inch long. Under direct visualization, I wear loupes magnifying glasses so I can see the nerve clearly and make an incision right here in the palm and go down to what’s called the transverse carpal ligament, which is the ligament that’s compressing the nerve. Then I split that ligament and that decompresses the nerve. And in so doing, generally it’s a very successful procedure and patients are very happy after having it done because they can feel their fingers again. That’s the open release. There’s also an endoscopic release, which I personally do not do and that involves actually using a camera to decompress the median nerve at the carpal tunnel.
There should be no long-term consequence from splitting the transverse carpal ligament. Patients do sometimes have some post-operative pain in the region of the incision from the transverse carpal ligament release, but that’s common. One of those problems is what’s called “pillar pain”. Pillar pain is tenderness in the palm – actually not right around the incision itself, but kind of on the outside – more in the bony region of the palm. What pillar pain is, is it’s pain in those bones near the carpal tunnel after surgery. I personally do not see it that commonly (and I do a lot of carpal tunnel surgery) but it’s something that is pretty easily identifiable when patients come in after surgery and they have pain in the palm that’s not right around the surgical incision. The good news is: generally that resolves with time and perhaps with some hand therapy.
The biggest risk of surgery would be infection and that’s less than 1%. It’s very uncommon to develop an infection after carpal tunnel syndrome – although not impossible. Other possible complications would be incomplete release of the transverse carpal ligament. That’s the actual ligament that’s compressing the median nerve, and if that were not to be fully decompressed, then it is possible that the symptoms would not fully resolve. Other potential issues after surgery would include pillar pain, which is pain in the palm after splitting the transverse carpal ligament. It’s actually pain in the bony region on either side of the incision. That generally resolves over the course of weeks to months. Sometimes a course of hand therapy can be helpful for that. Another very common finding after surgery is incisional pain – meaning that the incision itself (where the procedure is done) is tender, but that generally resolves within 6-12 weeks.
Recovery from carpal tunnel syndrome is variable – it’s patient by patient – but on average I would say patients are feeling pretty darn good around the 3-month point. Generally my protocol is to have the patients come back and see me 10 days after surgery, at which time I take the sutures out, get them going with hand therapy (if they need it – I’d say about 50% of patients opt for hand therapy), and get them moving. Usually after surgery – even 10 days – patients already have noted an improvement in their sensation. Then it just takes time for the incision to heal and for the pain and tenderness in the palm to resolve. Generally that pain and tenderness resolves over the course of 6-12 weeks, but usually around the 3-month point, patients are feeling very happy with their outcome.
To the best of my knowledge, there’s nothing new on the carpal tunnel front. The biggest breakthrough since I’ve been in practice has been the endoscopic carpal tunnel release, which I personally do not perform. I prefer to see the nerve under direct visualization when I perform a transverse carpal ligament release. One of the problems with an endoscopic release is that there can be potential irritation of the nerve because you’re sticking a camera into the region of the carpal tunnel and that camera can irritate the nerve. Another possibility would be incomplete release of the transverse carpal ligament. One of the advantages that’s been found a clinically to an endoscopic carpal tunnel release is a quicker return to work and activities, but the longterm outcome – whether it be an open carpal tunnel release or an endoscopic carpal tunnel release – has been found to be the same.
Carpal tunnel is a nerve problem. It’s a place in the wrist were a nerve has to go through a tight space – a tunnel. It has friends in there. Those friends in there are the tendons. The tunnel is made up of a half-pipe (as it were) of bone on the bottom, and then a ligament over the top. Typically as we age, the bones get thicker, the ligaments get thicker and our nerve and its friends (the tendons) get tight in there. That ends up with the symptoms of carpal tunnel.
My name is Matthew Enna. I’m an orthopedic surgeon in Beverly Hills, California and I have subspecialty certification in sports medicine and hand surgery. I did my undergraduate education at Washington University in St Louis. I went to medical school at Tulane University in New Orleans. I did my orthopedic residency at Brown University in Providence, Rhode Island, and I then did a an orthopedic trauma fellowship at Brown University, followed by hand and micro surgery fellowship at UCLA. After completing my hand fellowship at UCLA in 2008, I went into private practice in Santa Barbara for three years and then I decided to open my own practice in 2012 here in Los Angeles.
The median nerve is a nerve in the upper extremity to provide sensation to your thumb, index finger, middle finger, and ring finger. It also provides motor function, meaning your ability to move and have strength in your hand. So it has motor function as well as sensory function in the hand. We’re all different anatomically. We all have slight differences in our anatomy and some patients’ anatomy is such that they’re at an increased risk for developing carpal tunnel syndrome. For instance, they may just have a smaller space available for the median nerve, so they develop carpal tunnel syndrome more easily than someone else might.
Carpal tunnel syndrome is a compression of the median nerve in the palm. It’s very common in individuals who use their hands at work – including desk work or high impact labor. It generally presents with numbness and tingling in the thumb, index, middle, and ring finger.
Carpal tunnel syndrome is a compression phenomenon of the median nerve in the palm. Arthritis is a much more general term. “Arth” meaning joint. “Itis” meaning inflammation. What arthritis is, is it’s inflammation of a joint and that can be any joint in your body. They are very distinct entities. Patients with arthritis certainly can have carpal tunnel syndrome and vice versa, but generally arthritis will present with pain and stiffness. Carpal tunnel syndrome presents with numbness and tingling in the fingers.
If a patient has neck problems, it cannot cause carpal tunnel because carpal tunnel is a disorder of the median nerve at the palm. That being said, it is possible for a patient to have what’s called a double crush phenomenon where they can have numbness and tingling in their hand and it can be both as a result of compression of a nerve in the neck as well as compression of the nerve in the palm. So that’s called a double crush phenomenon because they have the two nerves being compressed in two different areas.
Carpal tunnel flare ups can last days, weeks, or they can be permanent, in fact. Patients can come in (usually they have had it for quite some time – weeks to months) and that’s what brings them into the doctor’s office. Usually once you have it, it’s a consistent problem until you see a medical professional. It’s rare for it to come on a one time basis and then just go away.
The tests that we use frequently in the office to exhibit patience for Carpal Tunnel Syndrome include inspection of the hand – just to look at the hand. Sometimes when carpal tunnel syndrome is severe enough, patients actually have atrophy in their hand. It’s called Thenar Atrophy, meaning in the palm, in the thenar region (which is the thumb region) right here *Demonstrates* patients can have wasting of the muscles because these muscles are innervated by the median nerve and if the median nerve is compressed to severely enough, that can lead to atrophy these muscles. So that’s a very good indicator of severe carpal tunnel syndrome – if a patient comes in with numbness and tingling in their hands and wasting of those muscles. Inspection is important. Also, we use a couple classic tests including the Tinel’s test. The Tinel’s test is where we actually tap on the palm right here in the region of the carpal tunnel *Demonstrates* and by tapping there (and you can try this at home) – If you tap there and your fingers begin to tingle in the thumb, index, middle, and ring finger, then that is a sign that you may have carpal tunnel syndrome. Another test that we commonly use is called the Phalen’s test. What the Phalen’s test is, is that we actually have the patient bend their wrist, flex the wrist and hold it for 30-60 seconds and see if the patients develop numbness and tingling in the thumb, index, middle, and ring fingers. That also is a very good diagnostic test for assessing for carpal tunnel syndrome. A third test I use to assess for carpal tunnel syndrome is what’s called the compression test. What that is (and again, you can try this at home) is you just put your thumb right here, right in the palm *Demonstrates* and just hold pressure. With application of pressure, oftentimes patients with carpal tunnel syndrome will develop numbness and tingling in the thumb index, middle, and specifically the radial half of the ring finger. This half of the ring finger is innervated by the median nerve. The outer portion is actually innovated, gets sensation from the ulnar nerve, so there’s a distinction. The ring finger, is helpful as a distinguisher between the two nerves. A general practitioner/primary care doctor should be able to diagnose carpal tunnel syndrome, but most likely they would end up referring you to a hand specialist.
If you’re concerned that you may have carpal tunnel syndrome, I would suggest looking at a few things. One would be: do you have numbness and tingling in your thumb, index finger, middle finger, and this half of the ring finger? If you do, you may have carpal tunnel syndrome. Something else you could do would be just as simple as tapping your palm right here *Demonstrates*. If you tap your palm right here and you start to get tingling in your ring finger, middle finger, index finger, and thumb, you may have carpal tunnel syndrome. Another test would be just bending your wrist like this *Demonstrates* for 30 seconds, maybe a minute. If you start to develop numbness and tingling in these fingers, you may have carpal tunnel syndrome. If you do, I would suggest you see a hand specialist for further evaluation.
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