Upper extremity strain can become the uninvited guest who never leaves for people who engage in repetitive movements, extreme positions, or forceful activities involving the hand and wrist. For most, pacing activities, judiciously using ice and rest, and modifying work and leisure pursuits will be enough to decrease stress on the affected parts. But in some cases, the rate of damage outstrips the ability to heal, and debilitating symptoms can result. With carpal tunnel syndrome, repeated compression, friction, or vibration at the wrist may cause median nerve injury that results in pain, tingling, numbness, incoordination, weakness, and muscular atrophy of the hand. When caught early, physical therapy treatment strategies can help patients manage painful symptoms and regain functional use of the hand, but when carpal tunnel syndrome has advanced beyond conservative management, PTs can help postoperative patients return to home and work activities.

A Pressing Problem

The most common upper extremity entrapment neuropathy, carpel tunnel syndrome is thought to be present in up to 10% of the U.S. population.^1,2 This seemingly straightforward compression syndrome of the median nerve within the carpal tunnel may result from a series of factors, ranging from inadequate anatomical space inside the carpal tunnel to changes in the body’s fluid balance, and from underlying inflammatory or metabolic disorders to external forces such as vibration, repetition, or poor positioning.

The carpal tunnel is a narrow passageway that is bordered by carpal bones on three sides; it is enclosed at the volar wrist by the transverse carpal ligament, the flexor retinaculum proximally, and the aponeurosis between the thenar and hypothenar muscles distally. This inflexible tunnel is unable to expand in the presence of fluid retention, soft tissue thickening, mechanical end-range positioning, or inflammation, making the contents of the tunnel vulnerable to compression. The nine flexor tendons (flexor pollicis longus, the four flexor digitorum profundus tendons, and the four flexor superficialis tendons) that supply the thumb and fingers travel through the carpal tunnel, as does the median nerve, which is the most superficial soft tissue structure within the carpal tunnel (Figure 1). The flexor carpi radialis tendon, although near the carpal tunnel, travels within the flexor retinaculum and is external to the carpal tunnel, as is the palmaris longus tendon (when present).

Figure 1. Contents of the Carpal Tunnel

Source: Figure 422 – Transverse Section Across the Wrist and Digits. The Muscles and Fasciae of the Hand. In: Gray’s Anatomy of the Human Body, 20th Edition. 1918. Philadelphia; Lea & Febiger.

When the wrist moves into flexion or extension, the normally elliptical shape of the median nerve is flattened against the transverse carpal ligament and flexor retinaculum, causing increased pressure within the tunnel. Transient nerve compression produces a conduction block in the median nerve fibers that normalizes upon the release of pressure. But repeated or prolonged pressure can result in segmental demyelination of the median nerve, beginning with the more superficial sensory fibers and then affecting deeper motor fibers. 

In classic studies, resting pressures at the carpal tunnel in a neutral wrist position are typically measured at less than 10 mmHg in normal individuals; in patients with carpal tunnel syndrome, mean pressures inside the tunnel in a neutral wrist position are usually above 30 mmHg, the threshold intracarpal pressure at which blood flow inside the median nerve decreases and axonal nutrient transport is impaired.³ Intracarpal pressures of patients with carpal tunnel syndrome can rise dramatically with pinching and gripping hand activities, reaching as high as 1,151 mmHg with maximum grip.⁴ It is unclear if increased pressures inside the carpal tunnel are causative or if they occur secondary to the carpal tunnel syndrome condition; either way, abnormally high pressures in the carpal tunnel, particularly when sustained or repeated, contribute to obstructed blood flow, back pressure that aids in the formation of edema, and ischemia of the median nerve.⁵ It is thought that median nerve ischemia is the cause of pain associated with carpal tunnel syndrome, rather than direct trauma to the nerve.⁶

Experts agree that carpal tunnel syndrome is most commonly caused by chronic, repetitive stresses on the median nerve within the carpal tunnel. But these stresses may be generated from a wide variety of factors: The carpal tunnel may be anatomically narrow, increasing the risk of positional nerve compression within an already crowded space; space-occupying structures such as tendons thickened from tenosynovitis or osteophytes formed after a traumatic injury may be present, encroaching on the tunnel; comorbid metabolic or inflammatory conditions may predispose the patient to compressive neuropathies; the patient may be retaining fluid due to pregnancy, kidney disease, or obesity; and there may be mechanical threats to the median nerve from direct pressure, poor positioning, or forces of vibration. There may also be a genetic predisposition for carpal tunnel syndrome. It is thought that carpal tunnel syndrome is most commonly triggered by chronic tenosynovitis of the flexor tendons that results in inflammation of the tendon sheaths and thickening of the tendons, clogging up the inflexible carpal tunnel and causing the characteristic symptoms of pain, tingling, and numbness.⁷

That Tingling Feeling

Because carpal tunnel syndrome is an impairment of initially sensory and then motor function of the median nerve, classic symptoms include pain, tingling, and numbness in the anterior palm, hand, and at least two of the radial three and a half digits (the thumb, index, middle, and radial side of the ring finger). Since the median nerve carries many autonomic nerve fibers to the hand, autonomic symptoms that affect the entire hand may also be present, resulting in sensations of hot and cold or changes in skin color or sweating response. With carpal tunnel syndrome, the most common patient complaint is a hand that “falls asleep” frequently and inadvertently drops objects. A hallmark symptom of carpal tunnel syndrome is tingling that wakes the patient at night but may be eased when shaking the hand and wrist (flick sign); it is thought that the nighttime pooling of fluids contributes to congestion at the carpal tunnel. When pain is present, it may be characterized as diffuse, deep, aching, or throbbing; it is typically restricted to the hand, but it may radiate up the forearm toward, but usually not crossing, the elbow. In mild cases, carpal tunnel syndrome may manifest as intermittent episodes of tingling, pain, and altered sensation. There may be a subjective sense of swelling at the wrist and palmar surface of the hand, which makes wearing rings and watches uncomfortable. As carpal tunnel syndrome progresses, symptoms occur more frequently until they become constant and are associated with atrophy of thenar muscles, especially the abductor pollicis brevis, although the opponens pollicis, flexor pollicis brevis, and the two radial lumbrical muscles may also be affected. Consequently, weakness and clumsiness may be present, especially with gripping activities that require the use of the thumb and fine motor tasks involving a pinch grip, such as when picking up small objects or tying shoelaces.

Overall, women are three times more likely than men to be affected by carpal tunnel syndrome,⁸ which is most commonly diagnosed between the ages of 30 and 60.⁹ Other risk factors include underlying diabetes mellitus, thyroid dysfunction, fluid retention during pregnancy or menopause, Raynaud’s disease, hypertension, renal failure, and autoimmune disorders such as rheumatoid arthritis and systemic lupus erythematosus. In such cases, carpal tunnel syndrome may be present bilaterally, although the dominant hand is typically more severely affected; sometimes, carpal tunnel syndrome is the first outward manifestation of underlying disease processes. Increased body mass index appears to be an independent risk factor, particularly in patients younger than age 63.¹⁰

Leisure activities that require repeated hand movements that involve the finger flexors, such as playing musical instruments or cooking, may also place individuals at higher risk. Those who enjoy bicycling and motorcycling are also vulnerable to carpal tunnel syndrome from the transmission of road vibration through the hands. Lifestyle factors such as smoking, using large quantities of salt in food preparation, and a sedentary lifestyle are associated with carpal tunnel syndrome due to the vascular effects of such practices, which may reduce blood flow or promote fluid retention.

Individuals working in hands-on occupations (e.g., manual therapists, dental hygienists, construction workers, and manufacturing laborers) are at increased risk for carpal tunnel syndrome. In a study of construction workers, those with carpal tunnel syndrome had a higher proportion of exposure to work tasks that involved forceful gripping, using the fingers in a pinch grip, using the fingers or thumb as a pressing tool, repeatedly lifting two or more pounds, and using vibrating hand tools.¹¹ Carpal tunnel syndrome is three times more common in individuals employed in assembly line work than in computer users, including manufacturing, cleaning, sewing, and meat, poultry, and fish packing settings.¹²

It remains uncertain if frequent computer users are more at risk than the general population to develop carpal tunnel syndrome; in a study of Mayo Clinic employees who used the computer for up to seven hours each day, there was no statistically significant evidence to suggest that those who keyboard frequently are more vulnerable to carpal tunnel syndrome than anyone else.¹³ Although keyboarding is not necessarily linked to carpal tunnel syndrome, there does appear to be a mild association between using a computer mouse for more than 20 hours per week and the development of carpal tunnel syndrome.¹⁴

Exploring the Tunnel

The diagnosis of carpal tunnel syndrome is made through a combination of patient history and physical examination, clinical tests, and diagnostic studies. The physical examination should include an evaluation of the hand, wrist, elbow, shoulder, and neck to rule out alternative causes of nerve compression and the possibility of referred spinal pain, particularly from the cervical nerve roots. The PT must remain aware that carpal tunnel syndrome may not be present in isolation, but it can occur in conjunction with cervical or thoracic outlet pathology that results in “double crush syndrome,” a condition in which a peripheral nerve is compressed at more than one location. A postural assessment should be performed in sitting and standing positions, and the patient must be questioned about sleeping postures.

Physical examination of the wrist should include observation of deformity (lipoma, ganglion cyst), discoloration, swelling, warmth, and tenderness. Sensation may be examined with light touch, two-point discrimination testing, Semmes-Weinstein monofilament testing, and pinprick tests. Sensation at the thenar eminence should be intact, as this is supplied by the cutaneous branch of the median nerve, which passes into the hand external to the carpal tunnel. Manual muscle testing should be performed and compared to the uninvolved side, and may reveal weakness of the wrist flexors, finger flexors, and thumb adductors and abductors. In the hand, muscular atrophy and weakness of the “LOAF” muscles may be discovered with advanced cases of carpal tunnel syndrome. Grip and pinch strength should be obtained with the handheld dynamometer and compared to the uninvolved side.

 

Although a thorough physical examination is important to help with differential diagnosis of other neurological or musculoskeletal disorders, provocative clinical tests may also be useful. Commonly performed clinical tests for carpal tunnel syndrome include the Tinel sign, Phalen sign, carpal compression test, and square wrist sign. 

With the Tinel sign, the examiner gently taps the median nerve at the wrist (median nerve percussion) to determine if a tingling sensation is elicited in the median nerve distribution. Although the Tinel sign is widely associated with carpal tunnel syndrome diagnostics, its accuracy as a diagnostic tool is questionable as it may not be present until significant axonal demyelination has occurred in moderate to severe cases of carpal tunnel syndrome.¹⁵ In one study of patients with confirmed carpal tunnel syndrome that resolved with surgery, only 25% of individuals under the age of 35, and 45% of individuals ages 35 and older, exhibited a Tinel sign.¹⁶ 

The Phalen sign is obtained by asking the patient to place the backs of the hands together, positioning the wrists at 90 degrees of flexion for up to one minute — a positive test is one in which tingling symptoms are reproduced. This test is one of the more sensitive and specific clinical tests for carpal tunnel syndrome.¹⁷ A reverse Phalen test, performed with the wrists positioned in 90 degrees of extension with the palms together (the “prayer” position), may also be positive in the presence of carpal tunnel syndrome. Although the Phalen test position is typically sustained for one full minute, a test interval of only 30 seconds is significantly correlated with both distal sensory and motor latency as observed on nerve conduction studies, and demonstrates good sensitivity for carpal tunnel syndrome.¹⁸ 

The examiner performs the carpal compression test by applying firm thumb pressure directly over the carpal tunnel for up to 30 seconds. Again, a positive test is one that reproduces tingling and pain in the median nerve distribution. As compared to the Tinel and Phalen tests, the carpal compression test is thought to have high reliability for carpal tunnel syndrome.¹⁹ 

The square wrist sign, although not a provocative test, has moderate sensitivity and specificity for carpal tunnel syndrome. It may be calculated as a ratio of wrist thickness (anterior-posterior dimension) divided by wrist width (medial-lateral dimension) as measured at the distal wrist crease: A ratio greater than 0.7 designates a “square wrist” that is associated with an increased risk of carpal tunnel syndrome, presumably because a relatively narrow wrist allows less room for the contents within the carpal tunnel.²⁰ 

Despite their widespread use, clinical tests such as those described above can only give brief insight into the true state of the median nerve. Objective clinical information about the status of sensory and motor median nerve fibers may be obtained by electrophysiologic studies, which are considered the diagnostic standard by the American Association of Electrodiagnostic Medicine, the American Academy of Neurology, and the American Academy of Physical Medicine and Rehabilitation.²¹ 

Because the sensory component of the median nerve is affected earlier in the disease progression of carpal tunnel syndrome than the motor component, patients undergoing nerve conduction velocity testing may be categorized according to the amount and type of nerve damage. When the speed of electrical impulses along the median nerve is slowed at the carpal tunnel, the diagnosis can be confirmed. Patients with mild carpal tunnel syndrome will exhibit solely sensory abnormalities, and those with moderate carpal tunnel syndrome will display both sensory and motor abnormalities. With severe carpal tunnel syndrome, patients will also demonstrate evidence of axonal loss in response to measurements of nerve conduction velocity and electromyography testing.

Medical and Surgical Management

Treatment for carpal tunnel syndrome is dependent on severity and typically involves a blend of nonsurgical and surgical approaches. In patients with mild to moderate carpal tunnel syndrome who have minor changes with nerve conduction studies and no overt thenar muscle atrophy, positive outcomes may be achieved with a combination of medication, local corticosteroid injections, and rehabilitation techniques that may include local modalities, carpal bone mobilization, wrist splinting, instruction in workplace modifications, and exercise.²²

In October 2008, the American Academy of Orthopaedic Surgeons released updated evidence-based guidelines for the treatment of carpal tunnel syndrome.²³ In the “AAOS Clinical Guidelines on the Treatment of Carpal Tunnel Syndrome: Summary of Recommendations,” conservative treatment, including splinting, ultrasound, and cold modalities, is indicated in conjunction with medical management such as oral and injected corticosteroids; use of heat therapy is contraindicated, perhaps because the potential pooling of fluids within the confines of the carpal tunnel may contribute to local congestion and increased median nerve compression. If carpal tunnel syndrome symptoms fail to resolve within two to seven weeks of treatment, an alternative nonsurgical approach should be considered. However, early surgery may be necessary in cases of documented median nerve degeneration.

Although carpal tunnel syndrome is not usually considered an inflammatory condition, there can be an inflammatory component to cases with underlying flexor tenosynovitis, one of the most common causes. Consequently, first-stage medical management of patients with carpal tunnel syndrome frequently includes oral nonsteroidal anti-inflammatory medications or oral corticosteroid medications. In some cases, diuretic medications may also positively influence carpal tunnel syndrome symptoms that are aggravated by swelling in the carpal tunnel.

Corticosteroids injected directly into the carpal tunnel may also be helpful in reducing symptoms associated with mild carpal tunnel syndrome, and studies show that direct injection provides superior short-term outcomes as compared to oral steroid medications; however, repeating a second injection does not appear to yield significantly increased benefits.²⁴ Patients with mild carpal tunnel syndrome (intermittent symptoms, minor nerve conduction velocity test abnormalities) respond well to local injections of glucocorticoids, and in one study 93.7% of 48 individuals with carpal tunnel syndrome reported significant improvement in symptoms, function, and nerve conduction velocity at three months post-injection, and 79% still enjoyed improved symptoms at 12 months after the injection.²⁵ In a Spanish study of 163 wrists, researchers found that local injection of corticosteroids was as effective as surgical decompression in alleviating carpal tunnel syndrome symptoms at one-year follow-up.²⁶ Local steroid injection may be appropriate as an intermediate step before considering surgery or in cases where surgery is undesirable, such as during pregnancy, but it is most commonly used as an adjunct to conservative care that includes physical therapy, workplace modifications, splinting, and exercise. 

Patients with moderate to severe carpal tunnel syndrome as evidenced on electrophysiologic testing and those with deteriorating hand function and thenar muscle atrophy may require surgery to decompress the median nerve at the carpal tunnel (carpal tunnel release). Although surgical intervention is considered a treatment option of last resort, surgical outcomes are generally good. Carpal tunnel release surgery may be performed via an open incision or endoscopically, with the goal of opening the roof of the carpal tunnel to allow more space inside for the median nerve and flexor tendons. Benefits of the open approach include faster operative time and a clear visual field, which allows superior visualization of anatomic structures and low complication rates — a recent study of 32 open surgeries found that 88% of patients experienced good outcomes of improved symptoms and hand function.²⁷ Benefits of the endoscopic approach include less postoperative discomfort and tissue damage and earlier return to work, but this approach requires greater surgical skill and carries a higher rate of reversible nerve injury complications. However, studies of endoscopic and open carpal tunnel release surgeries show that ultimately both methods are equally effective in resolving symptoms of carpal tunnel syndrome, with 8% of open release patients and 7% of endoscopic patients requiring repeat surgery by five years after the first surgical procedure was performed, due to recurring or persisting symptoms.^28,29 A technique to stretch the transverse carpal ligament via insertion and inflation of a balloon catheter via a small incision, percutaneous balloon carpal tunnelplasty, is still considered experimental. 

Regardless of the surgical approach chosen, the majority of patients experience nearly immediate relief of pain and tingling symptoms following surgery, but in up to 38% of patients, pillar pain (tenderness at the hook of the hamate and trapezial ridge where the transverse carpal ligament attaches) may transiently develop.³⁰ It is thought that in such cases, the inflammatory reaction associated with normal wound healing causes autonomic irritation of palmar nerves that can be resolved with an injection of local anesthetic.

Following open carpal tunnel release surgery, postoperative use of a bulky bandage to protect the surgical site combined with early physical therapy to restore manual dexterity and strength is recommended, as opposed to postoperative splinting and immobilization, to shorten recovery time and reduce pain scores.³¹ Following endoscopic surgery, formal physical therapy may not be necessary to speed recovery unless complications arise; one study demonstrated no significant differences in grip and pinch strength, pain scores, or time to return to work in patients receiving postoperative hand therapy versus controls.³² Recent analyses of research comparing surgical versus nonsurgical approaches for carpal tunnel syndrome reveal that for patients with moderate to severe carpal tunnel syndrome, surgical treatment is significantly better in relieving symptoms than conservative treatment, such as splinting.³³ In general, physical therapy can do the most good to alleviate mild to moderate symptoms of carpal tunnel syndrome by heading it off at the pass before it becomes entrenched and threatens to create more permanent nerve damage.

Rehabilitation for Recovery

Successful rehabilitation for the patient with mild to moderate carpal tunnel syndrome includes a variety of treatment strategies that focus on reducing inflammation, enabling smooth tendon gliding, restoring normal carpal mobility, and facilitating good functional use of the hand. As with most conditions, patient education is paramount to identify and modify aggravating activities, postures, sleep positions, and workstation parameters that may contribute to painful symptoms. Critical factors include avoidance of repetitive wrist and hand movements, awkward end-range positioning of the wrist in extreme flexion or extension, exposure to sources of vibration, and sustained gripping. Patients must be instructed to increase their awareness of how tightly they grip pens and pencils while writing and cell phones while talking, and how heavily they touch the keyboard while working on the computer. Ergonomic instruction to retrain patients to use the keyboard with less force, hold the mouse lightly, and minimize scrolling activities is important to reduce underlying flexor tenosynovitis and inflammation at the carpal tunnel. To avoid direct carpal compression, wrist rests should be used only briefly when pausing from typing, instead of as a permanent support during keyboarding. In addition, workstation and tool setup should be assessed to determine the optimal positioning of frequently used objects, and posture must be examined to facilitate a neutral wrist position to help minimize pressures at the carpal tunnel. It is also important to teach patients to pace activities in order to reduce flexor tendon strain that may exacerbate carpal tunnel syndrome and to embrace lifestyle changes if they need to lose weight, since increased body mass index is an independent risk factor for carpal tunnel syndrome. In general, patients with carpal tunnel syndrome should be encouraged to participate in some form of aerobic activity (e.g., stationary bicycle, treadmill, elliptical trainer) to enhance total body circulation.

In conjunction with medical management, standard conservative treatment for carpal tunnel syndrome begins with splinting to prevent positions of extreme wrist flexion and extension and to reduce pressures within the carpal tunnel, particularly at night. In a recent four-week study of patients with mild to moderate carpal tunnel syndrome, those placed in a neutral angle wrist splint each night had better reduction in symptoms than those who wore a cock-up splint.³⁴ However, there is moderate evidence that splints worn full-time, rather than just during the night, for several weeks may be best to reduce carpal tunnel syndrome symptoms³⁵; in general, splinting is most effective when done within the first three months of symptom onset.

The positive effects of splinting for mild to moderate cases of carpal tunnel syndrome may be augmented by other therapies, including therapeutic ultrasound and certain forms of manual therapy. In a study comparing various combinations of splinting, ultrasound therapy, and nerve and tendon gliding exercises, symptomatic improvement was superior in the group receiving all three interventions, with lasting effects for as long as eight weeks after the conclusion of therapy.³⁶ Yet the usefulness of nerve and tendon gliding exercises remain unclear, as some studies show weak benefits and others show no effect at all.^37,38 This may in part be due to differences in therapist technique: Nerve gliding exercises that inadvertently elongate the nerve bed can increase strain and tension on the already damaged median nerve, and care must be taken to slide the nerve through the carpal tunnel without elongating the nerve itself; this may be achieved with selective, careful wrist and elbow movements to retain slack along the neural pathway.³⁹

Other manual techniques used by PTs are under investigation to prove their effectiveness. One such treatment technique involves mobilizing the carpal bones in an attempt to normalize the pressures within the carpal tunnel, help disperse intraneural edema, restore normal accessory gliding of the carpal bones, and stretch the transverse carpal ligament and flexor retinaculum. While research on this approach is scant, one small study comparing carpal mobilization with neural mobilization demonstrated a significant benefit for patients with carpal tunnel syndrome who received manual therapy of either kind, as compared to those who did not receive hands-on care at all.⁴⁰

Other methods to relax the transverse carpal ligament have been attempted, including assisted stretching techniques and soft tissue mobilization. One technique, based on a classic study from 1999, in which the patient gently self-mobilizes the hand by squeezing the distal metacarpal heads together using the opposite hand, produces transient relief of symptoms by indirectly causing the transverse carpal ligament to slacken and open the narrowed carpal tunnel.⁴¹ Similarly, briefly touching the tips of the thumb and little finger together can bring about a slackened transverse carpal ligament, if done in a relaxed manner. Anecdotally, many therapists recommend that any stretching of tight forearm flexor muscles should be performed while maintaining a neutral wrist position in order to avoid increasing pressures within the carpal tunnel — this may be achieved by stretching the fingers and thumb into extension while maintaining a neutral wrist. As always, exercise instruction must be modified and adjusted according to individual response. Direct soft tissue mobilization, when targeted to the carpal tunnel, may help relax tight thenar and hypothenar muscles and stretch the flexor retinaculum, and in one study resulted in increased grip strength by the seventh therapy session.⁴² Another study found that soft tissue mobilization, whether performed with the therapist’s hands or with Graston instruments, resulted in improved nerve conduction latencies, wrist strength, and range of motion that was maintained by three-month follow-up.⁴³ Other therapists attempt to stretch the transverse carpal ligament and flexor retinaculum by using hand traction devices such as the C-TRAC, a pneumatic inflatable three-point leverage system, which in one small study resulted in decreased pain, tingling, and numbness in 79% of 15 patients.⁴⁴

Although there is a long list of treatment techniques that have yet to be proven effective and carry no recommendation by the American Academy of Orthopaedic Surgeons either for or against their use, there is evidence that some physical therapy modalities, such as pulsed ultrasound and, increasingly, low-level laser therapy may be useful in certain cases to reduce symptoms, improve nerve conduction latencies, and increase grip and pinch strength in patients with carpal tunnel syndrome.^{45,46,47,48,49,50} Research is ongoing, but there is a critical need for additional studies to focus on establishing the most useful parameters for therapeutic ultrasound and also to substantiate the efficacy of many other commonly used treatment modalities for which there is currently insufficient evidence. In the interim, as any good PT knows, treatment must be rendered according to the clinical judgment of the therapist and the response of the individual patient.

AAOS Clinical Guidelines for Carpal Tunnel Syndrome
Inconclusive Evidence For or Against Lifestyle Changes and Medical Treatments	Inconclusive Evidence For or Against Physical Therapy Treatments and Modalities
Activity modification Acupuncture Cognitive behavioral therapy Exercise, fitness Medications (anticonvulsants, antidepressants, diuretics, NSAIDs) Nutritional supplements, vitamin B6 Smoking cessation Stretching, yoga Systemic steroid injection Weight reduction	Cold laser Electrical stimulation Graston instrument-assisted therapy Iontophoresis Laser Magnet therapy Manipulation Massage therapy Phonophoresis Therapeutic touch

Source: AAOS Clinical Guidelines on the Treatment of Carpal Tunnel Syndrome. Available at: http://www.aaos.org/news/aaosnow/oct08/clinical3.asp

Light at the End of the Tunnel

Carpal tunnel syndrome, one of the most common peripheral neuropathies, is characterized by numbness and tingling paresthesias, pain, and weakness in the median nerve distribution of the hand. If left untreated, this life-altering diagnosis may result in progressive nerve damage, disability, and loss of hand function. Because carpal tunnel syndrome may be associated with other underlying metabolic or inflammatory disorders or confused with cervical radiculopathy, a comprehensive workup that includes electrophysiologic testing is necessary for accurate diagnosis. When caught early, mild to moderate cases of carpal tunnel syndrome are amenable to physical therapy treatment with instruction in activity modification to reduce extreme forces and positions, vibration, and repetitive activities through the hand and wrist, in conjunction with splinting the wrist in a neutral position to ensure low carpal tunnel pressures.⁵¹ Patients with moderate to severe cases may require surgical decompression to ultimately alleviate their symptoms. Overall, significant long-term symptom improvement (“cured” or “much improved” status) can be obtained in more than two-thirds of patients treated nonsurgically and in more than 90% of those treated surgically.⁵² Together with physicians, PTs help patients with carpal tunnel syndrome to regain strength, improve sensation, and restore functional abilities that enhance quality of life. When identified and treated promptly, carpal tunnel syndrome is amenable to physical therapy intervention, which may preclude the need for carpal tunnel release surgery; however, if surgical decompression becomes necessary, physical therapy can reduce postoperative recovery time and hasten the return to work and play.