Carpal tunnel syndrome may be defined as paresthesia itching, numbness, tingling sensation, and weakness in the inner side of the hand and carpal and metacarpal region due to compression of the median nerve that passage inner side of the wrist surrounded by the bones and the strong, fibrous band of connective tissue, and it is covered by a tendon called the flexor retinaculum. The median nerve origin from the brachial plexus and it is running the whole length of arms to the medial side of the elbow to goes through the wrist and up to the thumb, index, and middle finger of the hand.
Causes of Carpal Tunnel Syndrome
- Overextending or overusing the wrist joints sometimes plays a vital role. This may happen for instance or suddenly, put too much pressure on your wrist, or overstretch or twist it.
- Repetitive activities or working such as typing, writing, counting money, messenger massaging, android phone playing, and jackhammer actions of the hand or wrist which makes the wrist vibrate a lot, can also cause the tissue to swell.
Prolonged compression may cause median nerve injury through demyelination in older age.
Direct injury to the nerve through persistent scarring of the outer layer (mesovarium) leads to fibrosis tissue formation.
Abnormalities in synovial tissue in the wrist due to accident, trauma, that may increase the pressure over the median nerve.
Inflammation due to osteomyelitis, osteonecrosis in wrist results from increased pain expression of prostaglandin E2 and stimulate vascular endothelial growth factor.
- Cervical radiculopathy (especially C6/7) – It is looking for local neck pain on movement and neurological signs outside of the distribution of distal median nerve
- Ulnar neuropathy – It can be produced nocturnal paraesthesias; the distribution will usually be to the medial side of the hand that causes carpal tunnel syndrome
- Osteoarthritis of the metacarpophalangeal joint of the thumb – It is one of the most common causes of carpal tunnel syndrome and it can produce a spurious appearance of thenar muscle wasting with weakness or sensory deficit.
- Tendonitis – specific tests may help in diagnosis, such as Finkelstein’s test for De Quervain’s tenosynovitis
- Generalised peripheral neuropathies
- Motor neurone disease
- Multiple sclerosis
- Raynaud’s phenomenon
Symptoms of Carpal Tunnel Syndrome
Abnormal sensations and pain – It is the first symptoms of carpal tunnel syndrome that are felt the paresthesia, itching, numbness and pins and needle sensation in the parts of hand thumb.
- Acute and chronic pain – Pain in the thumbs and middle three fingers.
- Radiating pain – Radiating pain and tingling sensation in middle three fingers and thumb is the 2nd major symptoms of carpal tunnel symptoms. Sometimes the total hand in the medial side from the arms to radiate into forearms and finger of the hand.
- Morning and night pain – It is basically an increase in the night, travelling, and thrust force due to abnormal posture of the spine and gradually decreases after rest.
- Shaking hands – Most often pain may increase after handshaking.
According to the American Academy of Neurology’s guidelines, the symptoms are
- Pain and dull, aching discomfort in the hand, forearm, or upper arm
- Paraesthesias, itching in the hand
- Weakness or at the same time clumsiness of the hand may be feeling
- Dry skin, swelling, pain or colour changes in the hand in working times or travelling.
- Acute or chronic pain occurs in the distribution of the median nerve.
- Provocation or symptoms may increase in sleep time
- Increase pain and paresthesia of by sustained hand or arm positions change
- Provocation of symptoms by repetitive working such as typing, writing, counting money, messenger massaging actions of the hand or wrist
- Mitigation or transfer of symptoms by changing hand posture and position or shaking the wrist.
- The painful feelings may increase in reduction of gripping strength, hand function and pain in the hand, numbness, and tingling in the distribution of the thumb, index finger, middle finger, and the radial side of the ring finger [rx].
Diagnosis of Carpal Tunnel Syndrome
- The physical examination of the hands, arms, shoulders, and neck can help determine if the person’s complaints are related to daily activities or to an underlying disorder or problem. The wrist is examined for tenderness, swelling, warmth, and discolouration. Each finger should be tested frequently for sensation and the muscles at the base of the hand should be examined for strength and signs of spams and atrophy.
- Observe skin for lesions, swelling, or colour change that seen in the inner forearms muscle pain
When palpating over the compartment, you are observing temperature, tension, tenderness
Check pulses, blood pressure, temperature
Evaluate two-point discrimination and sensation
Evaluate the motor and sensory function of the elbow joint and wrist joints
Pain when getting out of bed
Inability to keep hand for a prolonged time
Tinel test – It is a manual test that is examined by your doctor’s taps on or presses on the median nerve in the person’s wrist. The test is considered positive when tingling in the fingers or a resultant shock-like sensation occurs.
The Phalen, or wrist-flexion, test -In this case, involves having the person hold his or her forearms upright by pointing the fingers down and pressing the backs of the hands together at the same time. Carpal tunnel syndrome is suggested if one or more symptoms, such as tingling or increasing numbness, is felt in the fingers within 1 minute. Doctors may also ask individuals to try to make a movement that brings on symptoms.
- Laboratory tests – Leukocytosis is one of the most important tests for carpal tunnel syndrome that supports the possibility of infection and bone-related disease. Blood cultures, urine examination, or other possible primary sites of carpal tunnel syndrome, a bone infection that obligatory when a septic infectious in wrist joint is being considered for examination. The and elevated inflammatory condition markers like ESR or CRP include suggesting an infectious or inflammatory disease condition of the carpal tunnel syndrome.
- A serum uric acid level – It is often considered by clinicians and doctors when got carpal tunnel syndrome is suspected, but it is not a reliable and dangerous condition as it may be spuriously elevated or high in acute inflammatory conditions or acutely during a or not
- Random blood glucose – The reference values for a normal random glucose test in an average adult are 80–140mg/dl (4.4–7.8 mmol/l), between 140-200mg/dl (7.8–11.1 mmol/l) is considered pre-diabetes, and ≥ 200 mg/dl is considered diabetes according to ADA guidelines you should visit your doctor or a clinic for additional tests to over sure.
- Ultrasound – It is basically done to investigate the thickness of the fascia, ligament injury with wrist joint are likely to have a thickened tendon with the associated fluid collection and that thickness values >4.0 mm that are the diagnostic of in carpal tunnel syndrome [rx]
- Electrodiagnostic tests – may help confirm the diagnosis of CTS. In a nerve conduction study, electrodes are placed carefully on the hand and wrist. Small electric shocks are applied and the speed with which nerves transmit impulses is measured with a record to compare with non-carpal tunnel syndrome. In electromyography, a fine needle is inserted into a muscle; electrical activity viewed on a screen can determine the severity of damage to the median nerve.
- MRI – It can help you to show the abnormal size of the median nerve. Magnetic resonance imaging (MRI) can show the anatomy of the wrist, tendons, cartilage, ligament injury, nerve injury, bone fracture, muscular contracture.
Treatment of Carpal Tunnel Syndrome
The treatment of carpal tunnel syndrome are
- Splinting – The initial treatment has usually started a splint worn at night. Splinting may help to prevent muscle contractures of thenar and hypothenar muscle of hand and wrist[rx]
- Avoiding daytime activities – If you confirm by testing and comparing symptoms of carpal tunnel syndrome at first take a break of your day to day activities and keep your hand in rest. If you feel the wrist is red, warm and swollen, applying cool packs that can help.
- Physiotherapy – It is one of the most common and effective non-pharmacological treatments in the world. It has a variety of treatment module to erase acute and chronic pain. It is especially helpful in muscle spasticity, spasms related carpal tunnel syndrome. Inflammatory and noninflammatory pain is treated by ultrasound, MRI, Shortwave, microwave, wax therapy, IRR, laser therapy, interferential current therapy, iontophoresis. Some studies have reported good outcomes with physiotherapy regimes of stretching and strengthening, with more favourable results than rest and reduced activity at short-term follow-up.[rx]
- Deep transverse friction massage – It is a special type of massage technique called transverse friction massage is often used to treat the carpal tunnel syndrome patients. It is applied to the tendons and the muscles, using the tips of one or two fingers to heal carpal tunnel syndrome.
- Transcutaneous electrical nerve stimulation (TENS) – It is called TENS devices that help to transfer electrical impulses that are helpful for the treatment of carpal tunnel syndrome to the nervous system through the skin. These are supposed to keep the pain signals from reaching the brain by blocking pain message signals.
- Extracorporeal shockwave therapy (ESWT) – It is a physiotherapy device that generates shock or pressure waves that are transferred to the tissue through the skin for healing carpal tunnel syndrome. This is assumed that to improve the circulation of blood in the tissue and speed up the healing process
- Nerve and tendon gliding exercises – It is done by manually to increase the range of motion, muscle strength that help to erase the pain and swelling.
- Alternative therapies – Acupuncture and chiropractic care have benefited some individuals but their effectiveness remains unproved. An exception is a yoga, which has been shown to reduce pain and improve grip strength among those with CTS.
- Over-the-counter drugs – In special circumstances, various medications can reduce the pain, the pain and swelling associated with carpal tunnel syndrome. Nonsteroidal anti-inflammatory drugs (NSAIDs), such as aspirin, ibuprofen, naproxen, aceclofenac, and other nonprescription pain relievers, may provide some short-term relief from discomfort.
- Prescription medicines – The corticosteroids (such as prednisone) or the drug lidocaine can be injected directly into the wrist to healing and remove overpressure in median nerve or taken by mouth (in the case of prednisone) to relieve pressure on the median nerve in people with mild or intermittent symptoms.
- Vitamin B1, B6, and B12 – It is essential for neuropathic pain management, pernicious anaemia, tennis elbow, with vitamin b complex deficiency pain, paresthesia, numbness, itching with diabetic neuropathy pain, myalgia, etc. A side effect may be nausea- vomiting, abdominal pain, cramping
- Nerve relaxant – It is basically used to reduce neuropathic pain, inflammation, nerve root entrapment, myalgia, neuralgia, and fibromyalgia, and carpal tunnel syndrome. Your doctor may prescribe gabapentin, pregabalin, vitamin B1, B6, B12, etc. Major side effects are abdominal pain, nausea- vomiting.
- Lidoderm patches – It is a prescription medicine that is used to reduce pain, swelling, tenderness, paresthesia, itching, numbness, and carpal tunnel syndrome. It has the anesthetic power that is helpful in carpal tunnel syndrome.
Surgical decompression opens several variations, with or without tenosynovectomy, transverse carpal ligament reconstruction, and external/internal neurolysis; all seem equally effective with no clear scientific evidence to support or use the more elaborate procedures. [rx rx]
There are two possible surgical procedures
Open carpal tunnel release – The surgeon makes a decision when and where and how to cut on the inside of the wrist and then cuts right through the flexor retinaculum.
Endoscopic carpal tunnel release – It is a safe and reliable surgical treatment where the surgeon has to make a cut on your palm and your wrist. They insert a very small camera that is called an endoscope through one of the cuts to monitor the procedure and guide an instrument through the second cut to then cut right through the flexor retinaculum. Another endoscopic technique involves using just one small cut in the wrist.