A Common Source Of Wrist & Hand Pain: Carpal Tunnel Syndrome (CTS)

Dr. Soraya Burrows

The human hand is such a sensitive and specialised structure; anatomically complex and strategically engineered by time and nature, having the ability to create such varied and precise movements.  ​

Our hands contain so many weird and wonderfully specialised sensory cells that function to collect information via touch, position, pressure or temperature in relation to our current surroundings. 
The information is continuously relayed to our brain where the appropriate networks of neurons pass precise instructions via the spinal cord, neural networks and down the nerves in our arms to the muscles responsible for generating the gestures we require.

This intricate sensory/motor control system is continuously checking itself and making small adjustments.  We could be typing away in an attempt to conquer the monstrous, multi-headed hydra-like inexhaustible queue of office emails, operating an electric sander to remove tired paint in an effort to restore an antique to its former glory or just the general lifting and carrying as we go about our everyday activities.  

With all these moving parts and capabilities made possible with our hands, we can create works of art and express ourselves.  .  

​We make music when we pick up an instrument, pour out our imaginings as we place pen to paper or brush paint on canvas.  
​Emotions and words can be expressed through unconscious body language, gestures or signing Auslan.
​We can nurture the plants in our garden, offer a neighbourhood cat a pat or hold a loved one when they require some comfort and soothing.  ​​

​When we’re limber and feeling good, we barely notice how much we rely on and require that normal baseline level of ease.  
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However, when things don’t go as planned and if an injury occurs, whether caused by simple tasks or other health conditions, the loss of our normal function is very apparent.  

One possible common condition responsible for hand pain is Carpal Tunnel Syndrome (CTS). 
It affects 4-5% of the population (1) and can be quite disruptive, affecting a variety of people, from pregnant women, office workers and the elderly, to tradesman and others who work directly with their hands. 

It seems to be caused by multiple factors, which could include (2);

• wrist and forearm injuries 
• repetitive activities 
• activities performed with poor posture
• manual labour, use of power tools
• desk work
• pregnancy
• congenital; meaning how the body is shaped from birth/early development
• medical conditions such as diabetes and hyperthyroidism
  
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Typically the frustrating experience of CTS is as follows (2,3);

• Slow developing pain in the palm and numbness of the thumb and first two fingers of one or both hands
• Initially pain is worse at night, then progresses to constant daytime pain and numbness
• Area is swollen and painful to touch
• Weakness and difficulty with wrist and hand movements
• Recent accident or injury

Many of the structures that operate the hand are sandwiched together and must pass through a channel at the wrist (the carpal tunnel) bordered by sturdy carpal (or wrist) bones and ligaments, particularly the transverse carpal ligament as the ‘unyielding ceiling’. 

Most of the space in this channel is occupied by rigid tendons that control finger movements, leaving only a small potential space for the squishy median nerve, which can be easily compressed here (1, 2). 

​Being the main sensory and motor supply for the palm of the hand, a squished median nerve can result in the frustrating and restrictive experience that Carpal Tunnel Syndrome is known for.  

If you are experiencing signs and symptoms such as those described, the best course of action is to consult your GP or manual therapist as early as possible. 

This could limit the impact on your everyday life activities and the need for any interventions in future. 

If CTS is left to progress, a cortisone injection may be beneficial. It was reported that approximately 75% of patients experience improvement following this procedure (4, 5).

Failing that, a small surgical procedure can be recommended.  It involves releasing the transverse carpal ligament (the mentioned ‘ceiling’ of the carpal tunnel), creating more space for the muscle tendons to glide together at the wrist, alleviating the direct pressure placed on the median nerve. 
Luckily surgical intervention for CTS has a very high success rate, with over 90% of patients reporting alleviation of symptoms (6, 7, 8),

However, it is important to remember that as far as your body is concerned, there is no such thing as 'minor' surgery! Even in the best case scenario, the carpal tunnel now has (even more rigid and unyielding) scar tissue around it, which can cause other issues.

So the best thing to do is avoid any intrusive interventions.

And it’s entirely possible!

Here’s where an osteopath can help as there are many strategies we can try. 

We take a detailed history with all our questioning, figure out what the scenario is and advise you what the next steps could be towards recovery and supporting you through the process. 

We can monitor the symptoms with you, establish what your baseline is, help you set goals over the short course of treatment with manual techniques and exercise and help you achieve those goals. 

If improvement is not seen, we can make a referral, speedy and early should the need arise, limiting possible lengthy times towards recovery and resolution. 

Along with osteopathic techniques for treatment, there are some simple and inexpensive things to try, some examples include (2, 3); ​

• Wearing a splint to hold your wrist in a neutral position at night, when the symptoms can become most intense,
• ensuring that your work station is set up with optimum ergonomics to limit further pressure placed on the median nerve from your posture,
• mobilising the hand, wrist and forearm with exercises and stretches to elongate, strengthen and relax structures,
• exercises addressing the cause and any compensations in other parts of the body that may be contributing to the overall experience.

Developing an understanding of how and why this is happening; knowledge alone can alter the experience and help settle the worry. 

Being informed is a powerful position to be in as you can select the best course of action and knowing what the possible benefits or disadvantages of the available options are. 


​CTS can be debilitating and impact negatively on your health and wellbeing and day-to-day activities.  That’s why getting treated as soon as possible is so important.  

By finding the right combination of strategies that are best for you, your osteopath can get you moving and back into your daily routines, whether it be gardening, writing, creating a masterpiece, or tackling a home renovation. 
Not to mention going back into battle with inexhaustible email queues – the multi-headed hydras!

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References:
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1. Aboonq, M.S., 2015. Pathophysiology of carpal tunnel syndrome. Neurosciences, 20(1), p.4.
2. Siu, G., Jaffe, J.D., Rafique, M. and Weinik, M.M., 2012. Osteopathic manipulative medicine for carpal tunnel syndrome. The Journal of the American Osteopathic Association, 112(3), pp.127-139.
3. Scott, K. and Kothari, M.J., 2005. Evaluating the patient with peripheral nervous system complaints. The Journal of the American Osteopathic Association, 105(2), pp.71-83.
4. Girlanda, P., Dattola, R., Venuto, C., Mangiapane, R., Nicolosi, C. and Messina, C., 1993. Local steroid treatment in idiopathic carpal tunnel syndrome short-and long-term efficacy. Journal of neurology, 240(3), pp.187-190.
5. Gelberman, R.H., Aronson, D.A.V.I.D. and Weisman, M.H., 1980. Carpal-tunnel syndrome. Results of a prospective trial of steroid injection and splinting. The Journal of bone and joint surgery. American volume, 62(7), pp.1181-1184.
6. Schmelzer, R.E., Della Rocca, G.J. and Caplin, D.A., 2006. Endoscopic carpal tunnel release: a review of 753 cases in 486 patients. Plastic and reconstructive surgery, 117(1), pp.177-185.
7. Quaglietta, P. and Corriero, G., 2005. Endoscopic carpal tunnel release surgery: retrospective study of 390 consecutive cases. In Advanced Peripheral Nerve Surgery and Minimal Invasive Spinal Surgery (pp. 41-45). Springer, Vienna.
8. Park, S.H., Cho, B.H., Ryu, K.S., Cho, B.M., Oh, S.M. and Park, D.S., 2004. Surgical outcome of endoscopic carpal tunnel release in 100 patients with carpal tunnel syndrome. min-Minimally Invasive Neurosurgery, 47(05), pp.261-265.