Carpal tunnel syndrome (CTS) is the most prevalent peripheral nerve neuropathy of the upper extremity that compression of the median nerve causes numbness, pain, tingling and weakness in the arm, hand and fingers [1, 2]. CTS can be categorised into mild (early), moderate (intermediate) and severe (advanced), based on severity. 4-5% of people experience this condition in the world [3].
Carpal tunnel is formed by boundaries below. Also, consists of nine flexor tendons namely the 4 flexor digitorum superficialis tendons (FDS), 4 flexor digitorum profounds tendons (FDP) and flexor pollicis longus tendon (FPL) and 2 bursae (the radial and ulnar). The radial bursa contains FPL and the ulnar bursa sits around the tendons of FDS and FDP.
| Boundaries of the carpal tunnel | Structures |
| Roof (Palmer side) | Flexor retinaculum (transversa carpal ligament) |
| Medial side (Ulnar side) | Hook of the hamate, the pisiform bone |
| Lateral (Radial side) | The scaphoid, the trapezium tubercles and flexor carpi radialis tendon |
| Base (floor) | The scaphoid, lunate, capitate hamate, trapezius and trapezoid |
Median nerve anatomy [4, 5]
| Pathway | Innervation | Variations of the branches |
| Sensory | Thumb, index, middle and the half of the ring fingers | Runs along the median nerve and goes into the carpal tunnel at the edge of the FCR and innervates the thenar eminence (cutaneous branch) |
| Motor | Lateral two lumbricals. abductor pollicis brevis, opponens pollicis and the superficial part of the flexor pollicis brevis | Starting points and its courses of the thenar branch: extraligamentous (46%), subligamentous (31%) and transligamentous form (23%). Location of the nerve bundles: radial to the median nerve (60%), anterior (20%) and central (18%) |
*A number of anatomical variations were found in this research [6].
Aetiology and risk factors [2,4]
·Age 45-59, 75-84
·Men<Women
·A bifid median nerve
·Using computers more than 20 hours weekly
· Increase in pressure of the tunnel
· A loss of the blood circulation
·Family history
·Smoking
-Acute CTS-
·Dislocation or fracture of the distal radius or the wrist
·Infection
·High-pressure injection
·Acute thrombosis
·Burns
-Extrinsic factors (increase in the volume in the tunnel on either side of the nerve)-
·Diabetes
·Pregnancies
·Hypothyroidism
·Menopause
·Obesity
·Use of oral contraceptive pill
·Kidney failure
·RA
-Intrinsic factors (Increase in the volume of the tunnel)-
·Fractures of the distal radius
·OA of the distal radioulnar joint
-Neuropathic (it can occur with or without increasing pressure within the tunnel)-
·Diabetes
· Excessive alcohol intake
· Vitamin deficiency or toxicity
-Dynamic CTS-
Dynamic CTS is the movement induced increase in the tunnel. Wrist flexion, extension, supination and flexion of fingers can contribute to compression of the median nerve.
Signs and symptoms
Severity of the CTS [4]
Median nerve can be compressed proximally in the transversa carpal ligament by the wrist flexion and distally near the hook of the hamate where it is the narrowest part.
| Stages | Signs and symptoms | Possible causes |
| Early | Intermittent symptoms at night (numbness, tingling and pain in the hand and fingers) Symptoms may be relieved by repositioning, shaking, moving hands and fingers | ·Increase in intercarpal and arterial pressure ·Prolonged or unconscious wrist flexion |
| Moderate | ·Symptoms (numbness, tingling, pain and weakness in gripping) appear during day and night Symptoms are eased when the compression is improved | · Abnormal circulation with the oedema ·Damaged myelin sheath and nodes of Ranvier |
| Severe | ·Hypotrophy or atrophy of the thenar eminence ·Motor and sensory deficit | ·Obstruction of the arterial flow ·Axonotmesis (damages of the axons)—–Recovery is dependant upon axonal regeneration |
Assessment and diagnosis [2, 4, 5]
°Reliability and accuracy vary in different studies. The study lists all available date for provocation tests on table 2-4 [5]. Date on this blog is from the evidence level I or II.
·Tinel’s sign (Sen: 50%, Spe: 77%, +LR: 0.98, -LR:0.78) [8].
·Phalen’s test (Sen: 63%, Spe: 73%, respectively, +LR: 1.30, -LR:0.58) [7, 8].
·Reverse phalen’s test (Sen: 57%, Spe: 78% )[7].
·ULNT 1 (median, criteria A) (Sen: 58%, Spe: 84%, respectively, +LR: 3.67, -LR:0.50) [9].
·ULNT 1 (median, criteria B) (Sen: 74%, Spe: 50%, respectively, +LR: 1.47, -LR:0.53) [9].
*Criteria A is considered positive when ULNT only reproduces symptoms that a patient experiences. If the pain or symptoms that the patient does not get, that is considered negative.
*Criteria B is considered positive when ULNT generates symptoms at the wrist, the hand, and fingers. This does not necessarily have to be patient’s symptoms.
·Carpal compression test (Sen: 64%, Spe: 83%, respectively, +LR: 0.91, -LR:1.20) [8].
·Scratch collapse test (Sen: 34%, Spe: 61%) (10).
*In this study, two surgeons performed 9 pain provocation tests to diagnose CTS, which showed that there was difference in accuracy by an examiner.
*Tinel’s sign, Phalen’s test and carpal compression test as well pain location, sensory and motor deficit should be considered to rule in.
Differential diagnosis [2, 5]
· Cervical radiculopathy C6-C7
· Thoracic Outlet Syndrome (TOS)
·Pronator teres syndrome
·Radial tunnel syndrome
·Peripheral neuropathy
· DeQuervain tendinopathy
· MS
·ALS
Outcome measures [5]
· DASH
·Upper extremity functional index
·Boston carpal tunnel questionnaire-symptom severity scale
·Boston carpal tunnel questionnaire functional scale
Conservative intervention
· Neural mobilisation
103 patients with mild-moderate CTS were randomised into two groups. Intervention group received 2 sessions weekly for 10weeks. The intervention group had received 3 sets of 60 repetitions of neural sliding and tensioning passive neural mobilisation with 15secounds rest between sets. This session lasted 20 mins. The control group did not receive any treatment during 10 weeks. This study showed that the intervention groups had improved pain level and symptoms. However, grip and muscle strength did not improve in both groups. [11].
·Joint Mobilisation
This systematic review reports that joint mobilisation may have a positive effect, yet joint mobilisation has been used in conjunction with other modalities. Thus, the efficacy of joint mobilisation in isolation needs more investigation [12].
·Manual therapy alone (massage techniques)
Manual therapy alone means here is the manual therapy apart from neural mobilisation or joint mobilisation. Manual therapy techniques such as deep transversa carpal ligament, first interosseous, palmer aponeurosis, scalene and pectoralis minor, pronator teres massages were found in the study [13, 14, 15]. Studies showed that manual therapy may have a upward effect on pain or symptoms, they were often used with other techniques such as neural mobilisation [13] and joint mobilisation (radio-carpal, radio-ulna)[14].
·Surgery or conservative intervention?
A systematic review reports that there was no statistically difference between two interventions for improvement in symptoms at 1-3months follow-up. However, at 6months mark, surgical intervention was superior to conservative treatment in terms of function and symptom severity [16].
Recurrent CTS post-surgery
Recurrent CTS can occur after the first surgery despite high successful rate (about 80%). Second operation due to recurrence seems to improve symptoms, yet a study illustrates that 80% of people still had some symptoms after 6 months of the second surgery. This study also reports that approximately 50% of people who underwent the surgical intervention were happy about the outcomes. Thus, patients should be informed the recurrence rate, outcomes and prognosis before undergoing an operation [17, 18].
References
[1] Kanafi Vahed, L., Arianpur, A., Gharedaghi, M., & Rezaei, H. (2018). Ultrasound as a diagnostic tool in the investigation of patients with carpal tunnel syndrome. European Journal of Translational Myology, 28(2). https://doi.org/10.4081/ejtm.2018.7406
[2] Genova, A., Dix, O., Saefan, A., Thakur, M., & Hassan, A. (2020). Carpal Tunnel Syndrome: A Review of Literature. Cureus. Published. https://doi.org/10.7759/cureus.7333
[3] Atroshi, I. (1999). Prevalence of Carpal Tunnel Syndrome in a General Population. JAMA, 282(2), 153. https://doi.org/10.1001/jama.282.2.153
[4] Chammas, M., Boretto, J., Burmann, L. M., Ramos, R. M., dos Santos Neto, F. C., & Silva, J. B. (2014). Carpal tunnel syndrome – Part I (anatomy, physiology, etiology and diagnosis). Revista Brasileira de Ortopedia (English Edition), 49(5), 429–436. https://doi.org/10.1016/j.rboe.2014.08.001
[5] Erickson, M., Lawrence, M., Jansen, C. W. S., Coker, D., Amadio, P., & Cleary, C. (2019). Hand Pain and Sensory Deficits: Carpal Tunnel Syndrome. Journal of Orthopaedic & Sports Physical Therapy, 49(5), CPG1–CPG85. https://doi.org/10.2519/jospt.2019.0301
[6] Demircay, E., Civelek, E., Cansever, T., Kabatas, S., & Yilmaz, C. (2011). Anatomic variations of the median nerve in the carpal tunnel: a brief review of the literature. Turkish Neurosurgery. Published. https://doi.org/10.5137/1019-5149.jtn.3073-10.1
[7] MacDermid, J. C., & Wessel, J. (2004). Clinical diagnosis of carpal tunnel syndrome: a systematic review. Journal of Hand Therapy, 17(2), 309–319. https://doi.org/10.1197/j.jht.2004.02.015
[8] Wainner, R. S., Fritz, J. M., Irrgang, J. J., Delitto, A., Allison, S., & Boninger, M. L. (2005). Development of a clinical prediction rule for the diagnosis of carpal tunnel syndrome. Archives of Physical Medicine and Rehabilitation, 86(4), 609–618. https://doi.org/10.1016/j.apmr.2004.11.008
[9] Bueno-Gracia, E., Tricás-Moreno, J. M., Fanlo-Mazas, P., Malo-Urriés, M., Haddad-Garay, M., Estébanez-de-Miguel, E., Hidalgo-García, C., & Krauss, J. R. (2016). Validity of the Upper Limb Neurodynamic Test 1 for the diagnosis of Carpal Tunnel Syndrome. The role of structural differentiation. Manual Therapy, 22, 190–195. https://doi.org/10.1016/j.math.2015.12.007
[10] Makanji, H. S., Becker, S. J. E., Mudgal, C. S., Jupiter, J. B., & Ring, D. (2013). Evaluation of the scratch collapse test for the diagnosis of carpal tunnel syndrome. Journal of Hand Surgery (European Volume), 39(2), 181–186. https://doi.org/10.1177/1753193413497191
[11] Wolny, T., & Linek, P. (2018). Is manual therapy based on neurodynamic techniques effective in the treatment of carpal tunnel syndrome? A randomized controlled trial. Clinical Rehabilitation, 33(3), 408–417. https://doi.org/10.1177/0269215518805213
[12] Sault, J. D., Jayaseelan, D. J., Mischke, J. J., & Post, A. A. (2020). The Utilization of Joint Mobilization As Part of a Comprehensive Program to Manage Carpal Tunnel Syndrome: A Systematic Review. Journal of Manipulative and Physiological Therapeutics, 43(4), 356–370. https://doi.org/10.1016/j.jmpt.2020.02.001
[13] Talebi, G. A., Saadat, P., Javadian, Y., & Taghipour, M. (2018). Manual therapy in the treatment of carpal tunnel syndrome in diabetic patients: A randomized clinical trial. Caspian Journal of Internal Medicine, 9(3). https://doi.org/10.22088/cjim.9.3.283
[14] Maddali Bongi, S., Signorini, M., Bassetti, M., del Rosso, A., Orlandi, M., & de Scisciolo, G. (2012). A manual therapy intervention improves symptoms in patients with carpal tunnel syndrome: a pilot study. Rheumatology International, 33(5), 1233–1241. https://doi.org/10.1007/s00296-012-2507-0
[15] Fernández-de-las Peñas, C., Ortega-Santiago, R., de la Llave-Rincón, A. I., Martínez-Perez, A., Fahandezh-Saddi Díaz, H., Martínez-Martín, J., Pareja, J. A., & Cuadrado-Pérez, M. L. (2015). Manual Physical Therapy Versus Surgery for Carpal Tunnel Syndrome: A Randomized Parallel-Group Trial. The Journal of Pain, 16(11), 1087–1094. https://doi.org/10.1016/j.jpain.2015.07.012
[16] Shi, Q., Bobos, P., Lalone, E. A., Warren, L., & MacDermid, J. C. (2018). Comparison of the Short-Term and Long-Term Effects of Surgery and Nonsurgical Intervention in Treating Carpal Tunnel Syndrome: A Systematic Review and Meta-Analysis. HAND, 15(1), 13–22. https://doi.org/10.1177/1558944718787892
[17] Jansen, M. C., Duraku, L. S., Hundepool, C. A., Power, D. M., Rajaratnam, V., Selles, R. W., & Zuidam, J. M. (2021). Management of Recurrent Carpal Tunnel Syndrome: Systematic Review and Meta-Analysis. The Journal of Hand Surgery. Published. https://doi.org/10.1016/j.jhsa.2021.05.007
[18] Sun, P. O., Selles, R. W., Jansen, M. C., Slijper, H. P., Ulrich, D. J. O., & Walbeehm, E. T. (2020). Recurrent and persistent carpal tunnel syndrome: predicting clinical outcome of revision surgery. Journal of Neurosurgery, 132(3), 847–855. https://doi.org/10.3171/2018.11.jns182598
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