Carpal tunnel treatment

What is carpal tunnel syndrome?

Carpal tunnel syndrome is a condition in which the median nerve is irritated or squeezed where it passes through the wrist. This often happens because the tendons in the wrist have become swollen or the tunnel has narrowed or stiffened from age changes and the median nerve that passes through the same tunnel is being affected. This nerve carries information back to the brain about sensations in your thumb and fingers. When the nerve is squeezed or irritated it can cause pain, aching, tingling or numbness in the affected hand. The symptoms tend to be worse at night and may disturb your sleep, but you may notice it most when you wake up in the morning. Hanging your hand out of bed or shaking it around will often relieve the pain and tingling. You may not notice the problem at all during the day, though certain activities – such as writing, typing, DIY or housework can bring on symptoms for some people.

What causes carpal tunnel syndrome?

Carpal tunnel syndrome is a common problem. It’s often caused by work-related activities, such as typing, and repetitive movements, although some cases may be related to arthritis of the wrist, thyroid disease and pregnancy. It can be mistaken for nerve irritation from the neck or elbow or they could exist at the same time making it difficult to fully diagnose. Your risk of developing it may be greater if your job places heavy demands on your wrist in a bent position or if you use vibrating tools.

What options help improve the symptoms?

Sometimes modifying the things that irritate the nerve can resolve the symptoms: not irritating the nerve allows it to settle back to a more normal level. In mild or moderate carpal tunnel where the power is still intact and the muscle of the thumb that sits in the palm is still a normal size, conservative options that do not require surgery are generally used to improve or resolve the symptoms.

1. Splints

Wearing a resting splint can help prevent the symptoms occurring at night, or a working splint can be useful if your symptoms are brought on by particular activities. Your doctor or physiotherapist can advise on where you can be fitted with a splint.

2. Steroid injections

To reduce inflammation, your doctor or a specialist physiotherapist can give you a steroid injection into your carpal tunnel. The injection may be uncomfortable, but the effects can last for weeks or months or even resolve the symptoms. A steroid injection into the wrist joint itself may help if you have arthritis in your wrist. Your pain should ease within two weeks and you should recover over approximately a four–six week period. There are specific risks of steroid injection and these need to be discussed with your clinician. These are very low and studies show this is a safe and effective procedure but may not last long term.

3. Exercises

Exercises to maintain the mobility, flexibility and movement of the nerves and tendons in the arm can help improve the symptoms and are especially important if you receive a steroid injection as they can help change the underlying reason for the carpal tunnel.

A. Wrist flexion and extension
Forearm supported on a table, hand relaxed over the edge.

Extend the wrist and clench your fist – relax and let your hand drop.

Repeat 10 times.

B. Passive wrist flexion
Forearm supported on a table with your hand over the edge and palm facing down.

Let your hand drop down. Gently assist the movement with your other hand.

Hold 20 secs. Repeat 5 times.

C. Assisted wrist extension
Hold the fingers of the hand to be stretched.

Gently extend the wrist until you feel the stretching at the inside of the forearm. Keep your elbow straight. Stretch approx. 20 secs.

Repeat 5 times.

4. Surgery

Surgery is not routinely indicated in patients suffering from occasional day time symptoms that are not interfering with their sleep.

Patients with at least six months of symptoms that affect their sleep on at least two–three nights a week, who are significantly affected at work or in day to day domestic activities and who have tried conservative splinting and/or been considered for an injection, can be put forward for surgery if they and their clinician feel this is appropriate.

Patients with permanent sensory loss, with frequent pins and needles, numbness or pain, muscle wastage or frequent night time symptoms (two – three nights a week) should be referred in a timely fashion to maximise the benefits of this procedure in consultation and agreement with their clinician.

At times where diagnostic uncertainly makes it difficult to confirm this is carpal tunnel a special test called a nerve conduction study or a steroid injection may be used to help with the diagnosis.

Surgery complications
All surgery has the potential of risk including infection and failure of the surgery to improve the symptoms. Carpal tunnel surgery is the most successful of all hand operations and it is important to remember that operation risk is very low but this operation carries specific risk. The procedure is a day case and performed under local anaesthetic and will usually take no more than 30 minutes. For some patients post carpal release feel unstable and weaker in the wrist. In others a neuroma or swelling can develop in a branch off the main nerve leading to long term pain at the site of the wound or more carpal tunnel symptoms.

If the surgery has been delayed and the nerve has been compressed for too long, there may be permanent damage that surgery is unable to correct. Usually these incidents are low but should be discussed with your surgeon if you have any specific concerns. In an analysis of many carpal tunnel studies the incidence of all operation risk in carpal tunnel is 2.03%.