Carpal tunnel syndrome
Options for treatment of Carpal Tunnel Syndrome, Ross Hauser, MD.
In 2017 surgeons at Thomas Jefferson University Hospital in Pennsylvania will published guidelines calling for a much more extensive examination of patients suffering from Carpal Tunnel Syndrome. If you have been diagnosed with Carpal Tunnel Syndrome or have been treated for Carpal Tunnel Syndrome, you may find this research enlightening.
Here is what the research says:
- In addition to the more common carpal tunnel and cubital tunnel syndromes, orthopaedic surgeons must recognize and manage other potential sites of peripheral nerve compression.
- The distal ulnar nerve may become compressed as it travels through the wrist, which is known as ulnar tunnel or Guyon canal syndrome.
- The posterior interosseous nerve (a forearm nerve branch that travels in back of the forearm) may become entrapped in the central region of forearm as it travels through the radial tunnel, which results in a pain syndrome without motor weakness.
- The median nerve may become entrapped in the proximal forearm, which can result in a variety of symptoms.
- Spontaneous neuropathy of the anterior interosseous nerve (a forearm nerve branch that travels in the front of the forearm) of the median nerve can be observed without external compression.
- Electrodiagnostic and imaging studies may aid surgeons in the diagnosis of these syndromes; however, a thorough physical examination is paramount to localize compressed segments of these nerves. An understanding of the anatomy of each of these nerve areas allows practitioners to appreciate a patient’s clinical findings and helps guide surgical decompression.1
So do I really have Carpal Tunnel Syndrome?
The chart on the left describes pain triggers coming from the neck and spine and radiating into the elbow, forearm and wrist.
Carpal tunnel syndrome is a progressively painful hand and arm condition caused by pressure, damage, or repeated injury to the median nerve at the wrist. Since pressure on the median nerve causes carpal tunnel syndrome, then anything that crowds, irritates or compresses the nerve in the canal, can lead to the symptoms. This pressure can come from swelling or anything that would cause the tunnel to become smaller.
Wrist surgery has limited and widely varying degrees of success in treating carpal tunnel syndrome. Surgery can also make the condition worse, especially when the condition has been misdiagnosed.
Seldom do patients and athletes find relief from the “Carpal Tunnel” complaints of pain in the hand and elbow with physical therapy and surgery because the diagnosis is so often wrong. The most common reason for pain in the elbow, referring to the hand, is weakness in the annular ligament, not from Carpal Tunnel Syndrome. (Please see our accompanying article on Tennis Elbow and the Annular Ligament).
Cervical ligament weakness and annular ligament laxity should always be evaluated prior to making the diagnosis of carpal tunnel syndrome.
A physician who understands the referral patterns of these ligaments should evaluate the individual with this condition before surgery is considered. Because most physicians do not know the referral pain patterns of ligaments, they do not realize that cervical vertebrae 4 and 5 and the annular ligament can refer pain to the thumb, index, and middle fingers. Ligament laxity can also cause numbness.
As noted earlier, the pain experienced in the wrist is often referred pain and may be due to an injured or weakened annular ligament which may lead to a misdiagnoses of carpal tunnel syndrome.
In the video below Ross Hauser, MD explains Carpal Tunnel Syndrome and Pseudo Carpal Tunnel Syndrome.
Caring Medical’s approach to carpal tunnel syndrome
Is surgery inevitable with a carpal tunnel syndrome diagnosis? Although the standard practice is to inject steroids or to prescribe anti-inflammatory medications, the end result with a diagnosis of carpal tunnel syndrome is usually surgery.
Actual carpal tunnel syndromes are caused by compression on the median nerve and pseudo carpal tunnel syndromes are caused by ligament weakness. They both may present with the same or similar symptoms but have entirely different pathology.
To differentiate the two syndromes, the physicians at Caring Medical would confirm an actual carpal tunnel syndrome diagnosis by ordering EMG/NCV (Electromyogram (EMG) and Nerve Conduction Studies) studies to measure the rate of nerve conduction. Confirmation of the diagnosis as well as the stage of the syndrome is determined by the degree of slowing of the nerve conduction.
If the syndrome is detected in the early stages, Neural Therapy treatment may be recommended. Neural therapy is a gentle healing technique developed in Germany that involves the injection of local anesthetics into autonomic ganglia, peripheral nerves, scars, acupuncture points, and trigger points. If, on the other hand, the carpal tunnel syndrome is at an advanced stage, traditional surgery may be necessary.
Comprehensive Prolotherapy treatment for pseudo carpal tunnel involves multiple injections of dextrose-based solution to the various ligament attachments around the elbow or wrist. Prolotherapy to all of the injured structures stimulates a natural inflammatory response in the weakened tissues.
Our body heals by inflammation, and therefore when these structures are injected with this solution, the mild and localized inflammation triggers a wound healing response. Regenerative cells are sent to the areas of the wrist or elbow that need healing, and collagen is laid down. This strengthens the weak wrist and elbow ligaments. They become tighter and stronger, and the original cause of pain and symptoms is eliminated.
For a discussion of Prolotherapy and nerve treatments please see our article: Neurofascial Prolotherapy
1 Strohl AB, Zelouf DS. Ulnar Tunnel Syndrome, Radial Tunnel Syndrome, Anterior Interosseous Nerve Syndrome, and Pronator Syndrome. J Am Acad Orthop Surg. 2017 Jan;25(1):e1-e10. doi: 10.5435/JAAOS-D-16-00010.