Are You Sure That’s Carpal Tunnel Syndrome? Getting to The Source of Wrist and Hand Pain

(Originally published as a two part article for Imbue Pain Relief Patch)

Part One

Many people who have pain or numbness in the wrist, hand, or fingers are told they have Carpal Tunnel Syndrome (CTS) and may believe surgery is their only option. But CTS is often misdiagnosed and there are numerous natural remedies and treatments that are worth trying before undertaking anything invasive.

The carpal tunnel is a space in the wrist through which nine tendons and a nerve pass into the hand. There are eight small bones in the wrist, called carpal bones. Four of these form a bowl-shaped depression on the palm side of the wrist that these tendons and nerve pass over. This could be thought of as the floor and sides of the carpal tunnel. The “ceiling” of the tunnel is a rather tight band of tissue (called the flexor retinaculum of the hand, or the transverse carpal ligament) right under the skin, which connects the bones to either side of the wrist and lies on top of the tendons and nerve.

In CTS, the carpal tunnel becomes too tight, causing compression and irritation of the nerve. This nerve – the median nerve – transmits sensation and initiates movement in the hand.  The main symptom of irritation of this nerve is a particular kind of sensitive, tingly, zingy pain and/or numbness of the palm and fingers. In particular, the thumb side of the hand is affected, including the thumb, index finger, middle finger, and maybe a bit of the ring finger (on the side toward the thumb). Also, the hand can become weak, and in a case of true CTS, if the nerve is compressed for a very long time, it can be permanently damaged, leading to shrinking of the muscles of the hand.

Conventional medicine doesn’t have a complete explanation as to why swelling within the carpal tunnel and entrapment of the median nerve occurs. Certain behaviors and medical conditions (such as fibromyalgia) may contribute to it. Most doctors and those who suffer from CTS believe that repetitive motions involving the wrist and hand, and prolonged gripping with the hand or bending of the wrist exacerbate the condition, though others dispute this claim. Typing is an especially common culprit, as are using hand tools, driving, playing sports involving a racquet, painting, writing, and working on an assembly line. Sleeping with the wrist bent also tends to be problematic. Some researchers have hypothesized that there is a genetic factor that predisposes some to develop CTS. The condition is more common in women than in men.

Doctors diagnose CTS in a number of different ways, and I have seen many patients who have been diagnosed with this condition who I don’t believe actually had it. If the muscle of the palm at the base of the wrist is weak and atrophied, this is a pretty good indicator that it is a median nerve problem. If there is mostly pain but not much numbness, it is less likely to be CTS. If tapping on the inside of the wrist, near the center of the wrist crease, causes tingling in the hand and fingers (called Tinel’s sign) it is more likely to be CTS. If pressing the hand toward the inside of the wrist and holding it there for one minute (called Phalen’s test) causes numbness in the hand and fingers, it is also more likely to be CTS, especially if numbness occurs quickly. If there is reduced sensation in the first three fingers but not in the palm, this, too, indicates a greater likelihood of true CTS. Electrodiagnostic studies (electromyography and nerve conduction tests) are considered by many to be the most reliable tests for diagnosing CTS. These tests compare how fast signals travel along the median nerve as compared to other nearby nerves. If CTS is present, the median nerve will conduct signals more slowly than normal nerves.

If you suspect you have CTS or a doctor has made this diagnosis, it’s important to determine if there are active trigger points in relevant muscles of the arm, neck, and upper back, as these can produce pain and numbness in the hand that is frequently misdiagnosed as CTS. I always hope to discover that trigger points (localized regions of strain, shortening, inflammation, and tightness in muscles) are the actual culprit in “CTS” cases, since this means the problem is muscular, not neurological, in nature. And muscles are usually very responsive to treatment.

There are several muscles that are capable of causing referred pain, numbness, or tingling in the hand. The most common are the forearm flexors. These are the muscles which originate near the elbow and narrow into the tendons that pass through the carpal tunnel. Trigger points in the fleshy parts of these muscles (the upper third of the inside aspect of the forearm) can produce discomfort in the forearm, wrist, hand, and fingers. Brachialis, a muscle of the upper arm that is partly covered by the biceps, can cause pain and numbness in the thumb and the fleshy mound of the palm adjacent to it. The scalenes muscles at the front of the neck can cause a similar sensation in the same area.

Some local trigger points – shown as X’s – and the pain patterns they produce. Each X is the (approximate) site of origin of the pain pattern indicated by shading of the same color. Therefore, a trigger point near the red X is one of the most common causes of CTS-like pain.

Trigger points in the infraspinatus muscle, one of the rotators of the shoulder which lies mostly over the back of the shoulder blade, can produce pain in the wrist, hand, middle fingers and thumb. The serratus posterior superior muscle of the upper back can also refer pain into the hand, although this pain tends to occur in the ring finger and pinky, while true CTS will affect mainly the other three fingers. Trigger points in the subscapularis muscle, between the shoulder blade and the back of the rib cage, can produce pain in the wrist. The subclavius muscle under the collar bone can produce pain and/or numbness in the wrist, hand, and fingers that is almost indistinguishable from that of CTS. The pectoral muscles of the chest and the latissimus dorsi muscle of the back can also cause hand and finger discomfort when aggravated by trigger points. In addition to these direct referral patterns from trigger points of muscles that are “upstream” of the symptoms, other disorders of the neck and shoulder region can cause numbness of the hand, such as a condition known as Thoracic Outlet Syndrome, in which nerves and/or blood vessels passing through this region are compressed. You can check out some pictures and more detailed explanations of these trigger points and their pain referral patterns in the wrist/hand pain section of my Pain Expert tool.

Unless a healthcare practitioner has thoroughly investigated each of these areas, it’s difficult to make a conclusive diagnosis of Carpal Tunnel Syndrome. Yet, most of the patients who have come to me with this diagnosis were never examined above the forearm. Next week I will discuss some of the treatment options for CTS. In the meantime, hold off on surgery.

Part Two

In part one of this article, I discussed the symptoms, mechanisms, and diagnosis of Carpal Tunnel Syndrome (CTS). This time, let’s look at treatment.

Treatments for CTS include the following:

• Acupuncture. I have seen acupuncture produce dramatic results in as little as one treatment (though I recommend a series of five to ten, with possible ongoing maintenance). The fine acupuncture needles can alleviate inflammation in the carpal tunnel, and can release shortened areas (myofascial trigger points) in the “bellies” (the fleshy upper part) of the flexor muscles that lead to the tendons that run through the carpal tunnel. They can also neutralize trigger points in muscles of the upper arm, shoulder, upper back, neck, and chest which may be implicated in the problem. Corresponding points – such as the opposite ankle – may also be used.

• Massage. Good, thorough, deep massage can often work wonders for CTS. A seasoned therapist will be sure to work on the entire upper limb, torso, and neck. A nice side benefit of both massage and acupuncture is that they are excellent at alleviating stress, which definitely plays a role in CTS. Which leads us to…

• Relaxation techniques. Meditation, biofeedback, taiji quan (tai chi), yoga, slow deep breathing, and other stress-reduction techniques all seem to be helpful for CTS. My patients with CTS often report that the condition is worse when they are under more stress.

Rest. Taking a break from activities that intensively use the hands is important. Set an alarm on your phone or computer to take a short break every 30 minutes. During this time, do some stretching, apply some heat to your forearms, wrists, and hands (or, briefly, cold).

Work Station Optimization. Whatever your work station is – a chair at a computer, standing at a table saw, driving a truck – it’s worth doing whatever you can to ensure good ergonomics. Get elbow and wrist support, use a split keyboard, grip less tightly, try a trackball, etc. If there is an OT or someone else who helps optimize workstations at your job, take advantage of their services.

• Splinting. Bending the wrist in either direction tends to flatten the carpal tunnel, which can exacerbate compression of the nerve.  Bending the hand downward (flexion) tends to be a bigger issue. A splint immobilizes the wrist to keep it from bending, giving the tendons and nerve more room.

In my opinion, splints are something of a band-aid. They aren’t a miracle treatment. But if you bend your wrists or clench your fists while sleeping, and wake up with lots of numbness/pain, a splint may be worthwhile. Whether you go with a splint or not, try to stop sleeping with your hands under your body or with your arm raised (don’t put your arm under your head/pillow).

Physical therapy. A good physical therapist can advise you on a stretching/exercise routine to practice daily. If you intend to do the same kinds of activities with your hands, you will likely need to have some sort of physical therapy routine that you do on a regular basis. Luckily, it doesn’t need to take long. Here are two examples: (1) Wrap a wide rubber band around the fingers of the hand that is affected (get all five finger tips in there). Then spread your fingers, hold them apart for a few seconds, and release. Doing this whenever you take a work break sometimes makes a big difference. (2) Flexing and extending the wrist against resistance. Either hold a light dumbbell in your hand – palm up – or hold one end of a light exercise band with the other end under your foot. Slowly flex your wrist and release ten times. Then turn your palm down and extend your wrist up and release ten times.

B Vitamins. Nearly all of the B vitamins are helpful at mitigating the impact of stress on us, and vitamin B6 is of particular value in CTS. Take a whole B complex once or twice a day, plus extra vitamin B6 (pyridoxine or P-5’-P), so that your total daily dose of B6 is 200 to 300mg a day. You should not exceed 300mg of B6 a day. It is best to break this amount up into two or three doses over the course of the day. B6 is healing to nerves and also helps remove excess fluid buildup in the body. In the case of CTS, fluid stagnation in the carpal tunnel may account for the compression that is occurring and B6 can relieve this.

Imbue Pain Relief Patch. Although the patch cannot create extra space in the carpal tunnel, it is an effective external pain reliever that many, many clients with wrist pain have reported works excellently to alleviate their discomfort.

Magnesium. Magnesium is a safe, mildly tranquilizing mineral, and a useful muscle relaxant. I usually have my patients take Natural Calm (a powdered form that dissolves in hot or cold water and tastes pretty good) or a similar product, one to two teaspoons, morning and night. If you have a laxative effect from it, reduce the dose.

Methyl Sulfonyl Methane. While usually thought of for muscle and joint pain, some users find that MSM, a natural form of sulfur, can alleviate the discomfort of CTS. A usual dose is 1000mg for every 50 pounds of your body weight, twice a day.

Surgery. Since the transverse carpal ligament is a relatively soft structure that forms the ceiling of the carpal tunnel (if your palm is facing up), it seems natural that someone should suggest simply cutting this ligament to make more space – and that’s exactly what surgeons do. The ligament is like a watch band that runs across the inside wrist. After it’s severed, the expectation is that it will scar back together, but with more slack than before, making the carpal tunnel more spacious. About 70% of people who get the surgery do experience some improvement, though it may be partial. Recovery usually takes six to twelve weeks – sometimes up to a year. Post-surgical scarring may be quite thick, resulting in a tighter carpal tunnel than before. Frequently, there is some permanent loss of grip strength, lifting strength, and reduced range of motion in the wrist.

Before undertaking any invasive treatment, I again urge you to get thoroughly examined by someone who is intimately familiar with structural disorders. Pain in this part of the hand can be produced by a problem with the fourth and fifth vertebrae of the neck; a loose ligament (annular) at the outside of the elbow; trigger points in the forearm (flexors), the upper arm (brachialis), the front of the neck (scalenes), under the collar bone (subclavius), the chest (pectorals), the upper back and shoulder (infraspinatus, subscapularis, serratus posterior superior, latissimus dorsi); and other problems of the bones, ligaments and cartilage of the upper trunk where a bundle of nerves called the brachial plexus exits from the torso.

Wishing you rapid relief from your pain.

 

Copyright 2012 by Peter Borten. No unauthorized reproduction in any form without permission.