3Case PresentationA 42-year-old Caucasian female presents to your office complaining of numbness and tingling in her right hand for approximately one year. The sensation is on the palmar surface of the thumb, index, and middle fingers, and ring finger. She states that sometimes it feels like her hand is “asleep,” while other times it feels like “pins and needles.” The symptoms occur at night and the only relief is “flicking” of the wrist.
4Case PresentationOccasionally, the pain is referred to the forearm and shoulder, but only during an acute flare-up. The patient has worked as a secretary at UNTHSC for the past 15 years.Physical examination: overweight female in NAD. Sensation full & = bilat; DTR’s 2+ & = bilat; slight atrophy and weakness of the thenar muscle and grip strength on the Rt.; decreased ROM of Rt. wrist compared to Lt.; positive Tinel’s and Phalen’s
7What is Carpal Tunnel Syndrome? This condition is most commonly described as an entrapment neuropathy of the median nerve at the wrist in the carpal tunnelThe tunnel is formed by the carpal bones and the transverse carpal ligamentContents of the tunnel include the flexor tendons and the median nerve
29Clinical Presentation Cutaneous Innervation Median nerve cutaneous sensory distributionPalmar surfaces ofThumbIndexMiddleLateral ½ of ring finger
30How does one get carpal tunnel syndrome? 1. Increase pressure within the canal.2. Compromise space within the canal.
31Pressure is increased in the carpal tunnel by: Both flexion and extension of the wrist.
32Space is compromised in the carpal tunnel by: Thickening of the tendon sheaths.Encroachment from other structures.
33Secondary Etiologies Systemic diseases Pregnancy Carpal Tunnel Mass Diabetes mellitusThyroid disordersRheumatoid arthritisPaget’s bone diseaseGoutMyxedemaMultiple myelomaAcromegalyHepatic diseaseDialysis patientsLeukemiaSx are frequently bilaterally with systemic diseasesPregnancyCarpal Tunnel MassGanglion cystLipomaDislocationMisc. mass effect
34SPECIFIC ETIOLOGIES *Nonspecific tenosynovitis Amyloidosis Rheumatoid arthritisHypothyroidismBoney deformities from fracturesOsteoarthritisPregnancyTumor
35Other Etiologies Dislocation of lunate bone. Malunited Colle’s fracture.Certain scaphoid fractures.Soft tissue masseslipomaganglionHypertrophy of the volar ligamentNo etiology.
36Pathophysiology of Carpal Tunnel Syndrome 1. Decreasing the volume of the tunnel.2. Increasing the volume of the contents of the tunnel.
37Clinical Presentation Compression of median nerve in carpal tunnelAnesthesiaParesthesiaPainMuscle weaknessDecreased ROMNight-time symptoms“Flick Sign”
38Workers involved in specialized tasks: 1. Require repetitive use of the hand and wrist while held in forced flexion.2. Carpal tunnel becomes tighter when wrist held in forced flexion.
39PathophysiologyFrequently associated with repeated or sustained activity of the fingers and hands (over-use injury)i.e. typing, repeated use of tools such as a screwdriver or socket wrench, etc.Repeated activity and/or inflammation leads to compressive effect in carpal tunnelFirst effect → obstruction of venous return from the nerveLeads to increased capillary distension and further increases in intratunnel pressure.Cyclic, self-amplifying impairment of nutrition to the nerve
40PathophysiologyAs the condition worsens, capillary circulation is sufficiently slowed → endoneurial edema, epineural edema, and intratunnel edemaIn final stages → arterial insufficiency and increasing mechanical deformation which cause nerve fiber destruction and fibrous replacement“Two Hit” theoryThe nerve must be compressed in two different areas along its length to produce symptomsCTS patients tend to have other musculoskeletal involvement at the wrist, elbow, shoulder, or neck
41Other proposed causes of Carpal Tunnel Syndrome: 1. “Double Crush” theory:nerve impairment occurs when single axons that are compressed in one region become especially susceptible to damage in another.2. Decreased blood supply to median n.3. Lymphatic or venous congestion.4. Upper thoracic dysfunction.5. Cervical dysfunctions - DJD
42SIGNS AND SYMPTOMSEarly - compression of sensory portion of median nervedecreased or lost sensation in the tips of the first 3 1/2 digits.“pins and needles” sensation of the digitsparesthesias increase with hand and wrist in forced flexionparesthesias may awaken patient - shake wrist
43Later Symptoms - Motor Changes Thenar atrophy - flattening on the radial side (atrophy of abductor pollicis brevis mm.)Subjective:weak gripweak thumb abductionloss of fine motor skillsdecreased pinch strength
44Physical Examination 1. Tinel’s sign 2. Phalen’s sign a. lightly tapping over volar aspect of wristb. + sign- tingling distally of 1st 3 1/2 digits.2. Phalen’s signA. George Phalen - hand surgeon of Cleveland clinic.B.Hyperflex both wrists against dorsal surface of each hand.C. + test- numbness in approx. 30 sec.
45Special Tests Phalen’s & Tinel’s Tests Wrist flexion to maximum for 60 secTinel’sTapping over transverse carpal ligamentSymptomsPainAnesthesiaParesthesia
46Diagnostic Tests Nerve Conduction Studies Electromyography help differentiate CTS from:lesions of proximal median nervebrachial plexusC6-C7 radiculopathy
47Electrophysiologic Studies Can separate CTS into:1. Median nerve demyelination conservative management.2. Axonal degeneration- may require surgical intervention.
48Magnetic Resonance Imaging Excellent noninvasive modality.Flattening of median nerve.Volar bowing or bulging of the flexor retinaculum.Increased T2 signal density:swollen median nerve.
54Current Therapies Education NSAIDs Physical medicine PT/OTPrevention of re-injuryStretchingInjections of the tendons within the carpal tunnelLidocaine, Marcaine, etc..SteroidsTranscarpal ligament surgical resectionOMT
55Surgical Treatment Open carpal tunnel release (OCTR). Endoscopic carpal tunnel release (ECTR).10% failure ratePatient may have co-existing conditions.
56OMT Treatment Plan Global Treatment Plan Transverse carpal ligament Carpal bonesIO membraneRadius & UlnaPectoralis minorClavicle1st ribSupraclavicular fasciaShoulder GirdleCervical spineThoracic spine
58Osteopathic Treatment Myofascial releaseArticulatoryMuscle energy
59OMT Techniques Opponen’s Roll Squeeze with Rapid Circumduction Wrist & Interosseous Membrane Ligament
60Myofascial Release1. Pressure applied centrally from the dorsal surface of the carpal bones.2. Simultaneously apply pressure to the edges of the carpal bones on the ventral surface of the wrist. (lateral and medial borders of the carpal tunnel.)3. Simultaneously the D.O. catches the patient’s thumb and pulls it back into hyperextension with abduction treating the attachment of the abductor pollicis brevis muscle.4. Digits and wrist are hyperextended (pulls flexor tendons into canal and distends canal from inside out.)
61Opponens Roll Technique Lateral axial rotation stretches the opponens pollicis muscle.Thenar abduction with extension and lateral rotation.
64Opponen’s RollGrasp first digit (thenar emin.) and fifth digit (hypothenar emin.) with each handContact pisiform and scaphoid bones with thumbsExtend wrist, abduct and laterally rotate first digit with counterforce over hypothenar areaUse thumbs to stretch at boney contact points the transverse carpal ligament in lateral/medial directionProvide stretch to transverse carpal ligament for 3-5 minutesPerform at each clinic visit and teach patient to perform technique at home on daily basis
65Myofascial Release1. Crisscross thumbs over medial and lateral borders of carpal tunnel.2. Apply gentle traction.3. Have patient abduct fingers and hold in abduction.4. With abduction maintained, have patient slowly flex involved wrist over D.O.’s crisscrossed thumbs.
73Articulatory Technique 1. D.O. applies a squeeze between his/her hands, producing traction at the joint as the thenar and hypothenar eminences separate.2. D.O. maintains the squeeze and applies the articulatory force as a circumduction of the patient’s wrist in a clockwise, then counterclockwise conical motion, carrying the dysfunction through the restrictive barrier.
75Squeeze with Rapid Circumduction Place heel of both hands over radiocarpal region of carpal bones & interlace fingersAttempt to distract fingers while squeezing fingers togetherCauses the heel of each hand to squeeze togetherCircumduct wrist in circular or figure eight fashionCare should be taken to maintain capsular tension throughout the articulatory sweepPerform at each clinic visit
76Ligamentous Articular Strain (Conrad Speece D.O.) Strains of the interosseous membranes result in a loss of the normal degree carrying angle of the wrist.
79Muscle Energy (interosseous membrane) 1. D.O. thumbs are crossed over the anterior surface of the patient’s forearm with interosseous dysfunction between his/her thumbs.2. The pad and tip of the thumb of the hand closest to the D.O. contacts the lateral side of the ulna. The thumb of the other hand contacts the medial side of the radius.3. Have patient attempt to pronate palm and use isometric counterforce.
83Extension With Anterior Carpal Glide 1. Extend wrist to the point of balanced ligamentous tension.2. Apply traction.3. Move joint into flexion to articulate the joint through the restrictive barrier.
87Adduction with Lateral Carpal Glide 1. Place wrist in adduction to the point of balanced ligamentous tension.2. Apply traction.3. Move the joint into abduction to articulate the joint through the restrictive barrier.
89Patient Stretches1. Patient places palm of affected extremity against wall.2. Patient “hooks” hypothenar region of opposite hand into thenar region of hand to be stretched.3. Thumb of affected extremity is grasped and extended.4. While holding thumb and thenar eminence, palm is placed against wall in extension.5. Elbow is tucked into patient’s iliac crest to assist with the stretch.