diagnosing carpal tunnel syndrome & causes of wrist pain

Carpal tunnel syndrome is a hand and arm condition that causes numbness, tingling and other symptoms. Carpal tunnel syndrome is caused by a pinched nerve in your wrist.

A number of factors can contribute to carpal tunnel syndrome, including the anatomy of your wrist, certain underlying health problems and possibly patterns of hand use.

Bound by bones and ligaments, the carpal tunnel is a narrow passage compression of median nerve, way located on the palm side of your wrist. This tunnel protects a main nerve to your hand and the nine tendons that bend your fingers.

Compression of the nerve produces the numbness, tingling and, eventually, hand weakness that characterize carpal tunnel syndrome.

Fortunately, for most people who develop carpal tunnel syndrome, proper treatment usually can relieve the tingling and numbness and restore wrist and hand function.

symptoms:

Mild carpal tunnel symptoms most often affect the hand and sometimes the forearm, but they can spread up to the shoulder. Symptoms include:

• Numbness or pain in your hand, forearm, or wrist that awakens you at night. (Shaking or moving your fingers may ease this numbness and pain.)
• Occasional tingling, numbness, “pins-and-needles” sensation, or pain. The feeling is similar to your hand “falling asleep.”
• Numbness or pain that gets worse while you are using your hand or wrist. You are most likely to feel it when you grip an object with your hand or bend (flex) your wrist.
• Occasional aching pain in your forearm between your elbow and wrist.
• Stiffness in your fingers when you get up in the morning.

With moderate or severe carpal tunnel symptoms, you may have numbness or reduced strength and grip in your fingers, thumb, or hand. It may be hard to:

• Do simple hand movements, such as brushing your hair or holding a fork. You may accidentally drop objects.
• Pinch an object between your thumb and first finger. (This is called loss of pinch strength.)
• Use your thumb while doing simple tasks such as opening a jar or using a screwdriver. With long-term carpal tunnel syndrome, the thumb muscles can get smaller and weaker (atrophy).

Symptoms most often occur in parts of the hand supplied by the median nerve: the thumb, the index finger, the middle finger, and half of the ring finger. The median nerve doesn’t affect your little finger. So if your little finger is affected, you may not have carpal tunnel syndrome.

Symptoms often occur in both hands, but they are usually worse in one hand than the other. You may first notice symptoms at night. People with carpal tunnel syndrome can usually fall asleep, but pain or numbness may wake them up.

Not all pain in the wrist or hand is caused by carpal tunnel syndrome. There are many other conditions with similar symptoms, such as:

• An injury to the muscles, ligaments, tendons, or bones.
• Nerve problems in the fingers, elbow, or neck.
• Arthritis in the thumb joint or wrist.

causes:

Causes of Wrist Pain/Carpal Tunnel Syndrome
Wrist pain is a very common pain disorder in modern daily life. Many job related activities such as using a computer, cutting hair, and carpentry, can overload the muscles of the forearm with daily repetitive tasks. Trigger points that refer pain to wrist are likely to develop from the muscular overload. Unfortunately, many people are misdiagnosed with Carpal Tunnel Syndrome in these situations, and undergo needless surgeries.
Symptoms such as numbness and tingling sensations in the fingers may also result from trigger points in muscles of the neck and shoulder region. People with these symptoms are often diagnosed as having Thoracic Outlet Syndrome.
Both Thoracic Outlet Syndrome and Carpal Tunnel Syndrome are disorders that are more likely to be created by trigger points than by anatomical or structural malformations. Not only can trigger points refer pain that mimics these disorders, but the muscle tension created by these trigger points will frequently compress nerves as they travel in the neck, shoulder, and forearm regions, and produce the other symptoms associated with these syndromes.

The Muscles and Trigger Points that Cause Wrist Pain
There are over ten muscles that can contain trigger points that produce wrist pain and/or numbness in the hand or fingers. The following four muscles are the most commonly involved.

• The Wrist Extensors
• The Wrist Flexors
• The Scalenes
• The Pectoralis Minor

      The Wrist Extensors are the muscles that are located on the back of the forearm. They attach on the lower portion of the upper arm bone (the humerus) and run down the forearm to attach to the wrist bones. These muscles contract to flex the wrist backward (like the motion of working the throttle on a motorcycle). Trigger points in these muscles refer pain to the back of the wrist region. They also can cause a person’s grip to be weak.

      The Wrist Flexors are the muscles that are located on the inside of the forearm. These muscles attach to the lower portion of the upper arm bone, and run down the inside of the forearm to attach to the wrist bones. Contracting these muscles causes the wrist to flex or curl. Trigger points in these muscles cause pain that is felt on the inside of the wrist, thumb, and fingers. People with these trigger points will have difficulty using scissors.

    The Scalene muscle group is found deep in the lower neck. It flexes the neck to the side and helps to lift the rib cage when you inhale sharply. Trigger points in the Scalene muscles can produce strong pain in the chest, shoulder, and shoulder blade regions. Pain, numbness, or tingling sensations may also travel down the arm to the wrist. Tension in this muscle may compress the nerves as they exit the neck region. This may contribute significantly to Thoracic Outlet Syndrome.

     The Pectoralis Minor muscle is a small muscle that lies underneath the larger Pectoralis Major muscle group. This muscle attaches to the Shoulder Blade behind the collar bone, and runs downward to attach to the upper ribs in the front of the upper body. This muscle can contain two trigger points that refer pain over the chest and shoulder regions, and sometimes the pain may extend down the inside of the arm. Trigger point produced tension in this muscle may cause it to compress nerves and blood vessels as they pass through the shoulder region. This nerve compression is frequently a component of Thoracic Outlet Syndrome, which causes pain and/or numbness in that travels down the arm and into the wrist, hand, and fingers.

tests and diagnosis:

Your doctor may conduct one or more of the following tests to determine whether you have carpal tunnel syndrome:

• History of symptoms. Your doctor will review your symptoms. The pattern of your signs and symptoms may offer clues to their cause. For example, because the median nerve doesn’t provide sensation to your little finger, symptoms in that finger may indicate a problem other than carpal tunnel syndrome.
  Another clue is the timing of the symptoms. Usual times when you experience symptoms due to carpal tunnel syndrome include while holding a phone or a newspaper, gripping a steering wheel, or waking up during the night.
• Physical examination. Your doctor will conduct a physical examination. He or she will test the feeling in your fingers and the strength of the muscles in your hand.
  Pressure on the median nerve at the wrist, produced by bending the wrist, tapping on the nerve or simply pressing on the nerve, can bring on the symptoms in many people.
• X-ray. Some doctors recommend an X-ray of the affected wrist to exclude other causes of wrist pain, such as arthritis or a fracture.
• Electromyogram. Electromyography measures the tiny electrical discharges produced in muscles. During this test, your doctor inserts a thin-needle electrode into specific muscles. The test evaluates the electrical activity of your muscles when they contract and when they’re at rest. This test can determine if muscle damage has occurred and also may be used to rule out other conditions.
• Nerve conduction study. In a variation of electromyography, two electrodes are taped to your skin. A small shock is passed through the median nerve to see if electrical impulses are slowed in the carpal tunnel. This test may be used to diagnose your condition and rule out other conditions.

Your doctor may recommend that you see a doctor trained in brain and nervous system conditions (neurologist), brain and nervous system surgery (neurosurgeon), hand surgery, rheumatoid arthritis, or other areas if your signs or symptoms indicate other medical disorders or need additional treatment.

treatment:

Carpal tunnel syndrome should be treated as early as possible after you begin to experience symptoms.

Some people with mild symptoms of carpal tunnel syndrome can ease their discomfort by taking more frequent breaks to rest their hands, avoiding activities that worsen symptoms and applying cold packs to reduce occasional swelling.

If these techniques don’t offer relief within a few weeks, additional treatment options include wrist splinting, medications and surgery. Splinting and other conservative treatments are more likely to help you if you’ve had only mild to moderate symptoms for less than 10 months.

Nonsurgical therapy

If the condition is diagnosed early, nonsurgical methods may help improve carpal tunnel syndrome. Methods may include:

• Wrist splinting. A splint that holds your wrist still while you sleep can help relieve nighttime symptoms of tingling and numbness. Nocturnal splinting may be a good option if you’re pregnant and have carpal tunnel syndrome.
• Nonsteroidal anti-inflammatory drugs (NSAIDs). NSAIDs such as ibuprofen (Advil, Motrin IB, others) may help relieve pain from carpal tunnel syndrome in the short term.
  There isn’t evidence, however, that these drugs improve carpal tunnel syndrome.
• Corticosteroids. Your doctor may inject your carpal tunnel with a corticosteroid such as cortisone to relieve your pain.
  Corticosteroids decrease inflammation and swelling, which relieves pressure on the median nerve. Oral corticosteroids aren’t considered as effective as corticosteroid injections for treating carpal tunnel syndrome.

If carpal tunnel syndrome results from an inflammatory arthritis, such as rheumatoid arthritis, then treating the arthritis may reduce symptoms of carpal tunnel syndrome, but this hasn’t been proved.

Surgery

If your symptoms are severe or persist after trying nonsurgical therapy, surgery may be the most appropriate option.

The goal of carpal tunnel surgery is to relieve pressure on your median nerve by cutting the ligament pressing on the nerve.

The surgery may be performed with two different techniques. Discuss the risks and benefits of each technique with your surgeon before surgery. Surgery risks may include incomplete release of the ligament, wound infections, scar formation, and nerve or vascular injuries. The final results of endoscopic and open surgery are similar.

• Endoscopic surgery. In endoscopic surgery, your surgeon uses a telescope-like device with a tiny camera attached to it (endoscope) to see inside your carpal tunnel and cut the ligament through one or two small incisions in your hand or wrist.
  Endoscopic surgery may result in less pain than does open surgery in the first few days or weeks after surgery.
• Open surgery. In open surgery, your surgeon makes a larger incision in the palm of your hand over the carpal tunnel and cuts through the ligament to free the nerve. This procedure may also be conducted using a smaller incision, which may reduce the risk of complications.

During the healing process after the surgery, the ligament tissues gradually grow back together while allowing more room for the nerve than existed before.

In general, your doctor will encourage you to use your hand after surgery, gradually working back to normal use of your hand while avoiding forceful hand motions or extreme wrist positions.

Soreness or weakness may take from several weeks to a few months to resolve after surgery. If your symptoms were very severe before surgery, symptoms may not go away completely after surgery.

Alternative forms of therapy can be integrated into your regular health plan to help you deal with the signs and symptoms of carpal tunnel syndrome. You may have to experiment to find a treatment that works for you. Still, always check with your doctor before trying any complementary or alternative treatment.

• Yoga. Yoga postures designed for strengthening, stretching and balancing each joint in the upper body, as well as the upper body itself, may help reduce the pain and improve the grip strength of people with carpal tunnel syndrome.
• Hand therapy. Preliminary evidence suggests that certain physical and occupational hand therapy techniques may help improve symptoms of carpal tunnel syndrome.
• Ultrasound therapy. High-intensity ultrasound can be used to raise the temperature of a targeted area of body tissue to reduce pain and promote healing. A course of ultrasound therapy over several weeks may help improve the symptoms of carpal tunnel syndrome.

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