Tingling sensation/paresthesia in thumb until middle finger radiating into forearm. Bilateral presentation possible

Patient Profile

• Female > male
• 40-60 years old
• Prevalence in female cleaning staff 48%
• Pregnant women up to 62%

Pathophysiology

Oftentimes, the symptoms present in patients with occupations that involve repetitive and forceful hand tasks. This may result in swelling of the tendons narrowing the carpal tunnel and compromising the median nerve. Practically anything that can cause such narrowing may be a possible cause of CTS:

• Trauma: radial fracture, hemorrhage, carpal bone luxation
• Tumors: lipoma, ganglion, osteophytes
• Swelling of tendons
• Arthritis

Furthermore, there are risk factors associated with peripheral nerve pathologies such as CTS. These are pregnancy, obesity, hypothyroidism, renal failure, diabetes, and rheumatoid arthritis

Course

The natural course of CTS is reported to be rather unfavorable with 32% – 58% of patients having a negative outcome at a one-year follow-up.

The course of conservatively managed CTS is highly variable but reported to improve over time. However, there are reports of an 85% chance of relapse between one to four years after treatment has ended.

History

Long history, without trauma: patients tend to wait long before consulting a doctor due to intermittent symptom course. With trauma: trauma can be cause of symptoms.

• Radiating
• Deep
• Electrifying
• Unpleasant tingling sensation
• Numbness
• Problems with fine hand tasks
• Leading symptom: numbness of hands

Physical Examination

Inspection
Muscular atrophy m. abd. pollicis, wrist appears quadratic

Active Examination
Strength: deficits in m. abd pollicis brevis & m. opponens pollicis. Possibly bottle sign (loss of strength with gripping)
Fine motor tasks: Difficulties to grip small objects

Functional Assessment
Not always easy to demonstrate; leaning or end range palmar flexion; in advanced stages possible bottle sign

Special Testing

Neurodynamics

ULTT 1 and 2

Passive Examination
ROM & Joint Play: Wrist, thumb, elbow, shoulder, C-Spine: no specific abnormatlies in CTS; C-Spine PPIVM PPAVM exam to rule out spine involvement

Additional Tests
Ultrasound and/or electrical neurography should be done for further diagnostics as Sens/Spec of special tests is poor

Differential Diagnosis

1. Radicular Syndrome C6/C7
2. TOS
3. Polyneuropathy
4. Median nerve lesion or PEP (e.g. pronator syndrome)
5. Polymyalgia
6. Raynaud’s Syndrome

Strategy

Conservative or surgical management. In both cases the goal is to decompress and create room for the nerve to move. Surgical release only if conservative management yields no success

Interventions

Conservative: Taping, bracing, neurodynamic techniques, carpal bone mobilizations, wrist mobilizations, ultrasound, corticosteroids

No clear evidence as to which conservative therapy is most effective

Surgical: Splitting of retinaculum to decompress the nerve

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