Carpal Tunnel Syndrome is a very common, painful disorder affecting the hand and wrist. It occurs when the median nerve (that travels through the wrist and base of the palm) gets squeezed/compressed under a band of tissue called a ligament (the transverse carpal ligament). This causes irritation of the nerve, resulting in pain and other symptoms along the course of the nerve.
What are the symptoms of Carpal Tunnel Syndrome?
Carpal tunnel syndrome causes pain at the wrist (sometimes radiating up the forearm), and numbness or tingling in the palms of the hand, and radiating to the thumb, index finger and middle finger.
The numbness is experienced differently by different people, some describing it a “burning” sensation, others describing it as “pins and needles” or “crawling ants”, while other patients (especially chronic cases) simply find that they can’t feel things properly and may have difficulty handling small objects, like buttoning their clothes when they get dressed, or telling the difference between different sizes of coins without looking at them.
Symptoms are initially POSTURE or ACTIVITY related.
The symptoms are often worse at night and the early mornings (patients often complain of waking up in the middle of the night with “pins and needles” of the hand and fingers. This is often a POSTURAL issue.
Patients may also start complaining of numbness after holding up the newspaper for a while, or while holding the steering wheel while driving, or while typing or while gripping cooking tools for example.
As the condition progresses and becomes more severe, the numbness and symptoms come about more and more often, and eventually are present throughout the day, and do not go away.
In the late stages, or in severe carpal tunnel syndrome – patients develop weakness of the thumb, and have difficulty grasping large objects (eg. A mug) or manipulating small objects (like paperclips or buttons)
Can symptoms be alleviated?
To alleviate symptoms, we must firstly (1) stop irritating the nerve, by halting and avoiding any aggravating activities, and (2) rest the tendons and the nerve at the wrist, to allow the swelling (inflammation) to recede, and the pressure on the nerve to be reduced.
First attempt to identify the aggravating activities – these are usually repetitive activities that require gripping (e.g. racquet sports, gym machines or golf for example), repetitive finger movements (e.g. typing, especially in awkward position such as a cramped work space or using a very small keyboard). It may take 1 to 2 weeks of reduced activity for the symptoms to improve.
To reduce the inflammation of the tendons travelling through the carpal tunnel, and relieve the pressure on the nerve, a short course of anti-inflammatory medications are helpful. And usually given together with a brace/or splint to immobilise the wrist. By immobilising the wrist in a neutral position, we keep the carpal tunnel in its widest position (flexing and extending the wrist narrows the carpal tunnel), and this helps relieve the pressure on the nerve. The splint or brace needs to be worn the whole day initially, until the symptoms subside, and then can be reduced to night-time and during specific activities (like typing).
Who is more susceptible to suffering from this syndrome, other than people with diabetes? What kind of jobs lead to a higher case of Carpal Tunnel Syndrome?
Anything that increases pressure on the median nerve can cause Carpal Tunnel Syndrome.
Repetitive activity. Certain factory line workers, typists, cashiers, carpenters etc. (people who use their wrists for repetitive actions)
Frequent use of vibrating tools (carpenters using hammer drills, construction workers using percussive road breaker etc) can cause irritation of the tendons and nerve.
Pregnancy. During pregnancy, hormonal changes predispose to “fluid retention” and swelling. As a result, the tendons may become more easily swollen, and compress the median nerve as they pass together through the carpal tunnel. This maybe further exacerbated by the many childcare and household tasks that the mother has to perform, like nursing, cradling, lifting baby.
Gender and Age: Women generally are more susceptible to getting carpal tunnel syndrome because their wrists are smaller, and perhaps also because of the nature of their work (housework etc). And carpal tunnel syndrome does become more common as people get older
Previous injury around the wrist – like fractures in the past, may cause narrowing of the carpal tunnel, and result in either acute carpal tunnel syndrome, or carpal tunnel syndrome many years later.
Gout or Arthritis – these conditions may cause chronic inflammation of the joints in the floor of the carpal tunnel, or inflammation of the tendons passing through the carpal tunnel, and cause compression of the nerve. In the case of gout, this may also cause crystal deposits in the tunnel and around the tendons causing direct pressure on the nerve.
Very occasionally, there are patients with other conditions that also cause hand numbness and these can mimic a carpal tunnel syndrome. An experienced doctor will often be able to differentiate these or may perform additional tests if there are doubts. Such conditions as cervical spondylosis (nerve root impingement at the neck), hyperthyroidism (overactive thyroid or excessive thyroid hormone), tumours in the carpal tunnel, pronator syndrome (a median nerve compression in the upper forearm), collagen-vascular-disorders (scleroderma, systemic lupus erythromatosus, polymyalgia rheumatic etc).
Can young people have Carpal Tunnel Syndrome?
YES. We have seen patients in a younger age group, and these usually always have an identifiable cause. We have seen students preparing for their O-levels or A-levels, who have increased their writing workload, and developed numbness of the fingers and pain at the wrist. Students with write with an awkward position (over flexing the wrist, and gripping the pen very tightly), can be particularly susceptible to developing carpal tunnel symptoms.
Other young patients we have seen may have symptoms related to sports. Eg. Patients who are training for competition who have increased their frequently of play (e.g. tennis or golf etc, requiring repetitive gripping), may start to develop carpal tunnel symptoms.
What are the short-term and long-term effects of Carpal Tunnel Syndrome and how do you treat the condition?
Early/Mild carpal tunnel syndrome can resolve with non-surgical treatments, while moderate to severe carpal tunnel syndrome may temporarily improve with non-surgical treatment but will likely recur over time.
It is important to realise that over time, repeated bouts of symptoms, and chronic compression of the median nerve, can cause irreversible and permanent damage to the median nerve for the severe case of Carpal Tunnel Syndrome. And treatments must be geared towards avoiding this. Any non-surgical treatments should be monitored closely and not delay definitive treatments if the symptoms are not getting better.
Carpal Tunnel Syndrome condition can be categorised into Early/Mild – Moderate – Severe
Staging of Carpal tunnel syndrome is often done by:
Clinically: that is by physical examination, and a good history. If there are significant provocative signs (manual maneuvers that doctors do during examination, to reproduce the patient’s symptoms), and a history of symptoms that is classical and of significant duration, and affecting key daily activities.
Electrophysiological tests: Nerve Conduction studies and Electromyography. These test stimulate the affected nerve and muscle and by monitoring any delays in their response, their status of their function can be quantified. These tests are quantitative and give additional information to the assessment.
Early/Mild Condition Carpal Tunnel Syndrome Treatments:
Younger patients with mild symptoms, or very recent symptoms (within weeks), or there is a reversible background condition (eg. Pregnancy) – should have a trial of conservative treatment (non-surgical treatments).
Moderate to Severe Carpal Tunnel Syndrome Treatments:
Often these patients have had the condition for some time, between 3 to 6 months, and the symptoms have gotten progressively worse in frequency and intensity, or has started to affect their work and daily activities.
A short trial of non-surgical treatments may be attempted here. But the condition is at risk of progressing to permanent damage the nerve, and a surgery will be discussed with the patient.
If the electrophysiological tests are abnormal (moderate to severe) – then surgery is usually suggested earlier rather than later, to prevent any further worsening of the condition that may result in permanent numbness or muscle weakening that may not be reversible in the later stages.
Severe Carpal Tunnel Syndrome Treatments:
Patients who have severe numbness or are complaining that they are “clumsy, and dropping things”. They have thumb weakness and muscle wasting in the palm (Thenar). Their electrophysiological tests are usually correspondingly abnormal.
The key here to quickly stop any further deterioration. A Carpal Tunnel release surgery is advised and performed as soon as possible. This alleviates the chronic pressure on the nerve, and patients will have an improvement to their symptoms, but in very severe cases, they may still have some residual symptoms of weakness or numbness. Chronic pressure does cause scarring of the nerve that may permanently compromise nerve function even after a carpal tunnel release.
In these cases, an additional tendon transfer surgery may be required to reconstruct the thumb movement that is lost.
Is surgery the only method to fully correct it, or are there any physio exercises, medication, or supplements that will help?
The alleviation of symptoms can be achieved by either:
Reducing the volume of the contents of the tunnel (reducing the swelling/inflammation of the tendons etc), or
Increasing the size of the tunnel.
To decrease inflammation and the swelling of the tendons caused by overuse, stop aggravating activities, rest and immobilise the wrist in a splint/brace, take anti-inflammatory medications. The first step is always to rest the wrist; exercises and physiotherapy to improve tendon excursion come later.
Acupuncture is not standard treatment for carpal tunnel syndrome. It may improve the sensation of numbness and pain transiently. But does not widen the carpal tunnel in a permanent way.
Vitamin B complex supplements may also alleviate the feeling of numbness and pain. Once again, these largely help with symptom control but does not cure the condition.
So with these non-surgical approaches – recurrence of symptoms remains a common occurrence. The symptoms improve with rest and initial treatment, but when patients return to regular work and sporting activity, the symptoms may recur again. These recurrences tend to be more common in patients who have had symptoms for a longer time (chronic), and the older the patient is, and if there is no identifiable obvious aggravating activity (ie, normal daily activity is enough to precipitate symptoms).
What is critical, is that any trial of conservative or non-surgical treatment, should not delay definitive treatment, or allow the condition to progress. So if conservative treatments are attempted, there must be a defined timeline and close followup. Patients who have initial improvements, must be conscious of the possibility of symptom recurrence, and must return to reassessment when this happens.
The median nerve does get progressively damaged from chronic pressure, and become scarred. When this occurs, the damage is permanent, and full recovery may not occur even after surgical release (surgical release should nonetheless still be performed whatever the stage, in order to halt any further progression).
To increase the size/circumference of the carpal tunnel, the transverse carpal ligament needs to be divided. This is a minor surgical procedure (often done under local anaesthesia as a day surgery procedure). Once the ligament is divided, the tunnel widens and there is more space for the tendons and the median nerve. This is a permanent change, and the condition hardly ever recurs there-after. This does not occur with other non-surgical treatments.
One important additional benefit of surgery is that after recovery, patients can return to all their normal activities (housework, sports, occupation etc) without worrying about their sport or work tools causing a recurrence. And this is important lifestyle choice, as patients can remain active and productive.
How do you prevent Carpal Tunnel Syndrome?
As has been discussed above, Carpal tunnel Syndrome is very common. Through the ages, the epidemiology of the condition may have changed – e.g. chief culprits nowadays is likely to be overuse typing on keyboards, as opposed to manual labor in the past. – but carpal tunnel syndrome remains exceedingly common in everyday life.
Avoiding repetitive gripping and wrist flexion activities wherever possible.
Taking Frequent breaks. With regular wrist and finger stretches, can help to alleviate the pressure on the nerve.
Identify symptoms early and initiate treatments early – splinting and oral anti-inflammatory medications for a start. And get assessed by a doctor early.
Symptoms are known to initially get better, and then recur again sometime later. Try to identify aggravating activities or postures, and work on eliminating these from your lifestyle. This may involve improving the ergonomics of your desk, computer or workstation. Or dividing up food preparation tasks. Vary your sports, so that you do a different exercise or sport each day, with time for rest and recovery in between.
Do not “live with symptoms”, “get used to the numbness” or ignore symptoms - patients have been known to ignore symptoms until they develop weakness, and this may not be entirely salvageable at that stage.
Dr. Jonathan Lee is the leading hand microsurgery and reconstructive surgeon in Singapore. He was featured in The New Paper in July 2019 in an article related to Carpal Tunnel Syndrome.