Michael D. Weaver, DO
Physical Medicine & Rehabilitation
Sports Medicine
October 16, 2013
Become familiar with the basic anatomy
of the wrist and causes of carpal tunnel
syndrome {CTS}.
 Obtain a better understanding of the
signs and symptoms associated with CTS.
 Become familiar with some of the various
testing and treatments for CTS.


Entrapment of the median nerve at the
carpal tunnel is the most common and
best characterized peripheral
compression neuropathy
› Prevalence: 2% Male & 3% Female
 0.1% to 10% of the population
 Higher rates reported in those individuals
involved in repetitive wrist motion activities
 No concrete data supporting cumulative trauma
› 50% of patients have bilateral CTS
 ~38% are asymptomatic in ‘uninvolved’ hand

Likely play a role by either increasing
pressure within the CT or increasing
susceptibility of the median nerve to
pressure, however CTS is largely idiopathic
› Normal – 2.5mm Hg (neutral)
› CTS – 32mm Hg increased to 94-110mm Hg with
wrist flexion/extension
 Neuronal changes in < 2 hours

Contributing Factors:
› Pregnancy, thyroid disorders, chronic kidney
disease, acromegaly, diabetes, obesity, smoking,
alcohol abuse, inflammatory arthritis, genetics

Chronic compression of nerve inhibits
axonal transport and epidural blood flow
which results in intraneural edema,
myelin thinning, nerve fiber
degeneration and fibrosis.
› Impaired nerve circulation
› Diminished nerve elasticity
› Decreased nerve gliding

Median nerve travels beneath transverse
carpal ligament along with 9 tendons
› Flexor Digitorum Profundus {FDP} – 4
› Flexor Digitorum Superficialis {FDS} – 4
› Flexor Pollicis Longus {FPL}

Provides motor and sensory input to a
portion of the hand

Clinical Features
› Pain, numbness, tingling in digits I-III
› Sparing of sensation to thenar eminence {palm}
 Palmar cutaneous sensory branch
› More commonly c/o entire hand and vague
complaints of pain in the shoulder and sharp
shooting pains up the forearm
 50% of patients reliably localize
 Neck pain is NOT an associated symptom

Usually worsen at night and can awaken
patients from sleep
› + flick sign
Exacerbated when driving or talking on
the phone
 Frequently dropping objects, weak grip
 Fatigues with repetitive activity


Visual Inspection
› Asymmetry
› Skin Changes
Strength
 Sensation

› Light touch/Pinprick
› Vibration
› 2 point discrimination

Provocative Maneuvers
Tinel’s sign
 Phalen Maneuver

› Reverse Phalen

Carpal Compression
› Durkan’s

Pronator Syndrome
› Compression of the median nerve as it
passes through the pronator teres muscle at
the elbow

Double Crush Syndrome
› Concomitant involvement of a pinched
cervical nerve root in the neck
 C6 and C7
› Thorough history and physical examination
Truly a clinical diagnosis
 Constellation of symptoms
 Use of diagnostic tools

› Ultrasound
› Electrodiagnostic Studies



Noninvasive
Allow for real-time
visualization of nerve
Assist in guided
injections
Nerve Conduction Studies
 Electromyography


Conservative
›
›
›
›
›
›
Activity modification
Wrist splints
Corticosteroid injection
US therapy
Nerve gliding
Medications
 Vitamin B6
 NSAIDs v oral steroids

Surgical
› Open v Endoscopic carpal tunnel release {CTR}

University of Louisville Physicians
› Physical Medicine & Rehabilitation
› Frazier Rehab Institute & Neuroscience Center
› 502.584.3377