Carpal Tunnel Syndrome

Carpal Tunnel Syndrome is compression of the median nerve as it passes through the bony canal (or carpal tunnel) of the wrist.  Symptoms are very similar as those found in Pronator Teres Syndrome, where the median nerve is compressed between the heads of the pronator teres muscle.

Causes of Carpal Tunnel Syndrome
Carpal tunnel syndrome is often seen in people with occupations that require repetitive movements of the wrist.  Some of these professions include massage therapists, check-out clerks, office workers who type a lot, and string musicians.  The median nerve passes through the carpal tunnel of the wrist with various other tendons and vessels. The carpal tunnel may be narrowed by bony callus formations or other bony changes that may occur with system conditions like rheumatoid arthritis.  Space occupying lesions like cysts or ganglia may also cause the carpal tunnel to narrow.  The structures that pass through the carpal tunnel may increase in size due to inflammation or irritation, swelling (as often seen in pregnant women), fibrosis, or scar tissue due to wrist related trauma.  In addition, carpal tunnel syndrome can be acute in nature when secondary to trauma, with infection, during an acute episode of rheumatoid arthritis, or a new activity requiring repetitive wrist movements.  Sometimes, there is no known cause of Carpal Tunnel Syndrome.

Signs & Symptoms
Carpal Tunnel Syndrome patients often complain of numbness and tingling felt in the palm of the hand, through the thumb, pointer and middle fingers.  Pain and burning sensations may also present.  The symptoms are often worse at night or in the early morning and will increase with repetitive use of the hand and wrist.  There may be heat and inflammation, tenderness and a boggy feel to tissue at the wrist.  The muscles of the forearm may be hypertonic and fascial restrictions may be present.  With Carpal Tunnel Syndrome, the pain may wake the patient from sleep and relief from all symptoms is usually sought out by elevating and shaking the hand or immersing them in warm water.  In chronic conditions there may be autonomic losses like sweating, redness and dryness of the skin and the muscles of the thumb may appear to have wasted.

Orthopedic Assessment
Some of the typical orthopedic assessment techniques a massage therapist may use are:

  • The patient may be asked to perform active & passive resisted ranges of the wrist.
  • The patient may be asked to perform resisted muscle strength testing of the muscles that cross the wrist joints.
  • Phalens and Reverse Phalens testing may be performed. This is where the patient is asked to hold their hands in a flexed position (for Phalens) against each other, or an extended or prayer position (for Reverse Phalens) for 60 seconds and report on symptoms.
  • Tinel’s test may also be performed. This is where the therapist taps along the nerve path to try and determine where the compression site is.

Massage Treatment Goals
Massage therapy can be used as a tool to help decrease sympathetic nervous system firing, pain, numbness, tingling and burning sensations. In addition, it can be used to help reduce swelling and inflammation while preventing tissue adhesions.  Therapeutic massage should be aimed at maintaining or improving joint and tissue health as well as muscle strength and preventing cyanosis.

Typical Massage Treatment
The entire upper limb and neck may be treated in instances of Carpal Tunnel Syndrome. The double crush theory suggests that in cases of Carpal Tunnel Syndrome there may be multiple areas of compression, none of which on their own are causing the symptoms, but instead symptoms are caused by the collective effect of each compression site combined.  Manual Lymph drainage techniques may be used to help reduce edema. General Swedish massage and fascial techniques may be used on the arm, pectoralis muscles and neck to help maintain tissue health and prevent tissue adhesions. Attachments release may be performed and trigger points may also be addressed in the arm, shoulder girdle and neck.  Passive and active stretching of the wrist may also be incorporated into therapeutic massage treatments.

Massage Contraindications & Precautions
Patients suffering Carpal Tunnel Syndrome may have sensory impairments. No extreme hydrotherapies or pressure depths should be used.  If muscle atrophy is present the treatment will have to be modified accordingly.  Blood flow to the hands and fingers may be impaired which may lead to tissue fragility in extreme cases. If edema is present the patient should be positioned for proper drainage.  And the therapist should not use any techniques that would cause further compression of the median nerve.

Typical Suggested Homecare
The patient may be asked to perform pain free passive stretches to the wrist, shoulder or neck, as well as squeezing and gripping exercises of the hand as necessary.  Contrast arm baths may help increase circulation while warm arm baths and/or heating pads on the forearm flexor muscles may help reduce symptoms. The patient may be asked to refrain from or reduce certain activities that overuse the wrist and hand.  It may be suggested that the patient wear a splint while sleeping or doing things that require a lot of hand movement, and/or perform self massage. If edema is present, it may be suggested that the patient use a cold compress to help reduce swelling.