Carpal Tunnel Syndrome
By Ken Rude, PT

I have this tree next to my driveway whose branches hang down into the driving space. I trim the lower branches back, but slowly the forces of nature grow more tree stuff, and that gradually droops down until I have to cut it back again. I suspect that next year there’s going to be more branches dangling down over my driveway again.

So what does this have to do with Carpal Tunnel Syndrome? Actually, plenty.

Carpal Tunnel Syndrome (CTS) is the name given to a process of events culminating in pain, numbness, weakness and loss of function in the hand. It can be so disabling that it is now at the top of the list for lost days of work in this country. The chances are good that you know someone who suffers or has suffered with the condition. Try this: next time you’re at a party: check everybody’s wrists for the telltale squiggly scar indicating a carpal tunnel surgery. If it’s a jumpin’ party, you’ll probably find at least one.

The carpal tunnel serves as the passageway through the wrist for the median nerve, one of the main nerves of the hand. A set of wrist bones, or carpals, mark the top of this passageway, and a tough band called the retinacular ligament closes off its base. The median nerve has to share the tunnel with nine tendons that go to your hand and fingers and allow them to move. Nature is very economical with space, so all these structures are packed in pretty tightly. You can best appreciate this arrangement if you chop off your hand and take a look. (Editor’s note; “CAUTION, DON’T DO THIS!” Our liability won’t cover it!)

NEWS FLASH!! DATELINE: 500,000 BC: Human beings appear to be evolving out of the primordial genetic muck. They spend their time swinging sticks and plucking primordial coconuts. Computer keyboards aren’t very much in evidence. Florida invents the punch-card ballot.

Okay, so maybe Beethoven and Bill Gates weren’t thinking evolutionary history when they helped popularize the keystroke. But here’s an anatomy lesson: grab and squeeze something with your left hand. Now, with your right hand, feel the muscles in your left forearm. All the muscles are acting, both in the front and the back. Then, with your right hand still on your left forearm, drop whatever you’re holding and tap your fingers like you were typing. You’ll feel the muscles on the underside of your forearm (the non-hairy side) are more active than the ones on the top. Now continue doing this for fifteen years, and when you’re done, please go on to the next paragraph.

Over all those years, the muscles on the underside have gotten a whole lot more work than the ones on the top. They should feel tight. Oh, I forgot to tell you that some of these muscles are attached to the wrist bones, and they exert a subtle but persistent pull that tends to pull them towards the retinacular ligament. This shrinks the area of the carpal tunnel, and all those tendons, which are kind of tough, are now crushing the median nerve. Which explains the numbness in your thumb and first two fingers. It also explains why my tree branches are hanging all over my car—the force of gravity acting unopposed makes things start to slump down. And the force of one set of muscles acting unopposed across a joint tends to pull our structures out of whack.

What does “unopposed” mean? Let’s look at your hand again. When you grasp something, your wrist cocks back. The muscles that do the squeezing are on one side, and by themselves they would bend your wrist forward. But they’re opposed by the muscles on the other side, which bend the wrist back. Now look at someone working on a keyboard. The wrists are pretty much straight, not bent back. The muscles that key are unopposed, so your wrist gets pulled out of whack. . . and the nerve gets pinched, and you go visit the doc.

A slight disclaimer: not all hand and wrist pains are CTS. And some CTS cases are caused by a deficiency in Vitamin B6. Other predisposing factors include pregnancy, obesity and diabetes. And probably individual builds make one person more at-risk for CTS than another. But it should be pretty clear that repetitive motions, such as typing, are behind the explosion of CTS cases we’ve seen in the past two decades.

So, whaddaya gonna do?

As a physical therapist, my first job is to see that you’ve got a splint to wear to bed. Most people first notice their CTS symptoms when they awaken. That’s because we tend to sleep with our wrists bent, which compresses the poor nerve that’s unfortunate enough to pass through the stingy carpal tunnel. Next, I’m going to try to find out what, if anything, you’re doing for prolonged periods that puts your hand so much at risk. With luck, this can be corrected, and you’ll start to get better.

Next, I’m going to provide you with a set of exercises to help develop the muscles on the back of your forearm. Those key-punching muscles have been unopposed for long enough! Exercises are usually slow to make a difference in how you feel, but if you do them long enough and consistently enough, they’re the surest way to prevent your problem from becoming a disability. I’ll also be stretching postural muscles all up and down your arm and doing some deep tissue work to try and break up any tightness that’s contributing to the nerve entrapment.

Then I’m gonna go home and cut that branch outta my driveway. But before I do that, I’m going to caution you that surgery may ultimately be an option for you, too. At this time, there’s no non-surgical formula that works for every case. Because things can go wrong, surgery should normally be a last resort, but it usually does successfully relieve the pressure on the nerve. The procedure is relatively simple. Just below the skin is the retinacular ligament, which as I said closes off one border of the carpal tunnel. The surgeon cuts through the ligament, and the nerve and nine tendons burst free like a beer belly that’s popped the buttons off your high-school shirt. Ahhh, that feels good! Well, not really, because it’s going to take a few weeks to a few months of healing and therapy before your hand is as good as new again.

If you should start having pain or numbness in your hand, get in to see your doctor soon. Please don’t wait for it to just go away. Its very presence may be a signal that you’re doing something wrong that will only make the problem worse, and CTS causes lots of disability. These symptoms are your wrist’s way of shouting “Help! I can’t breathe!” (okay, reader, you come up with a better metaphor). Ask the doctor if s/he’ll send you for therapy. If you’re looking for me, I’ll be in my driveway chopping away at some primordial genetic muck.

Ken Rude, PT, practices at Pine Plains Physical Therapy in Pine Plains, NY.