Carpal Tunnel Syndrome Part 2: Symptoms & Evaluation

By: CoordinatedHealthTV

- There are a few known things that can directly cause carpal tunnel syndrome, such as fractures, injuries to the wrist, anything that can cause increased pressure on the median nerve. Other things that can be associated with it, diabetes, rheumatoid arthritis, thyroid, any type of inflammation in the tendons that also pass through the carpal canal, along with the median nerve. This here is a diagram of the hand with the skin stripped away so we can see the structures underneath. The structure in yellow here is the median nerve which is the nerve affected by carpal tunnel syndrome. The muscle here is the muscle to the thumb. And that's also innervated by the median nerve.

There's a bridge here of tissue called the carpal ligament or transverse carpal ligament which is the culprit of carpal tunnel syndrome. And there's also other structures, such as tendons, that pass through this. We'll give you a better look of the carpal tunnel if we take a transverse section of this and look at it in a transverse cut. Here's the back of the hand. Here's the palm of the hand, so palm is facing down. Here is the carpal bones aligned in a row that make or form a C-shaped column.

And that C-shaped column is then bridged by the transverse carpal ligament. That forms a ring or a tunnel or a canal known as the carpal tunnel or carpal canal. There's nine tendons that pass through there along with a nerve, and that's the median nerve. The relevant surgery here is cutting this transverse carpal ligament to allow this opening here to become greater once the surgery is performed. In terms of activity that can cause carpal tunnel syndrome, things that in terms of job, repetitive type of work, particularly more manual labor, heavy working, repetitive, and particularly vibrational tools, jackhammers, power instruments, those types of things can directly cause or exacerbate carpal tunnel syndrome. There has been some link to other, less active, but repetitive activities such as typing and things like that. Most often the symptoms from carpal tunnel include numbness, tingling, vague sense of pain in the fingers of the hand and sometimes radiating up into the forearm and arm and sometimes shoulder even. Other common symptoms of carpal tunnel syndrome is loss of sleep or waking up from sleep, causing irritation, fatigue during the day.

A lot of times patients complain of dropping things. So anything that causes the nerve to be compressed, whether it be a position, wrist position too flexed or whether it be repetitive type of activity or even vibrational type of activity, that can bring on the symptoms and cause dropping of things, inability to sense small objects and inability to feel like they can button their shirts, pick up small coins, pick up small needles, anything of, you know, small objects. Bikers, we'll sometimes have problems with bikers saying that their hands fall asleep after riding prolonged periods of time on their bike. Driving a car, people will complain of their hands falling asleep and having to shake it out. And those are the types of symptoms that we most commonly see, the most common complaints from patients. So, Donna, the symptoms that you're describing are consistent with carpal tunnel syndrome. But what I'm going to do is test from your neck on down to your hands just to make sure there's no other things that could be causing this, okay? - Okay. So what I'm going to have you do is take your chin and touch it to your shoulder like this.

Carpal Tunnel Syndrome Part 2: Symptoms & Evaluation

Come over here and touch it, yep. And now to the opposite side. Good. Now bring your chin down to your chest and all the way back. And now take your ear and touch it to your shoulder, and same thing with the other side. Does any of that cause any pain in your neck or symptoms that radiate down into your hand? - No. - Okay, good. When we examine a patient for carpal tunnel syndrome or to rule our carpal tunnel syndrome, we're also looking for other things that may be a cause of their complaint.

So we'll do a full exam from the neck on down to the hand. Primarily, we're looking to rule out other common causes of similar complaints. Then we look for arthritis in the neck, degenerative disc disease, or spondylosis.

We'll look for any problems such as arthritis down in the wrist, arthritis up in the elbow, these types of things, anything else that we can rule out, other common causes or other causes that may confound or contribute to the symptoms that they're expressing. Carpal tunnel screening exam, we typically look for strength in the upper extremity. We'll test the strength of the muscles in the arm, the forearm, the hand, particularly the thumb. The thenar muscles are the muscles to the thumb that provide opposition of the thumb. And that muscle is specifically innervated by the median nerve which is the culprit in carpal tunnel syndrome. Other things that we look in terms of examination are carpal tunnel compression test. This is applying pressure directly over the carpal canal and trying to elicit or compress the nerve and elicit the symptoms that the patient complains of.

And typically we'll look for symptoms that radiate down into the thumb, the index, or the long finger and half of the ring finger. We'll also provide a test which is hyperflexion of the wrist, which is called the Phalen's test. And we try to compress or kink the nerve around the carpal, the transverse carpal ligament at that point and try to elicit the symptoms there. Those are primarily fairly diagnostic of carpal tunnel syndrome.

We'll also test for muscle strength of the thenar muscles. So we'll ask them to oppose and test the strength of those to see if there's any weakness in the muscles that are innervated by that median nerve. And finally, we'll test the sensation out in the fingertips. And we do that by a two-point discrimination, which is basically asking the patient to discriminate between one and two points separated by a given distance.

And there's a normal range that you'd like them to fall within and be able to distinguish two points from one. I usually ask them about their past medical history, what types of medical conditions that may contribute to carpal tunnel, such as diabetes, such as thyroidism, high blood pressure. Those are the types of things. We ask them about their vocation, what type of activities that they perform outside of work. Other things we'll ask them is nighttime symptoms, does it wake you up from night? How often does it wake you up from sleep? Does this interfere with your daytime? Are you fatigued and tired throughout the day? We'll commonly ask them about their symptoms of numbness and tingling or others. Do you have numbness and tingling? Do you have pain? Do you have problems buttoning your shirt, picking up small objects?.

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