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Carpal Tunnel Syndrome (CTS)

hand carpal tunnel

Carpal tunnel syndrome (CTS) is frequently described as a median nerve neuropathy caused by blood perfusion problems due to compression from tendon pathology at the wrist. Additionally, the brachial plexus has been implicated in muscle spasms (eg reduced upper limb tension testing range of motion) as well as 'double crush' injuries of the peripheral nerve. However, there may be a form of carpal tunnel symptomatology which involves the upper cervical spine and thoracic outlet syndrome (TOS). TOS has classically been attributed to compression of blood vessels of the anterolateral cervicothoracic triangle formed between the scalene muscles and the first rib. Scalene muscles are thought to become tight in upper chest breathers, in people with cervical ribs and as a compensatory mechanism for trapezius-serratus anterior dysfunction.

Symptoms of TOS have usually been described as pins & needles/numbness in the medial forearm (C8/T1 distribution). However, the upper cervical spine innervates the scalene and trapezius muscles as well as the diaphragm. Dysfunction of the upper cervical spine has the potential to result from overuse of the upper trapezius and levator scapula. This can lead to excessive compression of these joint causing neural irritation. Such irritation can create ectopic impulse generation into the spinal cord and scalene muscles whose tightness has been commonly implicated TOS. Due to the nature of TOS, muscles in the forearm can have their blood perfusion reduced, leading to premature fatigue and tightness. Importantly, the traditional examination procedures (Adson's manoeuvre, etc) for TOS aren't considered reliable unless taken into the context of the entire clinical reasoning process.

Scalene overuse may be a direct compensatory mechanism for reduced lateral excursion of the diaphragm in the inferior thorax. Additionally, this reduction in diaphragm function results in reduced core stability of the lumbar spine. Associated with reduced core stability are altered thoraco-lumbar fascia biomechanics with a potential increase in the tension of the latissimus dorsi. Increased tension of the latissimus dorsi affects scapula mobility at it's inferior angle, by reducing rib excursion, which may have a profound affect on serratus anterior function, as well as creating a 'tug-of-war' between the upper trapezius and latissimus dorsi.

Scapula mobility & stability are paramount considerations when treating a person who is suffering from TOS. Importantly, rehabilitation programmes should use exercises for eccentric and concentric strengthening of the serratus anterior and trapezius muscles. Additionally, stretches are incorporated for the scalene muscles and levator scapula, as well as soft tissue massage of these structures as well as pectoralis minor. Manual therapy techniques including joint mobilisations to the upper cervical spine, the cervico-thoracic junction, ribs and low thoracic spine, are combined with a home programme of Mulligan's NAG's, SNAG's and MWM's. In particular, self mobilisations of the upper ribs can be extremely useful in reducing scalene muscle tone as well as potentially afecting the ganglion stellatum. Taping of the inferior & superolateral angles of the scapula may enhance proprioceptive input, as well as 'unload' overused structures. Lateral diaphragmatic breathing and thoracic lateral flexion stretching is also important. Any excessive thoracic kyphosis will need to be addressed with joint mobilisation and appropriate exercise. Dry needling can be very useful in the treatment of overactive trigger points in the trapezius and levator scapula. However, care needs to be taken to avoid vital organs such as a pneumothorax if dry needling over lung fields. Naturally, any median nerve dysfunction in the remaining areas of the cervical spine should be addressed. Sympathetic nervous system function should also improve with enhanced thoracic spine mobility. Neural 'sliders' are also a useful part of a home exercise program.

Vascular Conditions

Virchow's Triad in the aetiology of thrombosis may be of assistence with differential diagnosis of vascular disease. The 3 variables include

  • Changes in vessel wall (endothelial damage)
  • Changes in blood flow (flow volume/stasis)
  • Changes in blood constituents (state of coagulability)

The latter may include screening questions for blood disordes (thrombolytic ones, reactive protein C, as well as Thalasaemia and Sickle Cell Anaemia), systemic inflammatory conditions (such as Lupus and Scleroderma), the use of oral contraceptives, smoking, diet and frequent flying.

Taylor & Kerry (2005) quote a paper from Sise et al (1989) reporting an average 2 year delay in diagnosis in young people where 93% could have been diagnosed with simple palpation of peripheral pulses.

Familial history may be important in differential diagnosis of vascular conditions. Additionally, a history of heavy smoking can lead to internal blood vessel pathology. Similarly, women who take the pill may also be at risk. Aortic stenosis may manifest as a result of arterosclerosis or due to underlying congenital defects. These are screening questions which need to be asked during the subjective examination. During the physical examination, the radial and brachial pulses should be examined at rest but usually need to be assessed immediately after exercise or in the compromising posture where symptoms normally manifest. Further testing should include ankle blood pressure monitoring of each side. Taylor & Kerry (2005) recommend 20 minutes of rest before testing systolic blood pressure in the left and right brachial artery, posterior tibial and dorsalis pedis and then using the "Ankle to brachial pressure index = Ankle systolic BP / Brachial systolic BP". 1 - 1.2 considered normal, 0.75 - 0.9 indicates moderate disease, 0.5 - 0.75 severe disease and <0.5 is limb threatening (see: Taylor AJ, Kerry R, 2005, Vascular syndromes presenting as pain of spinal origin. Ch 36 in Grieve's Modern Manual Therapy: The Vertebral Column. Ed Boyling JD & Jull GA Elsevier Churchill Livingstone).

The posture and type of injuries associated with certain sporting pursuits such as cycling (and rowing) may make these athletes particularly prone to upper limb and head/neck vascular conditions. Additionally, one of the most common cycling injuries involves landing on the shoulder or outstretched hand resulting in possible neurovascular traction injury, direct trauma and/or clavicular fracture. The latter has been associated with trapezius muscle dysfunction which can be a precipitating variable leading to Thoracic Outlet Syndrome (TOS). Symptoms of TOS can include typical symptoms of neck, shoulder, elbow and hand pain. Occasionally, people describe a sense of swelling (or fullness) in the arm, with/without concommitant pins & needles or numbess. Vascular components of TOS may be less prevelant than neurological ones, yet this may be due to mis-diagnosis as the plethora of tests (Adson's, Allen's Halstead's manoeuver, Roos's EAST test) may be falsely positive or negative and variable b/n examiners. Hence, the examination must use the multitude of variables at the clinicians disposal, both Subjective symptoms & Physical signs - inductive and deductive reasoning, to make sense of the clincal picture. When in doubt and further investigations are required, by using the weight of probability from many variables, it may also make the argument for further testing more convincing to a medical colleague.

Paget - Schroetter syndrome is a deep venous thrombosis of the subclavian - axillary venous system, also known as "effort thrombosis" (Rutherford 1998, Zell et al 2001) and may account for about 3-7% of all DVT's (Taylor & Kerry 2005). The average patient is in their late 20's to early 30's and males present 3 times more commonly than females. Most commonly complain of quick insidious arm pain (70% in dominant arm), with possible supraclavicular fossa and ipsilateral neck pain. Most commonly occurs in activity with repetitve upper arm, over shoulder height, movements. The usual aetiology is Virchow's Triad which means that specific screening questioning is required. Additionally, other risk factors may include thoracic outlet factors such as cervical rib, anomalous first rib, hypertrophy of the anterior scalene, subclavius or pectoralis minor as well as endogenous factors such as activated protein C resistance and anticardiolipin antibodies (Ellis 2000 in Taylor & Kerry 2005).

Taylor & Kerry suggest that observable signs of vascular compromise may include skin pallor or cyanosis - both resting and positional, swelling, and/or superficial venous dilation. Corneal arcus or xanthelasmas (yellowish raises skin changes) around both eyes may be associated with hyperlipidaemia and hypercholesterolaemia. Staining of fingers may be a more accurate indicator of tobacco consumption. Obesity and state of mental awareness may also reflect underlying cerebrovascular state.

Hand and digital examination should also include nail squeezing - indicative of capillary refilling time. These should be perfomed in various positions of potential vascular compromise. Nail abnormalities may be present. Pulses should be tested, stethescope auscultation should be undertaken and the pressure cuff sphygmomanometer and hand held doppler or automatic blood pressure monitor used (Taylor & Kerry 2005).

Taylor & Kerry (2005) argue quite strongly that vascular examination is such a miniscule part of both under-graduate and post-graduate degrees that we may be implicated in delayed diagnosis as well as the initiating of innapropriate treatment.

Mind Map for CTS

Importantly, examination and treatment of the scapulo-thoracic/cervical region along with examination of the carpal tunnel structures should be included at the initial consultation before the client goes rushing off to surgery. Although, many structures have been implicated in generating symptoms of carpal tunnel syndrome, the clinical reasoning process should clarify the extent of involvement of each and every structure. Confusion should be minimized through systematic assessment, treatment and exercise prioritization which reflect the clear explanations given to the client of predicted outcome.

As symptoms improve and mild weight bearing can be tolerated then 4 point kneeling exercises using a yoga mat may be commenced

Last update : 6 January 2008


 

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  • Thu 22 Dec 2016

    Ehlers Danlos Syndrome

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Additional symptoms associated with joints, such as stiffness, 'feeling like a 90 year old', clicking, clunking, popping, subluxations, dislocations, instability, feeling that the joints are vulnerable, as well as symptoms affecting other tissue such as paraesthesia, tiredness, faintness, feeling unwell and suffering flu-like symptoms. Autonomic nervous system dysfunction in the form of 'dysautonomia' frequently occur. Broad paper like scars appear in the skin where wounds have healed. Other extra-articular manifestations include ocular ptosis, varicose veins, Raynauds phenomenon, neuropathies, tarsal and carpal tunnel syndrome, alterations in neuromuscular reflex action, development motor co-ordination delay (DCD), fibromyalgia, low bone density, anxiety and panic states and depression. Age, sex and gender play a role in presentaton as it appears more common in African and Asian females with a prevalence rate of between 5% and 25% . Despite this relatively high prevalence, JHS continues to be under-recognised, poorly understood and inadequately managed (Simmonds & Kerr, Manual Therapy, 2007, 12, 298-309). In my clinical experience, these people tend to move fast, rely on inertia for stability, have long muscles creating large degrees of freedom and potential kinetic energy, resembling ballistic 'floppies', and are either highly co-ordinated or clumsy. Stabilisation strategies consist of fast movements using large muscle groups. They tend to activities such as swimming, yoga, gymnastics, sprinting, strikers at soccer. Treatment has consisted of soft tissue techniques similar to those used in fibromyalgia, including but not limited to, dry needling, myofascial release and trigger point massage, kinesiotape, strapping for stability in sporting endeavours, pressure garment use such as SKINS, BSc, 2XU, venous stockings. Effectiveness of massage has been shown to be usefull in people suffering from chronic fatigue syndrome (Njjs et al 2006, Man Ther, 11, 187-91), a condition displaying several clinical similarities to people suffering from EDS-HT. Specific exercise regimes more attuned to co-ordination and stability (proprioception) than to excessive non-stabilising stretching. A multi-modal approach including muscle energy techniques, dry needling, mobilisations with movement (Mulligans), thoracic ring relocations (especially good with autonomic symptoms), hydrotherapy, herbal supplementaion such as Devils Claw, Cats Claw, Curcumin and Green Tee can all be useful in the management of this condition. Additionally, Arnica cream can also be used for bruising. Encouragment of non-weight bearing endurance activities such as swimming, and cycling to stimulate the endurance red muscle fibres over the ballistic white muscles fibres, since the latter are preferably used in this movement population. End of range movements are either avoided or done with care where stability is emphasized over mobility. People frequently complain of subluxation and dislocating knee caps and shoulders whilst undertaking a spectrum of activities from sleeping to sporting endeavours. A good friend of mine, Brazilian Physiotherapist and Researcher, Dr Abrahao Baptista, has used muscle electrical stimulation on knees and shoulders to retrain the brain to enhance muscular cortical representation which reduce the incidence of subluxations and dislocations. Abrahao wrote : "my daughter has a mild EDS III and used to dislocate her shoulder many times during sleeping.  I tried many alternatives with her, including strenghtening exercises and education to prevent bad postures before sleeping (e.g. positioning her arm over her head).  What we found to really help her was electrostimulation of the supraspinatus and posterior deltoid.  I followed the ideas of some works from Michael Ridding and others (Clinical Neurophysiology, 112, 1461-1469, 2001; Exp Brain Research, 143, 342-349 ,2002), which show that 30Hz electrostim, provoking mild muscle contractions for 45' leads to increased excitability of the muscle representation in the brain (at the primary motor cortex).  Stimulation of the supraspinatus and deltoid is an old technique to hemiplegic painful shoulder, but used with a little different parameters.  Previous studies showed that this type of stimulation increases brain excitability for 3 days, and so we used two times a week, for two weeks.  After that, her discolcations improved a lot.  It is important to note that, during stimulation, you have to clearly see the humerus head going up to the glenoid fossa" Surgery : The effect of surgical intervention has been shown to be favourable in only a limited percentage of patients (33.9% Rombaut et al 2011, Arch Phys Med Rehab, 92, 1106-1112). Three basic problems arise. First, tissues are less robust; Second, blood vessel fragility can cause technical problems in wound closure; Third, healing is often delayed and may remain incomplete.  Voluntary Posterior Shoulder Subluxation : Clinical Presentation A 27 year old male presented with a history of posterior shoulder weakness, characterised by severe fatigue and heaviness when 'working out' at the gym. His usual routine was one which involved sets of 15 repetitions, hence endurance oriented rather than power oriented. He described major problems when trying to execute bench presses and Japanese style push ups.  https://youtu.be/4rj-4TWogFU In a comprehensive review of 300 articles on shoulder instability, Heller et al. (Heller, K. D., J. Forst, R. Forst, and B. Cohen. Posterior dislocation of the shoulder: recommendations for a classification. Arch. Orthop. Trauma Surg. 113:228-231, 1994) concluded that posterior dislocation constitutes only 2.1% of all shoulder dislocations. The differential diagnosis in patients with posterior instability of the shoulder includes traumatic posterior instability, atraumatic posterior instability, voluntary posterior instability, and posterior instability associated with multidirectional instability. Laxity testing was performed with a posterior draw sign. The laxity was graded with a modified Hawkins scale : grade I, humeral head displacement that locks out beyond the glenoid rim; grade II, humeral displacement that is over the glenoid rim but is easily reducable; and grade III, humeral head displacement that locks out beyond the glenoid rim. This client had grade III laxity in both shoulders. A sulcus sign test was performed on both shoulders and graded to commonly accepted grading scales: grade I, a depression <1cm: grade 2, between 1.5 and 2cm; and grade 3, a depression > 2cm. The client had a grade 3 sulcus sign bilaterally regardless if the arm was in neutral or external rotation. The client met the criteria of Carter and Wilkinson for generalized liagmentous laxity by exhibiting hyperextension of both elbows > 10o, genu recurvatum of both knees > 19o, and the ability to touch his thumbto his forearm Headaches Jacome (1999, Cephalagia, 19, 791-796) reported that migraine headaches occured in 11/18 patients with EDS. Hakim et al (2004, Rheumatology, 43, 1194-1195) found 40% of 170 patients with EDS-HT/JHS had previously been diagnosed with migraine compared with 20% of the control population. in addition, the frequency of migraine attacks was 1.7 times increased and the headache related disability was 3.0 times greater in migraineurs with EDS-HT/JHS as compared to controls with migraine (Bendick et al 2011, Cephalgia, 31, 603-613). People suffering from soft tissue hypermobility, connective tissue disorder, Marfans Syndrome, and Ehler Danlos syndrome may be predisposed to upper cervical spine instability. Dural laxity, vascular irregularities and ligamentous laxity with or without Arnold Chiari Malformations may be accompanied by symptoms of intracranial hypotension, POTS (postural orthostatic tachycardia syndrome), dysautonomia, suboccipital "Coat Hanger" headaches (Martin & Neilson 2014 Headaches, September, 1403-1411). Scoliosis and spondylolisthesis occurs in 63% and 6-15% of patients with Marfans syndrome repsectively (Sponseller et al 1995, JBJS Am, 77, 867-876). These manifestations need to be borne in mind as not all upper cervical spine instabilities are the result of trauma. Clinically, serious neurological complications can arise in the presence of upper cervical spine instability, including a stroke or even death. Additionally, vertebral artery and even carotid artery dissections have been reported during and after chiropractic manipulation. Added caution may be needed after Whiplash type injuries. The clinician needs to be aware of this possibility in the presence of these symptoms, assess upper cervical joint hypermobility with manual therapy techniques and treat appropriately, including exercises to improve the control of musculature around the cervical and thoracic spine. Atlantoaxial instability can be diagnosed by flexion/extension X-rays or MRI's, but is best evaluated by using rotational 3D CT scanning. Surgical intervention is sometimes necessary. Temperomandibular Joint (TMJ) Disorders The prevelence of TMJ disorders have been reported to be as high as 80% in people with JHD (Kavucu et al 2006, Rheum Int., 26, 257-260). Joint clicking of the TMJ was 1.7 times more likely in JHD than in controls (Hirsch et al 2008, Eur J Oral Sci, 116, 525-539). Headaches associated with TMJ disorders tend to be in the temporal/masseter (side of head) region. TMJ issues increase in prevelence in the presence of both migraine and chronic daily headache (Goncalves et al 2011, Clin J Pain, 27, 611-615). I've treated a colleague who spontaneously dislocated her jaw whilst yawning at work one morning. stressful for me and her! Generally, people with JHD have increased jaw opening (>40mm from upper to lower incisors). Updated 18 May 2017  Read More
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Updated : 10 May 2014

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Copyright Martin Krause 1999 - material is presented as a free educational resource however all intellectual property rights should be acknowledged and respected