ANATOMY

The carpal bones of the wrist form a convex arch on the dorsal side of the hand and concave on the palmar side. On the palmar side it is covered by the flexor retinaculum.

ANATOMY

CONTINUED

A total of nine tendons pass through the carpal tunnel: Flexor Digitorum Profundus (four tendons) Flexor Digitorum Superficialis (four tendons)

Flexor Pollicis Longus (one tendon)

Also the Median Nerve passes through the tunnel between the flexor digitorum profundus and flexor digitorum superficialis tendons.

OVERVIEW OF INJURY

Median nerve entrapment most commonly occurs in the carpal tunnel, however it can also be occluded as it passes under the scalenes entering the arm.

OVERVIEW OF INJURY

Carpal Tunnel Syndrome is a neuropathy caused by the entrapment of the median nerve by the within the tunnel by the flexor tendons with and the transverse carpal ligament

HISTORY
Symptoms: -Dull/achy discomfort in hand, forearm, or upper arm -Paraesthesia in hand (1st-3rd digits) -WEAKNESS -Swelling or discoloration of hand -Night pain

HISTORY
Potential Causes: -Repetitive motions of hand and wrist (flexion/extension) -Sustained arm or hand positions -Pregnancy -Vibration ergonomics -Congenital Predisposition

SPECIAL TESTS
Phalen's maneuver -- Performed by flexing the wrist gently as far as possible, then holding this position and awaiting symptoms. A positive test is one that results in numbness in the median nerve distribution when holding the wrist in flexed position within 60 seconds. The quicker the numbness starts, the more advanced the condition. Phalen's sign is defined as pain and/or paresthesias in the medianinnervated fingers with one minute of wrist flexion. Durkan test - carpal compression test, or applying firm pressure to the palm over the nerve for up to 30 seconds to elicit symptoms Tinel's sign

INSPECTION / PALPATION

-No gross deformity

-Usually no discoloration/ visible edema

-May present with decreased mass in thenar eminence compared bilaterally

TREATMENT - CONSERVATIVE

1. Modification of ADLs

2. Drugs (NSAIDs, steroid injection)

3. Ultrasound 4. Hand and wrist splinting

TREATMENT SURGICAL
-Surgical intervention involves the release of the transverse carpal ligament to release pressure within carpal tunnel. -OPEN vs. ENDOSCOPIC

DIFFERENTIAL DIAGNOSES
Cervical radiculopathy (especially C6C7) Brachial plexopathy (in particular of the upper trunk) Proximal median neuropathy (especially at the pronator teres level) Thoracic outlet syndrome CNS disorders

REHABILITION
- STM 7-10min ( Mostly effleurage to remove excess fluid) - PROM wrist all directions - Wrist FLEX/EXT/SUP-PRO 3x10 - Wrist FLEX/EXT stretches 3x30sec - Ice and E-stim 80-150pps x 10 mins (For pain control)

RETURN TO PLAY CRITERIA

No Pain No CTS Symptoms negative Phalens Test Full ROM and Strength