Carpal Tunnel Syndrome
Intersection Syndromele
Dequervain's Tenosynovitis
Guyon's Canal Syndrome
Trigger
Finger
Thoracic Outlet Syndrome
Impingement
Syndrome
Tennis Elbow
(Lateral Epicondylitis), Golfer's Elbow (Medial
Epicondylitis)
Radial
Tunnel Syndrome, and Cubital Tunnel Syndrome
Carpal Tunnel Syndrome
Introduction
Carpal tunnel syndrome (CTS) is a common problem that affects the hand and
wrist. This condition, or syndrome, has become the focus of much
attention in the last few years due to suggestions that it may be linked
to occupations that require repetitive use of the hands and wrists - such
as, you guessed it, typing. Some specialists, however, have differing
views on the origin of CTS. Recently quoted in a Miami-area hospital
newsletter by leading specialists of CTS,
"...despite popular opinion, Carpal Tunnel Syndrome is not caused
by using a keyboard."
Regardless of the opposing views, many people suffer from this syndrome.
In recent months, CTS has been categorized under a broader group of
disorders called Cumulative Trauma Disorders (CTD). This group includes
Repetitive Strain Injuries (RSI), Overuse Syndromes, and Repetitive Motion
Injuries (RMI). This article will briefly attempt to explain what carpal
tunnel syndrome is, how it is diagnosed, and describe the treatment
options available. Articles in future issues will discuss other disorders
which may mimic CTS including: Intersection Syndrome, Dequervain's
Tenosynovitis, Guyon's Canal Syndrome, Trigger Finger, Thoracic Outlet
Syndrome, Impingement Syndrome, Tennis Elbow (Lateral Epicondylitis),
Golfer's Elbow (Medial Epicondylitis), Radial Tunnel Syndrome, and Cubital
Tunnel Syndrome. All of these can be diagnosed in those who engage
repetitive motion activities.
Current Cost Estimates to Treat Carpal Tunnel Syndrome in the U.S.
Before we try to understand what CTS is, let's see the impact it has on
our economy. One firm estimates that it costs a company $37,000 in lost
work time, medical treatments and rehabilitation for each worker who
develops CTS (Respondex Systems, Dixon, IL, personal communication).
Workman's Compensation figures estimate $6,000 to $10,000 per case
(depending on whether only one hand is involved, or both hands are
involved); an average cost would be $8,000, in a well-managed case (David
C. Alexander, Auburn Engineers, Inc., Auburn, AL, in Dimmitt, 1995).
Because the incidence of CTS continues to increase (especially in work
requiring repetitive hand movements, particularly computer keyboard
users), it is important to consider painless, non-invasive, non-surgical
treatments, which can be administered by the patient him/herself at home,
and are low in cost. The estimated loss for the entire United States work
time, medical treatments and rehabilitation from Cumulative Trauma
Disorders has been nearly six billion dollars a year since 1997.
Anatomy
The Median Nerve
Carpal tunnel syndrome (CTS) is a condition which results when the median
nerve does not work properly. Usually, this is thought to occur because
there is too much pressure on the nerve as it runs into the wrist through
an opening called the carpal tunnel. It may be easier to understand how
this occurs if you understand some of the anatomy of the wrist. There are
eight carpal bones which make up the wrist joint. (Fig. 16) The median
nerve runs into the hand to supply sensation to the thumb, index finger,
long finger, and half of the ring finger. The nerve also supplies a
branch to the muscles of the thumb, the thenar muscles (the fat on the
palms of the hand near the thumb). These muscles help move the thumb and
are very important in moving the thumb so that you can touch each of the
other fingers. This motion is called opposition. The carpal tunnel is an
opening into the hand that is made up of the bones of the wrist on the
bottom and the transverse carpal ligament on the top. Looking at a cross
section of the wrist allows one to visualize the anatomy of the carpal
tunnel. Through this opening called the carpal tunnel, the median nerve
and the flexor tendons run into the hand. The median nerve will lie just
under the transverse carpal ligament.
The flexor tendons are important because they allow us to move the fingers
and the hand, such as when we grasp objects. The tendons are covered by a
slippery material called tenosynovium. The tenosynovium allows the tendons
to glide against each other as the hand is used to grasp objects. Any
condition that causes irritation or inflammation of the tendons can result
in swelling and thickening of the tenosynovium. As the tenosynovium
covering all of the tendons begin to swell and thicken, the pressure
begins to increase in the carpal tunnel - because the bones and ligaments
that make up the tunnel are not able to stretch in response to the
swelling. Increased pressure in the carpal tunnel begins to squeeze the
median nerve against the transverse carpal ligament - because the nerve is
the softest structure in the carpal tunnel. This is the inciting factor
for the pain! Eventually, the pressure reaches a point when the nerve can
no longer function normally. Pain and numbness in the hand begins.
One of the first symptoms of carpal tunnel syndrome is numbness in the
distribution of the median nerve. This is quickly followed by pain in the
same distribution. The distribution is important because it does NOT
include the little finger and the half of the ring finger closest to the
little finger.The pain may also radiate up the arm to the shoulder, and,
sometimes the neck. If the condition is allowed to progress, weakness of
the thenar (fat pads at the bottom of the thumb) muscles can occur. The
median nerve supplies innervation to these muscles. This results in an
inability to bring the thumb into opposition with the other fingers and
hinders one's grasp (of a drumstick e.g.).
Who gets it?
Carpal tunnel syndrome is common, affecting 0.1% of the general
population, and as many as 15% of workers in high-risk industries, such as
electronic parts assemblers, musicians, and dental hygienists. Although
the use of highly repetitive wrist movements appears to be correlated with
the development of carpal tunnel syndrome, other factors, such as medical
conditions like diabetes, rheumatoid arthritis, thyroid disease, and
pregnancy may be even more important and can result in irritation and
inflammation of the tenosynovium. Nonetheless, the incidence rises with
increasing repetition of hand use (such as typing, playing musical
instruments), and by a high level of force with each motion, (such as meat
packers), in whom the incidence of carpal tunnel syndrome has been
reported as high as 15%. A fracture of the wrist bones may later cause
carpal tunnel syndrome if the healed fragments result in abnormal
irritation on the flexor tendons. The key concept to remember is that
anything which causes abnormal pressure on the median nerve will result in
the symptoms of pain, numbness and weakness of carpal tunnel syndrome.
Diagnosis
Evaluation begins by your doctor obtaining a history of the problem,
followed by a thorough physical examination, which includes certain
maneuvers. These maneuvers are called the Phalen's and Tinel's tests.
(see Figs. 67,68) Your description of the symptoms and the physical
examination are the most important parts in the diagnosis of carpal tunnel
syndrome. Commonly, patients will complain first of waking in the middle
of the night with pain and a feeling that the whole hand is asleep.
Careful investigation usually shows that the little finger is unaffected.
This can be a key piece of information to make the diagnosis. If you
awaken with your hand asleep, pinch your little finger to see if it is
numb also, and be sure to tell your doctor if it is or is not. This will
be explained in detail in future issues, but briefly, the little finger
has a separate innervation. Other complaints include numbness while
using the hand for gripping activities, such as sweeping, hammering, or
driving. The major physical findings reflect that pressure is increased
in the carpal tunnel.
Other findings which many incorrectly associate with carpal tunnel
syndrome is the presence of a mass in the middle of the wrist called a
ganglion. These are cysts (sacs) which do not have much of any clinical
significance as they are located above all the major structures passing
through the wrist. They do become significant if large enough to obstruct
any structures or impede normal motion of the wrist, however. If this
occurs, surgery is perhaps the only form of treatment. (Fig. 56)
If more information is needed to make the diagnosis, your doctor may
request electrical studies of the nerves in the wrist. Several tests are
available to see how well the median nerve is functioning, including the
nerve conduction velocity (NCV). This test measures how fast nerve
impulses are conducted through the nerve. Obviously if the nerve is
damaged, the conduction through the nerve will be greatly slowed.
Treatment
Non-Operative Treatment
In the early stages of carpal tunnel syndrome, a simple brace will
sometimes decrease the symptoms, especially the numbness and pain
occurring at night. These braces simply keep the wrist in a neutral
position (not bent back too far nor bent down too far). When the wrist is
in this position, the carpal tunnel is as big as it can be - so the nerve
has as much room as possible. The brace needs to be worn at night while
you sleep to prevent the numbness and pain occurring at night. If you
have symptoms during the day as well, the brace may help reduce those
symptoms as well.
Anti-inflammatory medications may also help control the swelling of the
tenosynovium and reduce the symptoms of carpal tunnel syndrome. These
medications include the common over the counter medications such as
non-steroidal anti-inflammatory drugs (NSAIDS). There are many different
types of NSAIDs, including aspirin and other salicylates. Examples include
ibuprofen (Motrin, Advil), naproxen (Naprosyn), sulindac (Clinoril),
diclofenac (Voltaren), piroxicam (Feldene), ketoprofen (Orudis),
diflunisal (Dolobid), nabumetone (Relafen), etodolac (Lodine), oxaprozin
(Daypro), indomethacin (Indocin), and newer ones such as Vioxx, Ultram,
and Celebrex, which are currently being marketed. Please consult a doctor
for these newer medications. Aspirin is anti-inflammatory when given in
high doses, otherwise it is just a painkiller like acetaminophen
(Tylenol).
Since these medications are the most common form of treatment, their side
effect profile is equally important and should be known. Common side
effects include stomach upset, headache, drowsiness, easy bruising, high
blood pressure and/or fluid retention.
NSAIDs commonly cause dyspepsia, a burning, bloated feeling in the pit of
the stomach. In some patients, stomach inflammation (gastritis) or gastric
ulcers may occur. This can cause bleeding, either obvious an
eight carpal bones which make up the wrist joint. (Fig. 16) The median
nerve runs into the hand to supply sensation to the thumb, index finger,
long finger, and half of the ring finger. The nerve also supplies a
branch to the muscles of the thumb, the thenar muscles (the fat on the
palms of the hand near the thumb). These muscles help move the thumb and
are very important in moving the thumb so that you can touch each of the
other fingers. This motion is called opposition. The carpal tunnel is an
opening into the hand that is made up of the bones of the wrist on the
bottom and the transverse carpal ligament on the top. Looking at a cross
section of the wrist allows one to visualize the anatomy of the carpal
tunnel. Through this opening called the carpal tunnel, the median nerve
and the flexor tendons run into the hand. The median nerve will lie just
under the transverse carpal ligament.
The flexor tendons are important because they allow us to move the fingers
and the hand, such as when we grasp objects. The tendons are covered by a
slippery material called tenosynovium. The tenosynovium allows the tendons
to glide against each other as the hand is used to grasp objects. Any
condition that causes irritation or inflammation of the tendons can result
in swelling and thickening of the tenosynovium. As the tenosynovium
covering all of the tendons begin to swell and thicken, the pressure
begins to increase in the carpal tunnel - because the bones and ligaments
that make up the tunnel are not able to stretch in response to the
swelling. Increased pressure in the carpal tunnel begins to squeeze the
median nerve against the transverse carpal ligament - because the nerve is
the softest structure in the carpal tunnel. This is the inciting factor
for the pain! Eventually, the pressure reaches a point when the nerve can
no longer function normally. Pain and numbness in the hand begins.
One of the first symptoms of carpal tunnel syndrome is numbness in the
distribution of the median nerve. This is quickly followed by pain in the
same distribution. The distribution is important because it does NOT
include the little finger and the half of the ring finger closest to the
little finger.The pain may also radiate up the arm to the shoulder, and,
sometimes the neck. If the condition is allowed to progress, weakness of
the thenar (fat pads at the bottom of the thumb) muscles can occur. The
median nerve supplies innervation to these muscles. This results in an
inability to bring the thumb into opposition with the other fingers and
hinders one's grasp (of a drumstick e.g.).
Who gets it?
Carpal tunnel syndrome is common, affecting 0.1% of the general
population, and as many as 15% of workers in high-risk industries, such as
electronic parts assemblers, musicians, and dental hygienists. Although
the use of highly repetitive wrist movements appears to be correlated with
the development of carpal tunnel syndrome, other factors, such as medical
conditions like diabetes, rheumatoid arthritis, thyroid disease, and
pregnancy may be even more important and can result in irritation and
inflammation of the tenosynovium. Nonetheless, the incidence rises with
increasing repetition of hand use (such as typing, playing musical
instruments), and by a high level of force with each motion, (such as meat
packers), in whom the incidence of carpal tunnel syndrome has been
reported as high as 15%. A fracture of the wrist bones may later cause
carpal tunnel syndrome if the healed fragments result in abnormal
irritation on the flexor tendons. The key concept to remember is that
anything which causes abnormal pressure on the median nerve will result in
the symptoms of pain, numbness and weakness of carpal tunnel syndrome.
Diagnosis
Evaluation begins by your doctor obtaining a history of the problem,
followed by a thorough physical examination, which includes certain
maneuvers. These maneuvers are called the Phalen's and Tinel's tests.
(see Figs. 67,68) Your description of the symptoms and the physical
examination are the most important parts in the diagnosis of carpal tunnel
syndrome. Commonly, patients will complain first of waking in the middle
of the night with pain and a feeling that the whole hand is asleep.
Careful investigation usually shows that the little finger is unaffected.
This can be a key piece of information to make the diagnosis. If you
awaken with your hand asleep, pinch your little finger to see if it is
numb also, and be sure to tell your doctor if it is or is not. This will
be explained in detail in future issues, but briefly, the little finger
has a separate innervation. Other complaints include numbness while
using the hand for gripping activities, such as sweeping, hammering, or
driving. The major physical findings reflect that pressure is increased
in the carpal tunnel.
Other findings which many incorrectly associate with carpal tunnel
syndrome is the presence of a mass in the middle of the wrist called a
ganglion. These are cysts (sacs) which do not have much of any clinical
significance as they are located above all the major structures passing
through the wrist. They do become significant if large enough to obstruct
any structures or impede normal motion of the wrist, however. If this
occurs, surgery is perhaps the only form of treatment. (Fig. 56)
If more information is needed to make the diagnosis, your doctor may
request electrical studies of the nerves in the wrist. Several tests are
available to see how well the median nerve is functioning, including the
nerve conduction velocity (NCV). This test measures how fast nerve
impulses are conducted through the nerve. Obviously if the nerve is
damaged, the conduction through the nerve will be greatly slowed.
Treatment
Non-Operative Treatment
In the early stages of carpal tunnel syndrome, a simple brace will
sometimes decrease the symptoms, especially the numbness and pain
occurring at night. These braces simply keep the wrist in a neutral
position (not bent back too far nor bent down too far). When the wrist is
in this position, the carpal tunnel is as big as it can be - so the nerve
has as much room as possible. The brace needs to be worn at night while
you sleep to prevent the numbness and pain occurring at night. If you
have symptoms during the day as well, the brace may help reduce those
symptoms as well.
Anti-inflammatory medications may also help control the swelling of the
tenosynovium and reduce the symptoms of carpal tunnel syndrome. These
medications include the common over the counter medications such as
non-steroidal anti-inflammatory drugs (NSAIDS). There are many different
types of NSAIDs, including aspirin and other salicylates. Examples include
ibuprofen (Motrin, Advil), naproxen (Naprosyn), sulindac (Clinoril),
diclofenac (Voltaren), piroxicam (Feldene), ketoprofen (Orudis),
diflunisal (Dolobid), nabumetone (Relafen), etodolac (Lodine), oxaprozin
(Daypro), indomethacin (Indocin), and newer ones such as Vioxx, Ultram,
and Celebrex, which are currently being marketed. Please consult a doctor
for these newer medications. Aspirin is anti-inflammatory when given in
high doses, otherwise it is just a painkiller like acetaminophen
(Tylenol).
Since these medications are the most common form of treatment, their side
effect profile is equally important and should be known. Common side
effects include stomach upset, headache, drowsiness, easy bruising, high
blood pressure and/or fluid retention.
NSAIDs commonly cause dyspepsia, a burning, bloated feeling in the pit of
the stomach. In some patients, stomach inflammation (gastritis) or gastric
ulcers may occur. This can cause bleeding, either obvious and painful or
hidden and painless. This loss of blood may lead to anemia. To help
protect the stomach, NSAIDs should always be taken with food or directly
after a meal. Some patients may need additional medications to control
their stomach symptoms. Some may tolerate one kind of NSAID, but have
gastric irritation with others. A person on long-term NSAID therapy should
have a blood count periodically to insure that anemia from gastric
bleeding is not occurring. Patients with a history of gastric (stomach) or
duodenal (intestinal) ulcers should tell their physician before starting
on NSAIDs. Furthermore, any individual who will not accept blood products
for religious or other reasons, should inform their doctor of this prior
to starting therapy with NSAIDs.
Symptoms of headache or drowsiness are usually mild, but if severe, the
medicine may have to be stopped.
NSAIDs affect the function of platelets, a type of blood cell important in
normal blood clotting. Although aspirin has the greatest affect, all
NSAIDs have some affect on platelet function. If the function of these
cells is impaired, it will take longer for blood to clot and bruising can
occur more readily. Some patients are very susceptible and experience easy
bruising. If severe, the medication should be discontinued.
Symptoms are magnified at night because of position. The hand is at the
same level of the heart or slightly below while laying down leading to
pooling of the fluid in the soft tissues within the canal. Normal daily
activities of alternately moving the hands above and below the heart
prevents pooling somewhat. There are also hormonal changes which are
quite complicated that can lead to increased fluid retention at night. As
a remedy to this, some researchers believe that high doses of Vitamin B-6
can act as a diuretic and decrease fluid in the carpal canal leading to
relief of symptoms, although this has never been studied in detail.
The use of corticosteroids has been extensively reviewed and much relief
can be obtained from periodic injection directly into the carpal tunnel
but may provide only temporary relief. After 2 to 4 months, between 65 and
90% of patients can be expected to have recurrence of symptoms (Slater,
Jr. & Bynum, 1993). In one study, at 18 months after steroid injection,
only 22% of patients were still free of symptoms (Gelberman, Aronson,
Weisman, 1980).
In another study, only 11% of cases treated with steroid injection had
permanent relief and these were the mildest cases in the series (Goodman &
Foster, 1962). Operative release of the transverse carpal ligament is
performed in approximately 40% of CTS cases, followed by a 2-3 month
period of rehabilitation.
They are even using creams (CT creamÒ), but there are no studies to verify
its efficacy.
What about exercise?
There are numerous journals providing evidence that exercises may prevent
or control the symptoms of carpal tunnel syndrome. Another good
discussion of the technical aspects of reducing the risks of carpal
tunnel syndrome suggests that wrist position may contribute to the
problem. Workplace ergonomics have long been thought to be a contributing
factor and alteration of the worksite is a must for patients doing any
type of repetitive work. For drummers, the activity of playing in awkward
positions for long periods of time may put incredible strain on groups of
ligaments, joints and muscles, resulting in quick fatigue, thereby
progressing injury. It is very important to play with a comfortable
throne and to take frequent breaks.
What are some of these exercises? Here are a few adopted by the American
Academy of Orthopaedic Surgeons (AAOS).
Exercises
(at the start of playing the drums)
Extend and stretch both wrists and fingers acutely as if they are in a
hand-stand position. Hold for a count of 5.
Straighten both wrists and relax fingers.
Make a tight fist with both hands.
Then bend both wrists down while keeping the fist. Hold for a count of 5.
Straighten both wrists and relax fingers, for a count of 5.
Repeat exercise 10 times, then hang arms loosely at side and shake them
for a couple of seconds. Total exercise time: 5-10 minutes.
If these simple measures fail to control your symptoms an injection of
cortisone into the carpal tunnel may be suggested. This medication will
decrease the swelling of the tenosynovium and may give temporary relief of
symptoms. It is used not only to treat the problem, but serves to aid in
diagnosis. If you don't get even temporary relief from the injection, it
may be a sign that other problems exist that are causing the carpal tunnel
symptoms. There is also a newer way to get cortisone medications down
into the carpal tunnel. Iontophoresis is a technique where an electrical
current is used to move the molecules of the medication through the skin
down into the carpal tunnel. It is less painful than an injection, but is
probably not as effective.
Surgical Treatment
If all of the previous treatments fail to control the symptoms of carpal
tunnel syndrome, surgery may be required to reduce the pressure on the
median nerve. There are several different surgical procedures designed to
relieve pressure on the median nerve. The most common are the traditional
open incision technique described below, and the newer Endoscopic Carpal
Tunnel Release (see below) using a smaller incision and a fiberoptic TV
camera to help see inside the carpal tunnel.
Basic Steps in Open Carpal Tunnel Release
Step 1 A small incision, usually less than 2 inches, is made in the palm
of the hand. In some severe cases, the incision needs to be extended into
the forearm another 1/2 inch or so.
Step 2 After the incision is made through the skin, a structure called
the palmar fascia is visible. An incision is made through this material as
well, so that the constricting element, the transverse carpal ligament,
can be seen.
Step 3 Once the transverse carpal ligament is visible, it is cut with
either a scalpel or scissors, while making sure that the median nerve is
out of the way and protected.
Step 4 Once the transverse carpal ligament is cut, the pressure is
relieved on the median nerve.
Step 5 Finally, the skin incision is sutured. At the end of the
procedure, only the skin incision is repaired. The transverse carpal
ligament remains open and the gap is slowly filled by scar tissue.
A bulky dressing is applied to the hand following surgery. You should
leave this in place until your first office visit after the surgery.
Your sutures will be removed 10 - 14 days after surgery. You should avoid
any heavy use of the hand for 4 weeks after your surgery. You should not
get the stitches wet. Expect the pain and numbness to begin to improve
after surgery, but you may have tenderness in the area of the incision for
several months.
Endoscopic Carpal Tunnel release
The Procedure
Recently, a new procedure has become available to perform a release of the
transverse carpal ligament in those patients who need surgery. This
procedure utilizes the endoscope (a small fiberoptic TV camera) to look
into the carpal tunnel through a small incision in the wrist. The release
is then accomplished using special instruments designed to cut the
transverse carpal ligament - without cutting through the overlying palmar
skin.
Proponents of the procedure feel that patients heal faster, are able to
use the hand sooner, and have less problems associated with tenderness in
the palmar incision. Other physicians, however, are not convinced that
this procedure is better than the open incision technique. The endoscopic
method is more technically demanding (operator-dependent) and is probably
more expensive in most hospitals. There may be a higher complication rate
associated with the endoscopic method, primarily due to injury of the
nerves in the carpal tunnel. As more and more surgeons refine the
technique of this method, these questions will probably be addressed.
Basic Steps in Endoscopic Carpal Tunnel Release
The Incision
A small incision is made in the wrist just below the crease where the palm
starts. This incision allows the surgeon to place the arthroscope into the
carpal tunnel.
Entering The Carpal Tunnel
This allows the surgeon to open the carpal tunnel just below the
Transverse Carpal Ligament.
Placing the Cannula
Once the surgeon is sure that the instruments can be passed into the
carpal tunnel a metal or plastic cannula is placed along side the Median
Nerve. (The cannula is nothing more than a tube with a rounded end and a
slot along one side.)
Placing the Endoscope
The endoscope can be placed into the tube to look at the undersurface of
the Transverse Carpal Ligament, and make sure that the nerves and arteries
are safely out of the way.
Preparing the Release the Transverse Carpal Ligament
Through the cannula a special knife is inserted. This knife has a hook on
the end (similar to a seam ripper) that cuts backwards as the knife is
pulled back out of the cannula.
Cutting the Transverse Carpal Ligament
The slot in the cannula allows the hook to cut only in the direction the
slot is facing. The nerves in the carpal tunnel are protected by the tube
everywhere else.
The Transverse Carpal Ligament Divided
Once the knife is pulled all the way back, the Transverse Carpal Ligament
is divided - without making an incision in the palmar skin. Once
Transverse Carpal Ligament is divided the Median Nerve is no longer
compressed and begins to return to normal.
This is not a laser surgery, but rather surgery using fiber optic
technology, allowing a surgeon to operate "from the inside out." This
means that tender tissue is not violated and there is minimal if any pain
after the procedure. The main advantage of this technique is not only
minimizing the unsightly scar, but also increased recovery time which
allows you to return to work quickly.
The long term results of endoscopic release of Carpal Tunnel Syndrome is
excellent with many more benefits to the patient than traditional means of
treatment. Patients occasionally complain of some soreness in the palm
when resting their hand upon a hard object, but otherwise, there are
minimal complications or pain after the procedure.
The key to understanding Carpal Tunnel Syndrome is to think if this as a
pinched nerve which occurs in the wrist and leads to symptoms such as
numbness or tingling. These are many other painful conditions in the hand
and wrist which need to be evaluated by a surgeon specializing in such
problems. Confirmations by nerve conduction studies is usually done by
either a rehab medicine specialist or a neurologist.
Carpal Tunnel Syndrome is an easily diagnosable and treatable condition
when appropriately diagnosed by a trained physician. If you have pain in
your hands, take heart, don't give up, there are many options available.
Happy Drumming!
The topics covered in this article will be: Intersection Syndromes,
DeQuervain's tenosynovitis, Guyon's canal syndrome, Trigger finger, and
Thoracic Outlet Syndrome (TOS).
INTERSECTION SYNDROMES
Introduction
Intersection Syndrome is a painful condition that affects the radial
(thumb) side of the forearm where two muscles cross over, or intersect,
two underlying wrist tendons.
Anatomy
The upper muscle (extensor) group tendons connect with the thumb to pull
it away from the hand - and the lower set of tendons bends back, or
extends, the wrist. There are many bursae (sacs of fluid for cushioning)
all over the body where tissues must move against one another. It should
be noted that Intersection syndrome is often confused with another
condition called DeQuervain's tenosynovitis (see below), which is an
irritation of two of the tendons at the wrist also, but in a different
location.
Causes
The major cause of intersection syndrome is overuse of the wrist and hand
from wringing, grasping, turning and twisting type motions. As we know,
drummers perform all of these motions. The repeated movements of the
tendons rubbing against one another eventually causes irritation of the
tenosynovium, the lining around the tendons. This condition is referred
to as tenosynovitis. The synovium loses its slippery coating and the two
sets of tendons begin to rub together as they move. Most of the reported
cases involve a combination of heavy and repetitive use of the wrist
(meat-packers, drummers, heavy lifting)
Diagnosis
The diagnosis of intersection syndrome is commonly made based on the
history and physical examination alone. Simple tests are usually
required. The major problem can be distinguishing the syndrome from
DeQuervain's tenosynovitis, which is very similar. Careful attention must
be paid to where the pain is located - over DeQuervain's tunnel, described
below, or over the Intersection point.
Symptoms
The constant friction causes pain and swelling in the tenosynovium
surrounding the tendons. This can cause a restriction in the movement of
the tendons. A squeaking, crackling sound (referred to medically as
crepitus) may be heard as the tendons attempt to move against one another.
Crepitus is actually something you can feel better than you can hear. If
you place your fingers over the skin above the intersection point and move
the thumb there is a slight vibration - like two rough surfaces moving
against one another. Swelling and redness may occur over the area where
the two tendons rub against one another - at the intersection point. Pain
can spread down to the thumb or back up along the thumb (lateral, radial)
side of the forearm.
Prevention/Treatments
Ice can decreases the size of blood vessels in the sore area, helping to
halt inflammation and relieve pain. Ice massage is an easy and effective
way to provide first aid. Simply freeze water in a paper cup. When
needed, tear off the top inch, exposing the ice. Rub three to five
minutes around the sore area until it feels numb. Plus, there is plenty
of ice in a bar/nightclub!
A special brace called a thumb spica may be used to help rest the area,
keeping it in a safe position. Pain with activity is a sign that
irritation is occurring. Avoid movements and activities that increase
pain. Try and decrease your activities that are making the pain worse.
Take frequent breaks or limit the amount of time you are
performing/practicing that require repetitive wringing, grasping, turning
and twisting type movements of the wrist. Some players will wear
stabilizing braces, ACE bandages while they perform.
Anti-inflammatory medications may also help control the swelling of the
tenosynovium and reduce the symptoms. These medications include the
common over the counter medications such as non-steroidal
anti-inflammatory drugs (NSAIDS). There are many different types of
NSAIDs, including aspirin and other salicylates. Examples include
ibuprofen (Motrin, Advil), naproxen (Naprosyn), sulindac (Clinoril),
diclofenac (Voltaren), piroxicam (Feldene), ketoprofen (Orudis),
diflunisal (Dolobid), nabumetone (Relafen), etodolac (Lodine), oxaprozin
(Daypro), indomethacin (Indocin), and newer ones such as Vioxx, Ultram,
and Celebrex, which are currently being marketed. Please consult a doctor
for these newer medications. Aspirin is anti-inflammatory when given in
high doses, otherwise it is just a painkiller like acetaminophen
(Tylenol).
Since these medications are the most common form of treatment, their side
effect profile is equally important and should be known. Common side
effects include stomach upset, headache, drowsiness, easy bruising, high
blood pressure and/or fluid retention.
NSAIDs commonly cause dyspepsia, a burning, bloated feeling in the pit of
the stomach. In some patients, stomach inflammation (gastritis) or gastric
ulcers may occur. This can cause bleeding, either obvious and painful or
hidden and painless. This loss of blood may lead to anemia. To help
protect the stomach, NSAIDs should always be taken with food or directly
after a meal. Some patients may need additional medications to control
their stomach symptoms. Some may tolerate one kind of NSAID, but have
gastric irritation with others. A person on long-term NSAID therapy should
have a blood count periodically to insure that anemia from gastric
bleeding is not occurring. Patients with a history of gastric (stomach) or
duodenal (intestinal) ulcers should tell their physician before starting
on NSAIDs. Furthermore, any individual who will not accept blood products
for religious or other reasons, should inform their doctor of this prior
to starting therapy with NSAIDs.
Symptoms of headache or drowsiness are usually mild, but if severe, the
medicine may have to be stopped.
NSAIDs affect the function of platelets, a type of blood cell important in
normal blood clotting. Although aspirin has the greatest affect, all
NSAIDs have some affect on platelet function. If the function of these
cells is impaired, it will take longer for blood to clot and bruising can
occur more readily. Some patients are very susceptible and experience easy
bruising. If severe, the medication should be discontinued. An injection
of cortisone in the area of the bursa between the two sets of tendons may
give relief.
Surgery is rarely necessary in this condition. In cases where nothing
else has been of value in the treatment of intersection syndrome surgical
release of the bursa may be indicated. Surgery is performed by making an
incision in the skin above the intersection point. The tendons and the
tenosynovium around the tendons that are involved are inspected and any
irritated thickened tissue is removed. The skin is then repaired with
sutures and allowed to heal. Hopefully, removing the inflamed thickened
tenosynovium tissue will reduce the pain and allow the tendons to glide
more normally together once again.
DEQUERVAIN's Tenosynovitis
Introduction
Pain on the side of the wrist and forearm just above the thumb may be
DeQuervain's tenosynovitis. This is a common problem that is usually
easily diagnosed. Like many other problems caused by repetitive injury
to the hand and arm, this disorder results when the tendons (and the
covering of the tendons called the tenosynovium) become inflamed.
Anatomy
Two tendons are the problem in DeQuervain's tenosynovitis. The two
tendons involved are used to pull the thumb out and back from the hand.
They are named the abductor pollicis longus (APL) and the extensor
pollicis longus (EPL). These two tendons run in a tunnel on the side of
the wrist just above the thumb. The tunnel is formed by ligaments that
form an arch over the tendons to keep the tendons in place. The tendons
pass through a common tunnel in the forearm that is lined with a slippery
coating called tenosynovium as mentioned before. As with Intersection
Syndrome, tenosynovitis results.
Causes
Problems arise when the two tendons are unable to glide through the
tunnel. Repetitive activities exactly the same as those described above
for Intersection Syndrome may lead to inflammation of the tendons and the
covering around the tendons, the tenosynovium. This inflammation can
lead to swelling, which further hampers the smooth gliding action of the
tendons within the tunnel.
An injury to the tendons in this area can lead to irritation of the
tendons in the tunnel if scar tissue forms that makes it difficult for the
tendons to slide easily through the tunnel. Scar tissue is dead tissue
basically, devoid of innervation and blood supply. Other arthritis-type
diseases that affect the whole body, such as rheumatoid arthritis, can
also lead to a tenosynovitis in this area.
Symptoms
At first, the only sign of trouble may be soreness on the thumb side of
the forearm. If the problem isn't treated, pain may spread up the forearm
or down into the wrist and thumb. The sign of crepitus can again be
present. There may be swelling along the tunnel if the condition is
particularly severe. Use of the hand and thumb for grasping becomes
increasingly painful.
Diagnosis
As with Intersection Syndrome, the diagnosis of DeQuervain's tenosynovitis
is usually easily made on the
physical examination.
The Finklestein Test is one of the best tests used to make the diagnosis.
This is a test you can perform on yourself: Bend your thumb into the palm
and grasp the thumb with the fingers. Now bend your wrist away from your
thumb. Pain over the tendons to the thumb suggests the problem may be
DeQuervain's tenosynovitis. (Fig. 49)
Prevention/Treatments
Take frequent breaks or limit the amount of time you are performing tasks
that require repetitive wringing, grasping, turning and twisting type
movements of the wrist. Keeping the wrist in a neutral alignment may
help prevent this syndrome. The best way to keep the wrist in neutral
alignment is again, by wearing a brace or splint on the wrist and thumb.
These braces may be used for short term relief to rest the area and quiet
the inflammation.
Anti-inflammatory medications may also help control the swelling of the
tenosynovium and reduce the symptoms. (see above)
Again, if all else fails, surgery may be recommended to treat your
problem. Remember that the main cause of DeQuervain's tenosynovitis is
the constant rubbing of the tendons as they glide through the surrounding
tunnel. To remove this constant rubbing, surgical release of the roof of
the tunnel is done to give the tendons more space. The procedure is done
by making a small incision in the skin of the wrist, just above the tunnel
where the tendons run. The tendons and the tunnel are then located. An
incision is made to split the roof, or top, of the tunnel. Once this has
been done, the tube, or tunnel, formed by the ligaments opens to allow
more room for the tendons to move. This reduces the constant rubbing and
reduces the pain. The tunnel will eventually heal back, but it will be
larger than before, because it will heal back in the more open position.
Scar tissue will simply fill the gap where the tunnel was cut. This may
cause problems in the future as scar tissue is not as mobile as the tissue
it replaces. Mobility and range of motion may be severely decreased.
GUYON's Canal Syndrome
Introduction
Guyon's canal syndrome is a common nerve compression affecting the ulnar
nerve as it passes through a tunnel in the wrist called Guyon's canal.
(Fig. 62) This problem is similar to carpal tunnel syndrome, but involves
a completely different nerve! Sometimes both conditions can be causing a
problem in the same hand.
Anatomy
The ulnar nerve actually starts at the side of the neck, where the
individual nerve roots exit the spine through small openings between the
vertebra called foramen. The nerve roots then join together to form a
collection of three main nerves that travel down the arm to the hand. The
ulnar nerve is one of the collection of nerves, or the Brachial Plexus.
After leaving the side of the neck, the ulnar nerve then travels through
the armpit, down the arm to the hand and fingers. As it crosses the
wrist, the ulnar nerve and artery run through the tunnel known as Guyon's
canal. This tunnel is formed by two of the eight bones of the wrist, the
pisiform and hamate, and the ligament that connects them. After passing
through the canal, the ulnar nerve branches out to supply feeling to the
little finger and half the ring finger. Branches of this nerve also
supply the small muscles of the hand (the hypothenar or little finger
muscles) for motor innervation. This syndrome is much less common than
carpal tunnel syndrome (CTS), but may be present along with CTS. The
ulnar nerve supplies sensation to the little finger and half of the ring
finger, and if these fingers are involved in any symptoms of numbness,
compression of the ulnar nerve in Guyon's canal may be present. It is
critical that the area of compression be localized to either the wrist
(Guyon's canal), or the elbow (cubital tunnel, explained in the next
article), by physical examination and electrical studies prior to deciding
on a treatment plan.
Causes
Overuse of the wrist, especially in tasks bending the wrist down (flexing)
and out, or putting constant pressure on the palm may cause Guyon's canal
syndrome. Arthritis that involves the wrist bones and joints may
eventually result in compression of the ulnar nerve and the symptoms of
Guyon's canal. In some (fairly rare) cases, the ulnar artery that runs
right beside the nerve may be damaged and clot off. This can result in
symptoms arising from the nerve that are similar to Guyon's canal
syndrome. This probably occurs due to irritation on the ulnar nerve. A
simple test, called the Allen's Test, can determine arterial
insufficiency. (Fig. 118)
Another uncommon cause of ulnar nerve compression at the wrist may
be the
symptoms may be caused by a fracture of one of the small bones of the
wrist. One of the bones (the hamate bone) that actually forms one side
of Guyon's canal has a small spur that sticks out for attachment of
several ligaments in the wrist. This spur is called the hook of the
hamate bone. This small spur can be broken off. These fractures
sometimes occur in golfers from hitting the ground instead of the golf
ball, in baseball players while batting, or drummers who play on
electronic kits, by constantly striking the stiff pads, or rimshots. If
the spur begins to rub on the nerve, it may cause the symptoms of ulnar
nerve compression.
Symptoms
Usually, no matter what the cause of the compression on the ulnar nerve,
the symptoms are the same. The symptoms begin with a feeling of pins and
needles in the ring and little finger, starting in the early morning
before waking. (similar to Carpal Tunnel Syndrome but different fingers!)
This progresses to a burning pain of the wrist and hand, followed by
decreased sensation and eventually clumsiness in the hand. Remember that
the ulnar nerve also supplies many of the small (intrinsic) muscles of the
hand. The clumsiness occurs because of weakness in these muscles. The
weakness can show up as the inability to spread the fingers, and may
include a weak pinch in the thumb.
Diagnosis
The diagnosis of Guyon's canal syndrome begins with a careful history and
physical examination by your doctor. Compression can occur at several
areas along the ulnar nerve, and your doctor will want to find exactly
where the nerve is being affected. If it is unclear on the physical
examination where the point of compression is, electrical studies may be
ordered to try and find the area of compression. The Nerve Conduction
Test (NCV) measures how fast nerve impulses travel along the nerve and may
be ordered to pinpoint your problem. Other special tests may be required
to study the nerve. The NCV is sometimes combined with an electromyogram
(EMG). The EMG is done by testing the muscles of the forearm that the
ulnar nerve controls. Special instruments can be used to determine if the
muscles are working properly or not. If the muscles are not working
properly, then the nerve may not be working well.
Prevention/Treatments
Take frequent breaks or limit the amount of time you are performing tasks
that require flexing and turning out the wrist, or place constant pressure
on the palm. A wrist splint may be worn at night to decrease the pins and
needles sensation and to keep the wrist in a neutral position. Keyboard
operators may find that a wrist rest decreases the
symptoms.
Anti-inflammatory medications may be suggested by your doctor. (see above)
If simple measures fail to control your symptoms surgery may be needed to
relieve pressure on the ulnar nerve. Surgery involves making a small
incision along the course of the ulnar nerve in the skin of the palm. The
ligament that forms the roof of Guyon's canal is then cut to relieve the
pressure on the nerve. This results in the tight ligament springing open
a bit. Once the ligament is cut the nerve is usually free of pressure.
The nerve is then freed of all other soft tissue which may be causing
pressure and irritation. The skin is then sutured and allowed to heal.
The ligament that makes up the roof of the canal will eventually heal
back, but the canal will be larger than before, because it will heal back
in the more open position. Scar tissue will simply fill the gap where the
ligament was cut. (see above)
Trigger Digit
Introduction
Trigger finger, and thumb, is a condition affecting the movement of the
tendons as they bend the fingers or thumb toward the palm of the hand.
This movement is called flexion.
Anatomy
The tendons that move the fingers are held in place on the bones by a
series of ligaments which act similar to pulleys. These ligaments form an
arch on top of the bone that creates a sort of tunnel for the tendon to
run in along the bone. Tenosynovium lines these ligaments as well. The
tenosynovium reduces the friction and allows the flexor tendons to glide
through the tunnel formed by the pulleys as the hand is used to grasp
objects.
Causes
Triggering is usually the result of a thickening in the tendon that forms
a nodule. There may also be thickening of the pulley ligament as well.
The constant irritation from tendon repeatedly sliding through the pulley
causes the tendon to swell in this area and create the nodule. Rheumatoid
arthritis, partial tendon lacerations, graspoing drumsticks too tightly,
repeated trauma from pistol gripped power tools, or long hours grasping a
steering wheel can cause triggering. Infection or damage to the synovium
also cause a nodule to form in the tendon. Triggering can also be caused
by a congenital defect that forms a nodule in the tendon. The condition
is not usually noticeable until the infant begins to use its hands.
Symptoms
The symptoms of trigger finger or thumb include pain and a funny clicking
sensation when the finger or thumb is bent. Pain usually occurs when the
finger or thumb is bent and straightened. (Fig. 76) Tenderness usually
occurs over the area of the nodule - at the bottom of the finger or thumb.
The clicking sensation occurs when the nodule moves through the tunnel
formed by the pulley ligaments. With the finger straight, the nodule is
at the far edge of the surrounding ligament. When the finger is flexed,
the nodule passes under the ligament and causes the clicking sensation.
If the nodule becomes too large it may pass under the ligament, but
becomes stuck at the near edge. The nodule cannot move back through the
tunnel and the finger is locked in the flexed trigger position.
Diagnosis
The diagnosis of trigger finger and thumb is usually quite obvious on
physical examination. Usually there is a palpable click that can be felt
as the nodule snaps under the first finger pulley. If the condition is
allowed to progress, the nodule may swell to the point where it gets
caught and the finger is locked in a bent, or flexed position.
Prevention/Treatments
Unfortunately, there is very little that can be done by the physical
therapist once a finger or the thumb has developed triggering. A
cortisone injection into the sheath may decrease the inflammation and
shrink the nodule to relieve the triggering, but it will probably be short
lived. The usual solution for treating a trigger digit is surgery to open
the pulley that is obstructing the nodule and keeping the tendon from
sliding smoothly.
Thoracic Outlet Syndrome
Introduction
Thoracic Outlet Syndrome (TOS) is a condition affecting the shoulder, arm,
and hand. This condition is a very frustrating problem - both for the
patient and for the physician. It is extremely difficult to prove that
the diagnosis of Thoracic Outlet Syndrome is correct, because there is no
test that has a high degree of accuracy in showing the problem. Usually,
the diagnosis is made after all other causes of the symptoms have been
ruled out - a frustrating and slow process sometimes! This is referred to
as a diagnosis of exclusion.
Anatomy
The nerves and blood vessels that run into the arm and hand start at the
side of the neck. They exit from the side of the spine through small
openings between each vertebra called foramen. As they leave the spine
the nerves are referred to as nerve roots. The individual spinal nerve
roots then begin to join together to form the nerves that will run into
the arm and hand. The nerves travel between two muscles in the neck (the
scalene muscles), over the top of the rib cage, under the collarbone
(clavicle), through the armpit (axilla) and down the arm to the hand. The
area where the nerves and vessels leave the neck between the two scalene
muscles and over the first rib is know as the Thoracic Outlet. This
collection of nerves is called the Brachial Plexus.
Causes
There are probably several causes of TOS. The common underlying cause of
the syndrome is compression of the nerves and arteries of the arm in the
Thoracic Outlet. Some people have an extra first rib or an old fracture
of the clavicle, which limits the space for the vessels. A violent
injury, such as a car wreck while wearing a shoulder harness, may also
tear the scalene muscles. In the healing phases of this type injury, scar
tissue may form in the healing muscle, leading to compression of the
nerves and blood vessels. Compression can also occur with repetitive
activities that require the arms to be held overhead or extended forward.
The more likely cause is slouching forward and dropping the shoulders,
causing tension in the muscles at side of the neck and constricting the
arteries and nerves.
Symptoms
Symptoms of TOS include pain, weakness, numbness and tingling, swelling,
fatigue or coldness in the arm and hand. This syndrome can be very
difficult to diagnose. The symptoms can mimic many other conditions, such
as a herniated disk in the neck, carpal tunnel syndrome, and even bursitis
of the shoulder.
Diagnosis
Diagnosis of TOS can be difficult and frustrating. The history and
physical examination can be suggestive of TOS, but frequently the symptoms
are vague and difficult to track down. A chest X-ray may show an extra
cervical rib, and be helpful in the diagnosis.
Electrical tests of the nerves in the arm may be required. These tests
try and determine if the nerves in the arm and hand are being pinched -
between where they exit from the spine and where they end at the muscles
of the arm and hand. Other special tests to check whether or not the
blood vessels that run with the nerve are being pinched may be required to
confirm the diagnosis. Many times all of these test are negative and the
history and physical examination must be relied on to make the diagnosis.
Because the symptoms of TOS are so confusing, and can be caused by other
problems - such as a herniated disk in the neck - some tests may be done
to make sure that one of these other problems do not exist. This may
include X-rays of the neck or a MRI scan of the neck. This process is
required to rule out any other causes of your symptoms. Magnetic
Resonance Imaging does not use radiation to view structures as in the
X-ray. It does use very strong magnetic rays, and if you have steel or
clips in your body from previous surgeries, you should let your doctor
know before getting this test.
Prevention/Treatments
A home program of exercise is essential to the treatment of TOS and must
be performed consistently to produce benefits. Symptoms often respond to
an exercise program addressing healthy posture and muscle balance.
Stretching and strengthening along with awareness exercises can help
achieve optimal posture.
Symptoms caused by abnormalities in the bones and muscles may not respond
to physical therapy but good posture and overall conditioning are very
important in treating all causes of TOS. You should limit the length of
time the arms are used in outstretched or overhead positions, e.g.
drummers who may play ride cymbal above their head or shoulder. Carrying
and lifting heavy objects should also be kept at a minimum, so if you can
afford it hire a roadie! Just kidding. Simple things like taking frequent
breaks, changing positions, stretching or using a hand truck or cart can
bring relief. More specific treatments and exercises may be prescribed by
a physician or physical therapist. Rehabilitation may begin with a few
exercises to loosen up tight muscles and joints around the compressed
nerves and blood vessels. To help restore normal mobility, your therapist
may prescribe stretching and massage for the joints, muscles, and nerves.
Work hours can add up to problems. What changes can be made to help avoid
these problems?
Occupational ergonomics: A worksite specialist can evaluate your workplace
to determine safe alignment, worksite postures, and work-related
furniture.
Posture. Posture. Posture! The realization by the patient of the
importance of a proper posture is paramount to the treatment of thoracic
outlet syndrome.
Physical therapy, but by a professional who can apply the proper
techniques and exercises to the treatment.
Arm positions: Avoid holding your arms outward for prolonged time periods.
Work heights: Avoid overhead activities, especially if these positions
bring on symptoms. Reposition your drums and cymbals to less aggravating
positions.
Helpful hints
§ Decrease tension on the shoulder straps of your seat belt.
§ Use rest periods to decrease fatigue.
§ Women with large, pendulous breasts may benefit from a strapless
long-line bra.
§ Obese patients should seek advice for safe weight loss.
Things to avoid
§ Heavy lifting, pulling, pushing.
§ Rapid breathing.
§ Stress.
§ Looking up, bending the neck back.
§ Elevating the arms for long periods.
§ Carrying bags with a strap on the sore-side shoulder.
Long term management of this problem will probably have to rely on changes
in your worksite and activities - both at home, at work, and at play.
Changes may need to be made in overhead activities and heavy lifting. The
primary aim is to insure healthy work and recreational postures.
Surgery
Surgery for Thoracic Outlet Syndrome is usually a last resort. The
surgery is directed at removing the source of compression on the nerves of
the Brachial Plexus. If there is an extra rib present, this is usually
removed. Otherwise, surgery consists of simply releasing the constricting
elements and scar tissue around the nerves. This is usually done through
an incision under the arm, where the nerves of the brachial plexus run
into the arm. The surgery will require a general anesthetic - going to
sleep. You will probably need to spend at least one night in the
hospital.
Surgery for the first four conditions described above conditions can
usually be done as an outpatient. The surgery can be done using a general
anesthetic (where you are put to sleep) or some type of regional
anesthetic. A regional anesthetic is a type of anesthesia where the
nerves going to only a portion of the body are blocked. Injection of
medications similar to novocaine are used to block the nerves for several
hours. This type of anesthesia could be an axillary block (where the arm
is asleep) or a wrist block (where only the hand is asleep). The surgery
can also be performed by simply injecting novocaine around the area of the
incision.
