Carpal tunnel syndrome

Signs and Symptoms

Signs and symptoms of CTS include:

• Nighttime painful tingling in one or both hands, frequently causing sleep disturbance.
• Feeling of uselessness in the fingers.
• A sense that fingers are swollen even though little or no swelling is apparent.
• Daytime tingling in the hands followed by a decreased ability to squeeze things.
• Loss of strength in the muscle at the base of the thumb near the palm.
• Pain shooting from the hand up the arm as far as the shoulder.

What Causes It?

The carpal tunnel is filled with tendons (bundles of collagen fibers that attach muscle to bone) that control finger movement. Tasks requiring highly repetitive and forceful movements of the wrist can cause swelling around the tendons, resulting in a pinched nerve and producing CTS. Trauma, certain diseases, and pregnancy may also trigger CTS. On rare occasions, CTS may be genetic (some patients with CTS have carpal canals that are narrower than average). People who have short and wide hands with square wrists may also be at increased risk of CTS.

Who's Most At Risk?

People working with small hand tools in manufacturing, and those using a computer keyboard on a regular basis, are at highest risk.

Women are 2 to 5 times more likely than men to develop CTS. It most commonly occurs in people ages 30 to 60. CTS is associated with health conditions, such as diabetes, hypothyroidism, rubella, pregnancy, connective tissues diseases, obesity, and menopause. High caffeine, tobacco, or alcohol intake are other contributing risk factors.

What to Expect at Your Provider's Office

If you have symptoms of CTS, you should see your health care provider. Your provider can help determine which treatment or combination of therapies will work best for you.

Your provider will perform a physical examination and some simple tests to determine if you have lost any sensation, or if you have weakness in your thumb or fingers. Your provider may also perform more sophisticated diagnostic procedures ranging from a nerve conduction study to electromyography (EMG). You may also get x-rays or magnetic resonance imaging (MRI), or ultrasound imaging to reveal the cause and the nature of the injury.

Treatment Options

Management of CTS is based on severity. Your health care provider may put your wrist in a splint or brace to keep your wrist from bending, and to minimize or prevent pressure on the nerve. You will probably need to wear the splint full time for 3 to 4 weeks, then at night only. Putting ice on your wrist, massaging the area, and doing stretching exercises may also help.

Prevention

You can help prevent CTS or alleviate symptoms by making some simple changes in your work and leisure habits, such as:

• Stretch or flex your arms and fingers before beginning work and at frequent intervals.
• Alternate tasks to reduce the amount of repetitive movements.
• Modify or change daily activities that put pressure on your wrists.
• Modify your work environment. If you use a computer, have an adjustable keyboard table and chair, and a wrist rest.

Drug Therapies

Your provider may prescribe the following medications:

• Anti-inflammatory drugs, such as ibuprofen, to reduce inflammation (swelling, pain, and redness).
• Corticosteroids. A type of steroid, injected at the site of the carpal tunnel to reduce tendon swelling.
• Diuretics, if needed.

Surgical and Other Procedures

Patients who do not improve with medication and splinting may need surgery. Surgery provides complete relief in 95% of patients.

Complementary and Alternative Therapies

A comprehensive treatment plan for CTS may include a range of complementary and alternative therapies.

Nutrition and Supplements

You should only use supplements and complementary therapies under the supervision of a qualified practitioner. Some dietary supplements, herbs, or CAM treatments can potentially interfere with conventional medicines. Keep all providers informed regarding any therapies you may be considering.

Following these nutritional tips may help reduce symptoms:

• Eliminate all suspected food allergens, including dairy (milk, cheese, eggs, and ice cream), wheat (gluten), soy, corn, preservatives, and chemical food additives. Your provider may want to test you for food allergies.
• Eat foods high in B-vitamins and iron, such as whole grains (if no allergy), dark leafy greens (such as spinach and kale), and sea vegetables.
• Eat antioxidant-rich foods, including fruits (such as blueberries, cherries, and tomatoes), and vegetables (such as squash and bell pepper).
• Avoid refined foods, such as white breads, pastas, and sugar.
• Eat fewer red meats and more lean meats, cold-water fish, tofu (soy, if no allergy) or beans for protein.
• Use healthy oils in foods, such as olive oil or coconut oil.
• Reduce or eliminate trans fatty acids, found in commercially-baked goods, such as cookies, crackers, cakes, French fries, onion rings, donuts, processed foods, and margarine.
• Avoid coffee and other stimulants, alcohol, and tobacco.

You may address nutritional deficiencies with the following supplements:

• A multivitamin daily. Containing the antioxidant vitamins A, C, E, D, the B-complex vitamins and trace minerals such as magnesium, calcium, zinc, and selenium.
• Omega-3 fatty acids. Such as fish oil, 1 to 2 capsules or 1 tablespoonful (15 mL) of oil daily, to help reduce inflammation. Fish oils may increase bleeding in sensitive individuals, such as those taking blood-thinning medications (including aspirin).
• B-complex vitamin. 1 tablet daily, for symptoms of carpal tunnel. Some studies suggest low levels of riboflavin in the blood is associated with carpal tunnel syndrome and other inflammatory diseases.
• Vitamin C. 500 to 1,000 mg daily, as an antioxidant. Vitamin C can interact with some medications, including blood-thinning medications and chemotherapy agents. Speak to your doctor.
• Alpha-lipoic acid. 25 to 50 mg twice daily, for antioxidant support. Make sure you are not thiamine deficient if you take alpha-lipoic acid. Alpha-lipoic acid may interfere with certain thyroid medications and chemotherapy agents.
• Methylsulfonylmethane (MSM). 3,000 mg twice a day, to help reduce inflammation.

Herbs

Herbs are a way to strengthen and tone the body's systems. As with any therapy, you should speak with your provider before starting treatment. You may use herbs as dried extracts (capsules, powders, or teas), glycerites (glycerine extracts), or tinctures (alcohol extracts). Unless otherwise indicated, make teas with 1 tsp. (5 g) herb per cup of hot water. Steep covered 5 to 10 minutes for leaf or flowers, and 10 to 20 minutes for roots. Drink 2 to 4 cups per day. You may use tinctures alone or in combination as noted.

• Green tea (Camellia sinensis). Standardized extract, 250 to 500 mg daily, for inflammation and antioxidant and immune effects. Use caffeine-free products. You may also prepare teas from the leaf of this herb.
• Bromelain (Ananus comosus). Standardized, 40 mg, 3 times daily, for pain and inflammation. Bromelain may interfere with certain medications, including some antibiotics. Bromelain may increase bleeding in sensitive individuals, such as those taking blood-thinning medications, including aspirin. People who are allergic to latex, pineapple, wheat, papain, and grass pollen may be sensitive to bromelain.
• Turmeric (Curcuma longa). Standardized extract, 300 mg, 3 times per day, for pain and inflammation. Turmeric may increase bleeding in sensitive individuals, such as those taking blood-thinning medications, including aspirin.
• Cat's claw (Uncaria tomentosa). Standardized extract, 20 mg, 3 times per day, for inflammation. Cat's claw can interact with certain medications, including blood pressure medications. Cat's claw may worsen autoimmune conditions and leukemia.

Homeopathy

Although few studies have examined the effectiveness of specific homeopathic therapies, professional homeopaths may consider remedies for the treatment of carpal tunnel symptoms based on their knowledge and experience. Before prescribing a remedy, homeopaths take into account your constitutional type, includes your physical, emotional, and psychological makeup. An experienced homeopath assesses all of these factors when determining the most appropriate treatment for you.

An experienced homeopath can prescribe a regimen for treating CTS that is designed especially for you. Some of the most common acute remedies are listed below. An acute dose is 3 to 5 pellets of 12X - 30C every 1 to 4 four hours until symptoms clear up.

• Apis mellifica. For joints that are red, hot, or swollen.
• Arnica montana. 4 times per day, for a bruised, beat up feeling, soreness, achy muscles after trauma or overuse. This treatment may be especially effective if the gel or cream form is used topically.
• Guaiacum. For CTS that is improved by the use of cold applications.

Physical Medicine

Contrast hydrotherapy. Alternating hot and cold water applications -- may offer relief from CTS symptoms. This approach decreases inflammation, offers pain relief, and enhances healing. Immerse your wrists fully in hot water for 3 minutes, followed by 1 minute in cold water, and repeat 3 times. Do this 2 to 3 times daily.

Castor Oil Packs. Apply castor oil to a cloth, loosely wrap around wrist, and then cover with Saran Wrap. Apply a heating pad for a half hour, or without using a heating pad, sleep with the application on the wrist. Do this for 4 to 5 nights per week until improvement occurs.

Massage. Studies show that massage and trigger point therapy may help ease symptoms of CTS. Researchers recommend 30 minutes of massage twice a week.

Acupuncture

According to the National Institutes of Health, acupuncture may help treat CTS. Studies suggest that acupuncture restores normal nerve function and can provide long-term relief of pain associated with CTS. Acupuncturists treat people with CTS based on an individualized assessment of the excesses and deficiencies of qi located in various meridians. In the case of CTS, acupuncturists often target the liver, gallbladder, and kidney meridians.

Chiropractic

CTS is commonly treated by chiropractors. The methods most chiropractors use to treat CTS include manipulation of the wrist, elbow, and upper spine, ultrasound therapy, and wrist supports.

In one study, 25 individuals diagnosed with CTS reported significant improvements in several measures of strength, range of motion, and pain after receiving chiropractic treatment. Most of these improvements were maintained for at least 6 months.

A second study compared the effects of chiropractic care with conservative medical care (wrist supports and ibuprofen) among 91 people with CTS. Both groups experienced significant improvement in nerve function, finger sensation, and comfort. The researchers concluded that chiropractic treatment and conservative medical care are equally effective for people with CTS.

Massage

Massage may help prevent or relieve symptoms, especially in combination with rosemary or St. John's wort oil.

Prognosis/Possible Complications

Most people's symptoms clear up within a few months with conventional treatment. If left untreated, CTS in advanced stages can become serious, involving a loss of sensation, muscle deterioration, and permanent loss of function.

Following Up

If your wrist is placed in a splint or you receive corticosteroids, you will be monitored by your health care provider until treatment is completed. If you have surgery for CTS, you may need only a single follow up visit.

Supporting Research

Aufiero E, Stitik TP, Foye PM, Chen B. Pyridoxine hydrochloride treatment of carpal tunnel syndrome: a review. Nutr Rev. 2004;62(3):96-104.

Allampallam K, Chakraborty J, Robinson J. Effect of ascorbic acid and growth factors on collagen metabolism of flexor retinaculum cells from individuals with and without carpal tunnel syndrome. J Occup Environ Med. 2000;42(3):251-259.

Azar FM, Beaty JH, Canale ST, eds. Campbell's Operative Orthopaedics. 13th ed. Philadelphia, PA: Elsevier; 2007.

Baker NA, Moehling KK, Rubinstein EN, Wollstein R, Gustafson NP, Baratz M. The comparative effectiveness of combined lumbrical muscle splints and stretches on symptoms and function in carpal tunnel syndrome. Arch Phys Med Rehabil. 2012;93(1):1-10.

Banner R, Hudson EW. Case report: acupuncture for carpal tunnel syndrome. Can Fam Physician. 2001;47:547-549.

Baur JA, Sinclair DA. Therapeutic potential of resveratrol: the in vivo evidence. Nat Rev Drug Discov. 2006;5(6):493-506.

Blazar PE, Floyd WE, Han CH, Rozental TD, Earp BE. Prognostic indicators for recurrent symptoms after a single cotricosteroid injection for carpal tunnel syndrome. J Bone Joint Surg Am. 2015;97(19):1563-1570.

Cabrera C, Artacho R, Gimenez R. Beneficial effects of green tea -- a review. J Am Coll Nutr. 2006;25(2):79-99.

Castellanos J, Munoz-Mahammud E, Dominguez E, Del Amo P, Izquierdo O, Fillat P. Long-term effectiveness of corticosteroid injections for trigger finger and thumb. J Hand Surg Am. 2015;40(1):121-126.

Chiotis K, Dimisianos N, Rigopoulou A, Chrysanthopoulou A, Chroni E. Role of anthropometric characteristics in idiopathic carpal tunnel syndrome. Arch Phys Med Rehabil. 2013;94(4):737-744.

Katirji B. Disorders of peripheral nerves. In: Daroff RB, Jankovic J, Mazziotta JC, Pomeroy SL, eds. Bradley's Neurology in Clinical Practice. 7th ed. Philadelphia, PA: Elsevier; 2016:chap 107.

Davis PT, Hulbert JR, Kassak KM, Meyer JJ. Comparative efficacy of conservative medical and chiropractic treatments for carpal tunnel syndrome: a randomized clinical trial. J Manipulative Physiol Ther. 1998;21(5):317-326.

Di Geronimo G, Caccese AF, Caruso L, Soldati A, Passaretti U. Treatment of carpal tunnel syndrome with alpha-lipoic acid. Eur Rev Med Pharmacol Sci. 2009:13(2):133-139.

Elliott R, Burkett B. Massage therapy as an effective treatment for carpal tunnel syndrome. J Bodyw Mov Ther. 2013;17(3):332-338.

Fowler JR, Munsch M, Tosti R, Hagberg WC, Imbriglia JE. Comparison of ultrasound and electrodiagnostic testing for diagnosis of carpal tunnel syndrome: study using a validated clinical tool as the reference standard. J Bone Joint Surg Am. 2014;96(17):e148.

Frémont L. Biological effects of resveratrol. Life Sci. 2000;66:663-673.

Funk JL, Oyarzo JN, Frye JB, et al. Turmeric extracts containing curcuminoids prevent experimental rheumatoid arthritis. J Nat Prod. 2006;69(3):351-355.

Gonclaves C, Dinis T, Batista MT. Antioxidant properties of proanthocyanidins of Uncaria tomentosa bark decoction: a mechanism for anti-inflammatory activity. Phytochemistry 2005;66(1):89-98.

Hale LP, Greer PK, Trinh CT, James CL. Proteinase activity and stability of natural bromelain preparations. Int Immunopharmacol. 2005;5(4):783-793.

Holm G, Moody LE. Carpal tunnel syndrome: current theory, treatment, and the use of B6. J Am Acad Nurse Pract. 2003;15(1):18-22.

Kim LS, Axelrod LJ, Howard P, et al. Efficacy of methylsulfonylmethane (MSM) in osteoarthritis pain of the knee: a pilot clinical trial. Osteoarthritis Cartilage. 2006;14(3):286-294.

Labinskyy N, Csiszar A, Veress G, et al. Vascular dysfunction in aging: potential effects of resveratrol, an anti-inflammatory phytoestrogen. Curr Med Chem. 2006;13(9):989-996.

LeBlanc K, Cestia W. Carpal Tunnel Syndrome. American Family Physician. 2011;83(8):952-958.

Maddali Bongi S, Signorini M, Bassetti M, Del Rosso A, Orlandi M, De Scisciolo G. A manual therapy intervention improves symptoms in patients with carpal tunnel syndrome: a pilot study. Rheumatol Int. 2013;33(5):1233-1241.

Onder B, Yalcin E, Selcuk B, Kurtaran A, Akyuz M. Carpal tunnel syndrome and metabolic syndrome co-occurence. Rheumtaol Int. 2013;33(3):583-586.

Raimbeau G. Recurrent carpal tunnel syndrome. Chir Main. 2008;27(4):134-145.

Santiago FH, Vallarino R. Median neuropathy. In: Frontera WR, Silver JK, Rizzo TD, eds. Essentials of Physical Medicine and Rehabilitation. 3rd ed. Philadelphia, PA: Elsevier Saunders; 2015:chap 24.

Simopoulos AP. Omega-3 fatty acids in inflammation and autoimmune diseases. J Am Coll Nutr. 2002;21(6):495-505.

Skibska B, Jozefowicz-Okonkwo G, Goraca A. Protective effects of early administration of alpha-lipoic acid against lipopolysaccharide-induced plasma lipid peroxidation. Pharmacol Rep. 2006;58(3):399-404.

Wang HK. The therapeutic potential of flavonoids. Expert Opin Investig Drugs. 2000;9(9):2103-2119.

Yoon JH, Baek SJ. Molecular targets of dietary polyphenols with anti-inflammatory properties. Yonsei Med J. 2005;46(5):585-596.

Yuvienco C. Carpal Tunnel Syndrome. In: Ferri FF, ed.Ferri's Clinical Advisor 2017. 1st ed. Philadelphia, PA: Elsevier; 2017:250-250.e4.