Carpal Tunnel Syndrome: Ideas for Soft Tissue Therapists

One of my favorite things about the internet is that I get to communicate and discuss ideas with colleagues in this field that I may not have otherwise ever met.

One place were great conversation has come up is Twitter.  Recently, several of us had a brief discussion about Carpal Tunnel Syndrome, which inspired me to write this article and give some of my ideas about how soft tissue therapists can work with this issue that affects many.

What is it?

The carpal tunnel is the tunnel formed by the carpal bones of the hand and the transverse carpal ligament.

Carpal Tunnel Syndrome refers to the compression of the median nerve at the carpal tunnel in the wrist.  The median nerve is the nerve that feeds our first three fingers and half of the fourth finger (so our thumb, pointer finger, middle finger and part of our ring finger).  Often times, the median nerve can be compressed by the flexor tendons that share the space within the carpal tunnel.

When the space within the carpal tunnel is compromised, the median nerve can become aggravated and individuals will commonly complain of tingling, paresthsia (pins and needles), burning, shooting pains or numbness into the hand and typically the thumb, pointer finger and middle finger.  In addition to these various sensations, individuals will often display weakness, a loss of muscle function and possibly atrophy.

How does it happen?

Individuals who seem to be most prone to getting carpal tunnel syndrome are those that sit at a computer with their hand/wrist in the same posture for extended periods of the day or those who perform repetitive tasks everyday (musicians and especially guitar players can fall into this category).

While it is basically an overuse injury, overweight individuals or pregnant women can be prone to carpal tunnel syndrome as well due to increased edema (fluid retention) compromising the space in the carpal tunnel or even a traumatic injury in which one of the carpal bones is sublexed, causing it to move out of place and impede on the carpal tunnel.

Women may be more prone to carpal tunnel syndrome because they have a smaller carpal tunnel.

Additionally, others have noted the possibility of poor posture in those showing symptoms of carpal tunnel syndrome.

What can we do about it?

Traditional approaches to carpal tunnel syndrome have focused on the site of the pain (at the wrist) and often overlooked potential factors coming from higher up the chain (IE, forearm, upper arm, and neck).

As noted above, poor posture may play a role in carpal tunnel syndrome.  A 2009 study published in the Journal of Orthopedic and Sports Physical Therapy evaluated the correlation between forward head posture and cervical spine range of motion and carpal tunnel syndrome.  The researchers concluded that, “Patients with moderate carpal tunnel syndrome had greater forward head posture and decreased cervical range of motion when compared to healthy subjects.  Greater forward head posture was associated with a reduction in cervical range of motion.” The researchers, however, did state that, “no cause-and-effect relationship could be inferred from this study.”

I find that last statement interesting.  The researchers state later in the discussion that a cause-and-effect relationships cannot be drawn from this study because it is unknown if the forward head posture is the cause of the problem or if it is a consequence of the problem, as a way for the patient to attempt to move out of pain.

I will say that investigating these structures can be extremely important when working with clients suffering from carpal tunnel syndrome, as a forward head posture can place certain muscles on prolonged stretch and other muscles in a shortened position (obviously creating the reduction in range of motion as shown in this study and others), leading to possible trigger point formation and myofascial pain and dysfunction (as we will see later).

The researchers in the study above did hypothesize that, “Perhaps treatment directed at the cervical spine may enhance the outcome of patients with carpal tunnel syndrome.”

Addressing these issues may offer the client significant improvements in pain and function when other, more traditional approaches, have failed.

Soft Tissue Therapy Ideas

Several non-surgical approaches to carpal tunnel syndrome can be taken and depending on the therapist you see, that approach may be different.  The point of this paper is not to show that one approach is better than another, but rather to highlight some of my ideas with regard to soft tissue therapy when working on individuals suffering from carpal tunnel syndrome.

Altering habits of daily use is a typical starting point for those suffering from carpal tunnel syndrome.  By doing so, the individual breaks the cylce (so to speak) and gives the injured hand a break in the action and a little bit of rest.

Massage was also shown to help decrease signs and symptoms of carpal tunnel syndrome in a 2003 study in the Journal of Bodywork and Movement Therapies, with patients improving in function and decreasing symptoms after seeing a therapist for one 15-minute session once a week for four weeks (the patients were additionally given self-massage treatment plans, as a means of self-care, to be completed in between their weekly appointment)

Additionally, neural mobilization may be effective in decreasing the signs and symptoms of carpal tunnel syndrome, by decreasing neural tension and improving the normal and physiological state of the nervous system.

Looking elsewhere

While clients commonly complain of the pain down at their wrist, thumb and hand, the site of the pain may not always be the source.  It is important to rule out other factors higher up the chain that may be adding to or, in the case of trigger points, creating the symptoms.

Trigger points, myofascial lines and carpal tunnel syndrome

Several muscles may house trigger points that can mimic carpal tunnel syndrome.  In addition, the area that these muscles refer pain to can house satellite trigger points.  So, you may be treating a trigger point down near the wrist and the client may feel better temporarily, only to have the pain return after several days.  It is then that the therapist should look for trigger points in other muscles, usually more proximal to the body, which may be complicating the treatment process.  Evaluating the myofascial lines of the arm can be extremely useful in treatment and may give you a better idea of the source of pain for a particular client.

Some muscles that can refer trigger point like symptoms:

• Latissimus Doris
• Infraspinatus
• Scalenes
• Subscapularis
• Pectoralis Major
• Pectoralis Minor
• Subclavius
• Brachialis
• Brachioradialis
• Pronator Teres
• Flexor Carpi Radialis
• Flexor Pollicis Longus
• Adductor Pollicis
• Opponens Pollicis

It is important to note the muscles in the above group that may be put under greater stretch in a forward head posture, referring to the research cited earlier.  The scalenes, pectoralis major and minor can be prone to shortening in this type of posture.  In addition, the latissimus doris is both an internal rotator and extentensor of the arm, which puts it into a position that can cause greater tension on the brachial plexus (the bundle of nerves in the cervical region, where the median nerve begins its journey down the arm).  This internally rotated position is one common to those who hold office jobs and work on computers all day, causing these muscles to develop trigger points as a means of energy conservation.

Many of these muscles also share a common myofascial connection, as noted by Thomas Myers in his front of the arm line, which has two different tracks.

The first track starts at the pectoralis major, latisimus doris and teres major.  From there, the fascial connection moves to the medial intermuscular septum and then to the medial epicondyle (the attachment site for the pronator teres and several of the flexor muscles).  From the flexor tendons, the fascial connection ends at the palmer side of the hand and the fingers.

The second track begins at the pectoralis minor and draws a fascial connection to the coracobrachialis and short head of the biceps.  The biceps then connect to the radius, where the fascial connection continues with the flexor compartment and finishes at the thumb.

Obviously all of these connections are important to look at when palpating the tissue of someone suffering from carpal tunnel syndrome.  The forward head posture noted above may also create dysfunctional breathing, causing the scalenes to become over active and compress down onto the brachial plexus, creating carpal tunnel syndrome symptoms as well as other possible neurological symptoms.  This over activity of the scalenes in this instance may cause them to house trigger points which can also refer symptoms of carpal tunnel syndrome.  Because of this, it may be critical for the therapist or trainer to  re-teach proper breathing patterns and enhance core function as part of a possible long lasting treatment strategy for those suffering from carpal tunnel syndrome.

Conclusions

When assessing individuals complaining of hand, wrist or thumb pain, it is important to also evaluate other structures more proximal to the area of pain in order to form a more comprehensive treatment approach that provides the client with sustained relief.

The objective of this article was not to argue which treatment method is the best, but rather to offer some ideas for therapists to consider when dealing with carpal tunnel syndrome.

The information in this article is not to be used in place of a full medical evaluation.  If you are suffering from any of these symptoms, please consult a medical professional for a thorough examination.

If you would like information about Optimum Sports Performance and how we can help you, please email me at patrick@optimumsportsperformance.com

References

Neumann DA. Kinesiology of the Musculoskeletal System: Foundations for Physical Rehabilitation. Mosby. 2002.

De-La-Llave-Rincon A, Fernandez-De-Las-Penas C, Palacios-Cena D, Cleland JA. Increased Forward Head Posture and Resricted Cervical Range of Motion in Patients with Carpal Tunnel Syndrome. J Orth Sport Physical Therapy Sept. 2009;39(9):658-664.

Kendall FP, McCreary EK, Provance PG, Rodgers MM, Romani WA. Muscles: Testing and Function with Posture and Pain. Lippincott Williams & Wilkins. 2005. 5th ed.

Fields T, Diego M, Cullen C, Hartshorn K, Gruskin A, Hernandez-Reif M, Sunshine W. Carpal Tunnel Syndromes are Lessened Following Massage Therapy. J Bodywork and Movement Ther 2004;8:9-14.

Kostopoulos D. Treatment of Carpal Tunnel Syndrome: A review of non-surgical approaches with emphasis in neural mobilization. J Bodywork and Movement Ther 2004;8:2-8.

Davies C. The Trigger Point Therapy Workbook. New Harbinger Publications, Inc. 2004. 2nd ed.

Chaitow L, DeLany J. Clincal Application of Neuromuscular Techniques Vol. 1: The Upper Body. Churchill Livingstone. 2000. 1st ed.

Myers T. Anatomy Trains part 2. J Bodywork and Movement Ther 1997; 1(3):134-145.