FAQ Category: Hand

Little by little, researchers are coming to understand what’s behind the problem of trigger finger. Trigger finger (and trigger thumb) are conditions affecting the movement of the tendons as they bend or flex the fingers or thumb toward the palm of the hand.

The tendons that move the fingers are held in place on the bones by a series of ligaments called pulleys. These ligaments form an arch on the surface of the bone that creates a sort of tunnel for the tendon to follow along the bone. To keep the tendons moving smoothly under the ligaments, the tendons are wrapped in a slippery coating called tenosynovium. 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. When the flexor tendon gets pinched or stuck under the A1 pulley, a trigger digit develops.

A series of studies have been done examining this pulley mechanism called the A1 pulley under high-powered microscope called light microscopy. So far, the scientists have found that normal pulleys have three layers: an outer, middle, and inner layer. Each layer is made up of different types of cells and a different mixture of those cells. For example, the outer layer is formed by loose connective tissue with a good blood supply. The middle layer contains dense connective tissue. And the inner layer is the gliding layer made up of fibrous chondrocytes (cartilage cells).

Light microscopy has made it possible to look at the tissues with increasing magnification. The borders between each layer are visible, thickness of the layers can be measured, and the surfaces are easy to see, too. Pulleys from trigger fingers show various amounts of damage and destruction of the fibrocartilaginous layers of the pulley. Sometimes it is so thin, it disappears. Tiny cracks called fissures are common along with scar tissue and increased blood supply to the damaged area. Despite all of those changes, there are no signs of inflammation anywhere in the area.

It appears that increased mechanical stress from repetitive use of the fingers results in mild abnormalities that can gradually get worse over time. As the condition progresses, more and more of the gliding surface is destroyed and replaced by fibrosis (scar tissue) that has its own blood supply. As the pulley gets thicker and thicker, the tendon is less able to slide and glide underneath it.

You may have to ask the therapist that question since we don’t know exactly what kind of treatment you had. It sounds like possibly a treatment method called neurodynamic technique (NDT). Neurodynamics is the study of how the nervous system slides and glides as we move. Nerves such as the median nerve involved in carpal tunnel syndrome can become pinched, obstructed, or bound down by scar tissue, swelling, or other soft tissues surrounding the nerve.

The neurodynamic technique is a way of restoring the free flowing movement of nerve tissue as the joint moves. Treating carpal tunnel syndrome with the neurodynamic approach requires the therapist to understand the anatomy of the median nerve. Before applying the technique, the therapist conducts an examination of the median nerve including palpation and movement of the nerve. Tests are also performed to see if the nerve is involved, blocked, or obstructed in any way.

Altered nervous system movement is restored through a series of joint and limb positions and movements referred to as neurodynamic technique (NDT). For the neurodynamic technique, the patient may bend his or her head away from the side the therapist was mobilizing. The shoulder is pressed down by the therapist. The arm is lifted up away from the side, the forearm was turned up in a movement called supination (palm up as if asking for a bowl of soup).

The therapist keeps the downward pressure on the shoulder while moving the arm through a specific pattern of passive elbow, wrist, and hand motion. The purpose of these specific movements is to position the upper extremity in such a way that movement of the joints stresses the targeted nerve pushing it along its intended pathway.

At least that’s what we think is happening. A recent study from the University of Florida may have uncovered an interesting tidbit of information about this technique. It looks like the specific technique isn’t what works after all — it’s the patient’s expectations and response to treatment that makes a difference. How do they know that?

Well, they conducted a study involving 40 women with carpal tunnel syndrome. Everyone in the study was randomly assigned to one of two groups. The first group received this neurodynamic technique. The second (comparison) group received a very believable sham treatment. Patients in both groups completed a special survey that showed they were all expecting good results from whatever treatment they had.

Patients in both groups got better. There were no differences in outcomes. And measurements taken right after the treatment sessions showed a positive in-session response. Pain intensity decreased and they became less sensitive to pressure and temperature.

The authors of that particular study concluded that like many manual therapy hands on techniques, it’s not the specific method used that works as much as the patient’s response to being touched and their expectations of getting better as a result. The results of this study are consistent with other similar studies using a variety of different manual therapy techniques. This study shows that the success of the neurodynamic technique may not be related to movement of the nerve at all but more study is needed to better understand how and why neurodynamic technique works.

The bottom line for many patients is relieve from symptoms — that is a very acceptable outcome no matter how it comes about!

Carpal tunnel syndrome (CTS) causes pain, numbness, tingling, and weakness of the hand and wrist when the median nerve gets squeezed or pinched inside the carpal tunnel of the wrist. CTS is also referred to as nerve entrapment or compressive neuropathy. Any condition that decreases the size of the carpal tunnel or enlarges the tissues inside the tunnel can produce the symptoms of CTS.

The carpal tunnel is an opening through the wrist to the hand that is formed by the bones of the wrist on one side and the transverse carpal ligament on the other. The median nerve passes through the carpal tunnel into the hand. It gives sensation to the thumb, index finger, long finger, and half of the ring finger. It also sends a nerve branch to
control the thenar muscles of the thumb. The thenar muscles form the thick pad at the base of the thumb and let you touch the pad of the thumb to the tips of each finger on the same hand, a motion called opposition.

This thumb to hand oppositional movement is extremely important for a bowler, since it is part of the hand position used to pick up the ball, hold it, and then release it successfully. Hand therapists such as specially trained physical and occupational therapists often treat patients with carpal tunnel syndrome. A wide variety of treatment techniques are used such as splinting, activity modification, and stretching of the soft tissues. The method of stretching or stressing the nerve that you are referring to may be the neurodynamic technique (NDT). The neurodynamic technique is a relatively new treatment method that has become very popular in the last 10 years.

Neurodynamics was developed in Australia by a physical therapist by the name of David Butler. It is the study of how the nervous system slides and glides as we move. Nerves such as the median nerve involved in carpal tunnel syndrome can become pinched, obstructed, or bound down by scar tissue, swelling, or other soft tissues surrounding the nerve. The
neurodynamic technique is a way of restoring the free flowing movement of nerve tissue as the joint moves.

It is true the therapist takes the patient’s hand, wrist, and arm through different positions and movements designed to stress the median nerve. Some patients do report moderate pain with this technique. But they also say that they get the desired results. They become pain free and are able to resume all normal activities once again. This technique does require additional specialty training for the hand therapist. If you are interested in pursuing this approach, ask the therapist if he or she has been trained in neurodynamic techniques.

You may have to ask some indirect questions to find out more about what’s on your mother’s mind. Sometimes patients don’t really know themselves. There may be some fear about the results, cosmetic appearance, risks, loss of function during the recovery period, and inability to care for herself or other family members after surgery.

Sometimes there are financial concerns that patients don’t feel free to share with close family members. Your mother may not want to worry you or burden you with her financial problems. Some patients are convinced that surgery won’t help them. In their minds, there’s no sense even scheduling an operation. Others make the appointment but end up canceling for any number of reasons.

If your mother hasn’t had at least six to eight weeks of conservative care, this might be a good way to approach treatment. At least she would have a chance to try a nonoperative approach and with a little more time, her symptoms may improve. In fact, a small study of Korean women was recently published showing that the number one reason women who were scheduled to have surgery cancelled the surgery was because their symptoms got better.

Since this is not a life-threatening illness, your mother may have some time to decide for herself what’s best. You may even consider asking her straight out what her hesitations are and/or what’s holding her back. Don’t be surprised if she skirts the issue. If she doesn’t really know or doesn’t feel comfortable sharing her reasons, it may be best to give her some time to sort through the problem on her own.

Carpal tunnel syndrome is a common nerve compression problem in adults, so you might think with the number of people being treated for this problem that we would have a lot of data on it. But, in fact, there are far more studies investigating decision-making over joint replacements than carpal tunnel syndrome.

The most recent evidence-based approach has been to conduct electrodiagnostic tests such as nerve conduction velocity (NCV) and electromyography to confirm the diagnosis. If the results of these tests support a median nerve compression neuropathy, then surgery is advised. If the studies are negative, then patients are treated with conservative measures such as antiinflammatory medications, steroid injections, splinting, and/or exercises and hand therapy.

Knowing that those tests are not 100 per cent reliable, there are some patients who complete the recommended course of nonoperative care and still go on to have surgery because their symptoms don’t get better. Sometimes for patients who don’t get better (or who may even get worse), repeat electrodiagnostic tests are done after six months. At that point, they may show that degeneration of the nerve has occurred over time.

One small study of Korean homemakers with carpal tunnel syndrome of unknown cause may give you some insight into some peoples’ thinking. All were scheduled to have surgery. But after a four-week waiting period, 13 per cent cancelled the operation. When interviewed and asked why they cancelled, they said their symptoms had gotten better. For those patients who didn’t cancel, they reported the severity of their pain and numbness was the main reason they went ahead with the operation.

Knowing how other people decide may be interesting, but it may not always be helpful. Each patient must take into consideration the individual factors of his or her own situation. Test results, current function, goals, general health, and insurance coverage must all be evaluated when making the final decision. Your surgeon can also offer his or her perspective based on your history, age, and clinical findings.

Studies show that the number one reason for persistent or recurrent symptoms after carpal tunnel release surgery is an incomplete decompression. That means the retinaculum (band of tissue that goes across the wrist and puts pressure on the nerve) is cut but not all the way through. This doesn’t happen very often, but it is usually easily rectified by repeating the surgery to get a complete release of the retinaculum.

The surgeon will recommend a second (revision) surgery when all indications are that there was an incomplete release. Tests and measures must rule out the possibility of injury to the nerve during the first operation as a cause for your current symptoms. There are two ways of identifying intraoperative nerve damage. One is to conduct electrodiagnostic tests. These help measure nerve function (i.e., how well the nerve is transmitting signals or messages).

Before and after electrodiagnostic tests can be compared to see if there has been some additional nerve damage. A second surgery may be needed to repair any nerve damage. A second factor to consider when determining whether or not there has been additional injury or trauma to the nerve is the timing of the symptoms.

Symptoms that never really went away after surgery suggest persistent carpal tunnel syndrome. And again, the most common reason for that situation is an incomplete decompression. Symptoms that went away but later came back point to the possibility of fibrosis (scar tissue build up around the nerve).

Sometimes it’s not possible to know for sure what’s going on until the surgeon goes back into the carpal tunnel area and takes a look around. The retinaculum can be re-released if needed and the nerve can be inspected for any scarring, trauma, or other damage.

Don’t hesitate to ask what your surgeon thinks is causing your continued symptoms and why a second operation is necessary.

Carpal tunnel syndrome (CTS) is a common problem affecting the hand and wrist. Symptoms begin when the median nerve gets squeezed inside the carpal tunnel of the wrist. This is a medical condition known as nerve entrapment or compressive neuropathy. Any condition that decreases the size of the carpal tunnel or enlarges the tissues inside the tunnel can produce the symptoms of CTS.

The carpal tunnel is an opening through the wrist to the hand that is formed by the bones of the wrist on one side and the transverse carpal ligament on the other. Another name for tranverse carpal ligament is the retinaculum.

The median nerve passes through the carpal tunnel into the hand. It gives sensation to the thumb, index finger, long finger, and half of the ring finger. It also sends a nerve branch to control the thenar muscles of the thumb. The thenar muscles help move the thumb and let you touch the pad of the thumb to the tips of each finger on the same hand, a motion called opposition.

The median nerve and flexor tendons pass through the carpal tunnel. The median nerve rests on top of the tendons, just below the transverse carpal ligament. You can see how pressure from this ligament can cause nerve problems. The ligament may be too tight, too thick, and/or too close to the nerve. Cutting through the retinaculum releases this pressure and give the nerve some breathing room.

Sometimes surgically releasing the retinaculum in this way is all that’s needed. But in other cases, the surgeon can see that the nerve needs added protection from rubbing against structures that will irritate it further. If that’s a potential problem, then it may be necessary to put some padding between the nerve and the other structures. This is called nerve coverage. It’s done by taking a small piece of tendon or ligament from somewhere else and either wrapping it around the nearby tissues or placing it between the nerve and the surrounding tissues.

With health care costs soaring, everyone is looking for ways to trim the budget. Financial experts are taking common problems like carpal tunnel syndrome (CTS) and doing a cost analysis between operative and nonoperative treatment to help patients and surgeons in the decision-making process.

For years, its been recommended that anyone with carpal tunnel symptoms start with conservative (nonoperative) care first. But the results of new studies suggest just the opposite. It looks like surgery may be the new standard of care for anyone with electrodiagnostically proven carpal tunnel syndrome.

That phrase electrodiagnostically proven is the important key. Symptoms of wrist pain and numbness of the thumb, first two fingers, and half of the ring finger come with carpal tunnel syndrome. But unless electrodiagnostic tests are done, the patient does not have a confirmed, proven case of carpal tunnel syndrome.

What tests are we talking about? Several tests are available to see how well the median nerve is functioning, including the nerve conduction velocity (NCV) test and an electromyogram (EMG). The NCV test measures how fast nerve impulses move through the nerve. Slow or absent impulses is a sign that the nerve is not firing properly.

The EMG is done by testing the muscles of the forearm and wrist that are controlled by the median nerve to determine if they are working properly. If the test shows a problem with the muscle, the nerve that goes to the muscle might not be working correctly. This is similar to checking whether the wiring in a lamp is working. If the light still doesn’t work after you’ve put in a new bulb, you can begin to tell if there’s a problem in the wiring.

Knowing that nerve function is affected helps steer patients to surgery right away because this is not something that responds well to treatment with splinting or hand therapy. Rather than spending money on conservative care and still ending up with surgery, costs can be cut up front by beginning with surgery first. Waiting too long when there is known nerve damage could affect your results in a negative way with worse outcomes than if you had treatment sooner than later.

One thing to be aware of: there’s a difference between actual charges and reimbursement received for services. Charges are made for surgeons’ services, anesthesia, operating room costs, splints, therapists, injections, and testing. But costs paid out as reimbursement (the amount actually paid for those services) comes through one of three sources: Medicare, private insurance, and Workers’ Compensation.

Cost of care varies depending on who was paying for it. Costs are typically the highest for Workers’ Compensation patients and lowest for Medicare patients. Remember, these figures aren’t based on what was charged for services. These dollars paid reflect what the various organizations would pay for the services (i.e., reimbursement). Anyone who takes Medicare patients agrees to accept the reimbursement rate set by the government without charging the patient out-of-pocket for the difference between what was charged and what was paid. If you have a secondary insurance carrier, they usually pay the remaining unpaid portion billed for by doctors, therapists, and others.

For the best results, your decision should really be based on the results of electrodiagnostic tests. If you have a confirmed case of carpal tunnel syndrome from nerve entrapment, evidence suggests surgical treatment now, not two years from now. Some patients with mild symptoms do respond to conservative care, but they report less than optimal results. They say the painful symptoms don’t go away completely and that over time, all symptoms gradually come back. Many of these patients end up having surgery anyway. And waiting too long can compromise nerve function from unrelieved compressive forces.

Finding out what’s best for your health as well as what works for your pocket book can be a challenge. Talk with your surgeon about your test results and your best options. If surgery is needed now, most surgeons will work out a payment plan that patient’s can afford.

Well, we sympathize with your dilemma. With thousands of people affected by carpal tunnel syndrome every year (and around the world, not just in the US and Canada), this is a decision faced by many people. In fact, carpal tunnel syndrome is the most common nerve entrapment problem affecting the hand.

As the name suggests, nerve entrapment is a condition of pressure on the nerve (in this case, the median nerve) from some outside force. It could be from swelling inside the wrist, ganglion cysts, tumors, scar tissue, thickening of the ligament that crosses over the nerve, or one of dozens of other musculoskeletal or systemic causes.

That’s why a proper diagnosis is important — to be successful, treatment must be aimed at the underlying cause of the problem. It sounds like you’ve crossed the first and most important hurdle: diagnostic testing. Nerve conduction velocity tests help identify those patients who would be best served with conservative (nonoperative) versus surgical care.

Studies now show that patients with changes in nerve function (as shown by the electrodiagnostic tests you have had) should jump right to surgery as their first-line of treatment. Splinting and hand therapy just have not been proven effective for moderate-to-severe median nerve compression. You might get some relief of symptoms, but usually there is not complete pain relief or the symptoms are only improved for a short time before they come back again.

A recent study from Harvard Medical School confirmed this recommendation. They compared actual costs between conservative and surgical care. Patients were divided into two groups according to these two treatment approaches. They all had a diagnosis of carpal tunnel syndrome confirmed by nerve conduction velocity tests. They were evenly matched by age, gender, body mass index, severity of carpal tunnel syndrome, and so on.

In the end, half the nonsurgical group opted for surgery (after completing weeks of therapy). Only patients with mild carpal tunnel syndrome were helped by conservative care and all of those patients reported persistent pain and numbness even after therapy. When it came to counting the cost, surgery was faster and less costly for most patients with confirmed carpal tunnel syndrome.

Actually, you may be in luck. Researchers from the Netherlands took the time to review studies published and listed in PubMed (search engine for the U.S. government’s record of publications in the National Library of Medicine). They confined themselves to four specific hand disorders: 1) trigger finger, 2) Raynaud’s phenomenon, 3) Dupuytren’s disease, and 4) De Quervain’s disease.

That’s the good news. The bad news is they didn’t really find much to help them develop any kind of treatment guidelines for these conditions. There simply aren’t very many good, quality studies out there. The conclusion of their article was that there is a big need for some high-quality research in the area of effective treatment for painful conditions of the hand.

In the meantime, here’s a quick summary of what they did find. Steroid injections might be useful in the treatment of trigger finger, but there was only one (very small) study that compared steroid injections with a placebo injection so more study is needed in this area.

Raynaud’s phenomenon (RP) responded best to medications such as calcium channel blockers (to lower the blood pressure by keeping the blood vessels open). Laser therapy may also be effective. There was limited evidence to support the effectiveness of behavioral therapy with biofeedback (for temperature control) and the use of supplements like Ginkgo Biloba.

There were only four randomized controlled trials centered on the treatment of Dupuytren disease. Those all had to do with surgery, type of incision made, and postoperative procedures to control swelling. There was no evidence that any one particular approach worked best or had the most positive effects.

Studies of cortisone injections (with or without antiinflammatory drugs) and splinting did not show either one to be effective in treating the symptoms of De Quervain’s disease. Wearing a splint reduced pain for some patients but it didn’t last. As soon as the splints were removed and the thumb moved, the pain came right back. Injections seem to help, as two-thirds of the group was better three weeks later. But that was the same result as in the placebo group.

A lack of evidence is NOT the same as evidence that the treatment doesn’t work or should/should not be used. It just means that we have to get busy and do some studies in this area with a specific focus on treatment approaches for each hand disorder being considered.

Cupping is a healing method used in folk medicine in countries such as China, India, Arabia, Central Europe, and parts of Africa. Glasses applied to the skin create suction of the underlying skin and soft tissue. The stimulation helps improve circulation to the area.

The technique can be done dry or wet. Dry cupping is just as described here. Wet cupping adds an additional step of making tiny cuts in the skin that bleed. When the cups are partially filled with blood, they are removed (usually after five to 10 minutes).

How does cupping work? The actual physiologic mechanism remains unknown. There are several theories out there but no proven facts to explain it. The first theory is called the double-crush hypothesis.

The idea behind this theory is that carpal tunnel syndrome occurs when there has been nerve injury (irritation, compression) in the neck. Carpal tunnel symptoms are then the result of damage to flow of messages along the entire length of the nerve. The cupping applies vacuum pressure to the soft tissues and stimulates blood and lymph flow to the area. This, in turn, improves overall nerve function, even at the median nerve further down the arm.

A second theory is that wet cupping applies a noxious stimulus or counterirritation. The nervous system stops paying attention to the chronic pain of carpal tunnel syndrome and switches instead to this new, local source of nerve signals. The result is to override the chronic nerve pain long enough to turn it off permanently.

And finally, it has been suggested that cupping works simply because the person received some form of treatment and expected it to work. That’s called the placebo effect. There is a certain amount of placebo effect with any treatment. Why some placebos are more powerful than others remains another unknown factor.

Cupping is not well-known or used that often in the United States. People in China, India, Arabia, Central Europe, and parts of Africa may be more familiar with it. Cupping is a treatment used in folk medicine to improve circulation to a specific area of the body.

Suction cup type of glasses are applied to the skin to create suction of the underlying skin and soft tissue. The technique can be done dry or wet. Dry cupping is just as described here. Wet cupping adds an additional step of making tiny cuts in the skin that bleed. When the cups are partially filled with blood, they are removed (usually after five to 10 minutes). This is actually a form of the old treatment called blood letting.

The cuts should be made using a microlancet to make tiny puncture wounds. A microlancet is the tool used to stick your finger when taking a blood sample. The lancets are sterile. So are the suction cups that get applied to the skin. Unless the patient has difficulty forming immediate blood clots, the areas stop bleeding as soon as the cups are removed. Each site can be covered with a small bandage for 24 hours.

If applied in this manner with sterile technique by someone who has been trained, the treatment should be both safe and effective.

The elbow/forearm/wrist complex is just that — a complex mix of bones, ligaments, and other soft tissues. Damage to one can affect the others. A loss of motion such as you are having (called forearm supination) can be very distressing and limiting. But it’s not likely that the loss of that motion is a direct result of radial head resection (removal).

It’s more likely that damage to the interosseous membrane is at fault. The interosseous membrane connects the two bones of the forearm (radius and ulna) together from top to bottom. The interosseous membrane accounts for the majority of forearm stiffness.

Without this important protective feature, the forearm can’t resist force from the wrist to the elbow. At the same time, the diagonal orientation of fibers at a 20-degree angle make it possible to twist the bones while turning the palm up (supination) and palm down (pronation).

If you were unable to move your forearm for any length of time due to pain or cast immobilization after surgery, the interosseous membrane could have scarred down. If the membrane isn’t torn but just contracted, then a few sessions with a hand therapist might help to release that soft tissue and restore motion.

But if it was torn (partially or ruptured fully) at the time of the injury, you may have an additional undiagnosed injury that requires further treatment. The best way to figure out what’s going on and what to do about it is to see an orthopedic surgeon. If your community has a hand surgeon, take advantage of that person’s additional training in this specialty area. Get a proper diagnosis and find out just what your treatment options are, then go from there.

In order to ensure consistent results for all patients with various conditions like carpal tunnel syndrome, clinical practice guidelines are published. Organizations like the American Academy of Orthopaedic Surgeons review the literature and summarize findings based on current evidence available.

Physicians are advised to follow these guidelines in caring for patients with the specified condition. In the case of carpal tunnel syndrome, you can expect your physician to start by getting an accurate patient history. Questions should be asked about the symptoms (e.g., duration, severity, location). Previous treatment, lifestyle and activities, and any limitations in function due to symptoms are also recorded.

An exam comes next. The physical exam should include age, gender, weight and height, and range-of-motion and strength of the wrist and hand. Special tests for sensation, vibration, nerve irritation can be performed. Any obvious muscle atrophy (wasting) or other deformities should be noted. There are a variety of tests physicians already use to help identify the presence of carpal tunnel syndrome (e.g., Phalen’s, Tinel’s, reverse Phalen).

Electrodiagnostic tests are ordered for certain patients. Anyone with persistent numbness and/or who has muscle wasting of the thumbpad should have nerve conduction velocity (NCV) and electromyography (EMG) done. Both of those symptoms suggest severe nerve injury. Once this has been confirmed, then treatment can be determined. NCV and EMG have been able to sort out carpal tunnel from other nerve problems.

Feel free to ask whomever you see what his or her standard protocol is for the evaluation of carpal tunnel syndrome. If you have questions about anything included (or not included), don’t hesitate to ask. Early diagnosis and a plan of care based on the examination findings is the key to fast and successful treatment results.

Everyone likes to have a visual picture of what’s happening to them to cause their various symptoms. But sometimes the added expense doesn’t really yield the results we are looking for. In the case of carpal tunnel syndrome (CTS), experts from the American Academy of Orthopaedic Surgeons (AAOS) suggest you can save your money.

When the physician takes the clinical picture (signs and symptoms reported by the patient) and adds it to the results of clinical tests and electrodiagnostic tests (if needed), the diagnosis is more likely to be accurate. The combination of this data also makes it easier to formulate a plan of care. There is a need for research to find out which tests give the most accurate information and can be relied on to make the diagnosis. This could be a cost-cutting measure as well.

Studies show that advanced imaging studies such as CT scans or MRIs don’t improve the sensitivity or specificity needed in making the diagnosis of carpal tunnel syndrome. The physician’s interview of the patient and clinical exam are usually quite enough to make an accurate diagnosis and move on to the treatment plan. The quicker a patient is moved from diagnosis to intervention, the better the chance for an improved outcome.

The American Academy of Orthopaedic Surgeons has published a Clinical Practice Guideline (CPG) for physicians to use when planning treatment for patients with diagnosed carpal tunnel syndrome. The guideline has nine specific recommendations covering nonsurgical and surgical treatment. Efforts were made to address various topics studied including timing of surgery (early vs. late) and the use of local steroid injections, splinting, or ultrasound treatment.

You’ll notice the guidelines are for patients with diagnosed carpal tunnel syndrome. If you haven’t had your symptoms formally diagnosed, that would be the first step to finding the ideal treatment for you. Sometimes the best treatment is based on the underlying cause of the problem. Since most of the suggestions you’ve received have come from non-medical sources, perhaps you haven’t been tested specifically for carpal tunnel.

More specifically, the guidelines are for a specific subgroup of patients who have reversible carpal tunnel syndrome. Usually that means there is a mechanical cause of the nerve compression that can be changed. Patients with diabetes-induced CTS or other microscopic nerve damage from disease rather than compression need a different treatment approach.

Most of the time conservative (nonsurgical) care is recommended first for mechanically caused CTS. This can include local steroid injections, oral steroids, or physical therapy. The therapist may use ultrasound, splinting, nerve and tendon gliding exercises, and joint mobilization to help take pressure off the nerve.

If the selected treatment does not reduce or eliminate the symptoms after seven weeks, then another form of conservative (nonoperative) care should be tried. This could be any of the approaches already mentioned but not already tried. There is fair evidence that different patients benefit from a variety of nonsurgical approaches. It may be just a matter or trial and error to find the right mix for each patient.

Surgery may be done early when it looks like the nerve is already damaged. The goal is to prevent irreversible nerve damage. Otherwise, a three to six-month course of conservative (nonoperative) care is the usual standard before considering a more aggressive approach.

Carpal tunnel syndrome (CTS) is a common problem affecting the hand and wrist. Symptoms begin when the median nerve gets squeezed inside the carpal tunnel of the wrist. The carpal tunnel is an opening through the wrist to the hand that is formed by the bones of the wrist on one side and the transverse carpal ligament on the other. (Ligaments connect bones together.) This opening forms the carpal tunnel.

Any condition that decreases the size of the carpal tunnel or enlarges the tissues inside the tunnel can produce the symptoms of CTS. This syndrome has received a lot of attention in recent years because of suggestions that it may be linked with occupations that require repeated use of the hands, such as typing on a computer keyboard or doing assembly work. Actually, many people develop this condition regardless of the type of work they do.

Because a nerve is involved, careful monitoring is important. Compression on the median nerve for any reason can eventually cause permanent damage to the nerve. Treatment to reverse this compression and thereby reduce symptoms of wrist/hand pain, numbness, and/or tingling is advised.

Studies show that untreated or ill-treated (wrong treatment approach) carpal tunnel syndrome can get worse over time. Permanent loss of sensation and muscle strength can occur. The loss of grip and pinch strength is a potentially very disabling impairment.

If you are self-monitoring without the benefit of an orthopedic surgeon or hand specialist to guide you, it might be a good idea to start seeing someone with this type of medical background. Waiting too long for treatment may not be in your best interest.

Workers who are exposed to repetitive motions that result in pain, stiffness, loss of motion, and loss of function may have a condition called upper-extremity musculoskeletal disorder (UEMS). Knowing how a condition like this plays itself out is called the natural history. Telling you what to expect as the final outcome is the prognosis.

Experts in this area tell us that there isn’t a standard definition used by all to describe, define, or diagnose upper-extremity musculoskeletal disorders. That makes it difficult to categorize workers and then compare their outcomes in a study.

A recent study from France was published with results from a three-year outcome for workers having UEMS. They were all involved in highly repetitive work like yours (supermarket cashiers, assembly-line manufacturing, and the packaging industry). After collecting all the data about the workers, their symptoms, their status three years after the initial survey, they found that the single, biggest predictor of the future was the presence of symptoms in more than one site. This was called multisite disorders.

Workers who had a prior history of UEMS with a new set of symptoms had the worst results. This was especially true when they had pain in more than one of these areas: the neck, shoulder, elbow, wrist, and hand.

But there are ways to keep your problem from getting worse. Just handling the groceries in a more energy- and joint-conserving fashion will help. Use the automated belt to bring the items right to you before picking them up. Use both hands together to lift and move anything that weighs more than one-pound. Don’t pick up large containers of milk or juice with one hand. Use the handle with one hand (if available) and support under the bottom of the item with the other hand.

Don’t be afraid to wear a wrist support or splint. It could mean the difference between function and chronic disability. And start on a strengthening program for the wrists, hands, and upper extremities. Building muscle strength and mass can help protect the wrist ligaments and more delicate soft tissues of the wrist and hand that aren’t able to handle the stresses and strains of repetitive work of this type.

Not necessarily. The standard of practice for de Quervain’s is currently a trial of splinting, rest, and antiinflammatories. This is not based on hard core research data as this type of research on the treatment of de Quervain’s doesn’t exist.

But it’s clear that this treatment is palliative (makes patients feel better/gives pain relief). The net result might be to improve function and quality of life. It is not curative in the sense that it does not change the underlying disease process.

de Quervain’s tenosynovitis affects two thumb tendons. These tendons are called the abductor pollicis longus (APL) and the extensor pollicis brevis (EPB). On their way to the thumb, the APL and EPB tendons travel side by side along the inside edge of the wrist. They pass through a tunnel near the end of the radius bone of the forearm. The tunnel helps hold the tendons in place, like the guide on a fishing pole.

This tunnel is lined with tenosynovium. The tenosynovium is a slippery covering that allows the two tendons to glide easily back and forth as they move the thumb. Inflammation of the tenosynovium and tendon is called tenosynovitis.

In de Quervain’s tenosynovitis, the inflammation constricts the movement of the tendons within the tunnel. But more recent data shows that in some cases, there isn’t any active inflammation. This is considered a tendinosis, not a tendinitis.

With tendinosis, instead of finding cells that show an inflammatory process, the collagen fibers making up the tendons and tenosynovium are laid down in a haphazard fashion (every which way). Changes in the mucous cause these normally slippery structures to dry out. The tendons can no longer slide and glide smoothly. The dryness causes a painful catching of the tendon over the bone.

The natural history of this condition (what happens over time) is that it eventually goes away on its own. They say it is self-limiting. That’s why conservative (nonoperative) care (and the least invasive choice possible) is selected. If, after a reasonable trial, the symptoms are no better (or even worse), then a steroid injection may be helpful.

Accuracy in the placement of the needle to administer the steroid is extremely important. The surgeon must advance the needle administering the drug through the soft tissues inside the tendon sheath. The steroid drug must reach inside the sheath of both the abductor pollicis longus and the extensor pollicis brevis tendons to be effective.

As we said, most people with de Quervain’s just get better on their own over time. Surgery may be recommended if symptoms remain extremely painful even after six months of conservative care.

The differential diagnosis of wrist/thumb pain includes several possibilities. The only way to find out for sure is to see your doctor for an evaluation. He or she will take your history, look at your signs and symptoms, and perform some tests to identify the specific underlying problem.

It could be early arthritis but it’s more likely to be something like tendinitis, tendinosis, or de quervain’s tenosynovitis. Tendinitis is an inflammation of the tendon sheath (lining or covering) causing local swelling and pain.

Tendinosis refers to the fact that there’s no active inflammation present. Instead, cells taken from the tendons and tendon sheath show that the collagen fibers making up the tendons and tenosynovium are laid down in a haphazard fashion (every which way).

The tenosynovium is a slippery covering that allows the tendons to glide easily back and forth as they move the thumb. Changes in the mucous cause these normally slippery structures to dry out. The tendons can no longer slide and glide smoothly. The dryness causes a painful catching of the tendon over the bone.

de Quervain’s tenosynovitis is a fairly common cause of wrist and thumb pain that occurs with motions just like you are describing. This condition affects two thumb tendons: the abductor pollicis longus (APL) and the extensor pollicis brevis (EPB).

On their way to the thumb, the APL and EPB tendons travel side by side along the inside edge of the wrist. They pass through a tunnel near the end of the radius bone of the forearm. The tunnel helps hold the tendons in place, like the guide on a fishing pole.

This tunnel is lined with tenosynovium, which allows the two tendons to glide easily back and forth as they move the thumb. Inflammation of the tenosynovium and tendon called tenosynovitis constricts the movement of the tendons within the tunnel.

The treatment for each of these conditions is slightly different but usually involves rest, activity modification, and in the case of true inflammation, an antiinflammatory medication. In more severe cases, a local steroid injection into and underneath the tendon sheath can help reduce pain enough to keep moving. Surgery may be needed, but this is not usually considered until a course of three to six months of conservative care has been tried first.