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Carpal Tunnel Syndrome
Department of Osteopathic Manipulative
Medicine
University of North Texas Health Science Center
Texas College of Osteopathic Medicine
CARPAL TUNNEL
SYNDROME
Stuart F. Williams D.O.
Associate Professor
Osteopathic Manipulative Medicine
UNTHSC
Case Presentation
• A 42-year-old Caucasian female presents to
your office complaining of numbness and
tingling in her right hand for approximately
one year. The sensation is on the palmar
surface of the thumb, index, and middle
fingers, and ring finger. She states that
sometimes it feels like her hand is “asleep,”
while other times it feels like “pins and
needles.” The symptoms occur at night and
the only relief is “flicking” of the wrist.
Case Presentation
• Occasionally, the pain is referred to the
forearm and shoulder, but only during an
acute flare-up. The patient has worked as a
secretary at UNTHSC for the past 15 years.
• Physical examination: overweight female in
NAD. Sensation full & = bilat; DTR’s 2+
& = bilat; slight atrophy and weakness of
the thenar muscle and grip strength on the
Rt.; decreased ROM of Rt. wrist compared
to Lt.; positive Tinel’s and Phalen’s
Differential Diagnosis
•
•
•
•
•
•
Cervical radiculopathy
Cervical disc herniation
Thoracic outlet syndrome
Diabetes mellitus
Fracture/Dislocation
Carpal tunnel syndrome
Definition
• Median nerve entrapment at the wrist
What is Carpal Tunnel
Syndrome?
• This condition is most commonly described
as an entrapment neuropathy of the median
nerve at the wrist in the carpal tunnel
– The tunnel is formed by the carpal bones and
the transverse carpal ligament
– Contents of the tunnel include the flexor
tendons and the median nerve
INTRODUCTION
• Repetitive motion disorders account for
approximately 50% of all work-related
injuries.
• 2nd only to Low Back Pain
• Most common repetitive motion disorder
is Carpal Tunnel Syndrome.
ANATOMY
• Carpal Tunnel:
– space on the volar aspect of the wrist
formed by the carpal bones and the
transverse carpal ligament (flexor
retinaculum).
ANATOMY
• Boney Landmarks
– Proximal:
• pisiform bone - medially
• scaphoid bone - laterally
– Distal:
• hook of the hamate - medial
• trapezium bone - laterally
Right Hand- Carpal Bones
CONTENTS OF CARPAL
TUNNEL
• I. Median nerve
• II. 2 synovial sheathes
– 1st sheath
• 8 flexor digitorum profundi and superficialis
tendons.
– 2nd sheath
• flexor pollicis longus tendon.
Clinical Presentation
Cutaneous Innervation
• Median nerve
cutaneous sensory
distribution
– Palmar surfaces of
• Thumb
• Index
• Middle
• Lateral ½ of ring finger
How does one get carpal
tunnel syndrome?
• 1. Increase pressure within the canal.
• 2. Compromise space within the canal.
Pressure is increased in the
carpal tunnel by:
• Both flexion and extension of the wrist.
Space is compromised in the
carpal tunnel by:
• Thickening of the tendon sheaths.
• Encroachment from other structures.
Clinical Presentation
• Compression of median
nerve in carpal tunnel
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Anesthesia
Paresthesia
Pain
Muscle weakness
Decreased ROM
Night-time symptoms
“Flick Sign”
Workers involved in specialized
tasks:
• 1. Require repetitive use of the hand
and wrist while held in forced flexion.
• 2. Carpal tunnel becomes tighter when
wrist held in forced flexion.
Physical Examination
• 1. Tinel’s sign
– a. lightly tapping over volar aspect of wrist
– b. + sign- tingling distally of 1st 3 1/2 digits.
• 2. Phalen’s sign
– A. George Phalen - hand surgeon of
Cleveland clinic.
– B.Hyperflex both wrists against dorsal
surface of each hand.
– C. + test- numbness in approx. 30 sec.
Special Tests
Phalen’s & Tinel’s Tests
• Phalen’s
– Wrist flexion to
maximum for 60 sec
• Tinel’s
– Tapping over transverse
carpal ligament
• Symptoms
– Pain
– Anesthesia
– Paresthesia
OMT TREATMENT
• Transverse Carpal Ligament
• Carpal Bones
• Interosseous Membrane
Osteopathic Treatment
• Myofascial release
• Articulatory
• Muscle energy
OMT Techniques
• Opponen’s Roll
• Squeeze with Rapid Circumduction
• Wrist & Interosseous Membrane Ligament
Myofascial Release
• 1. Pressure applied centrally from the dorsal surface
of the carpal bones.
• 2. Simultaneously apply pressure to the edges of the
carpal bones on the ventral surface of the wrist.
(lateral and medial borders of the carpal tunnel.)
• 3. Simultaneously the D.O. catches the patient’s
thumb and pulls it back into hyperextension with
abduction treating the attachment of the abductor
pollicis brevis muscle.
• 4. Digits and wrist are hyperextended (pulls flexor
tendons into canal and distends canal from inside
out.)
Opponens Roll Technique
• Lateral axial rotation stretches the
opponens pollicis muscle.
• Thenar abduction with extension and
lateral rotation.
Opponen’s Roll
• Grasp first digit (thenar emin.) and
fifth digit (hypothenar emin.) with
each hand
• Contact pisiform and scaphoid
bones with thumbs
• Extend wrist, abduct and laterally
rotate first digit with counterforce
over hypothenar area
• Use thumbs to stretch at boney
contact points the transverse carpal
ligament in lateral/medial direction
• Provide stretch to transverse carpal
ligament for 3-5 minutes
• Perform at each clinic visit and
teach patient to perform technique
at home on daily basis
Myofascial Release
• 1. Crisscross thumbs over medial and
lateral borders of carpal tunnel.
• 2. Apply gentle traction.
• 3. Have patient abduct fingers and hold
in abduction.
• 4. With abduction maintained, have
patient slowly flex involved wrist over
D.O.’s crisscrossed thumbs.
Articulatory Technique
• 1. D.O. applies a squeeze between his/her
hands, producing traction at the joint as the
thenar and hypothenar eminences separate.
• 2. D.O. maintains the squeeze and applies
the articulatory force as a circumduction of
the patient’s wrist in a clockwise, then
counterclockwise conical motion, carrying
the dysfunction through the restrictive
barrier.
Squeeze with Rapid
Circumduction
• Place heel of both hands over
radiocarpal region of carpal bones
& interlace fingers
• Attempt to distract fingers while
squeezing fingers together
– Causes the heel of each hand to
squeeze together
• Circumduct wrist in circular or
figure eight fashion
• Care should be taken to maintain
capsular tension throughout the
articulatory sweep
• Perform at each clinic visit
Muscle Energy (interosseous
membrane)
• 1. D.O. thumbs are crossed over the anterior
surface of the patient’s forearm with
interosseous dysfunction between his/her
thumbs.
• 2. The pad and tip of the thumb of the hand
closest to the D.O. contacts the lateral
side of the ulna. The thumb of the other
hand contacts the medial side of the
radius.
• 3. Have patient attempt to pronate palm and
use isometric counterforce.
Flexion with Posterior Carpal
Glide
• 1. Flex wrist to balanced ligamentous
tension.
• 2. Apply traction.
• 3. Move joint into extension to articulate
through the restrictive barrier.
Extension With Anterior
Carpal Glide
• 1. Extend wrist to the point of balanced
ligamentous tension.
• 2. Apply traction.
• 3. Move joint into flexion to articulate the
joint through the restrictive barrier.
Abduction with Medial carpal
Glide
• 1. Wrist in abduction to balance
ligamentous tension.
• 2. Apply traction.
• 3. Move the joint into adduction to
articulate the joint through restrictive
barrier.
Adduction with Lateral Carpal
Glide
• 1. Place wrist in adduction to the point
of balanced ligamentous tension.
• 2. Apply traction.
• 3. Move the joint into abduction to
articulate the joint through the
restrictive barrier.
Patient Stretches
• 1. Patient places palm of affected extremity
against wall.
• 2. Patient “hooks” hypothenar region of
opposite hand into thenar region of hand to
be stretched.
• 3. Thumb of affected extremity is grasped and
extended.
• 4. While holding thumb and thenar eminence,
palm is placed against wall in extension.
• 5. Elbow is tucked into patient’s iliac crest to
assist with the stretch.