CARPAL TUNNEL SYNDROME

Carpal tunnel syndrome (CTS) is an entrapment

neuropathy caused by compression of the median
nerve as it travels through the wrist's carpal
tunnel.
 It is the most common nerve
entrapment neuropathy, accounting for 90%
of all neuropathies.
 Early symptoms of carpal tunnel syndrome
include pain, numbness, and paraesthesia.
 Symptoms typically present, with some
variability, in the thumb, index finger, middle
finger, and the radial half (thumb side) of the
ring finger.
 Pain also can radiate up the affected arm.
With further progression, hand weakness,
decreased fine motor coordination,
clumsiness, and thenar atrophy can occur.
Patients can be diagnosed quickly and
respond well to treatment but the best means
of integrating clinical, functional, and
anatomical information for selecting
treatment choices have not yet been
identified.
Aetiology
Carpal tunnel syndrome results from
increased pressure in the carpal tunnel and
subsequent compression of the median
nerve. The most common causes of carpal
tunnel syndrome include genetic
predisposition, history of repetitive wrist
movements such as typing, or machine work
as well as obesity, autoimmune disorders
such as rheumatoid arthritis, and pregnancy.
Pathophysiology
There is a wide spectrum of causative
pathologies, converging on two mechanisms
of disease, both of which lead to entrapment:
 A decrease in the size of the carpal tunnel
caused by such conditions as:
 Mechanical overuse (considered the
most common association)
 Osteoarthritis
 Trauma
 Acromegaly
 Disease states leading to augmentation of
carpal tunnel contents:
 Masses, For example, ganglion cysts,
primary nerve sheath tumours
 Deposition of foreign material,
e.g., amyloid
 Synovial hypertrophy in rheumatoid
arthritis
Clinical Presentation
CTS onset is generally gradual with tingling or
numbness in the median nerve distribution of
the affected hand.
Patients may notice aggravation of symptoms
with static gripping of objects such as a phone
or steering wheel but also at night or early in
the morning. Many patients will report an
improvement of symptoms following shaking
or flicking of their hand.
As the disorder progresses, the feeling
of tingling or numbness may become
constant and patients may complain of
burning pain.
The final symptoms are weakness and
atrophy of muscles of the thenar eminence.
These combined effects of sensory
deprivation and weakness may result in a
complaint of clumsiness and loss of grip and
pinch strength or dropping things,
Physical Therapy Management
Patients with mild to moderate symptoms can
be effectively treated in a primary care
environment 
Physical therapists should give advice
on modifications of activities and the
workplace (ergonomic modifications), task
modification, for example, taking sufficient
rest and variation of movements.
Often simple obvious alterations to the
working practice can be beneficial in
controlling milder symptoms of CTS.
Manual therapy techniques
include mobilisation of
 Soft tissue
 Carpal bone
 Median nerve
Other modalities include: ultrasound and
electromagnetic field therapy and splinting.
Research findings (varies)
 Physiotherapy modalities
(TENS and ultrasound) have little useful
effects on hand sensory discomfort.
 The evidence of the effectiveness of the
exercise and mobilization interventions is
limited and very low in quality.
 Evidence about post-operative
rehabilitation is also limited. None of
them seems to have a prevailing benefit
 SKIER’S THUMB

Skier's thumb is an acute partial or complete

rupture of the ulnar collateral ligament (UCL)
of the thumb’s metacarpophalangeal joint
(MCPJ) due to a hyperabduction trauma of
the thumb.
Whilst both terms are often used
interchangeably, skier’s thumb refers to the
cause as being acute injury. Gamekeeper’s
thumb specifically refers to the cause being
associated with a chronic injury to the UCL in
which it became attenuated through
repetitive stress.
UCL damage caused by Chronic injury may
have a serious risk of disabling instability,
pinch strength, and pain-free motion if not
treated adequately.
Aetiology
Skier’s thumb is caused by forced abduction
and hyperextension of the thumb. The UCL
tears mostly find place at the distal
attachment of the proximal phalange. But
proximal avulsion, proximal and distal bony
avulsion, isolated mid-substance tears and
mid-substance tears with bony avulsion do
also occur.
Mechanism of Injury
It is important to note that this injury is not
exclusive to skiers and can occur to anyone
where there is an extreme valgus stress force
applied to the thumb in abduction and
extension.
An acute UCL injury occurs following a
sudden, hyperabduction and hyperextension
forces at the MCP joint, whereas a forced
adduction movement would cause injury to
the RCL. 
With regards to skiing, the injury often occurs
when a person lands on an outstretched hand
while holding a ski pole, which causes forced
abduction of the thumb with extension. 
It is called skier’s thumb but can also occur in
football, handball, basketball, rugby, soccer
and even a handshake. If the injury to the UCL
is not treated properly this can lead to chronic
laxity, joint instability, pain, weakness and
arthritis in the MCPJ.
Clinical Presentation
The most common presentation is pain over
the ulnar aspect of the MCPJ of the thumb. If
the injury is acute there will be bruising and
inflammation.
There may be tenderness with palpation,
which localizes the injury to the ulnar aspect
of the thumb where the UCL is lesioned. In
more chronic cases the patients typically
complain of pain and weakness when using a
pincer grip. There also can be instability of the
thumb while doing these tasks. In the
instance of a Stenner lesion, there may also
be a palpable mass proximal to the adductor
aponeurosis.
Symptoms
These symptoms may occur minutes to hours
after the fall that created the injury:
 Pain at the base of the thumb in the web
space between thumb and index finger.
 Swelling of your thumb.
 Inability to grasp or weakness of grasp
between your thumb and index finger.
 Tenderness to the touch along the index
finger side of your thumb.
 Blue or black discoloration of the skin over
the thumb.
 Thumb pain that worsens with movement
in any or all directions.
  Pain in the wrist (which may be referred
pain from your thumb).
Grades of thumb sprains.
Thumb sprains are ranked by how much the
ligament is pulled or torn away from the
bone.
 Grade 1: Ligaments are stretched, but not
torn. This is a mild injury. It can improve
with some light stretching.
 Grade 2: Ligaments are partially torn (less
than 3mm). This injury may require
wearing a splint or a cast for 5 to 6 weeks.
 Grade 3: Ligaments are completely torn or
more than 3mm. This is a severe injury
that usually requires surgery.
 Grade 4: Failed immobilization and
required surgery as did all of those with a
Stenner lesion
Physical Therapy Management
The treatment of skier’s thumb is different for
partial and a complete rupture. Partial
ruptures are treated conservatively. The MCP
joint is immobilized, with the MCP fixed and
the IP joint remaining free to prevent
unnecessary stiffness. A navicular cast or
brace is usually used.
Swelling can be controlled with elevation
while supine and the use of cold compresses
as needed.
The primary goal of rehabilitation is
enhancing the patients' function and reducing
the time of functional recovery, the reported
treatment presents potential advantages in
the management of this frequent acute hand
injury.
Conservative treatment
Partial UCL injuries like ligament strains,
partial tears, low-demand patients and poor-
operative candidates, including patients with
degenerative MCP joint disease are effectively
treated conservatively.
Controversy also exists about treating a bony
skier’s thumb without surgery. The literature
however shows that if the MCP joint is stable
during testing and there is no dislocation of
the fragment, this injury can be treated
conservatively without reason for concern.
 For patients with:
 less than 30 degrees of valgus laxity of
extension of the MCPJ
 Less than 15 degrees difference
between sides and no signs of avulsion
fracture on radiographs.
Immobilisation
From 10 days up to 6 weeks, depending on
the degree of laxity during the initial
examination. Authors of a recent review on
skier’s thumb agreed on a 4-week period,
suggestions:
 A short-arm thumb spica cast
 Thermoplastic splint: allows for the
patient to begin movement of the
interphalangeal joint.
 A hand-based removable thumb spica
orthosis. The MCP joint is immobilized,
with the MCP fixed and the IP joint
remaining free to prevent unnecessary
stiffness.
 Wearing a splint will avoid putting radial
stress on the thumb and gives the
ligament time to heal. The optimal
positioning for the splint involves holding
the MCPJ in slight flexion with a slight
 ulnar deviation; the interphalangeal joints
should not be immobilized in the splint
After the period of immobilization is over, the
therapy can be started. Most likely the
patient will perform exercises that help
strengthen and stretch the joint in order to
regain full function in your thumb. The
patient should begin supervised hand therapy
during the period of immobilization.
Gentle flexion and extension range of motion
exercises can begin after about four weeks,
with the patient continuing to wear the splint
between therapy sessions. After 8 weeks
progressive strengthening exercises may
begin, but unrestricted activity is not allowed
until after 12 weeks. 
Gripping and pinching activities should not
start until 10-12 weeks and should be
advanced as tolerated; forceful gripping
activities are typically not tolerated until
about week 12
Treatment after surgery
The content of the physical therapy after
surgery is the same as those of the
conservative treatment, besides:

Duration of Immobilisation: usually 6
weeks is applied
 Control radiograph after immobilisation

Following surgery, a splint is usually worn for

four to five weeks. Immediate postoperative
motion of the operated joint produced faster
and better functional results. Therefor the use
of a functional splint is preferred, as well as
the early progressive start with moving within
the boundaries of pain. Athletes whose
injuries require surgery can usually return to
play in about three to four months. The study
of Derkash, considering pain, stability,
muscular force (tweezers grip) and
functionality in ADL, shows that less than 5%
of the patients experience a weakened
tweezers grip and stiffness. Pain was absent
or mild in 99% of the cases. 96% of the
treated patients were satisfied with the
results of the operation. When a secondary
operation is required, results were less
successful.
When the pain has subsided and the range of
motion has completely returned, the hand
can be completely used again. Usually this
takes about 3 months.
Exercises
Thumb active range of motion
With your palm flat on a table or other
surface, move your thumb away from your
palm as far you can. Hold this position for 5
seconds and bring it back to the starting
position. Then rest your hand on the table in a
handshake position. Move your thumb out to
the side away from your palm as far as
possible. Hold for 5 seconds. Return to the
starting position. Next, bring your thumb
across your palm toward your little finger.
Hold this position for 5 seconds. Return to the
starting position. Repeat this entire sequence
15 times. Do 2 sets of 15.
Wrist range of motion
 Flexion: Gently bend your wrist forward.
Hold for 5 seconds. Do 2 sets of 15.
 Extension: Gently bend your wrist
backward. Hold this position 5 seconds.
Do 2 sets of 15
 Side to side: Gently move your wrist from
side to side (a handshake motion). Hold
for 5 seconds in each direction. Do 2 sets
of 15
 Thumb strengthening: Pick up small
objects, such as paper clips, pencils, and
coins, using your thumb and each of your
other fingers, one at a time. Practice this
exercise for about 5 minutes
 Finger spring: Place a large rubber band
around the outside of your thumb and
fingers. Open your fingers to stretch the
rubber band. Do 2 sets of 15.
 Grip strengthening: Squeeze a soft rubber
ball and hold the squeeze for 5 seconds.
Do 2 sets of 15.
 Wrist flexion: Hold a can or hammer
handle in your hand with your palm facing
up. Bend your wrist upward. Slowly lower
the weight and return to the starting
position. Do 2 sets of 15. Gradually
increase the weight of the can or weight
you are holding.
 Wrist extension: Hold a soup can or
hammer handle in your hand with your
palm facing down. Slowly bend your wrist
up. Slowly lower the weight down into the
starting position. Do 2 sets of 15.
Gradually increase the weight of the
object you are holding.
DUPUYTRENS CONTRACTURE

Dupuytren contracture is a benign,

myeloproliferative progressive disease of the
palmar fascia which results in shortening,
thickening, and fibrosis of the fascia and
aponeurosis of the palm.
 Dupuytren disease is predominantly a
myofibroblast disease that affects the
hand/fingers and results in contracture
deformities.
 The most commonly affected digits are
the third and fourth digits.
 The disease begins in the palm as painless
nodules that form along longitudinal lines
of tension.
 The nodules form cords that produce
contracture deformities within fascial
bands and tissues of the hand.
  Dupuytren contracture is usually seen in
whites and the disorder is often bilateral;
when unilateral the right side is more
likely to be involved compared to the left.
 In many individuals, there is a family
history with males being more likely to be
affected than females.
Aetiology
Dupuytren disease is a genetic disorder
expressed in an autosomal dominant fashion,
but most frequently seen with a multifactorial
aetiology. It is associated with diabetes,
seizure disorders, smoking, alcoholism, HIV,
and vascular disease.
Ectopic manifestations beyond the hand can
be seen in Lederhosen disease (plantar
fascia), 10% to 30%; Peyronie disease (Dartos
fascia of the penis), 2% to 8%; and Garrod
disease (dorsal knuckle pads), 40% to 50%.
Clinical Presentation
Dupuytren contracture occurs slowly and
typically progresses over the course of several
years, but can also develop more rapidly over
weeks or months.
It typically affects older men of European
descent. This condition most commonly
begins with thickening of the skin on the
palm, resulting in a puckering or dimpled
appearance. As the condition progresses,
bands of fibrotic tissue form in the palmar
area and may travel distally toward the
fingers. This tightening and shortening
eventually lead to the affected fingers being
pulled into flexion. Dupuytren contracture
typically occurs bilaterally, with one hand
being more severely affected than the other.
Physical findings:
 Blanching of the skin when the finger is
extended
 Proximal to the nodules, the cords are
painless
 Pits and grooves may be present
 The knuckle pads over the PIP joints may
be tender
 If the plantar fascia is involved, this
indicates a more severe disease
(Lederhosen disease)
 The patient may not be able to place the
palm flat on the table
Physical Therapy Management
Conservative Approach
Physical therapy may
include ultrasound waves: heat (early stage of
the disease); brace/splint to stretch the digits;
a range of motion of the fingers to prevent
adhesions.
Postoperative Care/Rehabilitation
Patients often enter hand therapy to:
 Maintain the range of motion of the hand
and fingers is important (for many
activities of daily living), see hand
exercises
 Extension splints often are used in
conjunction with other modalities.
 Oedema and scar interventions.
 Should be undertaken for at least 3
months to prevent contractures.
  Maximal benefits of surgery are not
immediate, only become obvious after 6-8
weeks
A standard protocol for postoperative
management of Dupuytren disease is shown
below
 Within the initial 5 days postoperative,
the primary interventions are to educate
the patient on decreasing oedema and the
importance of performing a range of
motion exercises on the uninvolved
fingers.
 After 5-7 days postoperative, the primary
interventions shift to a range of motion
exercises and splinting.
 The exercises are adapted to each
subject’s individual goals and are based
on their impairment, physical status, and
competency.
 The types of splints used included volar
splints, dynamic extension splint, dynamic
 flexion splints, exercise splints, and wrist
splints.
The key fact to appreciate is that not all patients
need treatment.
 There are many treatments available for
Dupuytren contracture and none is ideal or
works consistently.
 Only symptomatic patients should be offered
treatment because all treatments have
complications.
 The patient must be educated about the
potential complications of treatments, which
are worse than the disorder itself.
 Close communication between the team is
essential in order to improve outcomes.
 Overall, only a few patients achieve a
desirable result.
 In many cases, prolonged physical therapy is
required to restore functionality