Subject: PT ORTHOPAEDICS

Topic : CARPAL TUNNEL

SYNDROME

Year : III YEAR BPT

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DEFINITION
• Compression of the median nerve as it travels
through the wrist's carpal tunnel leads to
entrapment neuropathy.

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Causes
• Multifactorial including both local systematic
factors
• Synovial thickness and scarring of tendon
sheaths/irritation
• Inflammation/ swelling of the tendons
(tendinitis)
• Overuse or repetitive wrist flexion, extension or
gripping activities
• Local trauma-fall/blow to the wrist with or
without radius or carpals #
• Rheumatoid arthritis or diabetes
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• Improper wrist postures
• Compressive forces from equipments
• Vibration against the tunnel
• Obesity
• Pregnancy

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Clinical features
Early symptoms:-
• Pain- can radiate up to forearm
-gripping/ holding onto objects
-shaking/ flicking hands
-constant and burning in nature
• Numbness
• Paresthesia
• Symptoms varying in thumb, index, middle and
half of the ring finger

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Progressive symptoms:-
• Hand Weakness
• Decreased fine motor coordination- loss of grip
• Clumsiness and thenar atrophy results from
sensory deprivation and weakness

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Assessment
• Subjective assessment
Demographic data
History of present illness
Past history
Medical history
Occupational history
• Objective assessment
Pain assessment

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Manual muscle testing: wrist flexors/extensors,
thenar muscles,
lumbricals of index and middle fingers

Range of motion:1-3 digits flexion, wrist flexion

Special tests: Phalen’s test,
Hoffman’s Tinel's sign, Carpal
compression test
Investigations: X-ray, MRI(any nerve involvement)
EMG, Nerve conduction studies.

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Functional assessment
• Boston Carpal tunnel Questionnaire
• DASH
• Brigham & Women’s Carpal tunnel Questionnaire
• Patient evaluation measures(PEM)

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Differential diagnosis
• Any dysfunction of the median nerve
• Cervicobrachial syndrome
• Median nerve entrapment syndrome
• Pronator teres syndrome
• Anterior interosseous nerve syndrome
• Injury to nerve digitales in palm

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Special tests
• Phalen’s test

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• The patient is asked to push the dorsal surface
of her hands together and hold this position for
30-60 seconds.
• This position will increase the pressure in the
carpal tunnel, in effect compressing the median
nerve between the transverse carpal ligament
and the anterior border of the distal end of the
radius.

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Carpal compression test

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• Patient position in standing or sitting.
• Patient forearm is supinated and then
examiner applies direct pressure over the
carpal tunnel (median nerve) between the
thenar and hypothenar eminence for 30
seconds.
• Positive test indicates any numbness, pain or
paresthesia in the distribution of median nerve.

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Hoffman’s Tinel's sign
• Four digital taps to the median nerve just
proximal to the distal wrist crease

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Goals
• Patient education
• Reduce pain
• Improve sensory function
• Restore wrist ROM
• Restore muscle strength for wrist flexors
• Improve gripping strength
• Make the patient functionally independent
• Improve quality of life

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Conservative management
• Modifying symptom provoking wrist movement
• Non-surgical: corticosteroid injections, NSAID’s
Oral/ local glucocorticoid
• Surgical: carpal tunnel release

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Management
• Modification of activities
• Ultrasound and TENS
• Carpal mobilizations
• Median nerve glides and mobilization
• Tendon gliding exercises
• Muscle strengthening
• Dexterity exercises
• Precision exercises
• Static Wrist orthosis

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Median nerve glides

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Tendon glides

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Dexterity exercises

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Carpal mobilization

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Thank you…

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