Carpal tunnel syndrome: sadly misdiagnosed all the time
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What is carpal tunnel syndrome?
Carpal tunnel syndrome is impingement or irritation of the median nerve within the carpal tunnel—an anatomical structure found at the base of your hand. When the median nerve becomes irritated in this region due to pressure, inflammation, and/or stretching, symptoms are likely to occur.
Carpal tunnel syndrome tends to occur in people who spend a lot of time using a PC with poor body mechanics; therefore, if you’re a PC gamer, you are more likely to experience this ailment.
More specifically, carpal tunnel syndrome is more likely to occur in your right hand due to prolonged extension of the wrist to hold the mouse.
Note: if you’re a console gamer, you are not necessarily excluded from the risk of developing carpal tunnel syndrome. However, due to the hand positions and movement patterns involved in gripping a console controller, it is significantly less common.
It’s important to know some basic anatomy of the wrist and hand to understand carpal tunnel syndrome.
To begin, the word “carpal” in carpal tunnel syndrome is in reference to the bones at the base of the hand. There are 8 carpal bones at the base of your hand—3 of which attach to your forearm and form the wrist joint.
These bones are oriented in 2 rows, proximal (closer to your wrist) and distal (closer to your fingers). The bones are listed from the thumb side to the pinky side of your hand with your palm facing upward.
- Proximal: scaphoid, lunate, triquetrum, pisiform
- Distal: trapezium, trapezoid, capitate, hamate
Across these bones is a band of fascia—a dense connective tissue—called the flexor retinaculum (often called the transverse carpal ligament). On the thumb side of your palm, it attaches to the scaphoid and trapezium bones. On the pinky side of your palm, it attaches to the pisiform and hamate bones.
The 8 carpal bones and the flexor retinaculum form the carpal tunnel. It is important to note that carpal tunnel is in reference to the normal, anatomical structures in your hands. “Carpal tunnel” is not a condition; rather, carpal tunnel syndrome is the condition! Through this tunnel, 10 structures pass from your forearm into your hand:
- Flexor digitorum profundus (4 separate tendons)
- These tendons flex (close) your fingers, including the finger tips
- Flexor digitorum superficialis (4 separate tendons)
- These tendons flex (close) your fingers, excluding the finger tips
- Flexor pollicis longus (1 tendon)
- This tendon flexes (closes) your thumb, including the thumb tip
- Median nerve
In your hand—beyond the carpal tunnel—the median nerve innervates 3 muscles:
- Opponens pollicis
- This muscle creates opposition of your thumb (e.g., pinching)
- Abductor pollicis brevis
- This muscle pulls your thumb away from your palm
- A portion of the flexor pollicis brevis
- This muscle flexes (closes) your thumb, excluding the thumb tip
The median nerve is also responsible for touch sensation for a large portion of your hand. The cutaneous innervation (touch sensation) includes:
- The palm side of your thumb, index, middle finger
- The medial portion (thumb side) of your ring finger
- On the back of your hand, only the tips of your thumb, index, and middle finger
The median nerve DOES NOT provide touch sensation to your pinky finger, the lateral (pinky) side of your ring finger, or the majority of the back of your hand!
Carpal tunnel syndrome occurs when there is compression or irritation of the median nerve within the carpal tunnel. The compression or irritation may be caused by:
- Injury: wrist injuries (sprains, strains, trauma, etc.) may cause inflammation which narrows the space within the carpal tunnel
- Overuse: repetitive strain injuries such as tenosynovitis may create inflammation in the tendon sheaths which can cause crowding within the carpal tunnel
- Hormones: changes in hormones (e.g., during pregnancy) may increase water retention; increased fluid volume may increase pressure inside the carpal tunnel
- Densification or adhesion formation in the flexor retinaculum
- Overuse imbalance: repetitive movement in one plane of motion may cause densification or adhesion formation in the flexor retinaculum, shortening the band of tissue and narrowing the space within the carpal tunnel
- Prolonged, static position: if the wrist is held in the same position for long periods of time, the flexor retinaculum may become tense, narrowing the space within the carpal tunnel
- Direct compression of the flexor retinaculum or median nerve
- Poor, prolonged wrist position: if the wrist is held in extension for long periods of time (e.g., wrists bent backwards on the edge of a keyboard), the flexor retinaculum is pulled tightly, putting pressure on the structures within the carpal tunnel
- Direct pressure: direct pressure at the base of the palm may compress the structures within the carpal tunnel
Signs and symptoms
If you’re affected by carpal tunnel syndrome, you may experience one or more of the following symptoms:
- Numbness and tingling
- The first sign is usually a change in sensation of your thumb, index, and middle finger
- You may notice pins and needles, tingling, or numbness in these fingers—often beginning at your finger tips
- If present, the weakness will only occur in your thumb
- You may notice weakness in gripping or pinching; for example, you may be more prone to dropping small items such as your keys
- Muscle wasting
- If the nerve compression is severe or chronic, you may notice atrophy (decrease in mass) of the muscles at the base of your thumb
Carpal tunnel syndrome does not cause any of the above listed symptoms in the pinky finger or pinky finger side of your wrist or hand. Those symptoms are more consistent with cubital tunnel syndrome.
Other common findings may include:
- More pronounced symptoms with extension of your wrist(s) (e.g., using a mouse or keyboard)
- Worsening symptoms at night
- Relief or improvement of symptoms after shaking out your hands
Note: paleness or blue color and/or cool or cold sensation along with tingling and numbness are indicative of blood flow occlusion. This may be a more serious condition, and you should consult your doctor or visit the emergency room if you are concerned about these symptoms.
Common mechanism(s) of injury
For gamers, carpal tunnel syndrome is more common for PC users due to the position of the hands over the keyboard and mouse. Common risks for PC users include:
- Poor hand position
- Allowing excessive extension of the wrists over the keyboard and/or mouse—will pull the flexor retinaculum taut and put pressure on the median nerve
- Direct compression
- If the hands and wrists are not properly supported, the pressure from resting on the desk may be enough to compress the median nerve
- Overuse and inflammation
- Overuse of the flexor tendons—such as pressing the keys on a keyboard—may eventually lead to tenosynovitis, an inflammatory condition which can compress structures within the carpal tunnel
- Chronic vibration
- Some providers claim long-term exposure to vibration may irritate nerves; using vibration on a console controller may lead to or exacerbate carpal tunnel syndrome
- Please note, we do not have an abundance of evidence to support this theory, but it has been reported anecdotally
The most common mechanisms of injury for carpal tunnel syndrome are direct compression of the median nerve, poor and/or prolonged static position, and inflammation.
For all hand and wrist injuries, we’ve created a comprehensive injury prevention program. Performing this exercise routine may help reduce your risk for all gamer injuries, including carpal tunnel syndrome.
Hand and wrist position: it is important to keep your wrists neutral!
- For PC gamers, elevate your wrists to be even with the keyboard and mouse
- Use a soft cushion for elevation to avoid intense compression of the median nerve
- For both PC and console gamers, between games/matches:
- Open and close your hands a few times
- Bend your wrists forwards-and-backwards, side-to-side, and roll your wrists a few times
Use and overuse: overuse may lead to tenosynovitis or other injury which can cause crowding of the median nerve:
- Take breaks to avoid overuse
- Be sure to warm-up your hands and wrists prior to gaming
- Perform the proper stretches when you’re done with your sessions
Generally speaking, surgery is not an appropriate treatment as surgery can sometimes worsen the problem. In practice, we have found the following treatments to be effective for the treatment and resolution of carpal tunnel syndrome:
- Fascial Manipulation®
- Anti-inflammatory modalities
- Contrast therapy: heat therapy followed by cold therapy
- Lymphatic massage
- Therapeutic exercises
- Functional Range Conditioning (FRC®): wrist PAILs/RAILs
- Wrist and hand mobility exercises (FRC®: wrist CARs)
- Median nerve glide from our injury prevention program
- Education in proper ergonomics
Following resolution, continuation of these protocols allows for prevention of this condition from reoccurring.