Light at the End of the Carpal Tunnel: Prevention and Treatment -- Alexander Haselkorn, MD -- 04/24/03
By Alexander Haselkorn
Repetitive stress injuries such as carpal tunnel syndrome are easy to get, but difficult to get rid of. Are wrist pads and ergonomic keyboards enough to avoid hurting yourself? Is surgery the only option for severe cases? We discussed prevention and treatment options with Alexander Haselkorn, MD, on WebMD Live.
The opinions expressed herein are the guest's alone and have not been reviewed by a WebMD physician. If you have questions about your health, you should consult your personal physician. This event is meant for informational purposes only.
Moderator: Hello Dr. Haselkorn. Welcome to WebMD Live. Let's get to our member questions.
Member: Do wrist wraps and braces really help to stop carpal tunnel for people on a production line that do the same job for 10 hours a day?
Haselkorn: Yes. That's actually the first step in treatment is to put the area at rest and mobilize with a wrist splint and usually a mild analgesic, such as acetaminophen or ibuprofen is used. The splint helps restrict the movement. It's thought that one of the problems in carpal tunnel syndrome is repetitive movement.
Member: I experience numbness in my ring and little finger. I have tried wrist splints but they do not help. I'm beginning to think the diagnosis of carpal tunnel is wrong, as it doesn't affect the thumb. Pain also felt in underside of arm. Any suggestions?
Haselkorn: Yes. The area that was mentioned is innervated by the ulnar nerve and not the median nerve; it involves the fifth and half of the fourth or ring finger. That's supplied by the ulnar nerve. The most common area where the ulnar nerve is compressed or irritated is at the elbow, and people usually refer to that as the funny bone. When you bang your elbow you feel a shock like sensation radiating into the fourth or fifth fingers or on the pinky side of the forearm. So the problem you describe is probably not carpal tunnel or median nerve problem and should be checked by your own doctor.
Member: I had surgery on both my hands for carpal tunnel. My right hand is doing great, my left is still experiencing numbness in the middle finger. The surgery on the left hand was done on Jan. 10. The doctor said that it was not normal, but not uncommon. Is the numbness going to disappear or I'm going to have this problem for a very long time?
Haselkorn: First, depending on how long the problem has been present, there are times when the median nerve is actually damaged. The operations are designed to relieve the pressure on the nerve, but if there's permanent damage in the nerve itself it may not recover.
The second point I make is that the operation itself always manifests a reaction, swelling, so if the swelling hasn't fully resolved it may be a result of the operation. It's still relatively early and you should not give up hope for a full recovery.
Member: Once you have wrist pain that may be carpal tunnel syndrome, are there exercises you can do to alleviate the pain?
Haselkorn: Yes. There are some exercises that can be done. They usually involve stretching of the fingers and also flexion and extension exercises of the wrist. A word of caution: One of the problems is that it's thought that carpal tunnel is brought about by repetitive movement and you don't want to overdo the exercises and aggravate the carpal tunnel problem.
On my web site wristhand.com there are some exercises that are mentioned, and also Roberta Bergman goes through a whole series of exercises that can be done for carpal tunnel syndrome in the video Say Goodbye to Wrist Pain -- information is on my web site.
Member: I have a pain at the top of my right wrist, just below my hand. The pain is not continuous, however after typing and web searching it is sometimes very painful. It has only been hurting for about four weeks. I think it may have something to do with the mouse I am using. Could just changing the mouse resolve this problem?
Haselkorn: It's difficult for me to give an exact opinion about the pain. It's important to localize the exact location of the pain, either the thumb or pinky side of the wrist. Restricting movement is the first step possible -- we mentioned the splint before. But I can't give you more information because I'm not exactly sure which side of the wrist. It may be due to the repeated movements you do. So modify the movement or restrict the movement and if it persists, see your own doctor.
Member: My doctor has tentatively diagnosed me with carpal tunnel but says that it's an atypical case. I don't get much numbness or tingling; my main problem is a general weariness and tiredness in my hand when doing things that require holding like stirring things, or writing, and it's very difficult to hold the shape to hold things. It causes a shooting pain up the inside of my arm. I've been wearing a splint at night and it helps some but not much. Everything is of course complicated by my lupus, which is in remission and it's a different type of pain. Is this like carpal tunnel and what are possible treatments I should be looking into?
Haselkorn: There is a possibility it could be carpal tunnel. There are certain manifestations that are classical, but not everybody has them. What you describe can be part of carpal tunnel problem. You did not mention whether you had an EMG test, which is done to confirm the presence of carpal tunnel syndrome, which is compression of the median nerve at the carpal tunnel, in the wrist. That would be an objective test to diagnose the problem. There are other tests also, such as an MRI, which actually show compression or swelling around the median nerve, another objective test. The EMG is really the standard test to confirm the diagnosis.
People with arthritis, including lupus, may develop swelling in the linings around the nerves and tendons, as well as the joints, and that would contribute to the carpal tunnel problem.
Moderator: What is involved in an EMG test?
Haselkorn: It's a test that's done to determine if there's nerve compression. Little fine needles are put into muscles and the electrical activity is measured, and from that it's possible to infer if there's irritation or compression of a nerve and where that compression is located. With carpal tunnel it's compression of the median nerve in the wrist area.
The carpal tunnel is a closed space on the palm side of the wrist, and through that closed space course the median nerve, and the flexor tendons are the structures that glide back and forth to allow bending of the fingers. It's thought that pressure builds up in that closed space. On the palm side a thick covering or ligament covers it, and on the top or backside of the hand are the two bones, the ulnar and the radius. It's thought that pressure builds up in that space and presses on the nerve.
Member: Will trigger thumb heal on its own? I injured the thumb pruning. It remains swollen and trigger thumb developed. Will it heal on its own? Any exercises?
Haselkorn: Trigger thumb or trigger finger occurs when a person flexes or extends his or her finger. A snapping or triggering occurs and it's very painful. The reason it occurs is because it's not in the wrist, it's in the base of the finger, just before the finger, in the proximal or palm area. The flexor tendon is covered by a thick covering, or sheath, and the first portion of that sheath begins in the palm. The first portion of the sheath has a little swelling on it, and what happens, the tendon, as it glides back and forth, hits that swelling and it snaps as it goes over it.
The best initial treatment is an injection of steroids with a little local anesthesia to reduce the swelling and to allow the tendon to glide back and forth without getting hung up on that swelling. In many cases it actually cures the problem.
Ultimately if it continues you need a very simple operation to just open the tendon sheath at that area to allow the tendon to glide effortlessly. The swelling may come and go on its own, but that's hit or miss; it can't be predicted. If it persists, you should seek treatment.
Incidentally, trigger finger is one of the repetitive strain injuries. The others are carpal tunnel syndrome, de Quervain's disease, and tennis elbow.
Member: I have developed de Quervain's disease (tenosynivitis) as inflamed tendons pain from my thumb to about three inches past my wrist on both hands. I have been wearing splints on both hands since Jan. 10. The thumbs are better, but I still have pain in the wrist bones. I have difficulty turning things, taking things over my head, and such. My doctor was trying to avoid cortisone shots. What do you think?
Haselkorn: Let me just mention that de Quervain's disease is on the thumb side of the wrist. It's another closed space; two tendons course over a bony prominence called the radial styloid. Those two tendons that course over that bony prominence become irritated.
You mentioned that you have been wearing splints. In my opinion the best initial treatment is a steroid injection. It's mixed with a local anesthesia. The steroid is confined in that area to reduce the inflammation and in many cases cures the problem quickly. I know a pinch is an unpleasant prospect, but I think it's the best initial approach.
If the problem persists, then again there's a simple operation that's done similar to the operation for trigger finger. It's the opening of that thick ligament and in effect it relieves the pressure. I mentioned steroid injection with trigger finger and now with de Quervain's disease. In my opinion, the steroid injection is the best initial approach. Just to complete the thought, I do not use steroid injections for carpal tunnel syndrome, because the steroid can irritate the nerve.
Member: I was three days away from getting an operation on both hands for carpal tunnel --symptoms were severe and electric analysis showed deterioration of the nerves. I tried prednisone 5 mg twice daily and in four days was almost entirely symptom free. What can I expect over the longer term as I cut back on the dosage and how fast should I cut back and can I go back on medication if symptoms reoccur?
Haselkorn: In my opinion, I don't think that oral steroids are a good choice for carpal tunnel syndrome. Carpal tunnel syndrome can come and go depending on activity. The second point that was made, the EMG showed deterioration of the nerve, and I think there's a long-standing process and you want to interrupt that process. You already may have permanent damage, from what you said, in the nerve. In your case, if it's a persistent problem, I would not use steroids; I would choose surgical treatment. In my opinion, the surgical treatment is safer than taking oral steroids.
Member: What if the pain is centered more in the center of the hand, through the wrist, as well as the middle fingers, after repetitive motion?
Haselkorn: That very well could be carpal tunnel syndrome. The carpal tunnel is located in the mid-palmar aspect of the wrist. It's the middle of the wrist on the palm side. Again, the median nerve and the flexor tendons course through that space, and the median nerve supplies sensation and innervates sensation in the thumb, index, middle finger, and the thumb side of the fourth, or ring, finger. Not everybody with carpal tunnel syndrome has the complete constellation of symptoms. They may have pain in only one or more fingers. The next step to diagnose the problem, other than being examined, using the EMG test to confirm it.
Member: I had carpal tunnel about eight years ago. Surgery corrected the problem, but I have been very active lately and began having pain.
Haselkorn: There are instances of recurrence, and a lot depends on the nature of the operation. There are at least a couple of approaches. One is a minimal approach, to just open the thick covering. In many instances that's done through an endoscope. The other is an open procedure in which the ligament or thick covering around the median nerve and tendons is removed. The lining is known as synovium and the operation is a synovectomy.
In a minimal procedure scarring can reoccur, as well as in the other more elaborate procedure, but it's less likely. You may be dealing with a recurrence. Sometimes the EMG does not always coordinate with the degree of symptoms, but you should have another EMG tests and compare it, if it's available, with the previous EMG test. MRI would also be useful.
Moderator: What should someone who is on a computer all day do to avoid developing hand or wrist problems, such as carpal tunnel syndrome?
Haselkorn: Obviously if it's part of earning your daily living or your livelihood it's not possible to completely stop. There are ergonomic devices and other things that people can do.
You can get this information at my web site wristhand.com. Roberta Bergman goes through some of those things there.
Member: I just had successful carpal tunnel surgery one month ago. I am doing well. How long can I expect this to last without symptoms reoccurring?
Haselkorn: Hopefully you're cured. There are instances of recurrence, but if the pressure has been relieved it may last. You should be optimistic.
Member: If an EMG has confirmed there is no carpal tunnel syndrome, what other conditions (with the same symptoms) could it be?
Haselkorn: If there are other problems it's important to go back and get it reevaluated. It's possible to have carpal tunnel and not have positive EMG. The EMG is very good, but it's not 100% in diagnosing. That's just one aspect. It takes time for the electrical changes to take place in the nerve and muscles, and there's a lag period of four weeks. If one develops symptoms and has an EMG before four weeks elapses, the EMG may not be abnormal.
There are instances where a problem is persistent and the symptoms are classical for carpal tunnel, then treatment for carpal tunnel and even surgery could be done, but that's not typical and I'm not advocating that as a general rule.
Member: Is there a certain specialist that deals with carpal tunnel or is it done more by a general doctor?
Haselkorn: I would recommend someone that does hand surgery on a regular basis. The operation itself is relatively straightforward, but I don't want to minimize it or tell you that it's not without problems, and it's important to be properly evaluated. Either a hand specialist or many orthopedic surgeons are capable of doing the operation and properly evaluating the problem.
Moderator: Dr. Haselkorn, we are almost out of time. Before we wrap up for today, do you have any final comments for us?
Haselkorn: One last point about carpal tunnel syndrome: People will usually feel the discomfort after the activity that's causing it and they're awakened at night with wrist pain, numbness, and usually try to shake their hands to relieve their discomfort. When they're sleeping, their wrist relaxes, becomes flexed, and the pressure occurs. Therefore, splints are used to maintain it in a neutral or extended position, especially at night.
Carpal tunnel is commonly or probably the most chronic of wrist problems. It is synonymous with wrist pain, but it's not the only problem, and if it persists you should check with your doctor to be sure.
thanks to Alexander Haselkorn, MD, and thank you members for joining us today.
For more information, please visit the WebMD health guides: Finger, Hand, and
Wrist Problems and Carpal Tunnel Syndrome
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