My wrist hurts! Do I have carpal tunnel?

Transcript

Prakash Chandran: Even something quite simple, such as typing away on a keyboard can actually put pressure on the wrist and lead to carpal tunnel syndrome. But several fine detailed jobs, such as sewing and carpentry can also have the same effect. So if you find yourself wearing wrist supports to work, what can you do to prevent things from getting worse? Today, we’ll be talking about symptoms, treatment and exercises with Dr. Greg Faucher, hand surgeon for Prisma Health.

This is Flourish, a podcast brought to you by Prisma Health. My name is Prakash Chandran. So Dr. Faucher, thank you so much for joining us today. I really appreciate it. Now, I’ve heard of carpal tunnel syndrome before, but maybe you can talk about what it is and how it’s caused.

Greg Faucher, MD: Thanks for having me. So carpal tunnel syndrome is very common and it is probably one of the most common presenting diagnoses for the hand surgeon’s office, and so you hear about it a lot. And I think it’s one of those diagnoses that can be mislabeled occasionally. So I think it’s good we’re talking about it today and go through it.

Carpal tunnel syndrome is the most common entrapment neuropathy in the upper extremity. And so what that means is it’s basically a pinched nerve that occurs at your wrist. And the nerve involved is the median nerve that gives sensation to the thumb, index finger, middle finger, and the thumb side of the ring finger, as well as to the muscle that allows you to pull the thumb away from the palm. And so those digits specifically tend to be affected with numbness, tingling, occasionally burning pain and, commonly, you find that symptoms affect you at night, it causes nighttime wakefulness, and with flexed wrist activities like driving, talking on the phone, reading a book.

Prakash Chandran: Okay, understood. So you’re starting to go into some of symptoms, like the numbness in your thumb or on your wrist, but maybe talk a little bit more specifically about the symptoms that one might experience at the onset of carpal tunnel and then, as it starts to get worse, how it expresses itself.

Greg Faucher, MD: So, numbness is one of the hallmark symptoms, no doubt. As we go through carpal tunnel syndrome when we first start to experience it, the first symptom tends to be sensory, so some sort of disturbance in how you feel things. And that tends to be something in the early stages that comes and goes. So for example, you may be blow drying your hair, driving for a period of time and you notice your fingers going numb. Oftentimes people shake out the hand and it gets better. And so that’s a transient symptom that comes and goes in the early stages.

As carpal tunnel syndrome progresses, the motor part of the nerve tends to become affected. And that’s where you might notice your grip feels weak. A lot of people describe dropping things, that’s a pretty common symptom. And then this can continue to progress to the sort of end-stage of carpal tunnel syndrome, which is where the numbness just doesn’t go away. It’s there at all times. There’s nothing really that you can do to get rid of it.

Prakash Chandran: Okay, understood. And let me just ask a more general question. What exactly causes carpal tunnel? Like I think you talked about the dynamics of what’s happening from a physiological standpoint, but is it the repetitive motion done in the wrong way? Maybe talk a little bit about that.

Greg Faucher, MD: So the very basic concept of carpal tunnel syndrome and the problem that’s going on is a size mismatch. So there’s a nerve running through, at baseline, a very tight space that’s also filled with other structures, including all of the tendons that allow you to flex your fingers. And at baseline, there is just enough room in that tunnel for your nerve and all of those tendons to fit.

If for any reason the other structures occupying that space increase in size, which can happen with inflammation and swelling, the nerve has nowhere to go, runs out of space. That space has no ability to expand. And that’s where that entrapment, that compression neuropathy comes into play. The things that we’ve looked at in our literature to sort of figure out why this happens have changed over the years. And the common thing that you hear is working on a computer for a long time. And certainly anything that involves repetitive activity can cause that inflammation in those tendons, the motor of the fingers, to become inflamed, to become thickened, and that’s where you end up with that size mismatch, where that nerve has nowhere to go and is being pinched.

Other things that are common to see are vibrational-type machinery, any machinery that causes vibration, probably the most classic one is a jackhammer, but it can be as benign as a hairdryer, the nerves do not respond well to vibration, that can also make the nerves thick. And then another thing that has been associated with carpal tunnel syndrome is increased weight or weight gain. Obesity is one thing that’s been linked to carpal tunnel syndrome as well.

Prakash Chandran: So going back to some of the symptoms or things that you’re feeling when you have carpal tunnel, is this something that you can treat at home? Like, are there exercises that you can do? Talk a little bit about that?

Greg Faucher, MD: So, like we mentioned, it’s very common, so I’ll have family members calling all the time saying, “I got a little numbness in my fingers,” then the first-line treatment hands down is to buy a brace, a Velcro wrist splint that you can find at any pharmacy that immobilizes the wrist, that prevents the risk from flexing or extending, and to wear that at nighttime. And the reason that is thought to work well, is that when you flex your wrist or you extend your wrist, the space available in the carpal tunnel actually diminishes. So

the position of the wrist where you have the most space in the carpal tunnel is at wrist neutral. And so by putting on a brace, that prevents that flexion extension. You’re leaving that carpal tunnel with the most room available. And the reason to do it nighttime is that oftentimes we sleep with our wrist flexed or extended under a pillow or under our head or chin, and, we’re putting that nerve in a compromised position all night while we sleep. We’re not awake to proactively protect against that. And so oftentimes, we’ll wake up with numbness and tingling, not allowing that nerve to recover from whatever we had done during the day. So nighttime splinting and usually for about six weeks is my first-line treatment and what I often have patients do the first time I see them.

Prakash Chandran: Okay. So, you know, I was just going to ask, when does it get more serious and when does it really come time to see a doctor? So you’re saying that if they call in, you’re talking about the splint or kind of the brace that they can wear during the evening. But as things start to get more severe, what exactly does that look like and then what does treatment look like after that?

Greg Faucher, MD: Right. So as carpal tunnel syndrome progresses, and it is absolutely a syndrome that can be progressive in nature, it can progress from a relatively mild state to a state that puts that nerve at risk permanently, which obviously is something that we want to prevent. The biggest clinical signs that you are progressing to a more serious phase of carpal tunnel syndrome is truly if that numbness does not go away. If you start to experience permanent numbness, that’s a sign that the end targets of the nerve are starting to die and that the nerve itself could be starting to die, which, once you get to that point, the results even with surgery are unpredictable and sometimes there’s incomplete relief.

And so truly, full-time numbness is something that I would look for. Also loss of the bulk of the muscle at the base of your thumb can be an indicator that you’re progressing into that severe category of carpal tunnel syndrome.

Prakash Chandran: So you just mentioned surgery. So that seems like the last resort, in terms of repairing carpal tunnel, talk a little bit about what that surgery looks like and the recovery time afterwards.

Greg Faucher, MD: Right. So there are a couple of different ways that that surgery is performed. One is open and one is endoscopic. The basic goal of both of the procedures is the same. The roof of the carpal tunnel is a thick ligament called the transverse carpal ligament. The floor is the bones of the wrist. So in order to make that tight space an open space and to decompress the nerve, we snip the ligament that is the roof of the carpal tunnel, that transverse carpal ligament. So that can be done with an incision in the palm that’s longitudinal, just at the base of the palm, where we go down and we snip that ligament, or it can be done from an incision at the wrist, which is transverse, where we go in with a scope and cut the ligament from within the tunnel. So either way, we’re decompressing that nerve at the wrist and allowing it to heal. So we’re sort of setting the healing process into motion, indirectly helping the nerve.

Those two procedures are both associated with very good success rates with very low complication rates. So they’re both very good and that’s what we look for as surgeons when we look for a good procedure. So it’s one of the most reliable and successful surgeries we as hand surgeons do. It’s very gratifying.

As far as open versus endoscopic carpal tunnel release, the most consistent difference between the two in the literature is that endoscopic carpal tunnel release allows for a little bit earlier return to work, probably around two weeks as compared to open carpal tunnel release. The return to work differs a little bit based on occupation. For patients who are mainly at a desk doing lighter administrative and desk work-type activities, I usually estimate about one to two weeks for return to work, and some are really motivated and go back even a little sooner. For patients who are working in more of a manufacturing line-type activity, then I usually estimate closer to about four to six weeks for return to work.

Prakash Chandran: Okay. So, we talked about this earlier that the fact that carpal tunnel is something that’s progressive, but what will happen if it’s not treated? Like there’s no way that it can actually self-repair or go away on its own, can it?

Greg Faucher, MD: Well, in the very mild stages, I think that’s possible. You know, I think that everybody can maybe have an episode that causes the nerves to sort of, you know, and, again, in the very mild stage, it can probably sort of self-resolve. But in those more severe stages, and as it continued to progress, the likelihood that it’s going to resolve on its own becomes less and less. So if it continued to progress, then the end targets of that nerve will lose their function. And what that means is that those fingers we talked about, the thumb, index, middle finger, half of the ring finger, could permanently lose sensation even with surgery and the muscle that allows you to bring the thumb away from the palm and then to oppose the other digits could also totally lose its ability to move the thumb. So it can definitely affect hand function pretty significantly.

Prakash Chandran: Yeah. So definitely a good idea to at least have it looked at. So if someone is experiencing the mild symptoms that you’re talking about, like just mild numbness, for example, that then goes away, what would be your recommendation? Should they perform some of those exercises or should they approach it in another way?

Greg Faucher, MD: This is a question I get asked fairly frequently. Is there a stretch? Is there an exercise that I can do to try to prevent it? Unfortunately, those therapy-type activities have not really garnered strong report supporting the literature. And so there’s not a whole lot from a therapy exercise stretching standpoint that I think can really prevent carpal tunnel syndrome.

I think one of the biggest things that I would sort of recommend is activity modification, where if you’re doing something like a few of the more problematic activities, one is moving, doing a lot of packing, spring cleaning, doing a lot of housework where you putting in floors or painting, anything like that that’s a little bit out of the ordinary that does involve repetitive hand use, if you start to notice any of these symptoms, any numbness or tingling, don’t muscle through it. That’s when you want to give yourself a break, think about going into a brace when you’re sleeping, even if you’ve identified a trigger-like activity, wearing that brace while you’re doing that activity can help to support that nerve so it doesn’t continue to progress to a more severe state.

Prakash Chandran: So just as we begin to close here, one question I always like to ask is, as a hand surgeon, you have a lot of experience, you’ve seen a lot of patients, what is one thing that you know to be true, that you wish that more patients knew before they came to see you?

Greg Faucher, MD: I’ll tell you this. One visit that’s hard as the person who has had carpal tunnel syndrome for years, and their numbness has been there full-time for years. And we already know, in that first visit, I know that we’ve let it go a little bit too far. And once it gets really far into that severe phase where there’s potentially permanent nerve damage, unfortunately, there’s not a whole lot that we can do for it. So in those cases, I wish we had met and seen each other a little bit earlier in the onset of the disease process so that we’d have more options for what we could do to treat it. And so that’s, I think, a big take on it, is as if any of those signs of permanent disease are present, there’s numbness at all times, loss of muscle bulk in the hand, that’s a reason really to go get checked out as soon as possible so that we can still have options available for treatment.

Prakash Chandran: Yeah. It just sounds like by the tone of your voice, that probably happens more often than you’d like, huh?

Greg Faucher, MD: Yeah, unfortunately, it does. It’s a difficult situation.

Prakash Chandran: Yeah. So for those listeners out there that are experiencing even slight numbness, definitely makes sense to go have it looked at, go make sure that it’s nothing more serious and to get it treated. So, Dr. Faucher, thank you again so much for your time and for educating us today. I truly appreciate it.

Greg Faucher, MD: My pleasure. Thank you for having me.

Prakash Chandran: That’s Dr. Greg Faucher, hand surgeon for Prisma Health. For more information, you can visit our website at PrismaHealth.org/Flourish. And to listen to other podcasts, just like this one, you can head over to Blog.PrismaHealth.org/Podcast. This has been Flourish, a podcast brought to you by Prisma Health. My name is Prakash Chandran. Thank you so much, and we’ll talk next time.