Carpal Tunnel Syndrome: What Are The Treatment Options?
What Are The Treatment Options For Carpal Tunnel Syndrome?
After parts 1 and 2 of our series on carpal tunnel syndrome (CTS), you now have a better understanding of the relevant anatomy (here) and how to diagnose yourself (here). Hey, maybe you’ve even gone on the deeper dive of understanding (here). More power to you.
If at this point you think you may be suffering from CTS, what follows is my quick primer on treatment.
Putting You In Control Of Your Care
I’ll be upfront on this one. CTS can be a little frustrating to treat, depending on how you look at it.
My preferred style of patient care is that of helping you find your own best treatment. Essentially, I give you as much ‘doctor information’ as I can (which is why I write these articles), and you choose what’s best for you and your life in that moment. This is based on your symptoms, what they prevent you from doing, and how they feel to you. You are not an algorithm.
But. This style shines when I have an array of available treatment options. You have wrist tendinitis? Well, we can (1) watch it for a while, (2) try therapy, (3) try activity modification, (4) try medications, (5) try bracing, (6) try injections, or (7) try surgery. I educate you about each path and you choose. In the end, only you know how your symptoms affect your life and how that aligns with the risks and benefits of each option.
Two Promising Options
So, back to CTS.
Effective treatment options are a bit more limited and thus frustrating for you and me. In terms of truly effective treatments? You essentially have nighttime wrist bracing and … surgery. There is of course always nuance, but suffice it to say that in most cases, therapy, rest, medications, and injections just don’t work in the long term.
To understand this, let’s return to our anatomy (full article here).
Your median nerve is pinched in the carpal tunnel. You’ll remember that the floor and walls of the carpal tunnel are made up of your wrist bones. The roof is a thick ligament that gets thicker as we age. The nerve travels through the tunnel alongside 9 tendons. Anything that causes the volume of this tunnel to shrink will pinch the nerve.
But First…What’s YOUR Cause?
And what are the two most common causes? Well, I like to think of one as dynamic and one as static.
The dynamic cause occurs when the walls and floor (wrist bones) collapse inwards. This happens in positions of extreme wrist flexion or extension (see Figure 1). And what do most of us do when we sleep? We curl up in a position of wrist flexion. This has been shown to increase carpal tunnel pressures drastically [1] and thus severely pinch the median nerve.
Figure 1 - Wrist flexion (or extension, the opposite of the above position) increases carpal tunnel pressures
The other most common cause is a static problem.
You may remember the ‘transverse carpal ligament.’ This is the ‘roof ligament’ of the carpal tunnel. This will often thicken as we age, eventually reaching a point where it continually compresses the median nerve.
Fit The Treatment To The Cause
Why do I belabor this dynamic vs static point? It has a direct correlation with treatment.
Imagine you come to me with CTS. And imagine I only have two options to treat CTS (mostly true). Yet I don’t truly know which cause is affecting you, as there’s no way to discern this immediately. Do you think I’m going to start off meeting you by rushing you to surgery? That’s no proper way to get to know somebody.
In fact, this is one of those cool moments in medicine where the treatment helps us get the diagnosis.
Brace Yourself
If I think you have CTS, the first thing I do is recommend you sleep in a wrist brace. Use this wrist brace only at night but every night for a minimum of 4 weeks. Preferably 6 weeks.
What does this do? This keeps your wrist straight and thus prevents the walls and floor of the carpal tunnel from collapsing every night for your 6-8 hours of sleep. Which prevents 6-8 hours of a pinched nerve. If you can prevent this for 4-6 weeks, your nerve will have time to heal…and if that was the primary cause of your CTS, then you are cured!
Consistency is key here. If you skip a night, your nerve will be compressed and the injury cycle starts all over.
Important note: please don’t wear the brace all day too or you’ll come back to me with stiff, painful wrists. A new problem we now have to treat.
The Truth About Carpal Tunnel Braces
A quick aside on wrist braces.
Please don’t get caught up in all the marketing. The truth is, it almost doesn’t matter what you use. All that matters is there MUST be a stiff piece of plastic or metal in the brace that crosses the wrist and thus prevents you from bending or extending your wrist (see Figure 2).
So that means neoprene compression wraps are not appropriate, as they don’t prevent wrist bending (see Figure 3).
Other than that, find something you can comfortably sleep in each night.
What If Carpal Tunnel Braces Don’t Work?
Back to the cool part — here’s where it helps us with the diagnosis.
If 4-6 weeks of reliable nighttime bracing does NOT help, then we can imply that your nighttime positioning is not the only problem. Meaning, your CTS is not of a dynamic origin, but rather a static. Meaning your roof ligament has thickened to a point of 24/7 nerve compression, and the volume of your carpal tunnel is permanently too small.
It doesn’t take a doctor’s training to figure out the solution for this one — we have to expand the volume of your carpal tunnel to restore the flow of blood, nutrients, and oxygen to your compressed median nerve. And that means…surgery.
Can you think of another way to alter your anatomy, other than surgery? Unfortunately, I can’t.
Carpal Tunnel Release Surgery
What are our options to expand your carpal tunnel volume? Well, in theory, either chip away at the bones of your wrist to expand the walls and floor (no thank you) or … simply divide the thick roof ligament.
And that’s exactly what we do in surgery. A carpal tunnel release surgery divides the roof of the carpal tunnel to create more space for the nerve. The volume of the tunnel expands, the nerve is no longer compressed, and this restores blood flow to the nerve to begin the healing process.
I’ll stop here for now as this is plenty to digest for a ‘short’ post.
Continue reading here for more about the surgery or here for special cases where our treatment options go beyond just bracing or surgery.
References:
[1]: Gelberman, R. H., Hergenroeder, P. T., Hargens, A. R., Lundborg, G. N., & Akeson, W. H. (1981). The carpal tunnel syndrome. A study of carpal canal pressures. JBJS, 63(3). https://journals.lww.com/jbjsjournal/Fulltext/1981/63030/The_carpal_tunnel_syndrome__A_study_of_carpal.9.aspx
