Wednesday, September 1

Carpal tunnel syndrome

Carpal tunnel syndrome does not just afflict computer users or office assistants. This condition, which involves the compression of nerves on the underside of the wrist, can affect almost anyone. In fact, carpal tunnel syndrome is one of the most common nerve-entrapment problems in sports, hampering athletes such as cyclists and pitchers.

What is carpal tunnel syndrome, how does it occur and can it be prevented? For answers to these and other questions, join Dr. Charles P. Melone, Jr., a member of the Association of Professional Team Physicians (PTP) and a hand surgery consultant for the New Jersey Nets, as he discusses this common and painful condition.

What is carpal tunnel syndrome?

Dr. Melone: Carpal tunnel syndrome is what we call a compression neuropathy -- a nerve injury resulting from mechanical pressure. In this case, the pressure is from a tight ligament band at the underside of wrist, the carpal tunnel. The pressure compresses the median nerve that travels through this narrow channel to the palm, hand and fingers, causing pain.

Is carpal tunnel syndrome an overuse injury?

Dr. Melone: That's a good question in light of the emphasis recently on repetitive stress syndrome, the use of computers and the association that carpal tunnel syndrome has received over the past few years. It's not an overuse syndrome -- there are definite, clearly documented risk factors for the development of carpal tunnel syndrome. They include the female gender, pregnancy, diabetes, rheumatoid arthritis, hyperthyroidism and alcoholism. But significantly, the relationship to specific jobs as a risk factor has not been clearly delineated. In fact, work has not proved to be a definite cause for the development of this, so the job-related risk factor at this point is still questionable.

There needs to be a differentiation between repetitive stress syndrome and cumulative trauma syndrome from carpal tunnel syndrome. The former is more tendinitis or muscle-pain ailments while the latter is a pinched nerve or a nerve injury. Use of computers may exacerbate carpal tunnel syndrome, but does it cause it? No. It has more to do with the risk factors and general health and lifestyle than it does with one's profession.

What are the symptoms?

Dr. Melone: The classical symptoms are pain in the thumb, index, long and part of the ring finger and pins and needles in the same distribution, more frequently at nighttime. Carpal tunnel syndrome can wake you up at night like a bad pinched nerve or a toothache. It can be similar to sciatica, which I had myself. It would wake me at 3 a.m.; you try and shake it off, literally and that's what people do with carpal tunnel. They try to shake their hands to alleviate the symptoms. From the pain and the pins and needles, people can start to lose dexterity in the most severe cases and develop numbness and weakness of the thumb, which is controlled by the median nerve.

How is carpal tunnel syndrome diagnosed and treated?

Dr. Melone: The optimal method of diagnosis is electro-diagnostic studies, an objective, specific study that should always be used in conjunction with a thorough history and physical examination. If you told me you were getting up at 3 in the morning with pain in your fingers and you tried to shake your hands out, I could tell you over the phone that you most likely had carpal tunnel syndrome. From that, we need to quantify the severity of the problem into mild, intermediate or advanced and the treatment depends on what stage you are in. If it's in an early stage, the physician might try splinting, anti-inflammatories or steroidal injections. (The injections are not into the nerve, but into the carpal tunnel). I think most physicians would agree, however, that an injection provides, at best, only transient relief of the problem.

Surgery is recommended for the intermediate stage if non-operative treatment fails or if nerve compression is severe. You decompress the nerve surgically through a small incision -- it's a relatively short operation done under local anesthesia, and in essence what it does is alleviate the pressure from the nerve by increasing the volume of the carpal tunnel by incising the offending ligament that's pressing on the nerve.

Q: I am 14 yrs. old and play baseball. Recently, I was playing and I felt a sharp pain on the lateral side of my elbow. It was throbbing for about 1 1/2 hrs. I did stretch before playing. When the injury occured, I applied ice to the elbow. Now, three days after, it is sore and doesn't hurt when I move it. What do you think happened, what caused it, and when should I be able to play again?
-- Greg Neeley, Bremen, Ind.

A: From Christian Peterson, D.O., assistant team physician for the Seattle Mariners:
"Elbow problems are common in baseball. Injury to the medial (inside) and lateral (outside) are normally due to an overuse injury. Most will respond to rest, ice and a mild anti-inflammatory medication. On occasion, the stress on the outside of the elbow is so great it can cause injury to the cartilage. If this occurs, a piece of cartilage can break off. If your elbow continues to have pain, locking or swelling, this may indicate an injury to the inside of your joint. An x-ray may help with the diagnosis. I would refer you to a local orthopedic surgeon. "

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Can carpal tunnel syndrome be prevented?

Dr. Melone: In some cases, preventative measures may prove successful: for example, by modifying your lifestyle to decrease the risk factors, especially those that can decrease blood flow to the susceptible median nerve. Because if you have decreased blood flow to the nerve, that's going to make it more vulnerable to compression. Also, if there is some activity that seems to exacerbate the problem, you should modify that activity. Ergonomics in the workplace is a good example -- making sure the seat is at the right level, the keyboard is correct, your posture is upright. But honestly, if you're susceptible to carpal tunnel syndrome, you're probably going to get it and that's the bottom line. For example, a lot of panaceas for carpal tunnel syndrome have come along, one of the most recent being the B-6 vitamin. People said if you take this vitamin, you won't get carpal tunnel syndrome. Well, it's efficacy is at best questionable.

What is the prognosis?

Dr. Melone: Again, timing is everything. In the intermediate phase, when we decompress the nerve through surgery, the prognosis is excellent. If the nerve injury goes untreated for a long period, then the nerve will become perhaps irreversibly damaged. Unsuccessful surgery is basically caused by two problems. No. 1 is the wrong diagnosis and the second is incorrect or poorly timed surgery. In other words, if you have a seriously damaged nerve and you have surgery, the operation may result in little, if any, improvement.

For established carpal tunnel syndrome, open surgery is the preferred method of treatment. Usually, no splinting is necessary post-operatively, so it's just a bandage on the hand and usage is permitted immediately. Most patients find that the so-called night pain is diminished or gone by the next day, so they feel better almost right away. Wound sensitivity resolves in six to eight weeks and function is markedly improved.

Dr. Charles P. Melone, Jr., a member of the Association of Professional Team Physicians (PTP), is a hand surgery consultant for the New Jersey Devils and New Jersey Nets. Dr. Melone received his undergraduate and medical degrees from Georgetown University in Washington, DC. In addition to being Clinical Professor of Orthopaedic Surery at New York University Medical Center, Dr. Melone is also Chief of the Division of Hand Surgery at Beth Israel Medical Center in New York.

The information, including opinions and recommendations, contained in this website is for educational purposes only. Such information is not intended to be a substitute for professional medical advice, diagnosis or treatment. No one should act upon any information provided in this website without first seeking medical advice from a qualified medical physician.

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