Physical Therapy Guide to Carpal Tunnel Syndrome
By: Dr. Abe Kopolovich, DPT, MBA
Carpal tunnel syndrome is a common condition that causes pain, numbness, and weakness in the wrist and hand. CTS can affect the use of the entire arm. It is caused by pressure on the nerve at the base of the palm (median nerve). Because of the constant demands people place on their hands and wrists, surgery may be needed when symptoms are severe. For many people with CTS, however, physical therapy treatment can relieve pain and numbness. It often can help restore normal hand, wrist, and arm use without the need for surgery.
Physical therapists are movement experts who improve quality of life through hands-on care, patient education, and prescribed movement. You can contact a physical therapist directly for an evaluation.
What is Carpal Tunnel Syndrome?
The carpal tunnel is a narrow passageway (about the size of a dime) on the palm side of your wrist. The tunnel protects the median nerve and the tendons that bend your fingers. When the tunnel narrows due to injury or other conditions, or the tendons and nerves in the tunnel swell and take up more space, pressure on the nerve increases. A wrist fracture or arthritis can cause the size of the tunnel to become smaller. The tendons or nerves can enlarge due to either inflammation or tendon changes with age. Pressure on the nerve can cause pain and weakness in your wrist and hand and numbness or tingling in some fingers. The most affected fingers are the thumb, index, middle, and sometimes, the ring finger. If this increased pressure continues over a long period, it can lead to CTS.
Extreme wrist positions and repeated finger use with a lot of force or vibration can contribute to CTS.
CTS is common in professions such as assembly-line work (meat packing in particular). It also is common among people with jobs requiring the use of hand tools, especially tools that vibrate. Although too much keyboard computer use can cause CTS, people who do assembly-line work are more likely to develop it. Using hand-held mobile devices, sewing, video gaming, and playing racquet sports or string instruments like the violin also can cause CTS.
The following health conditions also may lead to CTS in some people:
- Inflammation and swelling of the tendons of the wrist.
- Injuries to the wrist (strain, sprain, dislocation, fracture).
- Hormone or metabolic changes (pregnancy, menopause, thyroid imbalance).
- Fluid retention.
- Medications (such as steroids or chemotherapy).
- Degenerative and rheumatoid arthritis.
Signs and Symptoms
CTS usually starts gradually. Many people report waking up with numbness, tingling, or burning in their thumb, index, and middle fingers. Sometimes, the ring finger is affected. Many people feel the need to “shake out” their hands to try to relieve their symptoms.
As the condition worsens, the symptoms become more noticeable during the day. Symptoms often are worse when:
- Grasping heavy objects.
- Using a computer.
- Holding a cell phone.
- Gripping anything for a long period of time.
Hand weakness and more constant numbness may occur if the pressure on the nerve continues. You may find that you drop objects unexpectedly.
How Is It Diagnosed?
Physical therapists work together with other health care providers to accurately diagnose and treat CTS. Symptoms of CTS are typical. It is often possible to diagnose it without extensive testing. Your physical therapist will conduct a thorough evaluation to determine all the factors that may be contributing to your condition.
They will begin by asking you questions to gather information about your health history and condition. The interview will become more specific to the symptoms of CTS. They may be helped by forms you fill out before your first session. Your physical therapist may ask you:
- Did you experience an injury to the area?
- If so, how did your injury occur?
- Do you perform repeated tasks for your work, or for sport?
- How have you taken care of the condition, such as seeing other health care providers?
- Have you had imaging or other tests, and received their results?
- What are your current symptoms, and how have they changed your activities?
- Do you have pain. If so, where and how intense is your pain? Does pain vary during the day?
This information lets the physical therapist better understand what you are experiencing and helps to determine the course of your physical exam.
The physical exam will vary depending on your interview. Your physical therapist will observe the region of your symptoms and any movements or positions that cause pain. They also may examine other areas of your body, such as your neck and upper extremity. They may:
- Watch you reach for objects.
- Ask you to grip different-sized objects and hold them in certain positions for an amount of time.
- Assess the mobility and strength of your forearm, wrist, and hand. This will help to determine if other areas of the body need treatment to improve your condition.
- Gently, but skillfully, feel around your arm and wrist region to find exactly where it is most painful.
Several tests may be used to help diagnose or rule out CTS, including:
- An examination of your neck, shoulder, and arm and down to your fingers to rule out other conditions. Many patients have been told they have CTS, only to learn that the pain is coming from another area.
- A grip strength test of your fingers and thumb.
- Sensory tests.
- Wrist and hand range-of-motion tests.
- A wrist flexion (Phalen) test. Your physical therapist will have you push the backs of your hands together for one minute. Tingling or numbness in your fingers that occurs within 60 seconds may suggest CTS.
- Tinel’s Sign test. Your physical therapist will use a reflex hammer or finger to tap over the median nerve at your wrist. Tingling in the thumb and index and middle fingers may indicate CTS.
- Electrical and nerve studies. Your physical therapist may conduct an electromyogram, or EMG, and a nerve conduction velocity test. These tests measure the amount of nerve transmission and help determine how severe your CTS is.
In some cases, your physical therapist may refer you to a doctor or other health care provider for additional testing or treatment.
After the evaluation, your physical therapist will discuss their findings with you and may work with you to begin a treatment program to improve your condition.
How Can a Physical Therapist Help?
Your physical therapist will develop a personalized treatment plan based on your specific case.
With early-stage CTS, conservative care is recommended as a first step. Physical therapy treatment can be effective to reduce your symptoms and help you get back to your everyday activities.
Depending on the causes of your CTS, your physical therapy program may include:
Patient education. Your physical therapist will teach you ways to improve your condition and keep it from getting worse. This may include education on the importance of:
- Changing wrist positions (such as avoiding bent-wrist positions for long periods).
- Proper neck and upper-back posture (avoiding forward-head posture or slouching).
- Safety precautions when using sharp utensils, tools, or other implements. This is especially important if your physical therapist detects changes in your levels of feeling.
- “Stretch breaks” during your work or daily routine.
Stretching exercises. Your physical therapist will teach you gentle stretching exercises to improve your wrist, hand, and finger flexibility.
Strengthening exercises. Your physical therapist may teach you exercises to strengthen muscles to help you keep better posture. Once your symptoms have decreased, strengthening exercises for the hand, wrist, and forearm may be prescribed.
Splinting. Your physical therapist may recommend that you use a splint at night to reduce discomfort.
Cold and heat treatments. Your physical therapist may use cold or heat treatments, or recommend you use ice or heat to relieve pain.
They may also recommend options for your work, home, and leisure activities as part of your treatment plan. These may include:
- A work site assessment. If you sit at a desk and work on a computer, it is important to properly align your keyboard to avoid working in a bent-wrist position.
- Increasing the size of tool and utensil handles by adding extra material for a more comfortable grip.
- Using special gloves or wraps around tool handles to reduce vibration if it is a factor at your workplace.
- Wearing gloves to keep your wrist and hands warm.
- Reducing or stopping activities that increase your symptoms until they are less frequent or intense.
The goals of physical therapy are to:
- Reduce your symptoms without the need for surgery.
- Allow you to be as active and functional as possible.
Help you resume your normal work, home, and leisure activities.
Physical Therapy After Surgery
If the evaluation reveals that your CTS is more severe, or if your symptoms persist, your physical therapist may refer you to consult with a surgeon. If surgery is needed, the surgeon will release the band of tissue that forms the roof of the carpal tunnel. This will decrease the pressure on the median nerve.
Physical therapy treatment is important after surgery to:
- Prevent scar tissue formation.
- Help restore strength to the wrist.
- Help you learn to change habits that may have led to symptoms in the first place.
Your physical therapy treatment after surgery may include:
- Scar management to keep the skin supple and flexible.
- Exercises to glide the nerve within the healing tunnel.
- Stretching exercises to improve mobility of the wrist and fingers and improve function.
- Strengthening exercises to improve the strength of the wrist and hand muscles and improve function.
- Education about proper posture and wrist position to avoid carpal tunnel compression in home/leisure activities.
- A work site visit or mock-up to show you proper workstation set-up. This can help with posture and positions to prevent CTS from recurring. It also can reduce your risk for developing other nerve injuries.
Can This Injury or Condition Be Prevented?
There is no single proven strategy for preventing CTS, but there are ways to reduce stress to your hands and wrists. Since there are several factors that can contribute to developing CTS, one single solution may not be effective.
The following are effective ways to decrease stress to your hands and wrists:
- Improve your posture. Make sure your posture is appropriate to the task you are doing. Proper alignment of your trunk, neck, and shoulders can prevent too much strain and improper positioning of the wrists and hands.
- Take frequent breaks. When doing repeated activities, give your hands a break by doing occasional stretching exercises. If possible, alternate your hands when completing some tasks. Spread your fingers apart to avoid constantly being in a gripping position.
- Reduce force. Most people use more force than needed when working with their hands. Decrease the force you use to type. Relax your grip to avoid muscle fatigue and strain. When writing by hand for long periods, use a larger-handle pen or soft gel grip.
- Neutral wrist position. Avoid bending your wrists for long periods. Keep your wrists in a straight or neutral position when doing lengthy tasks. This means your wrist should not be bent up (extended) or down (flexed).
- Work-area adjustments. Have a physical therapist examine your work area to make sure it fits your height, posture, and tasks. Make sure not to rest your wrist on the edge of your desk. Simple adjustments can help avoid unnecessary strain.
- Keep your hands warm. You are more likely to develop hand pain and stiffness if you work in a cold environment. If you cannot control the temperature, wear gloves to keep your hands and wrists warm.
- Maintain good health. Paying attention to your general health is an important step in preventing CTS. Staying physically active and keeping a healthy weight may help control diseases and conditions that may lead to CTS.
What Kind of Physical Therapist Do I Need?
All physical therapists are prepared through education and experience to treat a variety of conditions, including CTS. However, you may want to consider:
- A physical therapist who is experienced in treating people with arm and hand disorders and one who has experience in ergonomics and work site evaluations. Ergonomics involves understanding the fit between the person, their equipment, and their environment.
- A physical therapist who is a certified hand therapist, or CHT.
A physical therapist who is a board-certified clinical specialist or who has completed a residency or fellowship in orthopedic physical therapy. This physical therapist has advanced knowledge, experience, and skills that may apply to your condition.