Symptoms

Back Pain

The back and spine are designed to provide a great deal of strength, protecting the highly sensitive spinal cord and nerve roots, yet flexible, providing for mobility in all directions.

However, there are many different parts of the spine that can produce back pain, such as irritation to the large nerve roots that run down the legs and arms, irritation to small nerves inside the spine, strains to the large back muscles, as well as any injury to the disc, bones, joints or ligaments in the spine.

Acute back pain comes on suddenly and usually lasts from a few days to a few weeks. Chronic back pain is typically described as lasting for more than three months.

Back pain can take on a wide variety of characteristics:

  • The pain may be constant, intermittent, or only occur with certain positions or activities
  • The pain may remain in one spot or refer or radiate to other areas
  • It may be a dull ache, or a sharp or piercing or burning sensation
  • The problem may be in the neck or low back but may radiate into the leg or foot (sciatica), arm or hand.

 

 

 

Neck Pain

Our neck, also called the cervical spine, begins at the base of the skull and contains seven small vertebrae. Incredibly, the cervical spine supports the full weight of your head, which is on average about 12 pounds. While the cervical spine can move your head in nearly every direction, this flexibility makes the neck very susceptible to pain and injury.

The neck’s susceptibility to injury is due in part to biomechanics. Activities and events that affect cervical biomechanics include extended sitting, repetitive movement, accidents, falls and blows to the body or head, normal aging, and everyday wear and tear. Neck pain can be very bothersome, and it can have a variety of causes.

Here are some of the most typical causes of neck pain:

  • Injury and Accidents: A sudden forced movement of the head or neck in any direction and the resulting “rebound” in the opposite direction is known as whiplash. The sudden “whipping” motion injures the surrounding and supporting tissues of the neck and head. Muscles react by tightening and contracting, creating muscle fatigue, which can result in pain and stiffness. Severe whiplash can also be associated with injury to the intervertebral joints, discs, ligaments, muscles, and nerve roots. Car accidents are the most common cause of whiplash.
  • Growing Older: Degenerative disorders such as osteoarthritis, spinal stenosis, and degenerative disc disease directly affect the spine.
  • Osteoarthritis, a common joint disorder, causes progressive deterioration of cartilage. The body reacts by forming bone spurs that affect joint motion.
  • Spinal stenosis causes the small nerve passageways in the vertebrae to narrow, compressing and trapping nerve roots. Stenosis may cause neck, shoulder, and arm pain, as well as numbness, when these nerves are unable to function normally.
  • Degenerative disc disease can cause reduction in the elasticity and height of intervertebral discs. Over time, a disc may bulge or herniate, causing tingling, numbness, and pain that runs into the arm.
  • Daily Life: Poor posture, obesity, and weak abdominal muscles often disrupt spinal balance, causing the neck to bend forward to compensate. Stress and emotional tension can cause muscles to tighten and contract, resulting in pain and stiffness. Postural stress can contribute to chronic neck pa

 

 

Headaches/Migraines

If you have a headache, you’re not alone. Nine out of 10 Americans suffer from headaches. Some are occasional, some frequent, some are dull and throbbing, and some cause debilitating pain and nausea. What do you do when you suffer from a pounding headache? Do you grit your teeth and carry on? Lie down? Pop a pill and hope the pain goes away? There is a better alternative.

Research shows that spinal manipulation – one of the primary treatments provided by doctors of chiropractic – may be an effective treatment option for tension headaches and headaches that originate in the neck. A 2014 report in the Journal of Manipulative and Physiological Therapeutics (JMPT) found that interventions commonly used in chiropractic care improved outcomes for the treatment of acute and chronic neck pain and increased benefit was shown in several instances where a multimodal approach to neck pain had been used1. Also, a 2011 JMPT study found that chiropractic care, including spinal manipulation, improves migraine and cervicogenic headaches2.

Headache Triggers

Headaches have many causes, or “triggers.” These may include foods, environmental stimuli (noises, lights, stress, etc.) and/or behaviors (insomnia, excessive exercise, blood sugar changes, etc.). About 5 percent of all headaches are warning signals caused by physical problems. The remaining 95 percent of headaches are primary headaches, such as tension, migraine, or cluster headaches. These types of headaches are not caused by disease; the headache itself is the primary concern.

The greatest majority of primary headaches are associated with muscle tension in the neck. Today, Americans engage in more sedentary activities than in the past, and more hours are spent in one fixed position or posture (such as sitting in front of a computer). This can increase joint irritation and muscle tension in the neck, upper back and scalp, causing your head to ache.

 

 

Herniated Disc

There are many causes of a herniated disc, but it all comes down to this:  your intervertebral disc (the cushion in between your vertebrae in your spine) pushes out or bulges or even ruptures.  This very contained disc , starts to take up more room than it should, and it can, as you’re probably well-aware, cause you a lot of pain.

Herniated Disc Cause #1:  Wear and Tear on the Spine

Pain from a herniated disc is often the result of daily wear and tear on the spine. This is also called degeneration.

Our backs carry and help distribute our weight, and those intervertebral discs are made to absorb shock from movement (such as walking, twisting, and bending).  Because our discs work so hard to help us move so well, they can become worn out over the course of time.

The annulus fibrous (the tough outer layer of the disc) can start to weaken, allowing the nucleus puplosus (the jelly-like inner layer) to push through, creating a bulging or herniated disc.

Herniated Disc Cause #2:  Injury

A herniated disc can also be caused by an injury.  You can herniate a disc in a car accident, for example:  the sudden, jerking movement can put too much pressure on the disc, causing it to herniate.

Or you can herniate a disc by lifting a heavy object incorrectly, or by twisting extremely.

Herniated Disc Cause #3:  A Combination of Degeneration and Injury

It may be that an intervertebral disc has been weakened by wear and tear (degeneration), making it more prone to herniation, should you experience a traumatic event.

Or it could be that your disc has become so weakened that something that doesn’t seem like a very traumatic event can cause a herniated disc.  This is the case when people herniate a disc sneezing (it does happen!).  A sneeze doesn’t seem like a traumatic event that could lead to injury, but if you have an already-weakened disc, then the sudden force of a sneeze can herniate a disc.

The 4 Stages of a Herniated Disc

There are 4 stages to the formation of a herniated disc, as shown here:

?disc
Progression of Herniated Disc
 

  1. Disc Degeneration: During the first stage, the nucleus pulposus weakens due to chemical changes in the disc associated with age. At this state, no bulging (herniation) occurs; it’s just that the disc starts to dry out and becomes less able to absorb the shock of your movements.
  2. Prolapse: During prolapse, the form or position of the disc changes. A slight bulge or protrusion begins to form, which might begin to crowd the spinal cord or spinal nerves (depending on where the bulge is).
  3. Extrusion: During extrusion, the gel-like nucleus pulposus breaks through the tire-like wall of the annulus fibrosus but still remains within the disc.
  4. Sequestration: During the last stage, the nucleus pulposus breaks through the anulus fibrosus and even moves outside the disc in the spinal canal.

 

Facet Arthropathy

Facet Joints

Each vertebral level of the spine consists of three joints. There is a joint between the bodies of two vertebra connected by an intervertebral disc, and two facet joints which connect one vertebra to the other. The facet joints are on the posterior aspect of the spine, with one located on each side. These three joints form a tripod system. The function of the facet joints is to provide support, stability and mobility to the spine. In addition to promoting mobility, these joints also help restrict excessive motion. This ensures that the spine moves with precision.

The facet joints are synovial joints, which have articular cartilage that covers the ends of the bones. Articular cartilage has a smooth and shiny surface, which allows the ends of the bones to slide freely over each other. In addition, each joint is surrounded by a protective sleeve of soft tissue called a capsule, and is lubricated by synovial fluid. Each joint can be a source of pain if irritated or inflamed.

Arthritis is described as the wearing, degeneration, or loss of articular cartilage in a joint. The three most common types of joint arthritis are osteoarthritis, rheumatoid arthritis, and traumatic arthritis. Arthropathy occurs when arthritis affects the facet joints.

Causes

Facet joints, like other synovial joints, are susceptible to wear and tear, degeneration, inflammation and arthritic changes. Inflammation and degenerative changes to the facet joints may result in pain, loss of motion, and if severe encroachment or pinching of the nerve exiting the spinal column. Causes of facet joint arthropathy include:

  • Degeneration or general wear and tear of the joint, can cause arthritis.
  • Disc degeneration may cause loss of height between vertebra, placing a greater compression force on the posterior facet joints.
  • Extension (backward) motions can produce compression on the facet joints which can lead to degenerative and eventual arthritic changes.
  • Sudden fall or trauma like a motor vehicle accident can result in a facet joint irritation.
  • Genetic factors can contribute to the likelihood of degenerative joint disease.
  • Repetitive stress injuries like those from lifting or carrying heavy loads, or performing over the head motions that keep the neck and head in an extended position can cause facet joint irritation.
  • Muscle weakness and poor posture.
  • Joint stiffness.
  • Sedentary lifestyle.

Symptoms

When a facet joint is irritated the symptoms will depend on the location of the facet joint and what soft tissue structures are affected. Symptoms can vary from mild to severe and may mimic the symptoms of a disc problem. Other common symptoms include:

  • Pain in the neck, shoulder blade or radicular to the shoulder into the arm. Pain is rarely felt in the hand or fingers.
  • Pain and tenderness localized at the level of the involved facet joint.
  • Muscle spasm and changes in posture in response to the injury.
  • Loss of motion of the neck including an inability to turn the head, look up or bend backward, or move sideways to the effected side.
  • Sitting for extended periods of time or performing activities overhead will be difficult.
  • Increased size or visible deformity of the joint.
  • A sensation of “cracking” or “crunching” with movement of the spine.

Treatment

Treatment of facet joint arthropathy will depend on the severity of the condition. Treatment recommendations for lumbar facet joint arthropathy include:

  • Rest: avoid the activities that produce the pain (bending, lifting, or twisting, of the spine and lower back)
  • Medication to reduce inflammation (anti-inflammatory drugs and pain medication)
  • Ice: apply ice to the cervical spine to help reduce pain and associated muscle spasm. Apply ice right away and then at intervals for about 20 minutes at a time. Do not apply directly to the skin.
  • An exercise regiment designed specifically to address the cause of the symptoms and facet joint irritation.
  • Bracing or the use of supports may be necessary to reduce stress on the facet joints, muscles and lumbar spine.
  • Steroidal medication to reduced inflammation in moderate to severe conditions.
  • Facet joint injections directly to the involved joint.
  • Physical therapy to reduce inflammation, restore joint function, improve motion, and help return to full function.

Pinched Nerves- Tingling & Numbness

A pinched nerve in the spine is typically caused when surrounding tissues are putting pressure on the nerve. These tissues could consist of surrounding bone, cartilage, muscle, tendons or any other tissues that are inflamed or that have otherwise invaded the nerve’s space. As a result, the nerve’s signals can be both interrupted and amplified, manifesting as tingling, numbness, muscle spasms or shooting pains that travel from the location of the pinched nerve to other areas of the body.

There are many conditions of the neck and back that can result in nerve impingement. Examples of specific pinched nerve causes in the spine include:

Several factors can increase a person’s chances of pinching a spinal nerve. For example, individuals who are obese carry excess weight that puts added pressure on the spine, and this can accelerate the weakening of the spine’s discs, which occurs naturally during the aging process. Displaced intervertebral disc tissue is a common cause of pinched nerves. As spinal degeneration, which leads to pinched nerves, can also be caused by repetitive movements, someone with a profession that requires frequent, repetitive motions may also be at risk.

Pinched nerve treatment can vary depending on the underlying condition. Once your physician has confirmed that a pinched nerve is causing your symptoms, he or she may recommend special exercises, physical therapy, anti-inflammatory medications, pain medications or corticosteroid injections to minimize the effects of a pinched nerve.

If you have tried these treatments for a few months and you are not experiencing relief of your symptoms, your physician might suggest the possibility of pinched nerve surgery. The purpose of this surgery is to remove any tissue in the spinal column that is impinging on the affected nerve(s), providing you with a more permanent form of relief. Whereas traditional open spine surgeries might require checking into a hospital for several days.

 

Sciatica

Sciatica is a symptom. It consists of leg pain, which might feel like a bad leg cramp, or it can be excruciating, shooting pain that makes standing or sitting nearly impossible.

The pain might be worse when you sit, sneeze, or cough. Sciatica can occur suddenly or it can develop gradually. You might also feel weakness, numbness, or a burning or tingling (“pins and needles”) sensation down your leg, possibly even in your toes. Less common symptoms might include the inability to bend your knee or move your foot and toes.

What causes sciatica?

Sciatica might be a symptom of a “pinched nerve” affecting one or more of the lower spinal nerves. The nerve might be pinched inside or outside of the spinal canal as it passes into the leg.

Conditions that cause sciatica:

  • A herniated or slipped disc that causes pressure on a nerve root — This is the most common cause of sciatica.
  • Piriformis syndrome — This develops when the piriformis muscle, a small muscle that lies deep in the buttocks, becomes tight or spasms, which can put pressure on and irritate the sciatic nerve.
  • Spinal stenosis — This condition results from narrowing of the spinal canal with pressure on the nerves.
  • Spondylolisthesis — This is a slippage of one vertebra so that it is out of line with the one above it, narrowing the opening through which the nerve exits

How is sciatica diagnosed?

A complete medical history, including a review of your symptoms, and a physical exam can help the health care provider diagnose sciatica and determine its cause. For example, he or she might perform a straight-leg-raise test, in which you lie on your back with your legs straight. The health care provider will slowly raise each leg and note the elevation at which your pain begins. This test can help pinpoint the affected nerves and determine if there is a problem with one of your discs.

Other diagnostic tests might be performed to look for other causes of sciatic pain. Depending on what your health care provider finds, he or she might recommend further testing. Such testing might include:

However, most patients with sciatica can be treated without the need for further diagnostic testing.

How is sciatica treated?

The goal of treatment is to decrease pain and increase mobility. Treatment most often includes limited rest (on a firm mattress or on the floor), physical therapy, and the use of medicine to treat pain and inflammation. A customized physical therapy exercise program might be developed.

Medicine — Pain medicines and anti-inflammatory drugs help to relieve pain and stiffness, allowing for increased mobility and exercise. There are many common over-the-counter medicines called non-steroidal anti-inflammatory drugs (NSAIDs). They include aspirin, ibuprofen (Motrin, Advil), and naproxen (Naprosyn, Aleve).

Muscle relaxants, such as cyclobenzaprine (Flexeril), might be prescribed to relieve the discomfort associated with muscle spasms. However, these medicines might cause confusion in older people. Depending on the level of pain, prescription pain medicines might be used in the initial period of treatment.

Physical therapy —The goal of physical therapy is to find exercise movements that decrease sciatic pain by reducing pressure on the nerve. A program of exercise often includes stretching exercises to improve flexibility of tight muscles and aerobic exercise, such as walking.

The therapist might also recommend exercises to strengthen the muscles of your back, abdomen, and legs.

Spinal injections — An injection of a cortisone-like anti-inflammatory medicine into the lower back might help reduce swelling and inflammation of the nerve roots, allowing for increased mobility.

Surgery — Surgery might be needed for people who do not respond to conservative treatment, who have progressing symptoms, and are experiencing severe pain.

Surgical options include:

  • Microdiscectomy — This is a procedure used to remove fragments of a herniated disc.
  • Laminectomy — The bone that curves around and covers the spinal cord (lamina), and the tissue that is causing pressure on the sciatic nerve are removed.

Many people believe that yoga or acupuncture can improve sciatica. Massage might help muscle spasms that often occur along with sciatica. Biofeedback is an option to help manage pain and relieve stress, which can affect your ability to cope with pain. These are referred to as alternative therapies.

What complications are associated with sciatica?

Chronic (ongoing and lasting) pain is a complication of untreated sciatica. If the “pinched nerve” is seriously injured, chronic muscle weakness, such as a “drop foot,” might occur.

What is the outlook for people with sciatica?

Sciatic pain usually goes away with time and rest. Most people with sciatica (80 percent to 90 percent) will get better without surgery. About half of affected individuals recover from an episode within six weeks.

Can sciatica be prevented?

Some sources of sciatica are not preventable, such as degenerative disc disease, back strain due to pregnancy, and accidental falls.

Although it might not be possible to prevent all cases of sciatica, you can take steps to protect your back and reduce your risk.

  • Practice proper lifting techniques. Lift with your back straight, bringing yourself up with your hips and legs, and holding the object close to your chest. Use this technique for lifting everything, no matter how light.
  • Avoid/ stop cigarette smoking, which promotes disc degeneration.
  • Exercise regularly to strengthen the muscles of your back and abdomen, which work to support your spine.
  • Use good posture when sitting, standing, and sleeping. Good posture helps to relieve the pressure on your lower back.
  • Avoid sitting for long periods.

References

  • National Institute of Arthritis and Musculoskeletal and Skin Diseases. Health Handout: Back Pain. Accessed 6/25/2014.
  • American Academy of Orthopaedic Surgeons. Sciatica. Accessed 6/25/2014.
  • American Chiropractic Association. Sciatica. Accessed 6/25/2014.
  • Merck Manuals for Medical Professionals. Sciatica. Accessed 6/25/2014.
  • Woods RP, Seamon J. Chapter 21. Arthritis & Back Pain. In: Stone C, Humphries RL. eds. CURRENT Diagnosis & Treatment Emergency Medicine, 7e. New York, NY: McGraw-Hill; 2011.library.ccf.org. Accessed 6/25/2014.

 

Shoulder Pain- Frozen Shoulder

What causes frozen shoulder?

Frozen shoulder can develop when you stop using the joint normally because of pain, injury, or a chronic health condition, such as diabetes or a stroke. Any shoulder problem can lead to frozen shoulder if you do not work to keep full range of motion.

Frozen shoulder occurs:

  • After surgery or injury.
  • Most often in people 40 to 70 years old.
  • More often in women (especially in postmenopausal women) than in men.
  • Most often in people with chronic diseases.

How is frozen shoulder diagnosed?

Your doctor may suspect frozen shoulder if a physical exam reveals limited shoulder movement. An X-ray may be done to see whether symptoms are from another condition such as arthritis or a broken bone.

How is it treated?

Treatment for frozen shoulder usually starts with nonsteroidal anti-inflammatory drugs (NSAIDs) and application of heat to the affected area, followed by gentle stretching. Ice and medicines (including corticosteroid injections) may also be used to reduce pain and swelling. And physical therapy can help increase your range of motion. A frozen shoulder can take a year or more to get better.

If treatment is not helping, surgery is sometimes done to loosen some of the tight tissues around the shoulder. Two surgeries are often done. In one surgery, called manipulation under anesthesia, you are put to sleep and then your arm is moved into positions that stretch the tight tissue. The other surgery uses an arthroscope to cut through tight tissues and scar tissue. These surgeries can both be done at the same time.

Can frozen shoulder be prevented?

Gentle, progressive range-of-motion exercises, stretching, and using your shoulder more may help prevent frozen shoulder after surgery or an injury. Experts don’t know what causes some cases of frozen shoulder, and it may not be possible to prevent these. But be patient and follow your doctor’s advice. Frozen shoulder nearly always gets better over time.

 

Tennis Elbow- Golfers Elbow

Where Is the Pain?

Tennis elbow is a pain focused on the outside of the arm, where your forearm meets your elbow.

It’s related to a muscle and tendons in your forearm. Tendons connect your muscles to your bones. When you constantly use your arm in a repetitive motion, the tendons at the elbow end of a certain muscle — the extensor carpi radialis brevis (ECRB) muscle — may develop small tears.

The tears lead to inflammation and may put stress on the rest of your arm, making it painful to lift and grip things. Left untreated, it can become chronic (that’s medical-speak for “ongoing”).

Tennis elbow affects up to 3% of the population, particularly adults between 30 and 50 years of age. But less than 5% of cases are linked to tennis.

What Causes Tennis Elbow?

Tennis elbow is a classic repetitive stress injury caused by overuse. Any activity that strains the muscles around the elbow over and over again can cause it. There’s also a version golfers get called “golfer’s elbow.”

In tennis, hitting a backhand puts some stress on your forearm muscles, which repeatedly contract when you hit the ball. If you have poor technique or grip the racquet too tightly, that stress may increase in the tendons that connect the forearm muscles to the elbow. The tendons may get small tears.

The more you do it — and tennis is a game of repeated strokes — the greater the chance for tennis elbow.

You can get it from other racquet sports, such as squash or racquetball. You can also get it from jobs or activities that involve repetitive arm motion, such as:

  • Tree-cutting (repetitive use of a chain saw)
  • Painting
  • Carpentry
  • Playing some types of musical instruments

Butchers, cooks, and assembly-line workers are among the groups that get it often.

Golfer’s elbow differs from tennis elbow in that the pain is focused on the inside of the elbow. But the causes are similar: tendon tears caused by repetitive movement, whether it’s a golf swing, lifting weights, or simply shaking hands.

Hip Pain- Sacoiliac Pain

What Is the SI Joint?

Its full name is the sacroiliac joint. There are two of them in your lower back, and they sit on each side of your spine. Their main job is to carry the weight of your upper body when you stand or walk and shift that load to your legs.

What Does the Pain Feel Like?

It could be a dull or sharp. It starts at your SI joint, but it can move to your buttocks, thighs, groin, or upper back.

Sometimes standing up triggers the pain, and a lot of times you feel it only on one side of your lower back. You may notice that it bothers you more in the morning and gets better during the day.

It’s more common than you might think. About 15%-30% of people who hurt like this have a problem with the SI joint.

Why Is This Happening?

The pain starts when your SI joint gets inflamed. There are several reasons it could happen. You could hurt it when you play sports or if you fall down. You might also get this problem from an activity that gives the area a regular pounding, like jogging.

Do you take uneven strides when you walk because one of your legs is longer than the other? That could be a cause of SI joint pain.

Sometimes you start hurting when the ligaments that hold your SI joint together are damaged, which may make the joint move abnormally.

Arthritis can lead to the problem. A type that affects your spine, called ankylosing spondylitis, can damage the SI joint. You’ll also hurt when the cartilage over the SI joint slowly wears away as you age.

SI joint pain may also start if you’re pregnant. Your body releases hormones that cause your joints to loosen up and move more, which leads to changes in the way the joints move.

Knee/Ankle Pain

What to Do

Signs & Symptoms

Get immediate care.

Pain, redness (may have shades of red, purple, and blue), and swelling in the ankle or leg. Bluish color in the toes. May be followed by severe shortness of breath that came on all of a sudden. May include coughing up blood or pink-frothy sputum. Chest pain.

Deep-vein thrombosis (DVT) with or without a blood clot to the lung

Contact doctor.

Swelling of both ankles at the same time. Shortness of breath. May have dry cough or cough with pink, frothy mucus.

Heart failure

See “Peripheral Artery Disease.”

Muscle pain in one or both legs. Fatigue in the thighs, calves, and feet. This improves with rest. Open sores on the lower leg, ankles, or toes. Weak or no pulse in the affected limb. Cold or numb feet. Pale, bluish-colored toes.

Peripheral artery disease

See “Broken Bones” and “Dislocations.”

Any of these signs with pain after a leg or ankle injury: A bone sticks out or bones in the injured limb make a grating sound; the injured limb looks deformed, crooked, or the wrong shape; a loss of feeling in the injured limb; and cold, blue skin under the affected injured area; the limb is very painful and/or swollen or one that can’t bear weight, or inability to move the limb.

Broken bone or dislocation

See “Sprains & Strains.”

Pain in the leg or ankle after an injury that does not keep you from moving the limb.

Sprain or strain; sport or other overuse injury

Contact doctor. Get an immediate appointment for a red streak up the leg.

Pain with fever, redness, tenderness, pus at a wound site. A red streak up the leg (rarely).

Infection

See “Gout.”

Sudden, severe pain in the knee or ankle joint, usually just on one side. The pain can be felt even when clothing is rubbed against the joint. The joint area is swollen, red or purplish in color, feels warm, and is very tender to the touch.

Gout

Contact doctor.

Leg pain that radiates from the lower back. Pain or stiffness in the knees. Bowing of the legs or other bone deformity. Unexplained bone fractures. May have headache, dizziness, hearing loss, and/or ringing in the ears.

Paget’s disease. This is a bone disorder that progresses slowly. Most persons with this disease do not develop symptoms.

See “Sciatica.”

Sharp pain from the buttocks down the leg. Numbness and tingling in the leg.

Sciatica

See “Arthritis.”

Pain, stiffness, and swelling, usually in both knees or ankle joints. The joint looks deformed. Weakness and fatigue. Dry mouth and dry, painful eyes.

Rheumatoid arthritis

See “Arthritis.”

Pain, stiffness, and sometimes swelling of the knee or ankle joints. Often, the joint has gotten tender over months or years and may look enlarged or distorted.

Osteoarthritis

See “Osteoporosis.”

Leg or ankle pain with gradual loss of height; stooped posture; backache; and/or past bone fractures, especially in the wrists and hips.

Osteoporosis

See “Varicose Veins.”

Pain or itching in the legs with swollen and twisted veins that look blue and are close to the surface of the skin. The veins bulge and feel heavy. Swelling in the legs and ankles.

Varicose veins

See “Care” section “For Lyme Disease” and “To Protect Yourself From Lyme Disease.”

Muscle or joint pain and chronic swelling of the knee joints that develop months or years after a deer-tick bite and a bulls-eye red rash with pale centers.

Lyme disease

Follow guidelines for “Bursitis.”

Pain and swelling around the knee joint. The pain gets worse with movement. Fever (maybe).

Bursitis

Follow guidelines for “Flu.”

Aches in leg muscles and joints with fever and/or chills; headache; dry cough; sore throat; and fatigue.

Flu

See “To Prevent Leg Cramps” and “Self-Care For Leg Cramps” below.

Sudden, sharp, tightening pain in the leg, often the calf. The muscle feels hard to the touch. The pain subsides after a minute or so and the muscle relaxes.

Leg cramp

Care

Self-care and medical care for leg and ankle pain depends on the cause. Find out what the cause could be from the “Leg Pain & Ankle Pain Chart” above. Follow the guidelines for the suspected cause(s).

For Paget’s disease, most persons do not have symptoms bad enough to need treatment. Self-care measures on this page can help persons with mild symptoms. Some persons may need prescribed medicines. These include anti- inflammatory drugs and calcitonin, which alters bone metabolism. Bone surgery may be needed to improve walking.

Self-Care:

For Pain, in General:

•  Take an over-the-counter medicine for pain. If the pain is not better after a few doses, call your doctor.

•  Use a heating pad (set on low), a hot pack, or a moist, warm towel on the area of pain. If the pain is due to an injury, don’t use heat for 48 hours. Use R.I.C.E.

For Leg Cramps:

•  Sit with your leg flat on the floor. Pull your toes toward you. Point your heel away from you. Stretch the cramped muscle.

•  Have someone massage the cramped muscle gently, but firmly.

•  Apply a heating pad (set on low), a hot pack, or moist warm towel to the muscle cramp.

•  Rub the muscle that is cramping. Rub upward from the ankle toward the heart. (Note: Do not rub a leg if you suspect phlebitis or thrombosis.)

For Paget’s Disease:

•  If needed, take an over-the-counter medicine for pain.

•  Take other medicines as prescribed by your doctor.

•  Get regular checkups to detect hearing loss.

 

TMJ Dysfunction

Your temporomandibular joint is a hinge that connects your jaw to the temporal bones of your skull, which are in front of each ear. It lets you move your jaw up and down and side to side, so you can talk, chew, and yawn.Problems with your jaw and the muscles in your face that control it are known as temporomandibular disorders (TMD). But you may hear it wrongly called TMJ, after the joint.

What Causes TMD?

We don’t know what causes TMD. Dentists believe symptoms arise from problems with the muscles of your jaw or with the parts of the joint itself.

Injury to your jaw, the joint, or the muscles of your head and neck — like from a heavy blow or whiplash — can lead to TMD. Other causes include:

  • Grinding or clenching your teeth, which puts a lot of pressure on the joint
  • Movement of the soft cushion or disc between the ball and socket of the joint
  • Arthritis in the joint
  • Stress, which can cause you to tighten facial and jaw muscles or clench the teeth

    What Are the Symptoms?

    TMD often causes severe pain and discomfort. It can be temporary or last many years. It might affect one or both sides of your face. More women than men have it, and it’s most common among people between the ages of 20 and 40.

    Common symptoms include:

    • Pain or tenderness in your face, jaw joint area, neck and shoulders, and in or around the ear when you chew, speak, or open your mouth wide
    • Problems when you try to open your mouth wide
    • Jaws that get “stuck” or “lock” in the open- or closed-mouth position
    • Clicking, popping, or grating sounds in the jaw joint when you open or close your mouth or chew. This may or may not be painful.
    • A tired feeling in your face
    • Trouble chewing or a sudden uncomfortable bite — as if the upper and lower teeth are not fitting together properly
    • Swelling on the side of your face

    You may also have toothaches, headaches, neck aches, dizziness, earaches, hearing problems, upper shoulder pain, and ringing in the ears (tinnitus).

Carpal Tunnel

Carpal tunnel syndrome

Description

An in-depth report on the causes, diagnosis, treatment, and prevention of carpal tunnel syndrome.

Alternative Names

Repetitive stress injuries

Highlights

Overview:

  • Carpal tunnel syndrome (CTS) develops from problems in a nerve in the wrist — not the muscles, as some people believe.
  • Symptoms of carpal tunnel syndrome usually progress gradually over weeks and months, or sometimes years.
  • Anyone with recurrent or persistent pain, numbness and tingling, or weakness of the hand should consult a doctor for an evaluation.
  • It is not completely known how the process leading to carpal tunnel syndrome actually evolves, and how nerve conduction (the transmission of the nerve signal) through the wrist changes.
  • In general, carpal tunnel syndrome develops when the tissues around the median nerve of the hand swell and press on the nerve.
  • Early in the disorder, the process is reversible. Over time, however, the insulation on the nerves may wear away, and permanent nerve damage may develop.
  • It is often very difficult to determine the precise cause of carpal tunnel syndrome

Risk Factors:

  • CTS is associated with a family history of the disorder.
  • Many studies indicate that women have a significantly higher risk for carpal tunnel syndrome than men do.
  • Older people are at higher risk than younger adults.

Treatment:

  • It is critical to begin treating early phases of carpal tunnel syndrome before the damage progresses.
  • A conservative approach to CTS, which may include corticosteroid injections and splinting, is the first step in treating this disorder.
  • Surgery is usually an effective treatment choicefor people with the more classic signs and symptoms of carpal tunnel syndromewho fail conservative treatment.

Introduction

Carpal tunnel syndrome (CTS) is a disorder that causes pain and weakness in the hand and wrist. CTS develops from problems in a nerve in the wrist — not the muscles, as some people believe. The symptoms of CTS can range from mild to incapacitating.

The Carpal Tunnel and Median Nerve

To understand how carpal tunnel syndrome arises, it is important to know the parts of the hand and wrist that are involved.

The Carpal Tunnel. The carpal tunnel is a passageway that forms beneath the strong, broad transverse ligament. This ligament is a bridge that extends across the lower palm and connects the bones of the wrist (carpals) that form an arch below the tunnel.

The Median Nerve and Flexor Tendons. The median nerve and nine flexor tendons pass under the ligament bridge and through the carpal tunnel (similar to a river). They extend from the forearm up into the hand:

  • The flexor tendons are fibrous cords that connect the muscles in the forearm to the fingers (two to each finger and one to the thumb). They allow flexing of the fingers and clenching of the fist.
  • The median nerve plays two important roles. It supplies sensation to the palm side of the thumb, index, middle, and ring fingers, and to the flexor tendons. It provides function for the muscles at the base of the thumb (the thenar muscle).

Wrist anatomy

The median nerve travels through a compartment in the wrist called the carpal tunnel. The ligaments that traverse the nerve are not very flexible. Any swelling within the wrist compartment can put excessive pressure on structures such as the blood vessels and the median nerve. Excessive pressure can constrict blood flow and cause nerve damage. The symptoms from the compression cause pain, loss of sensation, and decreased function in the hand.

The Carpal Tunnel Syndrome Process

It is not completely known how the process leading to carpal tunnel syndrome actually evolves, and how nerve conduction (the transmission of the nerve signal) through the wrist changes. In general, carpal tunnel syndrome develops when the tissues around the median nerve swell and press on the nerve. Early in the disorder, the process is reversible. Over time, however, the insulation on the nerves may wear away, and permanent nerve damage may develop.

The following events have been observed in the hands of people with carpal tunnel syndrome:

  • The protective lining of tendons (called the tenosynovium) swells within the carpal tunnel. Some research suggests that this swelling is caused by a buildup of fluid (called synovial fluid) under the lining. Synovial fluid normally lubricates and protects the tendons.
  • The transverse ligament, the band of fibrous tissue that forms the roof over the median nerve, becomes thicker and broader.
  • The swollen tendons and thickened ligament press on the median nerve fibers, just as stepping on a hose slows the flow of water through it. This compression reduces blood flow and oxygen supply to the nerve, while slowing the transmission of nerve signals through the carpal tunnel. Some cases of carpal tunnel syndrome may be due to enlargement of the median nerve rather than compression by surrounding tissues.

The result of these processes is pain, numbness, and tingling in the wrist, hand, and fingers. Only the little finger is unaffected by the median nerve.

Symptoms

Symptoms of carpal tunnel syndrome usually progress gradually over weeks and months, or sometimes years. Anyone with recurrent or persistent pain, numbness and tingling, or weakness of the hand should consult a doctor for a diagnosis. Symptoms often develop as follows:

  • Initial symptoms include pain in the wrist and palm side of the hand. Problems commonly occur in both hands. (Even when only one hand is painful, the other hand often shows signs of nerve conduction abnormalities when tested.)
  • Early on, the patient also usually reports numbness, tingling, burning, or some combination of symptoms on the palm side of the index, middle, and ring fingers. (Typically the fifth finger has no symptoms.) Such sensations may radiate to the forearm or shoulder.
  • Over time, the hand may become numb, and patients may lose the ability to feel heat and cold. Patients may experience a sense of weakness and a tendency to drop things.
  • Patients may feel that their hands are swollen even though there is no visible swelling. This symptom may actually prove to be an important indicator of greater CTS severity.

Symptoms may occur not only when the hand is being used but also at night when the patient is at rest. Even in cases where work is the suspected cause, symptoms typically first occur outside of work. In fact, the disorder may be distinguished from similar conditions by pain that occurs at night after going to bed.

Causes

Biological Causes. Carpal tunnel syndrome is considered an inflammatory disorder caused by repetitive stress, physical injury, or a medical condition. It is often very difficult, however, to determine the precise cause of carpal tunnel syndrome. No tests are available to identify a specific cause. Except in patients with certain underlying diseases, the biological mechanisms leading to carpal tunnel syndrome are unknown.

Working Conditions versus Medical Problems. Although some studies suggest that more than half of CTS cases are associated with workplace factors, there is no strong evidence of a cause-and-effect relationship. In fact, most studies now strongly suggest that carpal tunnel syndrome is primarily associated with medical or physical conditions such as diabetes, osteoarthritis, hypothyroidism, and rheumatoid arthritis.

CTS also tends to occur in people with certain genetic or environmental risk factors. These risk factors include obesity, smoking, alcohol abuse, or significant mental stress. CTS sometimes runs in families, which suggests that it has some type of genetic origin. When people who are susceptible to CTS are subjected to repetitive hand or wrist work, the risk for CTS can become significant. CTS, then, is very likely to be due to a combination of factors that lead to nerve damage in the hand.

Work-Related Issues and Carpal Tunnel Syndrome

High Force and Vibration. Even though medical and physical conditions may be the initial culprits leading to CTS, certain working conditions may be linked to nerve damage. Work that involves high force or vibration is particularly hazardous, as is repetitive hand and wrist work in cold temperatures.

In addition to CTS, other disorders of the hand and wrist result from these work-related movements. They include the following:

  • Hand-arm vibration syndrome — tingling and numbness that persist even after the vibration stops
  • Cumulative trauma (repetitive stress) disorder
  • Overuse syndromes
  • Chronic upper limb pain syndrome

All of these problems are generally associated with repetitive and forceful use of the hands, resulting in damaged muscles and bones of the upper arms.

Medical Conditions

Several medical conditions increase the risk for, or even cause CTS. The main conditions associated with CTS are diabetes, hypothyroidism, rheumatoid arthritis, osteoarthritis, obesity, and pregnancy. Many of the underlying diseases that contribute to the development of CTS are also associated with more severe forms of CTS.

Diabetes. CTS is a very common feature of diabetic neuropathy, one of the major complications of diabetes. Neuropathy is decreased or distorted nerve function; it particularly affects sensation. Symptoms include numbness, tingling, weakness, and burning sensations, usually starting in the fingers and toes and moving up to the arms and legs. About 6% of patients with CTS have diabetes. Up to 85% of patients with type 1 diabetes develop CTS. The development of CTS symptoms is related to the patient’s age, and the length of time that he or she has had diabetes.

Autoimmune Diseases. In autoimmune diseases, the body’s immune system abnormally attacks its own tissue, causing widespread inflammation, which, in many cases, affects the carpal tunnel of the hand. Such autoimmune diseases include rheumatoid arthritis, systemic lupus erythematosus, and thyroiditis, which can lead to hypothyroidism. Some experts believe that CTS may actually be one of the first symptoms in a number of these diseases. Studies also suggest that CTS patients with these disorders are more likely to have severe CTS that requires surgery.

Diseases that Affect Muscle and Bones. Arthritis, gout, and other medical conditions that damage the muscles, joints, or bones in the hand may cause changes that lead to CTS.

Structural Abnormalities. Inborn abnormalities in the bones of the hand, wrist, or forearm may contribute to CTS.

Chronic Kidney Insufficiency. People who have hemodialysis for chronic kidney damage often experience a buildup of a certain type of protein, called beta 2-microglobulin, in the hand. This buildup can result in CTS. The longer the person has been receiving hemodialysis, the greater the risk of CTS. Certain drugs and procedures (particularly a procedure called hemodiafiltration) may be able to reduce microglobulin build-up.

Other Diseases. Other medical conditions may cause or increase susceptibility to CTS:

  • Down syndrome
  • Amyloidosis (a progressive disorder of the connective tissues)
  • Acromegaly (a disease that leads to abnormally large hands and feet due to excessive growth hormone)
  • Tumor on the median nerve (removing the tumor often successfully treats CTS in these cases)

Medications. According to case reports, many medications may increase the risk for temporary CTS. They include certain medications that affect the immune system (such as interleukin-2) and anticlotting drugs (such as warfarin). The evidence is conflicting as to whether corticosteroids and hormone replacement therapy may increase the risk of CTS. More research is needed before a cause-and-effect relationship can be established.

Injuries

Bone dislocations and fractures can narrow the carpal tunnel and put pressure on the median nerve.

Hormonal Changes

Hormonal fluctuations in women play a role in CTS. Such fluctuations may lead to fluid retention and other changes that cause swelling in the body. Fluid retention is one reason that CTS may develop during pregnancy.

Genetic Factors

CTS is associated with a family history of the disorder. Certain physical characteristics or medical conditions that are associated with CTS also run in families. Carpal tunnel syndrome in young people most likely has a genetic component.

Other genetic factors that may contribute to this disorder include abnormalities in certain genes that regulate myelin, a fatty substance that insulates nerve fibers.

Risk Factors

Evidence suggests that about 3% of women and 2% of men will be diagnosed with carpal tunnel syndrome during their lifetime. The condition peaks in women over age 55. Still, determining how many people actually have CTS is very difficult. Many people who report CTS symptoms have normal test results. Other people have abnormal test results but no symptoms.

Age

Older people are at higher risk for CTS than younger adults. CTS is very rare in children.

Women

Many studies indicate that women have a significantly higher risk for carpal tunnel syndrome than men. According to the National Institutes of Health, women are three times more likely than men to have carpal tunnel syndrome. The explanation for this greater risk is unknown, but it may be related to the smaller size of a woman’s carpal tunnel. Hormonal changes also appear to play a major role in CTS.

In pregnant women, CTS may occur in both wrists. CTS that begins during pregnancy is usually not severe and persistent enough to require treatment. Although cases eventually go away on their own after delivery, symptoms may persist for 6 months or more.

CTS has also been shown to increase:

  • After delivering a baby
  • During menopause

Women are also at a much higher risk for autoimmune disorders than men. These disorders are significantly linked to CTS.

Obesity and Lack of Fitness

Being overweight is a consistent risk factor for CTS. Greater body mass appears to reduce the speed of nerve messages into the hand. Obesity is also related to poor physical fitness, which may increase risk. Weight is strongly linked to CTS in patients under age 63, but it may be a less important factor as people get older.

Specific Workers at Risk for CTS

Workers who use their hands and wrists repetitively are at risk for CTS, particularly if they work in cold temperatures and have factors or medical conditions that make them susceptible to the condition.

Computer Users and Typists. Repetitive typing and key entry has traditionally been associated with missing work due to CTS. The risk for CTS in this group, however, is still much lower than it is in occupations involving heavy labor. Although more than 10% of computer users complain of CTS symptoms, the evidence implicating computer use as a major cause of CTS is weak.

Other Very High-Risk Workers. Workers in the meat and fish packing industries and those who assemble airplanes have the highest risk for CTS, according to one study. Meat packers complained of pain and loss of hand function as long ago as the 1860s. Even today, the incidence of carpal tunnel syndrome in the meat, poultry, and fish packing industries may be as high as 15%. CTS may also affect as many as 10% of automobile workers.

Musicians. Musicians are at very high risk for CTS and other problems related to the muscles and nerves in the hands, upper trunk, and neck. In one study, 20% of musicians reported CTS or other nerve disorders in the hands and wrists.

Highest to Lowest Numbers of CTS Events by Job. The following is a list of occupations published by the Bureau of Labor Statistics, which rates workers with the highest to lowest total numbers of CTS-related events:

  • Cooks, institution and cafeteria
  • Electrical power-line installers and repairers
  • Painters, construction and maintenance
  • Highway maintenance workers
  • Welders, cutters, solderers, and brazers
  • Bus and truck mechanics and diesel engine specialists
  • Construction laborers
  • Maids and housekeeping cleaners / Industrial machinery mechanics
  • Laborers and freight, stock, and material movers, hand
  • Automotive service technicians and mechanics
  • Bus drivers, transit and intercity
  • Maintenance and repair workers, general
  • Telecommunicationsequipment installers and repairers, except line installers
  • Janitors and cleaners, except maids and housekeeping cleaners / Foodpreparation workers
  • Truck drivers, heavy and tractor-trailer
  • Heating, air conditioning, and refrigeration mechanics and installers
  • Truck drivers, light or delivery services
  • Correctional officers and jailers
  • Driver/sales workers / Nursing aides, orderlies, and attendants
  • Carpenters

SOURCE: Bureau of Labor Statistics, U.S. Department of Labor, November 2011

Workers’ Compensation and CTS. The issues surrounding workers’ compensation make it difficult to accurately determine whether labor conditions cause carpal tunnel pain. However, CTS is a major contributor to workers’ compensation cases.

Psychosocial Factors in the Workplace. Studies indicate that psychosocial factors in the workplace, such as intense deadlines, a poor social work environment, and low levels of job satisfaction are major contributors to carpal tunnel pain.

At Home and Play. People who intensively cook, knit, sew, do needlepoint, play computer games, do carpentry, or use power tools are at increased risk for CTS. Long-distance cycling may worsen symptoms of carpal tunnel syndrome.

Other Physical Characteristics

Square Wrists. Some (but not all) studies have reported a higher risk for CTS in people with square wrists (the thickness and width are about the same) than in those with the more common rectangular wrists.

Palm Shape. In one study, patients with palms that were both shorter and wider than average, and who also had shorter third fingers, were more likely to have CTS than those without these hand characteristics.

Poor Upper Back Strength. Some researchers claim that poor upper back strength makes people more susceptible to poor posture and injuries in the upper extremities, including carpal tunnel syndrome.

Smoking and Alcohol Abuse

Cigarette smoking slows blood flow, which is why smokers have more severe symptoms and slower recovery than nonsmokers. Increased alcohol intake has been associated with CTS in people who also have other risk factors.

Other Factors

Poor nutrition, previous injuries, and stress can increase the risk for carpal tunnel syndrome. In addition, high levels of so-called “bad” cholesterol (low-density lipoprotein, or LDL) have been linked to an increased risk of CTS.

Prognosis

Carpal tunnel syndrome can range from a minor inconvenience to a disabling condition, depending on its cause and persistence, and the patient’s individual characteristics. Many cases of CTS are mild, and when symptoms don’t last long, they often get better on their own. Once a woman with pregnancy-associated CTS gives birth, for instance, the swelling in her wrists and other symptoms almost always subside. Proper treatment of the medical conditions that cause CTS can often help reduce wrist swelling.

In severe untreated cases, however, the muscles at the base of the thumb may whither, and loss of sensation may be permanent. CTS can become so crippling that people can no longer do their jobs or even perform simple tasks at home.

Impact on Work and Livelihood

According to a report from the Bureau of Labor Statistics, carpal tunnel syndrome was associated with the second longest average time away from work (27 days) among the major disabling diseases and illnesses in all private industries. (Fractures were first, with an average of 30 days away.)

Eventually, workers with CTS may be forced to give up their livelihood. In one study, nearly half of all patients with CTS changed jobs within 30 months of their diagnosis. Because of the controversy surrounding the issue of carpal tunnel syndrome and workers’ compensation, workers may not always receive compensation payments.

Prevention

Because many factors can contribute to carpal tunnel syndrome, there is no single way to prevent it. Treating any underlying medical condition is important. Simple common sense may help minimize some of the risk factors that predispose a person to work-related CTS or other cumulative trauma disorders. A patient can learn how to adjust the work area, handle tools, or perform tasks in ways that put less stress on the hands and wrists. Proper posture and exercise programs to strengthen the fingers, hands, wrists, forearms, shoulders, and neck may help prevent CTS.

Corporate Efforts

Many companies are now taking action to help prevent repetitive stress injuries. In a major survey, 84% reported that they were modifying equipment, tasks, and processes. Nearly 85% were analyzing their workstations and jobs, and 79% were buying new equipment. It should be stressed, however, that there has been no evidence that any of these methods can provide complete protection against CTS. The optimal corporate approach, if possible, is to reallocate workers with repetitive stress injuries to other jobs.

Preventing CTS in Keyboard Workers

Altering the way a person performs repetitive activities and replacing old tools with ergonomically designed new ones may help prevent inflammation in the hand and wrist. Most of the interventions described below have been found to reduce repetitive motion problems in the muscles and tendons of the hand and arm. They may reduce the incidence of carpal tunnel syndrome, although there is no definite proof of this effect.

Rest Periods and Avoiding Repetition. Anyone who does repetitive tasks should begin with a short warm-up period, take frequent breaks, and avoid overexertion of the hand and finger muscles whenever possible. Employers should be urged to vary their employees’ tasks and work.

Taking multiple “microbreaks” (about 3 minutes each) reduces strain and discomfort without decreasing productivity. Such breaks may include the following:

  • Shaking or stretching the limbs
  • Leaning back in the chair
  • Squeezing the shoulder blades together
  • Taking deep breaths

Good Posture. Good posture is extremely important in preventing carpal tunnel syndrome, particularly for typists and computer users.

  • The worker should sit with the spine against the back of the chair with the shoulders relaxed.
  • The elbows should rest along the sides of the body, with wrists straight.
  • The feet should be firmly on the floor or on a footrest.
  • Typing materials should be at eye level so that the neck does not bend over the work.
  • Keeping the neck flexible and the head upright maintains circulation and nerve function to the arms and hands. One method for finding the correct head position is the “pigeon” movement. Keeping the chin level, glide the head slowly and gently forward and backward in small movements, avoiding neck discomfort.

Good Office Furniture. Poorly designed office furniture is a major contributor to bad posture. Chairs should be adjustable for height, with a supportive backrest. Custom-designed chairs, made for people who do not fit in standard chairs, can be expensive. However, these costs can save companies on the medical expenses that follow injuries related to bad posture.

Voice Recognition Software. For CTS patients who must use a computer frequently, a variety of voice recognition software packages (ViaVoice, Voice Xpress, Dragon NaturallySpeaking, MacSpeech) are available that allow virtually hands-free computer use.

Keyboard and Mouse Tips. Anyone who uses a keyboard and mouse has options that may help protect the hands.

  • Adjust the tension of the keys so they can be depressed without excessive force.
  • Keep the hands and wrists in a relaxed position to avoid excessive force on the keyboard.
  • Replace the mouse with a trackball device and the standard keyboard with a jointed-type keyboard.
  • Use wrist rests, which fit under most keyboards, to help keep the wrists and fingers in a comfortable position.
  • Keep the computer mouse as close to the keyboard and the user’s body as possible, to reduce shoulder muscle movement.
  • Hold the mouse lightly, with the wrist and forearm relaxed. New mouse supports are also available that relieve stress on the hand and support the wrist.
  • Cut mouse pads in half to reduce movement.

Innovative keyboard designs may reduce hand stress:

  • Ergonomic keyboards allow the user to adjust and modify hand positions and key tension. Most have a split or “slanted” keyboard that places the wrists at an angle. Studies suggest these keyboards help keep the wrist in a more neutral position.
  • The continuous passive motion (CPM) keyboard lifts and declines gently and automatically every 3 minutes to break tension on the hands and wrist.
  • A keyless keyboard (orbiTouch) is an innovative device that uses two domes. The typist covers the domes with his or her hands and slides them into different positions that represent letters.

Reducing Force from Hand Tools

The force placed on the fingers, hands, and wrists by a repetitive task is an important contributor to CTS. To alleviate the effect of force on the wrist, design tools and tasks so that the wrist position is the same as it would be if the arms dangled relaxed at the sides.

  • No task should require the wrist to deviate from side to side or to remain flexed or highly extended for long periods of time.
  • The handles of hand tools such as screwdrivers, scrapers, paintbrushes, and buffers should be designed so that the force of the worker’s grip is distributed across the muscle between the base of the thumb and the little finger, not just in the center of the palm.
  • People who need to hold tools (including pencils and steering wheels) for long periods of time should grip them as loosely as possible.
  • In order to apply force appropriately, the ability to feel an object is extremely important. Tools with textured handles are helpful.
  • If possible, people should avoid working at low temperatures, which reduces sensation in the hands and fingers.
  • Power tools and machines should be designed to minimize vibrations.
  • Wearing thick gloves, when possible, may lessen the shock transmitted to the hands and wrists.

Hand and Wrist Exercises for the Prevention of Carpal Tunnel Syndrome

Hand and wrist exercises may help reduce the risk of developing carpal tunnel syndrome. Isometric and stretching exercises can strengthen the muscles in the wrists and hands, as well as in the neck and shoulders, improving blood flow to these areas. Performing the simple exercises described below for 4 – 5 minutes every hour may be helpful.

Exercises for Carpal Tunnel Syndrome

Wrists Exercise 1

  • Make a loose right fist, palm up, and use your left hand to press gently down against the clenched hand.
  • Resist the force with the closed right hand for 5 seconds. Be sure to keep your wrist straight.
  • Turn your right fist palm down, and press the knuckles against the left open palm for 5 seconds.
  • Finally, turn your right palm so the thumb-side of the fist is up, and press down again for 5 seconds.
  • Repeat with your left hand.
Exercise 2

  • Hold one hand straight up shoulder-high with your fingers together and palm facing outward. (The position looks like a shoulder-high salute.)
  • With the other hand, bend the hand you are exercising backward with the fingers still held together and hold for 5 seconds.
  • Spread your fingers and thumb open while your hand is still bent back and hold for 5 seconds.
  • Repeat five times with each hand.
Exercise 3 (Wrist Circle)

  • Hold your second and third fingers up, and close the others.
  • Draw five clockwise circles in the air with the two fingertips.
  • Draw five more counterclockwise circles.
  • Repeat with your other hand.
Fingers and Hand Exercise 1

  • Clench the fingers of one hand into a tight fist.
  • Release, fanning out your fingers.
  • Do this five times. Repeat with the other hand.
Exercise 2

  • To exercise your thumb, bend it against the palm beneath the little finger, and hold for 5 seconds.
  • Spread the fingers apart, palm up, and hold for 5 seconds.
  • Repeat five to 10 times with each hand.
Exercise 3

  • Gently pull your thumb out and back and hold for 5 seconds.
  • Repeat five to 10 times with each hand.
Forearms (stretching these muscles will reduce tension in the wrist)
  • Place your hands together in front of your chest, fingers pointed upward in a prayer-like position.
  • Keeping your palms flat together, raise your elbows to stretch your forearm muscles.
  • Stretch for 10 seconds.
  • Gently shake your hands limp for a few seconds to loosen them.
  • Repeat frequently when your hands or arms tire from activity.
Neck and Shoulders Exercise 1

  • Sit upright and place your right hand on top of your left shoulder.
  • Hold that shoulder down, and slowly tip your head down toward the right.
  • Keep your face pointed forward, or even turned slightly toward the right.
  • Hold this stretch gently for 5 seconds.
  • Repeat on the other side.
Exercise 2

  • Stand in a relaxed position with your arms at your sides.
  • Shrug your shoulders up, then squeeze your shoulders back, then stretch your shoulders down, and then press them forward.
  • The entire exercise should take about 7 seconds.

Diagnosis

Carpal tunnel syndrome is most accurately diagnosed using a medical history, the patient’s descriptions of symptoms, a physical examination, and electrodiagnostic tests that measure nerve conduction through the hand.

Diagnosing CTS, however, is not straightforward. Only a small fraction of patients exhibit all three factors necessary for a clear diagnosis:

  • Classic CTS symptoms
  • Specific physical findings
  • Abnormal electrodiagnostic test results

Many people have abnormal electrodiagnostic test results without classic symptoms or any symptoms at all. Furthermore, about 15% of the population has symptoms that are consistent with CTS, but in most of these people, test results do not indicate the disorder.

MRI, CT scans, and other imaging tests are not useful for diagnosing carpal tunnel syndrome.

Symptom Description and Severity

Many cases of CTS result from a medical problem that is worsened by repetitive stress factors at work. The patient should give the doctor a detailed history and description of any complaints, in any part of the body. The patient should report in detail any daily activities that require repetitive hand or wrist actions, abnormal postures, or other regular situations that could affect the nerves in the neck, shoulders, and hands. The patient should also report whether the symptoms are more likely to appear at night, or after particular tasks.

Questionnaires. The use of specific questionnaires that score results can accurately assess the severity of the condition.

Hand Diagram. A diagram of the hand and wrist, usually divided into six regions, is a very useful diagnostic tool. Patients are asked to indicate where their symptoms are, including pain, numbness, or tingling, by locating the affected areas on the diagram. They may also be asked to rate the severity of their symptoms. A diagnosis is probable if at least two of fingers 1, 2, or 3 have these symptoms, and if there is pain in or near the wrist. CTS is possible if at least one of these fingers has symptoms. It is unlikely if there are no symptoms in these fingers, the palm, or the wrist.

Ruling out Underlying Medical Disorders

One of the most important first steps in diagnosing CTS is to evaluate any underlying medical disorders that may be contributing to the condition. Experts emphasize the need to fully examine patients with symptoms of CTS. Relying only on CTS symptoms and personal or work histories may fail to detect (and thus properly treat) underlying medical conditions that could be serious. If the doctor suspects that an underlying medical condition may be exacerbating the symptoms of CTS, laboratory tests will be performed. Tests for thyroid disease and rheumatoid arthritis may be helpful. The doctor may take an x-ray, for example, to check for arthritis or fractured bones.

Arthritic Conditions. Arthritic conditions, including rheumatoid arthritis, gout, and osteoarthritis, can all cause pain in the hands and fingers that may mimic carpal tunnel syndrome.

Muscle and Nerve Diseases. Any disease or abnormality that affects the muscles and nerves, including those in the spine, may produce symptoms in the hand that mimic carpal tunnel syndrome.

Ruling Out Other Cumulative Trauma Disorders

About 25% of patients with suspected work-related cumulative trauma or repetitive stress disorders have evidence of other conditions that resemble, but are not carpal tunnel syndrome. A definitive diagnosis is often difficult. Most of these disorders require treatments similar to those used for CTS: rest, immobilization, steroid injections, and surgery if conservative treatment is unsuccessful.

Other Cumulative Trauma Disorders

Location Description
The Median Nerve in Other Locations Repetitive work can cause pressure on the median nerve in locations other than the wrist and can also affect other nerves in the arm and hand. The branch of the median nerve that runs through the palm of the hand can be damaged directly by repeated pounding or by the use of certain tools that are gripped with the palm, such as needle-nosed pliers. The median nerve can also be pinched in the forearm.
Guyon Canal Syndrome (Commonly called ulnar tunnel syndrome) The ulnar nerve can, like the median nerve, be trapped as a result of repetitive stress. When this nerve is trapped, the condition is sometimes referred to as ulnar tunnel syndrome. It is more correctly known as Guyon canal syndrome, however, because this is the name of the passage through which the ulnar nerve passes.

General symptoms are similar to those of carpal tunnel syndrome, but patients experience a loss of sensation in the ring and little finger and in the outer half of the palm. Guyon canal syndrome can be a separate problem, although it commonly occurs with CTS. In such cases, release surgery for CTS usually also relieves the ulnar nerve entrapment.

The ulnar nerve can also be affected at the elbow.

De Quervain’s Tenosynovitis Tenosynovitis is swelling of the slippery covering of the tendons that move the thumb. When it causes pain on the side of the wrist and forearm right below the base of the thumb, it is known as De Quervain’s tenosynovitis. (Finklestein’s Test may help identify this. Make a fist that encloses the thumb, and bend the wrist sideways and down away from the thumb. If it causes pain, it is likely to be De Quervain’s tenosynovitis.) It may be treated with splints or corticosteroid injections. In severe cases release surgery is effective.
Digital Flexor Tenosynovitis (Trigger or Snapping Finger) Digital flexor tenosynovitis, commonly called trigger or snapping finger, is brought on when a tendon thickens, leaving the finger or thumb in a bent position. This disorder usually occurs when the tendons form a knot. It may be a problem in people with hypothyroidism, diabetes, gout, rheumatoid arthritis, or connective tissue disorders. Digital flexor tenosynovitis can cause pain and a clicking sound when the trigger finger or thumb is bent and straightened. It can be effectively treated with corticosteroid injections.
Thoracic Outlet Syndrome Thoracic outlet syndrome is caused by the compression of nerves or blood vessels running down the neck into the arm. The compression occurs at the first rib in the front of the shoulder. This may happen after an accident or simply from repeatedly slouching. It can produce symptoms very similar to those of CTS. Other symptoms may include Raynaud’s phenomenon (changes in sensation and temperature in the hand). A doctor may be able to diagnose the condition by detecting reduced blood flow in the arm as the patient raises the affected hand and turns his or her head toward the opposite side. Although the condition is uncommon, a correct diagnosis is important to differentiate it from CTS, since treatments differ. Surgery may be required to relieve pressure on the nerves and blood vessels.

Physical Assessment Tests for Carpal Tunnel Syndrome

The doctor will perform a physical exam.

The following findings are helpful in identifying carpal tunnel syndrome:

  • Less sensitivity to pain where the median nerve runs to the fingers
  • Thumb weakness
  • Inability to tell the difference between one and two sharp points on the fingertips (this is a late sign of carpal tunnel)

Flick Signal. One important and simple test of carpal tunnel is the “flick” signal:

  • The patient is asked, “What do you do when your symptoms are worse?”
  • If the patient responds with a motion that resembles shaking a thermometer, the doctor can strongly suspect carpal tunnel.

Testing for Thumb Weakness. Two questions are useful in determining thumb weakness:

  • Can the thumb rise up from the plane of the palm?
  • Can the thumb stretch so that its pad rests on the little finger pad?

Provocation Tests. Certain tests can produce symptoms:

  • Phalen’s Test. In Phalen’s test, the patient rests the elbows on a table and lets the wrists dangle with fingers pointing down and the backs of the hands pressed together. If symptoms develop within a minute, CTS is indicated. (If the test lasts for more than a minute, even patients without CTS may develop symptoms.) This test may be particularly important in determining the severity of CTS and assessing the results of treatment.
  • Tinel’s Sign. In the Tinel’s sign test, the doctor taps over the median nerve to produce a tingling or mild shock sensation.
  • Pressure Provocation Test. The doctor presses over the carpal tunnel for 30 seconds to produce tingling or shock in the median nerve.
  • Tourniquet Test. This test uses an inflatable cuff that applies pressure over the median nerve to produce tingling or small shocks.
  • Hand Elevation Test. The patient raises his or her hand overhead for 2 minutes to produce symptoms of CTS. The test was has been proven to be accurate and may provide useful information when combined with the Tinel’s and Phalen’s tests.

Electrodiagnostic Tests

Electrodiagnostic tests analyze the electric waves of nerves and muscles. These tests can help detect median nerve compression in the carpal tunnel.

Electrodiagnostic tests should be used if clinical or provocative tests are positive and the patient is considering surgery. These tests are the best methods for confirming a diagnosis of CTS. Doctors who perform these tests should be certified by the American Board of Electrodiagnostic Medicine, which uses rigorous standards in qualifying doctors. Specific electrodiagnostic tests, called nerve conduction studies and electromyography, are the most common ones performed. Nerve conduction tests can also detect other problems that cause CTS symptoms, such as pinched nerves in the neck or elbow, or thoracic outlet syndrome.

  • Nerve Conduction Studies. To perform nerve conduction studies, surface electrodes are first fastened to the hand and wrist. Small electric shocks are then applied to the nerves in the fingers, wrist, and forearm to measure how fast a signal travels through the nerves that control movement and sensation. Nerve conduction tests are fairly accurate when done on patients with more clear-cut symptoms of carpal tunnel syndrome. They are less accurate in identifying mild CTS, however. Patients should be sure their practitioners perform tests that compare a number of internal responses, not just the responses of muscles located in the palm at the base of the thumb. They should also make sure the tests measure responses on the second or third fingers.
  • Electromyography. To perform electromyography, a thin, sterile wire electrode is inserted briefly into a muscle, and the electrical activity is displayed on a viewing screen. Electromyography can be painful and is less accurate than nerve conduction. Some experts question whether it adds any valuable diagnostic information. They suggest that its use be limited to unusual cases, or when other tests indicate that the condition is aggressive and may increase the risk for rapid, significant injury.

Although electrodiagnostic studies are frequently done to confirm the diagnosis of carpal tunnel syndrome in patients with classic symptoms, they are also performed on patients with symptoms that do not point to carpal tunnel syndrome as clearly. Doctors must interpret test results in these patients more carefully.

Portable electrodiagnostic testing. Portable electronic devices are being evaluated for measuring nerve conductivity. They are relatively quick and easy to use on a large scale in an industrial facility. However, these devices have not been not well studied in clinical trials.

Limitations. Electrodiagnostic studies are not well standardized, and certain conditions can skew the results of either test:

  • Obesity can slow the speed of electrical conduction.
  • Women and the elderly normally have slower conduction times than younger adult men.

Compression of the median nerve

A diagnosis of carpal tunnel syndrome may follow testing the affected hand for numbness, tingling, weakness or pain in specific areas. Muscle and nerve conduction tests may also help affirm or rule out carpal tunnel syndrome.

Treatment

It is critical to begin treating early phases of carpal tunnel syndrome before the damage progresses. A conservative approach to CTS, which may include corticosteroid injections and splinting, is the first step in treating this disorder. The conservative approach is most successful in patients with mild carpal tunnel syndrome. If the initial treatment doesn’t improve symptoms in 2 – 7 weeks, another treatment or surgery should be tried.

Some patients may start with surgery if there is evidence of nerve damage. Studies suggest that surgery is a better option for severe CTS. Surgery improves function and symptoms better than splinting or anti-inflammatory drugs plus hand therapy over the long term. The improvements last for more than 6 months.

Even among patients with mild CTS, there is a high risk of relapse. Some researchers are reporting better results when specific exercises for carpal tunnel syndrome are added to the program of treatments.

Limiting Movement. If possible, the patient should avoid activities at work or home that may aggravate the syndrome. The affected hand and wrist should be rested for 2 – 6 weeks. This allows the swollen, inflamed tissues to shrink and relieves pressure on the median nerve. If the injury is work related, the worker should ask to see if other jobs are available that will not involve the same hand or wrist actions. Few studies have been conducted on ergonomically designed furniture or equipment, or on frequent rest breaks. However, it is reasonable to ask for these if other work is not available.

Conservative Treatment Approach. The following conservative approaches have been shown to provide symptom relief in the short term, although their long-term effectiveness isn’t yet known:

  • Wrist splints
  • Injected or short-term oral corticosteroids
  • Ultrasound

Nonsteroidal anti-inflammatory drugs (NSAIDs) may provide short-term relief of symptoms, but have not been found to help the basic problem go away. NSAIDs include common pain relievers such as aspirin and ibuprofen (Advil). Diuretics, magnet therapy, laser acupuncture, vitamin B6, exercise, or chiropractic care also do not help clear up carpal tunnel syndrome. Other approaches being investigated include omega-3 fatty acid supplements.

Underlying Conditions. It is important to treat any underlying medical condition that might be causing carpal tunnel syndrome. For example, reducing inflammation in rheumatoid arthritis or other forms of inflammatory disorders that directly cause CTS is very helpful. Hypothyroidism and diabetes are diseases associated with an increased risk of CTS. The treatments for such diseases may offer some relief for CTS symptoms.

Wrist Splints

Wrist splints can keep the wrist from bending. They are not as beneficial as surgery for patients with moderate-to-severe CTS, but they appear to be helpful in specific patients, such as those with mild-to-moderate nighttime symptoms that have lasted for less than a year.

Typically the splint is worn at night or during sports. The splint is used for several weeks or months, depending on the severity of the problem, and it may be combined with hand and finger exercises. Benefits may last even after the patient stops wearing the splint.

Corticosteroids

Corticosteroid Injections. Corticosteroids (also called steroids) reduce inflammation. If restricting activities and using painkillers are unsuccessful, the doctor may inject a corticosteroid into the carpal tunnel.

In CTS, steroid injections (such as cortisone or prednisolone) shrink the swollen tissues and relieve pressure on the nerve. There is good evidence that they offer short-term symptom relief in a majority of CTS patients. However, in about half of cases, symptoms return within 12 months. Generally a second injection does not provide any added benefit. Another concern with the use of these injections in moderate or severe disease is that nerve damage may occur even while symptoms are improving.

Corticosteroid injections are helpful for pregnant patients, as their symptoms often go away within 6 – 12 months after pregnancy.

Most doctors limit steroid injections to about three per year, because they can cause complications, such as weakened or ruptured tendons, nerve irritation, or more widespread side effects.

Low-Dose Oral Corticosteroids. A short course (1 – 2 weeks) of oral corticosteroid medicines may provide relief for some people, but the relief does not usually last. Long-term use of these medications can cause serious side effects.

Ultrasound

Ultrasound uses high-frequency sound waves directed toward the inflamed area. The sound waves are converted into heat in the deep tissues of the hand, opening the blood vessels and allowing oxygen to be delivered to the injured tissue. Ultrasound is often performed along with nerve and tendon exercises. Ultrasound treatment appears to be effective in the short term, but its long-term benefit remains unknown.

Yoga and Other Exercise Programs

Yoga. Very limited evidence suggests that yoga practice may provide some benefit for patients with carpal tunnel syndrome. Yoga postures are designed to stretch, strengthen, and balance upper body joints.

General Exercise Program. Some experts have reported that people who are physically fit, including athletes, joggers, and swimmers, have a lower risk for cumulative trauma disorders. Although there is no evidence that exercise can directly improve CTS, a regular exercise regimen using a combination of aerobic and resistance training techniques strengthens the muscles in the shoulders, arms, and back; helps reduce weight; and improves overall health and well-being.

Nonsteroidal Anti-Inflammatory Drugs (NSAIDs)

Nonsteroidal anti-inflammatory drugs (NSAIDs), which include aspirin and ibuprofen (Advil), are the most common pain relievers used for CTS. They block prostaglandins, the substances that dilate blood vessels and cause inflammation and pain. However, there are few well-conducted studies to determine their role in CTS. To date, there is no evidence that they offer any long-term relief, and regular use can have serious side effects. Therefore, NSAIDs are generally not used for the long-term treatment of carpal tunnel symptoms.

Other Conservative Approaches

Ice. Ice may help with acute pain. Some patients have reported that alternating warm and cold soaks is beneficial. (If hot applications relieve pain, most likely the problem is not caused by CTS but by another condition that produces similar symptoms.)

Low-Level Laser Therapy. Some investigators are working with low-level laser therapy (LLLT), which generates extremely pure light in a single wavelength. The procedure is painless. However, two trials comparing laser therapy to conservative treatment or a placebo laser treatment found no real benefit from this therapy.

Alternative Therapies

Many alternative therapies are offered to people with carpal tunnel syndrome and other repetitive stress disorders. Few of these therapies have any proven benefit, however. People should learn how alternative therapies may interact with other medications they are taking, or impact other medical conditions they have, and they should check with their doctor before trying any of these therapies.

Vitamin B6. Vitamin B6 (pyridoxine) is often used for carpal tunnel syndrome. Studies have not supported its benefits, however, either in oral or cream form. It should also be noted that excessively high doses of vitamin B6 can be toxic and cause nerve damage.

Acupuncture. Acupuncture is often used to relieve CTS symptoms. Although the treatment looks promising for symptom relief, there isn’t enough solid research at this point to recommend it for CTS. More studies are needed to evaluate its benefit.

Chiropractic Therapies. Chiropractic techniques may be helpful for some people whose problems are caused by pinched nerves. There is little evidence, however, to support the use of chiropractic therapies for carpal tunnel syndrome.

Magnets. Magnets are a popular but unproven therapy for pain relief.

Botulinum toxin type A. Intracarpal injections of botulinum toxin type A (Botox) have not been well studied.

Surgery

Carpal tunnel release surgery is among the most common surgeries performed in the United States. In various trials, 70 – 90% of patients who underwent surgery were free from nighttime pain afterward. Studies have found that surgery provides a greater benefit over the long term compared with splinting or anti-inflammatory drugs plus hand therapy.

Candidates for Surgery

Although evidence strongly suggests that surgery is more effective than conservative approaches (at least in patients with moderate-to-severe CTS), the decision about whether to have surgery to correct CTS, and when to have it, is not always clear. Electrodiagnostic and other tests used to confirm CTS are not always perfect or useful in determining the best candidates for surgery.

As a result, surgery does not cure all patients. A number of experts believe that release surgery is performed too often. Some recommend a full trial of conservative treatment (such as splints, anti-inflammatory agents, and physical therapy) before choosing surgery. Others warn that CTS is often progressive and will worsen over time without surgery, and that surgery is better than splints and conservative measures for pain relief in cases where carpal tunnel syndrome is likely present.

Factors that may increase the chances of successful surgery:

  • Having surgery performed within 3 years of being diagnosed with the disorder
  • Being in good general health
  • Having very slow nerve conduction results, but also having reasonably good muscle strength before surgery
  • Having symptoms that are worse at night than during the day

Factors that may reduce the chances for success:

  • Having very severe symptoms before surgery, such as:
    • Continual numbness
    • Muscle weakness and wasting
    • Very poor nerve conduction results
  • Symptoms that have been present for more than 10 months
  • Being over 50 years old
  • Performing heavy manual labor, particularly working with vibrating tools. Only slightly more than half of people who use vibrating hand-held tools are symptom-free 3 years after a CTS operation.
  • Patients who are on hemodialysis have good initial success, but the condition deteriorates in about half of these patients after around a year and a half.
  • Poor mental health or alcohol abuse
  • Patients with diabetes and high blood pressure may be more likely to require a second operation.

Standard Release Surgical Procedures

CTS surgery can be performed through a standard open release, a mini-open technique, or endoscopy. There is no clear evidence to suggest that one surgical technique is much better than another over the long term.

Open Release Surgery. Traditionally, surgery for CTS has involved an open surgical procedure performed in an outpatient facility. In this procedure, the carpal ligament is cut free (released) from the median nerve. This relieves pressure on the median nerve. The surgery is straightforward.

Carpal tunnel surgical procedure

In treating carpal tunnel syndrome, surgery may be required to release the compressed median nerve. The open release procedure involves simply cutting the transverse carpal ligament.

The Mini-Open Approach. In recent years, more surgeons have adopted a “mini” open — also called short-incision — procedure. This surgery requires only a 1-inch incision, but it still allows a direct view of the area (unlike endoscopy, which is viewed on a monitor). The mini-open approach seems to reduce recovery time, pain, and recurrence rate compared to an open approach. However, over the long term there doesn’t seem to be any significant difference between the mini-open approach and the standard open release.

Endoscopy. Endoscopy for carpal tunnel syndrome is a less invasive procedure than standard open release.

  • A surgeon makes one or two 1/2-inch incisions in the wrist and palm, and inserts one or two endoscopes (pencil-thin tubes).
  • The surgeon then inserts a tiny camera and a knife through the lighted tubes.
  • While looking at the underside of the carpal ligament on a screen, the surgeon cuts the ligament to free the compressed median nerve.

Patients who have endoscopic surgery report less pain than those who have the open release procedure, and they return to normal activities in about half the time. Nevertheless, at this time the best evidence available does not show any significant long-term advantages of endoscopy over open release in terms of muscle, grip strength, or dexterity. The endoscopic approach may even carry a slightly higher risk of pain afterward. This may be due to a more limited view of the hand with endoscopy. (In the open release procedure, the surgeon has a full view of the structures in the hand.) Because of this reduced visibility, there are more concerns about irreversible nerve injury with endoscopic carpal tunnel release than with open carpal tunnel release. However, larger studies have shown an extremely low number of complications when the procedure is performed by experienced physicians.

Recovery after Surgery

Timing of Recovery. For some patients, release surgery relieves symptoms of numbness and tingling immediately.

  • People who have the operation on both hands will need someone to help them at home for about 2 weeks.
  • Returning to strenuous work right after surgery may cause the symptoms to return. Patients who work in strenuous jobs generally stay out of work for at least a month and often much longer, depending upon the type of surgery and the severity of the condition. Recovery time appears to be faster with endoscopy or mini-open release than with open release.
  • People who perform light office work will return to work much sooner, although possibly with some limitations.
  • Immediately after surgery, patients usually experience a decline in grip strength and dexterity. Studies have reported a wide range of recovery in this area. The scar may remain tender for up to a year.
  • Peak improvement (the best level of improvement a patient can reach) may take a long time (up to 10 months).

Physical Therapy. Physical therapy following surgery has not been shown to speed up recovery or affect the final outcome of CTS surgery.

Complications and Long-Term Outcome

Treatment failure and complication rates of CTS surgery vary.

Complications after surgery may include the following:

  • Nerve damage with tingling and numbness (usually temporary)
  • Infection
  • Scarring
  • Pain
  • Stiffness
  • Loss of some wrist strength is a complication that affects 10 – 30% of patients. Some patients who have jobs requiring significant hand and wrist strength may not be able to perform them after surgery. These workers may also have problems in other parts of the upper body, including the elbows and shoulders. These problems do not go away with surgery and can persist. Studies indicate that 10 – 15% of patients change jobs after a CTS operation.

If pain and symptoms return, the release procedure may be repeated.

Reasons for procedure failure include:

  • Incomplete release of the ligament
  • Extensive scarring
  • Recurrence of the disorder due to underlying medical conditions

Patients who had open release surgery appear more likely to require repeat operations compared with those who have had endoscopic surgery.

Resources

References

BakerNA, Moehling KK, Rubinstein EN, Wollstein R, Gustafson NP, Baratz M. The comparativeeffectiveness of combined lumbrical muscle splints and stretches on symptomsand function in carpal tunnel syndrome. Arch Phys Med Rehabil.2012;93(1):1-10.

Cellocco P, Rossi C, Boustany SE, di Tanna GL, Costanzo G. Minimally invasive carpal tunnel release. Orhtop Clin North Am. 2009;40(4):441-448.

Huisstede BM, Hoogvliet P, Randsdorp MS, Glerum S, van Middelkoop M, Koes BW. Carpal tunnel syndrome. Part I: Effectiveness of nonsurgical treatments — a systematic review. Arch Phys Med Rehabil. 2010;91:981-1004.

Huisstede BM, Randsdorp MS, Coert JH, Glerum S, van Middelkoop M, Koes BW. Carpal tunnel syndrome. Part II: effectiveness of surgical treatmetns — a systematic review. Arch Phys Med Rehabil. 2010;91:1005-1024.

Jarvik JG, Comstock BA, Kliot M, Turner JA, Chan L, Heagerty PJ, et al. Surgery versus non-surgical therapy for carpal tunnel syndrome: a randomized parallel-group trial. Lancet. 2009;374(9695):1074-1081.

Keith MW. American Academy of Orthopaedic Surgeons clinical practice guidelines on the diagnosis of carpal tunnel syndrome. J Bone Joint Surg Am. 2009;91(10):2478-2479.

Keith MW. American Academy of Orthopaedic Surgeons clinical practice guidelines on the treatment of carpal tunnel syndrome. J Bone Joint Surg Am. 2009;91(1):218-219.

Peters-Veluthamaningal C, Winters JC, Groenier KH, Meyboom-de Jong B. Randomised controlled trial of local corticosteroid injections for carpal tunnel syndrome in general practice. BMC Fam Pract. 2010;11:54.

Shi Q,MacDermid JC. Is surgical intervention more effective than non-surgicaltreatment for carpal tunnel syndrome? A systematic review. J Orthop Surg Res.2011;6:17.

Sim H, Shin BC, Lee MS, Jung A, Lee AH, Ernst E. Acupuncture for carpal tunnel syndrome: A systematic review of randomized controlled trials. J Pain. 2010 Nov 17. [Epub ahead of print]

Wright PE. Carpal Tunnel, Ulnar Tunnel, and Stenosing Tenosynovitis. In: Canale ST, Beaty JH. (eds.) Canale & Beaty: Campbell’s Operative Orthopaedics, 11th ed. Philadelphia, PA: Mosby;2007.

 

Pregnancy Pains

During pregnancy, your body goes through numerous changes as it supports the healthy development of your baby and prepares for delivery. With these changes, you will probably experience various aches and pains, many of which are normal. However, you may wonder which pains are considered normal and which may be a cause for concern.

Cramping

Image of woman experiencing pregnancy pain from crampingAs your uterus stretches, it is normal to experience cramping. Other causes of cramping may include gas and constipation. If cramping becomes worse than menstrual cramping, especially if it is accompanied with bleeding and lower back pain, it is important to contact your doctor as soon as possible. It is also important to contact your doctor if you experience severe painon one side during early pregnancy.

Headaches

Image of pregnant woman with a headacheHeadaches are also common during pregnancy. However, if they are severe and do not go away after resting or taking Tylenol, or if you notice vision changes or light sensitivity, contact your health care provider immediately. Keep in mind that while you can take Tylenol (acetaminophen) during pregnancy, it is important to avoid taking Advil and Motrin (aspirin and ibuprofen).

Back Pain

Image of woman experiencing back pain during pregnancyLower back pain is also normal during pregnancy as your body shifts its center of gravity, causing strain to your lower back muscles. Hormonal changes and weakened abdominal muscles can also contribute to lower back pain. Talk with your doctor if the pain persists for more than two weeks or if it is severe. If you experience painful urination and/or bleeding along with the lower back pain, contact your doctor immediately, as these could be signs of complications.

Sciatic Nerve Pain

Sciatic nerve pain is characterized by numbness, tingling, or pain extending from the lower back down the legs. As the uterus grows, the sciatic nerve–which runs from the lower back down the back of the legs–may have pressure put on it. Your baby and relaxed pelvic joints may put additional pressure on the sciatic nerve.

Certain movements, such as bending, lifting, and walking may exacerbate sciatic pain. While sciatic nerve pain is not generally a reason for concern, you should notify your doctor if you are experiencing such pain, particularly if the pain is persistent or if you have difficulty walking.

Leg Cramps

Image of a woman with leg cramp pains during pregnancyLeg cramps are fairly common during the secondand third trimesters, especially at night. In addition to painful cramping, you may also notice a jumpy sensation in your legs. Such cramping may be due to carrying additional pregnancy weight, pressure from the baby on the blood vessels and nerves that connect to your legs, and changes in circulation that occur during pregnancy.

Make sure to stay hydrated, and try not to sit or stand in the same position for a long time. Stretching, massaging your legs, or taking a warm bath may also help. If the cramping becomes severe, or if your leg becomes red, swollen, or warm contact your physician as soon as possible.

Round Ligament Pain

Round ligament pain occurs as the uterus grows, causing the round ligaments to stretch. This can cause sharp pain in the abdomen, side, hip, or groin area and can be triggered by certain movements such as turning in bed or standing up. This is not a reason for concern.

However, if the pain lasts for more than a few minutes, contact your health care provider right away.

Braxton-Hicks Contractions

Braxton-Hicks contractions are practice contractions (also known as false labor) that may begin during the second trimester. These contractions help prepare your body for actual labor and may feel like a tightening sensation in your uterus, lower abdomen, or groin area.

Unlike true labor contractions, Braxton-Hicks contractions do not follow a set pattern and may vary in their intensity and length. Such contractions are generally uncomfortable rather than painful. If your contractions are painful or if you have more than six within an hour, this could be a sign of preterm labor, so it is important to contact your doctor to determine if they are true labor contractions.

Other Pain

Other types of pain you should not ignore include sharp stabbing pain that lasts more than a few minutes, burning or painful urination, shoulder pain, and upper right quadrant (URQ) abdominal pain, generally under the right ribs. Contact your doctor if you experience any of these or other severe pain.

Last Update: 08/2015

Compiled from the following sources:

A.D.A.M., Inc. (2015). Aches and pains during pregnancy. Retrieved from http://www.nlm.nih.gov/medlineplus/ency/patientinstructions/000580.htm

American College of Obstetricians and Gynecologists. (2014). Easing back pain during pregnancy. Retrieved from https://www.acog.org/-/media/For-Patients/faq115.pdf?dmc=1&ts=20150330T1833308806 Harms, R.W. (Ed.). (2004). Mayo Clinic guide to a healthy pregnancy. New York, NY: Harper Collins Publishers Inc. March of Dimes Foundation. (n.d.). Leg cramps. Retrieved from http://www.marchofdimes.org/pregnancy/leg-cramps.aspx# March of Dimes Foundation. (n.d.). Abdominal pain or cramping. Retrieved from http://www.marchofdimes.org/pregnancy/abdominal-pain-or-cramping.aspx Murry, M. M. (2014, September 10). Round ligament pain: Understanding this pregnancy complaint. Message posted to http://www.mayoclinic.org/healthy-living/pregnancy-week-by-week/expert-blog/round-ligament-pain/bgp-20111536Preeclampsia Foundation. (2010). Signs & symptoms. Retrieved from http://www.preeclampsia.org/health-information/sign-symptoms?gclid=CI6n0fP30MQCFZE0aQodM1wAvQ#headache

Fatigue

 

 

 

Arthritis

Arthritis is very common but is not well understood. Actually, “arthritis” is not a single disease; it is an informal way of referring to joint pain or joint disease. There are more than 100 different types of arthritis and related conditions. People of all ages, sexes and races can and do have arthritis, and it is the leading cause of disability in America. More than 50 million adults and 300,000 children have some type of arthritis. It is most common among women and occurs more frequently as people get older.

Common arthritis joint symptoms include swelling, pain, stiffness and decreased range of motion. Symptoms may come and go. They can be mild, moderate or severe. They may stay about the same for years, but may progress or get worse over time. Severe arthritis can result in chronic pain, inability to do daily activities and make it difficult to walk or climb stairs. Arthritis can cause permanent joint changes. These changes may be visible, such as knobby finger joints, but often the damage can only be seen on X-ray. Some types of arthritis also affect the heart, eyes, lungs, kidneys and skin as well as the joints.

There are different types of arthritis:

Degenerative Arthritis

Osteoarthritis is the most common type of arthritis. When the cartilage – the slick, cushioning surface on the ends of bones – wears away, bone rubs against bone, causing pain, swelling and stiffness. Over time, joints can lose strength and pain may become chronic. Risk factors include excess weight, family history, age and previous injury (an anterior cruciate ligament, or ACL, tear, for example).

When the joint symptoms of osteoarthritis are mild or moderate, they can be managed by:

  • balancing activity with rest
  • using hot and cold therapies
  • regular physical activity
  • maintaining a healthy weight
  • strengthening the muscles around the joint for added support
  • using assistive devices
  • taking over-the-counter (OTC) pain relievers or anti-inflammatory medicines
  • avoiding excessive repetitive movements

If joint symptoms are severe, causing limited mobility and affecting quality of life, some of the above management strategies may be helpful, but joint replacement may be necessary.

Osteoarthritis can prevented by staying active, maintaining a healthy weight, and avoiding injury and repetitive movements.

Inflammatory Arthritis

A healthy immune system is protective. It generates internal inflammation to get rid of infection and prevent disease. But the immune system can go awry, mistakenly attacking the joints with uncontrolled inflammation, potentially causing joint erosion and may damage internal organs, eyes and other parts of the body. Rheumatoid arthritis and psoriatic arthritis are examples of inflammatory arthritis. Researchers believe that a combination of genetics and environmental factors can trigger autoimmunity. Smoking is an example of an environmental risk factor that can trigger rheumatoid arthritis in people with certain genes.

With autoimmune and inflammatory types of arthritis, early diagnosis and aggressive treatment is critical. Slowing disease activity can help minimize or even prevent permanent joint damage. Remission is the goal and may be achieved through the use of one or more medications known as disease-modifying antirheumatic drugs (DMARDs). The goal of treatment is to reduce pain, improve function, and prevent further joint damage.

Infectious Arthritis

A bacterium, virus or fungus can enter the joint and trigger inflammation. Examples of organisms that can infect joints are salmonella and shigella (food poisoning or contamination), chlamydia and gonorrhea (sexually transmitted diseases) and hepatitis C (a blood-to-blood infection, often through shared needles or transfusions). In many cases, timely treatment with antibiotics may clear the joint infection, but sometimes the arthritis becomes chronic.

Metabolic Arthritis

Uric acid is formed as the body breaks down purines, a substance found in human cells and in many foods. Some people have high levels of uric acid because they naturally produce more than is needed or the body can’t get rid of the uric acid quickly enough. In some people the uric acid builds up and forms needle-like crystals in the joint, resulting in sudden spikes of extreme joint pain, or a gout attack. Gout can come and go in episodes or, if uric acid levels aren’t reduced, it can become chronic, causing ongoing pain and disability.

Diagnosing Arthritis

Arthritis diagnosis often begins with a primary care physician, who performs a physical exam and may do blood tests and imaging scans to help determine the type of arthritis. An arthritis specialist, or rheumatologist, should be involved if the diagnosis is uncertain or if the arthritis may be inflammatory. Rheumatologists typically manage ongoing treatment for inflammatory arthritis, gout and other complicated cases. Orthopaedic surgeons do joint surgery, including joint replacements. When the arthritis affects other body systems or parts, other specialists, such as ophthalmologists, dermatologists or dentists, may also be included in the health care team.

What Can Be Done About Arthritis?

There are many things that can be done to preserve joint function, mobility and quality of life. Learning about the disease and treatment options, making time for physical activity and maintaining a healthy weight are essential. Arthritis is a commonly misunderstood disease.

 

Plantar Fasciitis-

  • Illustration showing plantar fascia and location of heel pain

    Plantar fasciitis

Plantar fasciitis (PLAN-tur fas-e-I-tis) is one of the most common causes of heel pain. It involves inflammation of a thick band of tissue that runs across the bottom of your foot and connects your heel bone to your toes (plantar fascia).

Plantar fasciitis commonly causes stabbing pain that usually occurs with your first steps in the morning. As you get up and move more, the pain normally decreases, but it might return after long periods of standing or after rising from sitting.

Plantar fasciitis is more common in runners. In addition, people who are overweight and those who wear shoes with inadequate support have an increased risk of plantar fasciitis.

Symptoms

Plantar fasciitis typically causes a stabbing pain in the bottom of your foot near the heel. The pain is usually the worst with the first few steps after awakening, although it can also be triggered by long periods of standing or rising from sitting. The pain is usually worse after exercise, not during it.

Causes

Under normal circumstances, your plantar fascia acts like a shock-absorbing bowstring, supporting the arch in your foot. If tension and stress on that bowstring become too great, small tears can arise in the fascia. Repetitive stretching and tearing can cause the fascia to become irritated or inflamed, though in many cases of plantar fasciitis, the cause isn’t clear.

Risk factors

Though plantar fasciitis can arise without an obvious cause, factors that can increase your risk of developing plantar fasciitis include:

  • Age. Plantar fasciitis is most common between the ages of 40 and 60.
  • Certain types of exercise. Activities that place a lot of stress on your heel and attached tissue — such as long-distance running, ballistic jumping activities, ballet dancing and aerobic dance — can contribute to an earlier onset of plantar fasciitis.
  • Foot mechanics. Being flat-footed, having a high arch or even having an abnormal pattern of walking can affect the way weight is distributed when you’re standing and put added stress on the plantar fascia.
  • Obesity. Excess pounds put extra stress on your plantar fascia.
  • Occupations that keep you on your feet. Factory workers, teachers and others who spend most of their work hours walking or standing on hard surfaces can damage their plantar fascia.

Complications

Ignoring plantar fasciitis may result in chronic heel pain that hinders your regular activities. Changing the way you walk to minimize plantar fasciitis pain might lead to foot, knee, hip or back problems.

 

Scoliosis

  • Comparing normal curves in spine with scoliosis

    Scoliosis

Scoliosis is a sideways curvature of the spine that occurs most often during the growth spurt just before puberty. While scoliosis can be caused by conditions such as cerebral palsy and muscular dystrophy, the cause of most scoliosis is unknown.

Most cases of scoliosis are mild, but some children develop spine deformities that continue to get more severe as they grow. Severe scoliosis can be disabling. An especially severe spinal curve can reduce the amount of space within the chest, making it difficult for the lungs to function properly.

Children who have mild scoliosis are monitored closely, usually with X-rays, to see if the curve is getting worse. In many cases, no treatment is necessary. Some children will need to wear a brace to stop the curve from worsening. Others may need surgery to keep the scoliosis from worsening and to straighten severe cases of scoliosis.

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