Wrist pain & carpal tunnel
Neurological (nerve) problems – Carpal tunnel
Carpal tunnel symptoms often come at night and spread to involve most of the hand, usually sparing the little finger area. Numbness, tingling or burning may be felt and the symptoms can even spread up the forearm. In really severe cases, it can cause an intense burning pain, enough to reduce one patient at our clinic to tears.
People with carpal tunnel often feel the need to shake the hand to get rid of it, or they may want to hang the affected arm over the edge of the bed.
Carpal tunnel is due to median nerve irritation. This is a nerve that begins near the neck and feeds a lot of the muscles of the hand. At several points along its length it travels between or through muscles that, if tight, can compress and irritate it.
What tests are there?
When we suspect this problem, our examination will normally involve adding pressure at these points to see if the nerve is unusually sensitive. The ultimate & most reliable test is to measure the conduction along the nerve to see if it has been affected, but in many cases the symptoms can be re produced by simple and non invasive tests involving putting the wrist in specific positions.
One place where compression can happen is from the ligaments that cross the front of the wrist. If the nerve conduction tests are positive and these ligaments are very tight, then surgery is often performed to ease the pressure. This is normally reserved for more severe cases which have not responded to hands-on treatment.
A case study
A woman in her forties came for treatment complaining about numbness starting in the middle fingers of both hands before spreading to the whole hand. The problem started about 6 weeks earlier & came only when in bed. Movement quickly relieved it, but because it would return several times in one night, her sleep was very disturbed.
The fact that it was in both hands was unusual. On examination, the upper back was very stiff and restricted in its movement, whilst the wrists themselves seemed hypermobile – meaning that she had more flexibility there than your average person.
Asking the right questions is always helpful in making a diagnosis and finding out why things happen. In her case she had recently stopped work, and her problem had improved somewhat since. So work was obviously a contributing factor to the problem.
But of more importance was the fact that she had a habit of sleeping with one or other hand bent forward against her head. In this position the median nerve is compressed. In fact this is one of the tests commonly used to see if someone has carpal tunnel. So in effect she was sleeping in the test position, but for a lot longer than a test would be done for!
She responded very rapidly to treatment on the upper back with the attacks becoming less frequent from the first visit & disappearing completely after a couple of months.
Other hand & wrist problems
Not all hand symptoms are due to problems in the hand or wrist. Cab drivers, for example, who might spend hours with their elbows resting on the driver’s window sill, may compress & irritate the ulnar nerve under the elbow – this is the location of the pain most of us have experience when banging the ‘funny-bone’ !
Similarly, cyclists can also experience the same ulnar nerve irritation, but this time in the hand itself due to continuous compression against the handle bars. A different compressed nerve, this time the radial nerve coming out of the lower neck can result in weakness of the muscles running down the back of your forearm, leading to a reduced ability to bend the hand back.
On your first visit for wrist pain or carpal tunnel we will identify which nerve is affected and where it is being irritated.
A fall on the outstretched arm and hand is a common source of fracture of a bone under your thumb (the scaphoid). Pain in this area should always be investigated with x ray as a fracture can leave a bony fragment of the scaphoid without blood supply, leading to necrosis (death!) of the fragment and further complications.
Faulty joint mechanics & abnormal restricted movement of the small bones of the wrist area and the two long bones of the lower arm (radius & ulnar) create problems that seem to come about for no obvious reason. In such cases, an x-ray or MRI may show nothing despite the pain & the patient may still be in pain despite advice to do various hand exercises or wear a splint.
Subtle restrictions in these joints won’t be observable with imaging, but can cause continued pain if they are not treated.
These are more likely causes of hand pain in older patients, but the onset of arthritis can be brought forward by trauma or repetitive long term use of heavy hand held tools such as hammers. As elsewhere in the body, such as the lower back, patients will often find that although we can’t get rid of the wear and tear, they can be a lot more comfortable and enjoy more mobility with treatment.
As with most musculo-skeletal conditions, there are causes of hand & wrist pain which are linked to diseases rather than to local problems. Diabetes, gout, bone tumours, rheumatoid arthritis & thyroid problems can also be responsible. These need considering as potential contenders in the diagnostic process.