Case Presentation

• A 42-year-old female presents to your

clinic complaining of numbness and
tingling in her right hand for approximately
one year. The sensation is on the palmar
surface of the thumb, index, and middle
fingers, and ring finger. She states that
sometimes it feels like her hand is ''asleep,"
while other times it feels like ''pins and
needles." The symptoms occur at night
and
the only relief is ''flicking'' of the wrist.
 Case Presentation
• Occasionally, the pain is referred to the
forearm and shoulder, but only during an
acute flare-up. The patient has worked as
a secretary at bosch for the past 15 years.
• Physical examination: overweight female in
NAD. Sensation full & = bilat; DTR's
2+ & = bilat; slight atrophy and weakness
of the thenar muscle and grip strength on
the Rt.; decreased ROM of Rt. wrist
compared to Lt.; positive Tinel's and
 Differential Diagnosis

• Cervical radiculopathy
• Cervical disc herniation
• Thoracic outlet syndrome
• Diabetes mellitus
• Fracture/Dislocation
• Carpal tunnel syndrome
 Definition
• Median nerve entrapment at the wrist
 What is Carpal Tunnel
Syndrome?
• This condition is most commonly described
as an entrapment neuropathy of the
median nerve at the wrist in the carpal
tunnel
- The tunnel is formed by the carpal bones and
the transverse carpal ligament
- Contents of the tunnel include the flexor
tendons and the median nerve
 INTRODUCTION
• Repetitive motion disorders account for
approximately 50°/o of all work-related
injuries.
• 2nd only to Low Back Pain
• The most common repetitive motion
disorder is Carpal Tunnel Syndrome.
 ANATOMY
• Carpal Tunnel:
- space on the volar aspect of
the wrist formed by the carpal bones
and the transverse carpal ligament
(flexor retinacuIum).
 ANATOMY
• Boney Landmarks
- Proximal:
• pisiform bone - medially
• scaphoid bone - laterally
- Distal:
• hook of the hamate - medial
• trapezium bone - laterally
 Right Hand- Carpal Bones

Dorsal view

,---R a d t U I

Tubtrcle Of rac,u1
Sty0t0
°' v,..... Styk>ld process of ulna SlylOid PfOCHS of ra.d,us

Tut>t,cio 01 acaptiold

Trapezium

Capitale

5
2 3 • 4
3 2

Metacarpals
Metacarpals
 CONTENTS OF CARPAL
TUNNEL
• I. Median nerve
• 11. 2 synovial sheathes
- 1st sheath
• 8 flexor digitorum profundi and superficialis
tendons.
- 2nd sheath
• flexor pollicis longus tendon.
 Ligaments of Wrist
Palmar view with structures passing through and over carpal
Palmar carpal ligament
tunneltendon
Palmaris longus Radius 1, --'---U l n a
r - - - - 1 n t e r o s s e o u s membrane
(thickening of deep fascia,

L
cut and reflected)
""' - - - - U l n a r a. and n.
Radial a. and
superficial =- .
paImar b r a n c h - - - - - l - - - , - - c : : :
Flexor carpi
ulnaris tendon
f ��
Flexor carpi . , _ - - - Flexor
radialis t e n d o n - - -::: digitorum
profundus
Flexor pollicis Flexor digitorum
tendons
longus tendon superficialis tendons

Median n. Pisiform
Deep branch of ulnar a.
• and n.
Hamulus of hamate
Palmar aponeurosis
Tubercle of scaphoid
Tubercle of trapezium
Flexor retinaculum \ C>Novarlis

5
s 4
l-1 - - -2 v
- - - - - - Metacarpals J
 Clinical Presentation
Cutaneous
Innervation
• Median nerve
cutaneous sensory
distribution
- Palmar surfaces
t
',;,.-.

--- -
of -
/;: ........-·1 ..7"'

'
2

• Thumb =-
• Index /
• Middle
 How does one get carpal
tunnel syndrome?
• 1. Increase pressure within the canal.

• 2. Compromise space within the canal.

 Pressure is increased in the
carpal tunnel by:

• Both flexion and extension of the wrist.

 Space is compromised in the
carpal tunnel by:
• Thickening of the tendon sheaths.

• Encroachment from other structures.

 Clinical Presentation

• Compression of median
nerve in carpal tunnel
- Anesthesia
- Paresthesia
-P a i n
- Muscle weakness
- Decreased ROM
- Night-time symptoms
- "Flick Sign"
 Workers involved in specialized
tasks:
• 1. Require repetitive use of the hand
and wrist while held in forced
flexion.
• 2. Carpal tunnel becomes tighter when
wrist held in forced flexion.
 Physical Examination
• 1. Tinel's sign
- a. lightly tapping over volar aspect of wrist
- b. + sign- tingling distally of 1st 3 1/2 digits.
• 2. Phalen's sign
- A. George Phalen - hand surgeon of
Cleveland clinic.
- B.Hyperflex both wrists against
dorsal surface of each hand.
- C. + test- numbness in approx. 30
sec.
 Special Tests
Phalen's & Tinel's Tests

• Phalen's
- Wrist flexion to
maximum for
60 sec
• Tinel's
- Tapping over !
f
transverse carpal
• Symptoms
ligament
- Pain
- Anesthesia
- Paresthesia
 OMT TREATMENT
• Transverse Carpal Ligament
• Carpal Bones
• Interosseous Membrane
 Osteopathic Treatment
• Myofascial release
• Articulatory
• Muscle energy
 OMT Techniques

• Opponen's Roll
• Squeeze with Rapid Circumduction
• Wrist & Interosseous Membrane Ligament
 Myofascial Release
• 1. Pressure applied centrally from the dorsal surface
of the carpal bones.
• 2. Simultaneously apply pressure to the edges of
the carpal bones on the ventral surface of the wrist.
(lateral and medial borders of the carpal tunnel.)
• 3. Simultaneously the D.O. catches the
patient's thumb and pulls it back into
hyperextension with abduction treating the
attachment of the abductor pollicis brevis muscle.
• 4. Digits and wrist are hyperextended (pulls
flexor tendons into canal and distends canal from
inside out.)
 Opponens Roll Technique
• Lateral axial rotation stretches the
opponens pollicis muscle.
• Thenar abduction with extension and
lateral rotation.
 Supination

- - - -

Pronation

Fi.gure 4. Forearni/wrisl. supin.at.ion

rt.o and pronatinn ( b o t t o m ) testing.

Neutral
_

_,,,,...,, \
---
Axial rotatio
"opponen

-
- --
Figure a. OµporumR roU nu,neuuer. 1,efl
l Wa x e d or rwmral poi;1lion. Hight: Thenar
abduction with exlensinn and l.areral rota­
tion
 Opponen's Roll
• Grasp first digit (thenar em.in.) and
fifth digit (hypothenar emin.) with
each hand
• Contact pisiform and scaphoid
bones with thumbs
• Extend wrist, abduct and
laterally rotate first digit with
counterforce over hypothenar area
• Use thumbs to stretch at boney
contact points the transverse carpal
ligament in lateral/medial direction
• Provide stretch to transverse
carpal ligament for 3-5 minutes
• Perform at each clinic visit and
teach patient to perform technique
at home on daily basis
 Myofascial Release
• 1. Crisscross thumbs over medial and
lateral borders of carpal tunnel.
• 2. Apply gentle traction.
• 3. Have patient abduct fingers and hold
in abduction.
• 4. With abduction maintained, have
patient slowly flex involved wrist over
D.O.'s crisscrossed thumbs.
 Articulatory Technique
• 1. D.O. applies a squeeze between
his/her hands, producing traction at the
joint as the
thenar and hypothenar eminences separate.
• 2. D.O. maintains the squeeze and
applies the articulatory force as a
circumduction of the patient's wrist in a
clockwise, then counterclockwise conical
motion, carrying the dysfunction through
the restrictive barrier.
 Squeeze with
Rapid
•
Circumduction
Place heel of both hands over
radiocarpal region of carpal
bones & interlace fingers
• Attempt to distract fingers
while squeezing fingers together
- Causes the heel of
each hand to squeeze together
• Circumduct wrist in circular or
figure eight fashion
• Care should be taken to maintain
capsular tension throughout the
articulatory sweep
• Pe1form at each clinic visit
 Bones of Forearm~
Right radius and ulna
i n pronatlon
Right radius and ulna (antenor v,ew)
In auplnation _,J..---Tr o c h l e a r n o l c h - - - - l l i­
(anlenor view)
_ _ , 1 , - -c o r o n o l d process

Tuberos1ty
of radius - - 1 - - - 4

Anterior
sur1ace

Anlerior
Anterior margin
margin-....1.!....._
. . - . _ ; ; ; . - - - - lnterosseous
membrane i..;·
lnterosseous
m a r g i n - --4- ---
•-- -l n t e r o s s e o u s
marg,n

Dorsal Groove lor

extensor
carp, radialts
Groove for longus and
extensor brev1s mm.
poltCIS
longus m.
Groove for Area lor
extensor ol<tensor
dog torum poll,c1s brevls
and and abductor
extensor
1nd1Cis mm poll1c1s
 Muscle Energy (interosseous
membrane)
• 1. 0 . 0 . thumbs are crossed over the
anterior surface of the patient's
forearm with interosseous
dysfunction between his/her thumbs.
• 2. The pad and tip of the thumb of the hand
closest to the 0 . 0 . contacts the lateral
side of the ulna. The thumb of the
other hand contacts the medial side of the
radius.
• 3. Have patient attempt to pronate palm and
use isometric counterforce.
 Flexion with Posterior Carpal
Glide
• 1. Flex wrist to balanced ligamentous
tension.
• 2. Apply traction.
• 3. Move joint into extension to articulate
through the restrictive barrier.
 Extension With Anterior
Carpal Glide
• 1. Extend wrist to the point of balanced
ligamentous tension.
• 2. Apply traction.
• 3. Move joint into flexion to articulate the
joint through the restrictive barrier.
 ,

I .... .
t. ·-.,:;;
;:_
, .

.-�!
•JS.'•

A
,
,._ . t.....
·t-
.tl· f;f:_.:,; -1
».·
&:.-
•,,r!'
J ;• . ·

Ii. • . , . •
_..::.�j,...:.•_,"'•.

.. ,......
r:, I' • -.· ••...• ,1··
k• •• " l ) • . .
...:··
. .-.. .......
• ,..
• ..'.•.•.-:·;);-:1,
·.'
''
.,?•. J' -.,
 Abduction with Medial carpal
Glide
• 1. Wrist in abduction to balance
ligamentous tension.
• 2. Apply traction.
• 3. Move the joint into adduction to
articulate the joint through restrictive
barrier.
Adduction with Lateral Carpal
Glide
• 1. Place wrist in adduction to the point
of balanced ligamentous tension.
• 2. Apply traction.
• 3. Move the joint into abduction to
articulate the joint through
the restrictive barrier.
 Patient
Stretches
• 1. Patient places palm of affected extremity
against wall.
• 2. Patient "hooks" hypothenar region of
opposite hand into thenar region of hand to
be stretched.
• 3. Thumb of affected extremity is grasped and
extended.
• 4. While holding thumb and thenar
eminence, palm is placed against wall in
extension.
• 5. Elbow is tucked into patient's iliac crest to
,
7

_......... . . .
Fi_gure 2. Selfstretch for carpal canal with potieut .5eated. Both
tl1e11ar and wrist COfl!p()llellbi areOfiJiresscd. Pl.adng the formrmbetween
the thighs allows control of the wri. t component of the stretch and
frees the other hand for lrut thenar portirm. Slowly squeezing the
thighs together extends thP wrist and digits.
 .
I
I
.. ,
•. '

,i, , I
\
'I

Figure 1. Self-stretch for carpal canal with pa.tient sw.nding. Both thenar and wrist components are addressed. Use of a wall frees the other
1

hand to control the thumb. 1'he focused ui.ews on the right :;lww the elbow tucked into theiliac crest, so that as the patient leans forward
(see enlargement on the left), the body weight assisl.s the stretch.