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Hand & Wrist

Carpal Tunnel Syndrome

Carpal tunnel syndrome is a common problem that affects hand function. It is caused by compression of a major nerve, the median nerve, in the wrist leading to symptoms of pain, numbness and weakness in the affected hand. It is the most common nerve entrapment syndrome estimated to affect around 5% of all adults.

If you think you might have carpal tunnel syndrome, here are some ways to prevent it and treat it if it does occur.

What is nerve entrapment syndrome?

Nerves are like broadband cables carrying signals to body parts telling them what to do and receiving information from these areas sending them back to the centre. Just like cables, there can be information bottlenecks caused by areas of entrapment, but instead of slow download speeds, video lag during a Zoom meeting or when playing a video game, you experience symptoms like muscle weakness, pins and needles, numbness etc. depending on what area the nerve is supplying.

These areas of nerve entrapment typically occur where a nerve crosses a joint and is bordered by bone, at least on one side. Compression of the median nerve in the carpal tunnel accounts for 90% of all nerve compression syndromes.

What is Carpal Tunnel Syndrome (CTS)?

The carpal tunnel (carpus = wrist (Latin)) is a narrow passageway that runs along the front of your wrist. It is formed by the wrist bones and a tight transverse carpal ligament that holds down the tendons that bend your fingers. It also contains the median nerve that supplies muscles and sensation to areas in the hand.

Carpal tunnel syndrome occurs when pressure builds up on the median nerve inside the carpal tunnel because of swelling or inflammation of the nerve or surrounding structures. This can cause numbness, tingling, pain, weakness, and sometimes even loss of feeling in some of the fingers.

CTS usually affects people who do repetitive tasks with their hands for long periods of time. For example computer keyboard users, musicians, assembly line workers, etc. Symptoms may be mild at first but worsen over time.

Who is at risk of developing carpal tunnel syndrome?

Anyone can develop carpal tunnel syndrome but some people have a higher risk. These include:

  • Age 50+.
  • Women.
  • People who have had a previous break or surgery on the wrist.
  • Those who work with vibrating equipment.
  • Individuals who spend hours using keyboards every day. That's including video gamers.

Common symptoms of Carpal Tunnel Syndrome?

Common signs and symptoms include:

  • Numbness or tingling in one or more fingertips.
  • Weakness of grip strength - you may struggle to open a jam jar.
  • Painful burning sensations along the course of the median nerve (thumb, index and middle finger).
  • Difficulty using tools such as scissors, knives, forks, toothpicks, writing utensils, etc.
  • Waking at night with hand symptoms that want you to shake it out.


What are the causes of carpal tunnel syndrome?

There are many factors that contribute to the development of carpal tunnel syndrome including:

  • Repetitive motion
  • Overuse injuries
  • Obesity
  • Diabetes
  • Rheumatoid arthritis
  • Osteoarthritis
  • Hyperthyroidism
  • Hypothyroidism
  • Vitamin deficiency
  • Alcohol abuse
  • Smoking
  • Excessive caffeine intake
  • Medications like steroids, anti-depressants, blood thinners, diuretics

How do you diagnose Carpal Tunnel Syndrome?

Diagnosis begins by taking a thorough medical history. You will be asked about any recent injury or illness, medications taken, family health history, occupation, hobbies and other risk factors that may be associated with your symptoms.

A thorough physical examination is done looking for evidence of CTS and how established it is. A test you can do at home to check for CTS is the Phalen's manoeuvre or wrist-flexion test:

Press the back of your hands and fingers together with your wrists flexed fully and your fingers pointing down. Stay in this position for at least one or two minutes. If your fingers develop a tingle or get numb, then you likely have carpal tunnel syndrome and you should arrange to see a specialist. Click here to schedule your appointment.

Nerve conduction study testing sensory function and motor function of the nerves of the hand help determine whether the problem lies within the nerves, the muscles surrounding them or coming from a different site altogether. They also help determine how severe your CTS is. This test is only requested when necessary because it can be uncomfortable to undergo.

Several medical conditions can first present with symptoms of carpal tunnel syndrome, espescially when both sides are affected.

What treatments are available for carpal tunnel syndrome?

Treatment options vary depending on the severity of your symptoms:

Mild cases will often respond to rest from activities that cause the symptoms. If you must continue you can modify your activity: e.g. take frequent breaks, use a wrist rest if you use a keyboard.

Wearing a wrist splint or trialling a short course of non-steroidal anti-inflammatory drugs (NSAIDs), if appropriate, can help alleviate symptoms in mild cases.

Hand therapy is another option for those suffering mild symptoms.

Steroid injection into the area around the median nerve is effective in cases where there may be a reversible cause.

For more severe cases, surgical intervention may be required. This involves decompression of the carpal tunnel by dividing the transverse carpal ligament either through an open or key-hole/endoscopic procedure. The procedure is straightforward with excellent results (recurrence rate less than 5%) if done at the right time. 

Having undergone surgical training Dr Ade has, ahem, first-hand experience surgically managing CTS and knows when you will be best served with surgery over conservative treatment.

Carpal tunnel syndrome is a completely reversible condition if addressed early, but if there is delay in attending to it the eventual nerve damage can be irreversible.

Trigger Finger/Trigger Thumb

Have you noticed one of your fingers, or thumb, is painful when you try to straighten it? Or the finger gets stuck bent and you have to physically straighten it? You may have a trigger finger or trigger thumb. Read on to find out more about this common yet treatable condition.

What is a trigger finger?

A trigger finger or trigger thumb sometimes referred to as stenosing tenosynovitis, is a condition that affects one or more of the tendons in the hand making it difficult to bend and/or straighten the affected finger or thumb. The ring finger and thumb are most often affected.

The (A-1) pulley that holds the flexor tendon down in your palm becomes inflamed and thickened making it difficult for the tendon to glide through when the finger bends. With time the tendon may develop a nodule that can usually pass through the pulley but catches when you straighten your fingers causing a popping sensation. The nodule can get stuck but then release suddenly, like a trigger being pulled.

What causes trigger finger?

Activities and occupations that require repeated and prolonged gripping, such as the use of shears or handheld tools, have been associated with developing the painful condition.

Medical conditions like diabetes, rheumatoid arthritis and thyroid disease are known risk factors for developing triggering of the fingers. There is even a link with having carpal tunnel syndrome.

What are the symptoms of trigger finger/trigger thumb?

Symptoms of trigger finger may start with discomfort felt at the base of the affected finger or thumb, where the finger joins the palm. You may experience stiffness with finger motion or a reduction in the range of motion.

As the condition worsens the finger will catch or lock when you attempt to straighten it and this may occur more frequently at night or early in the morning.

How is the diagnosis of trigger finger/trigger thumb made?

The good news is that a trigger finger is easily diagnosed through taking your medical history and performing a physical examination. A diagnostic ultrasound scan, done at the time of your appointment, can help confirm the diagnosis but is not always necessary.

A trigger finger or trigger thumb may be the first sign of a medical condition like poorly controlled diabetes mellitus, so it's important you undergo a thorough medical assessment.

When should you see a doctor?

Getting medical treatment early once you develop symptoms of a trigger finger or trigger thumb reduces your chances of having prolonged or recurrent symptoms.

If your finger is hot and swollen, you should seek medical care urgently as you may have an infection.

How do you treat a trigger finger?

Treatment of a trigger finger is usually based on non-operative management strategies. Outside of activity modification and non-steroidal anti-inflammatory medications treatment options include:

  • Splinting - If you do not want or are not able to have a steroid injection nightly splinting of the involved fingers for several weeks has been shown to be effective at reducing symptoms in up to 65% of patients.
  • Corticosteroid injection - A steroid injection into the tendon sheath (around the tendon), at the level of the symptoms, is very effective at reducing pain and triggering. This is the most commonly used treatment because it is successful in almost all cases unless you have had the condition for a long time,  you have diabetes mellitus or have multiple fingers affected in which case your long-term success rate from an injection can be lower.
  • Surgery - If non-operative/conservative measures fail to relieve your symptoms then surgical release of the A-1 pulley is recommended. This is a very straightforward procedure typically carried out by a hand surgeon.

If you think you have a trigger finger or trigger thumb click here to make an appointment so we can help rid you of this common condition.

De Quervain's tenosynovitis

De Quervain tenosynovitis is a painful condition that affects the tendons of the thumb side of the wrist. Commonly associated with sports and occupations that involve tight gripping/ twisting movements of the wrist, and new mothers caring for their infants, de Quervain is now recognized as a common cause of wrist pain in video gamers of all ages.

What is de Quervain's tenosynovitis?

De Quervain (pronounced dih-kwer-VAIN) tenosynovitis develops when the two tendons around the base of the thumb (abductor policis longus and extensor policis brevis) become constricted and inflamed by the thickening of the band of connective tissue (the extensor retinaculum) that normally functions to stop the tendons from bowstringing when you move them. This is similar to what happens when you get a trigger finger, only this is on the back (first extensor compartment) of the wrist.

The exact cause is not clear but we believe it is the result of overuse of the wrist and thumbs.

Who gets de Quervain tenosynovitis?

  • Women are 8-10 times more likely than men to develop the condition.  Mothers of newborns are particularly prone. It's not clear if this is due to the hormonal changes that occur around pregnancy or activities associated with infant care.
  • Individuals who play sports or activities where you have to grip tightly, such as golf and racquet sports.
  • People who type or knit for long periods.
  • Video gamers - Using the joystick on a console controller or "thumbing" a touch screen is more likely to cause the condition over using a keyboard and mouse.

What are the symptoms of de Quervain tenosynovitis?

At first, you may only notice pain or stiffness around the thumb side of your wrist that comes on gradually after a prolonged period of repetitive activity like video gaming.

This may develop into severe pain when you perform actions like gripping and raising objects with your wrist in a neutral/straight position, such as lifting your baby out of a bath or cot.

If not attended to early a swelling can develop at the site of the pain.

How do you diagnose de Quervain tenosynovitis?

De Quervain is easily diagnosed by your doctor by taking a careful history and performing a physical examination.

A useful test you can try yourself is Eichoff's test: make a fist wrapping your fingers around your thumb then gently angle your wrist down away from your thumb. Be careful, this can be very painful!

When you attend your appointment an in-clinic ultrasound scan may be used to help confirm the diagnosis.

Treatment options for de Quervain tenosynovitis

The first line of treatment you can try at home is to rest the wrist through activity modification and wearing a wrist/thumb splint.

You can apply ice packs for pain relief and or take nonsteroidal anti-inflammatory medication, if you are able to, and have taken guidance from an appropriate healthcare professional.

Corticosteroid injection into the extensor tendon sheath is very effective at resolving pain and reversing swelling over the tender area. Steroid injection alone has a cure rate of 83% compared to 14% for splinting.

For cases that do not respond to non-operative treatment, surgery is recommended.

Ganglion cysts of the hand and wrist

Finding a lump on any part of your body can be very concerning indeed. What's the cause of it? Is it serious? What can I do about it?

While there are many serious causes for lumps and bumps one of the most common ones we encounter are ganglion cysts. These are non-cancerous fluid-filled sacs that form around joints and along tendons. 

For the majority of us, these are harmless lumps that are merely unsightly. However, because they can cause discomfort, affect function, and there is a need to confirm what they are, it is still important to seek medical attention.

What are the symptoms of ganglion cysts?

In the majority of cases ganglions are painless lumps you may first notice out of the blue or someone else comments on. They can be painful to press against, and if large enough may restrict the range of motion of a joint.
They can cause pain if they press against a sensitive structure like a nearby nerve, or damage to local structures like the nail bed causing abnormal nail growth.

The first time you may become aware of a ganglion is when you get pain at the back of the wrist when you do actions that push the joint to full extension/backwards, e.g. receiving a barbell in a front-rack position, doing a push-up or an upward-facing dog pose in yoga.

Common location of ganglion cysts

Ganglion cysts most commonly occur at the back of the wrist (dorsal wrist ganglion cyst), but they can also be found:

  • at the front near the base of the thumb (palmar wrist ganglion cyst) 
  • on the back of a finger nearest the nail (dorsal digital ganglion cyst)
  • on the palm side of a finger where it meets the palm (flexor tendon sheath ganglion cyst) 
  • and around other body parts like the shoulder, knee, foot and ankle joints.

Causes of ganglion cyst

The cause remains unknown; however, there is an association with a previous history of joint trauma and joint arthritis.

Theories include:

  • Joint stress from an acute injury or repetitive microtrauma causes a rent in the joint capsule. This allows leakage of joint fluid into the surrounding tissue. A reaction between this fluid and local tissue results in the creation of the gelatinous cystic fluid and the formation of the cyst wall.
  • Abnormal mechanics of a worn or unstable joint stimulates nearby cells to produce mucin, the main component of the jelly-like content of cysts. Over time these collections can increase in size or coalesce to form a larger collection. This may explain why ganglions can fluctuate in size.

How do you diagnose a ganglion cyst?

Shoulder MRI. Large ganglion cyst eroding the neck of the scapular

Diagnosis of ganglion cysts is typically made by physical examination. A small rubbery lump is felt tethered in place by its attachment to the underlying joint capsule or tendon sheath. The lump may fluctuate in size and occur at characteristic locations.

For cases where the lump is not obvious, ultrasound imaging done during your appointment can help reveal the diagnosis.

An x-ray will show if there is an underlying arthritic joint or if bone erosions exist that would give an indication of how long the ganglion has been there.

MRI scans can provide excellent soft-tissue contrast and allow us to see the characteristic of a cystic mass and the relation to surrounding structures.

Treatment for ganglion cysts

Contrary to tales of yore please refrain from reaching for a King James Bible, or the nearest tome, to bash your ganglion cyst. We have more reliable, and less painful methods, today to rid you of the lump.

The initial treatment option is usually observation as most ganglions don't cause an issue, other than their unsightliness. Roughly 50% of ganglions will disappear on their own so if it doesn't bother you leave well alone.

If the lump is problematic the cyst fluid can be aspirated/drained and a steroid injected into the sac. This is a straightforward outpatient procedure done under ultrasound guidance. There is a variable risk of recurrence though.

Before having surgery for a painless ganglion cyst ask yourself, is it worth it swapping a lump for a scar?

Surgical excision is usually reserved for those cases that come back after an attempted aspiration injection and continue to be bothersome. The whole cyst wall is removed and the tail/pedicle that communicates with the joint is tied off. This of course comes with the usual risk of surgery and a 10% risk of recurrence.

If you have a lump in your hand or wrist you are concerned about click here to schedule an appointment.

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