If you’ve ever experienced numbness, tingling, or pain in your hands, fingers, and/or forearm, you know all too well the discomfort and disruption that carpal tunnel syndrome (CTS) can bring to your day-to-day routine. From work productivity to leisure activities, and even sleep, carpal tunnel syndrome can impact your daily life in ways you may not expect.

What is Carpal Tunnel Syndrome?

Carpal tunnel syndrome is the most experienced nerve disorder, accounting for 90% of all neuropathies. In the wrist, there is a narrow canal referred to as the carpal tunnel. In this canal, you’ll find various tendons and the median nerve, one of the main nerves leading to the hand. This nerve provides sensation to the thumb, index, and middle fingers, and half of the ring finger — the pinky finger is typically not affected.

Carpal tunnel syndrome occurs when the median nerve is compressed.

“The carpal tunnel is a tight space, and nine tendons and your median nerve need to share that space. Some people are prone to having a smaller tunnel than others or they have an inflammatory condition, most commonly tendonitis, that affects the space in that tunnel,” says

Tim Niacaris, M.D., an orthopedic surgeon with Texas Health Hand and Upper Extremity Specialists, and on the medical staff at Texas Health Arlington Memorial Hospital.

When these tendons swell, they take up space in the carpal tunnel, crushing the median nerve and blocking its access to blood flow.

“When the nerve can’t get blood, it starts telling you that something's going wrong,” Niacaris adds. “And the way it does that is by causing tingling, numbness and pain.”

Risk Factors

While Niacaris notes many people believe constant repetitive movement or finger use is the main cause of carpal tunnel syndrome, it’s not as straightforward as you may think.

“The cliché is that repetitive motion tasks are the main cause of carpal tunnel, but the reality is, some people are just more predisposed to getting carpal tunnel syndrome,” he explains. “One predisposition is anatomic, meaning some people have smaller wrists and/or smaller carpal tunnels than others and all these tendons have to go through that smaller space.”

Another common risk factor involves having an ongoing inflammatory condition, such as tendonitis or arthritis, which inflames the tendons, causing the nerve to compress.

One lesser-known risk factor is pregnancy. Carpal tunnel syndrome is common during pregnancy, particularly in the third trimester, with more than a third of women reporting symptoms. While the exact cause of carpal tunnel syndrome during pregnancy is not fully understood, it is believed to be due to the increased fluid retention and swelling that occurs during pregnancy, as well as hormonal changes that can cause the ligaments in the wrist to become more relaxed.

Other risk factors include:

• Past injury
• Diabetes
• Older age
• Thyroid disorders
• A mass in the carpal tunnel

While carpal tunnel syndrome is more prevalent in women, Niacaris adds the difference isn’t profound enough to mark gender as a true risk factor.

“To put it simply, everyone and anyone can get carpal tunnel syndrome, not just people in a certain profession or a certain demographic,” he says. “I see people of all ages, all professions, and all walks of life. Anyone can get carpal tunnel syndrome and it’s oftentimes not within your control. Some people are just more prone to it than others and these risk factors can be an added layer.”

Symptoms

Numbness and tingling in the hands are the two most common symptoms people experience with carpal tunnel syndrome. However, symptoms can change according to the time of day.

Common daytime symptoms can include:

• Tingling in the fingers.
• Decreased feeling in the fingertips.
• Difficulty using the hand for small tasks, like:
• Handling small objects.
• Grasping a steering wheel to drive.
• Holding a book to read.
• Writing.
• Using a computer keyboard.

Numbness and pain are common nighttime symptoms, often waking people up or keeping people from falling asleep.

“Something very common for nerve conditions is that they’re typically worse at night. Patients will try to sleep and their hands will go numb, be painful or tingle, and this wakes them up,” Niacaris explains. “This is probably one of the most challenging symptoms for most people because they can't get a good night’s sleep.”

As carpal tunnel syndrome worsens, symptoms will become more constant and bothersome.

These symptoms can include:

• Weakness in the hand.
• Inability to perform tasks that require delicate motions (such as buttoning a shirt).
• Dropping objects.

In the most severe condition, the muscles at the base of the thumb will visibly shrink in size (atrophy).

“Carpal tunnel syndrome is a progressive condition, so oftentimes these symptoms can come and go over the course of months or even years,” Niacaris explains. “Most of the time, people start with mild symptoms. But a lot of patients don't recognize the symptoms. They think they might have just flared something up or pulled a muscle, so they let it go on for years and years. The longer you let it go, though, the worse the symptoms are going to get and that’s when you’ll start seeing things like dropping items or the loss of muscle mass or weakness.”

Diagnosis

Your doctor will discuss your symptoms and medical history and examine you. Next, tests are performed, which may include:

• Tinel’s sign: In this test, the physician taps over the median nerve at the wrist to see if it produces a tingling sensation in the fingers.
• Wrist flexion test (or Phalen test): In this test, the patient rests his or her elbows on a table and allows the wrist to fall forward freely. Individuals with carpal tunnel syndrome will experience numbness and tingling in the fingers within 60 seconds. The more quickly symptoms appear, the more severe the carpal tunnel syndrome.
• X-rays: X-rays of the wrist may be ordered if there is limited wrist motion, or evidence of arthritis or trauma.
• Electromyography (EMG): This determines how well the median nerve itself is working and how well it controls muscle movement.

“Most of the time, we can make a diagnosis by just doing an examination and discussing your history,” Niacaris explains. “A lot of times, we will often get a nerve conduction study, or an EMG, and that tells us the status of your nerves. As I said, this is a progressive condition, so the EMG can give us a good idea of how long this has been going on and we can have a more informed discussion on what the patient can expect their results to be following treatment.”

Niacaris notes that EMGs and other nerve conduction studies can also highlight if any other nerve issues are going on.

“Carpal tunnel syndrome is only one peripheral neuropathy that can lead to hand numbness,” he adds. “Sometimes people have other nerve conditions in conjunction with carpal tunnel syndrome, so these studies can help us identify that and provide a more informed treatment plan.”

Treatment Options

Carpal tunnel syndrome can be treated in two ways: non-surgically or with surgery. Each approach has its own set of advantages and disadvantages.

Generally, non-surgical options are employed for milder cases, enabling individuals to maintain their daily routines without disruption. On the other hand, surgical procedures are considered in more severe instances, often yielding highly favorable results.

Non-Surgical Treatments

Non-surgical treatments are usually tried first. Treatment begins by:

• Wearing a wrist splint at night.
• Taking nonsteroidal anti-inflammatory drugs, such as ibuprofen.
• Cortisone injections.

“Typically speaking, the non-operative treatment for this is to do splinting at night with some special splints for about six weeks and see if symptoms improve,” Niacaris says. “We can also do steroid injections, but it’s something that I do very rarely; not because it’s not effective but because it’s just a temporary solution for most patients. I’ll do these injections for patients who need surgery but can’t do it right away, and it’ll bide them a bit more time. But injections are not without risk, and that risk is pretty on par with the risk of surgery, so if you’re considering the injection, that’s when we’d discuss considering surgery as well.”

Surgical Treatments

Surgery is recommended when carpal tunnel syndrome does not respond to non-surgical treatments or has already become severe.

During the surgery, the surgeon cuts through the ligament that covers the carpal tunnel to make more space for the nerve and tendons. This eases the pressure on the median nerve and relieves the symptoms of carpal tunnel syndrome.

There are two main types of carpal tunnel release surgery: open and endoscopic. Both are considered outpatient procedures, meaning there is typically no overnight hospital stay.

In open surgery, the surgeon makes a larger cut or incision up to 2 inches from the wrist to the palm, while in endoscopic surgery, the surgeon inserts a camera into the wrist through a small surgical cut and views the monitor to see inside the wrist.

After the surgery, the ligament comes back together, but with more room for the median nerve to pass through.

“While open carpal tunnel surgeries are still performed, I’d say most carpal tunnel release surgeries are endoscopic these days. It’s what I do for most of my patients,” Niacaris. “Because the incision is smaller and along the wrist, versus in the middle of the palm for open surgery, it really comes down to convenience and recovery for the patient. In open surgery, we are cutting through a lot of tissue and it’s all occurring in an area of your hand that gets a lot of use. Think about all the things you do daily that put pressure on your palm — pushing up from your chair, opening a door, etc. In endoscopic, we can get underneath the ligament without having to disrupt all that other tissue, and your wrist gets less direct action compared to your palm.”

Although complications are possible with any surgery, your doctor and surgical team will take steps to minimize the risks. The most common complications of carpal tunnel release surgery include:

• Bleeding
• Infection
• Wound healing issues
• Nerve aggravation or injury

Recovery from both open and endoscopic carpal tunnel release surgery can take anywhere from a few days to a few months. However, you may be able to get back to doing light activities sooner with endoscopic versus open surgery, with the biggest difference occurring within the first two weeks of recovery.

“The day after surgery, my patients are doing normal light activities. I won't let them do anything strenuous with their hands, but if they want to type, play on their phones, etc. they can. You just don't want to be lifting anything or doing anything strenuous,” Niacaris explains. “If you take it easy for two weeks, by the end of the two weeks you’ll most likely be cleared and have absolutely no restrictions. But if you don’t take it easy, you’re just prolonging your recovery. I tell my patients; you don't rob Peter to pay Paul. You're going to pay for it one way or another.”

A typical recovery timeline you can expect: 

• 2-7 days: Most patients can return to light-duty work.
• 4 weeks: Patients should regain full mobility of their fingers by this time or should be working with a therapist to regain mobility.
• 6-8 weeks: Patients should be back to nearly full daily life and sporting activities, but still will feel some soreness in the palm to deep pressure or touch.
• 6-12 weeks: If you have surgery on your dominant hand and do repetitive activities at work, you may require this amount of time for a full recovery before you can return to work.
• 3-4 months: It usually takes this amount of time to recover, and up to 1 year before hand strength returns. How much strength returns will vary by how far the condition progressed prior to surgery and adherence to physical therapy.

Most people who have carpal tunnel surgery find that their symptoms are cured and do not come back. 

“Probably the No. 1 thing I hear people say is, ‘Why did I wait so long to do this? This is great,” says Niacaris. “Some of the most annoying aspects of the condition go away almost immediately after surgery. They’re just gone. I’ve had patients tell me their first night after surgery was the best sleep they’ve gotten in years. You still have surgical recovery and all of what that involves, but the most irritating components can be gone immediately.”

Prevention

Carpal tunnel syndrome can be difficult to prevent due to the often-uncontrollable causes and various daily activities that can contribute to it.

“With cardiac risk, for example, there are a lot of things you can do to lower your risk, even if you have risk factors you cannot change, such as genetics. Unfortunately, there just isn’t that much you can do to lower your risk of developing carpal tunnel syndrome,” he explains. “Sure, you could avoid certain activities that exacerbate it like driving or using the phone or typing, and a myriad of other things, but at what cost? I would never suggest to patients that they change careers or stop doing what they love in an attempt to avoid carpal tunnel syndrome.”

Adjusting your workstation, including ensuring proper seating and positioning of your hands and wrists, can help decrease some factors that can lead to carpal tunnel syndrome.

Additionally, you can adopt the following preventive measures:

• Maintaining a straight wrist position while sleeping.
• Ensuring your wrists stay in a neutral, straight position when using tools.
• Minimizing repetitive and forceful bending (flexing) and extending of your wrists.
• Reducing frequent, vigorous gripping with the wrist in a bent position.
• Incorporating regular breaks during repetitive tasks.
• Incorporating conditioning and stretching exercises both before and after engaging in activities.
• Monitoring and properly treating medical conditions linked to carpal tunnel syndrome.

The Takeaway

Surgery for carpal tunnel syndrome has a very high success rate of over 90%. Following treatment, many symptoms are relieved quickly, such as the sensation of tingling in the hands and nighttime disturbances.

“The biggest misconception I hear and want to clear up is that carpal tunnel syndrome will go away with time,” Niacaris. “In general, carpal tunnel syndrome does not go away unless you have a reversible condition that is contributing to it, such as pregnancy. It’s progressive, but it’s not progressive linearly. You’ll have good days and bad days. You’ll have good months and bad months. Some people even have good years and bad years. That’s the nature of inflammatory conditions; you’ll cycle through phases of inflammation and then no inflammation. The fact that it can come and go in terms of symptom severity, people often think they just flared it up and it’ll go away. But it will eventually progress to a point where it’s severely affecting your quality of life and may also lead to permanent dysfunction of your hand. Once you lose that function, you can’t get it back.”

To find a hand and wrist specialist near you, visit TexasHealth.org.