Entrapment Neuropathies (carpal tunnel, cubital tunnel, tarsal tunnel)

Carpal Tunnel Syndrome

Carpal tunnel syndrome is a common, painful, progressive condition that is caused by compression of the median nerve at the wrist area. Common symptoms of carpal tunnel syndrome include numbness and tingling sensation in all the fingers except little finger; pain and burning sensation in hand and wrist that may radiate up the arm and elbow; and weakness in hand with diminished grip strength. Exact causes of the condition are not known. However certain factors increase the risk of developing carpal tunnel syndrome and they include congenital abnormalities, repetitive motion of hand and wrists, fractures and sprains, hormonal imbalance, and other medical conditions such as hypothyroidism, rheumatoid arthritis, diabetes, obesity, gout, overactive pituitary gland, or the presence of a cyst or tumor in the canal.

Carpal tunnel syndrome may be treated using conservative approaches or surgery. The conservative treatments include:

  • Treating underlying medical conditions
  • Immobilization of the hand and wrist with a splint or wrist brace for 4-6 weeks
  • Rest the hand for 2 weeks or more
  • Ice packs to avoid swelling
  • Avoid activities that tend to worsen the symptoms
  • Medications such as non-steroidal anti-inflammatory drugs and steroid injections
  • Strengthening and stretching exercises once symptoms diminish

If conservative treatment options fail to resolve the condition your surgeon may recommend surgical procedure.

Carpal Tunnel Release Surgery

Carpal tunnel syndrome can be treated with carpal tunnel release surgery. Traditional surgery involves up to a 2- inch incision in the palm and wrist area, whereas endoscopic surgery involves one or two half-an-inch incisions and the use of an endoscope. During the surgery, the transverse carpal ligament will be dissected to release the pressure on the median nerve and enlarge the carpal tunnel. Your surgeon will decide which options are best for you based on your general and medical conditions.

Your surgeon may suggest you to practice certain post-operative procedures for better recovery and to avoid further complications.

  • Elevate the hand above heart level to reduce swelling
  • A splint may be worn
  • Ice packs to the surgical area to reduce swelling
  • Keep the surgical incision clean and dry; cover the area with plastic wrap when bathing or showering
  • Physical therapy may be ordered to restore wrist strength
  • Eating a healthy diet and not smoking will promote healing

Most patients suffer no complications following carpal tunnel release surgery. However, some patients may suffer from pain, infections, scarring, and nerve damage causing weakness, paralysis, or loss of sensation and stiffness in the hand and wrist area.

Cubital Tunnel Syndrome

Cubital tunnel syndrome is a condition characterized by compression of the ulnar nerve in an area of the elbow called the cubital tunnel.

The ulnar nerve travels down the back of the elbow behind the bony bump called the medial epicondyle, and through a passageway called the cubital tunnel. The cubital tunnel is a narrow passageway on the inside of the elbow formed by bone, muscle, and ligaments with the ulnar nerve passing through its center. The roof of the cubital tunnel is covered with a soft tissue called fascia.

When the elbow is bent, the ulnar nerve can stretch and catch on the bony bump. When the ulnar nerve is compressed or entrapped, the nerve can tear and become inflamed leading to a variety of symptoms, called cubital tunnel syndrome.

Signs and symptoms

In general, signs and symptoms of cubital tunnel syndrome arise gradually, progressing to the point where the patient seeks medical attention. Left untreated, cubital tunnel syndrome can lead to permanent nerve damage in the hand. Commonly reported symptoms associated with cubital tunnel syndrome include:

  • Intermittent numbness, tingling, and pain to the little finger, ring finger, and the inside of the hand. These symptoms occur more frequently at night, and with elbow bending or prolonged resting on the elbow.
  • Aching pain to the inside of the elbow
  • Weakness in hand with diminished grip strength
  • Diminished sensation and fine motor control in the hand causing the person to drop objects or have difficulty in handling small objects.
  • Muscle wasting in the hand and permanent nerve damage, if left untreated.

Causes

The common causes responsible for cubital tunnel syndrome, include:

  • Trauma
  • Repetitive motion
  • Frequent pressure on the elbow for extended periods due to sitting posture
  • Medical Conditions such as bone spurs, ganglion cysts, or tumors in the cubital tunnel leading to pressure and irritation of the ulnar nerve.

Diagnosis

Your physician will perform the following:

  • Medical history
  • Physical examination

Your physician may order X-ray and electro diagnostic tests such as electromyography and nerve conduction studies. These tests can assist your doctor in determining how well the nerve is functioning and locate areas of muscle wasting and nerve compression.

Treatment

Your physician will recommend conservative treatment options initially to treat the symptoms unless muscle wasting or nerve damage is present.

Conservative treatment options may include:

  • Avoid frequent bending of the elbow.
  • Avoid pressure to the elbow by not leaning on it. Elbow pads may be worn to decrease pressure when working at a desk.
  • Wear a brace or splint at night while sleeping to keep the elbow in a straight position. You can also wrap the arm loosely with a towel and apply tape to hold in place.
  • Avoid activities that tend to bring on the symptoms.
  • NSAIDs (Non-Steroidal Anti-Inflammatory Drugs) such as ibuprofen or aspirin may be ordered to reduce swelling.
  • Referral to OT (occupational therapy) for instruction in strengthening and stretching exercises may be recommended.

If conservative treatment options fail to resolve the condition or if muscle wasting or severe nerve compression is present, your surgeon may recommend a surgical procedure to treat your condition.

The goal of cubital tunnel surgery is to reduce the pressure on the ulnar nerve by providing more space for the nerve to move freely and to increase blood flow to promote healing of the ulnar nerve. There are different surgeries that can be performed to treat your condition, such as:

  • Medial epicondylectomy: This surgery involves removing the medial epicondyle, the bony bump on the inside of the elbow, enabling the ulnar nerve to glide smoothly when the elbow is flexed and straightened.
  • Ulnar nerve transposition: This surgery involves creating a new tunnel in front of the medial epicondyle and transposing (moving) the ulnar nerve to the new tunnel.

Your surgeon will decide which options are best for you depending on your specific circumstances.

Post-Operative Care

After surgery, your surgeon will give you guidelines to follow depending on the type of repair performed and the surgeonís preference. Common post-operative guidelines include:

  • A bulky dressing with a plaster splint is usually applied following surgery for 10-14 days.
  • Elevating the arm above heart level and moving the fingers are important to prevent swelling.
  • The arm dressing is removed after 10-14 days for removal of the sutures.
  • Elbow immobilization for 3 weeks after surgery is usually indicated, longer depending on the repair performed.
  • Ice packs are applied to the surgical area to reduce swelling. Ice should be applied over a towel to the affected area for 20 minutes every hour. Keep the surgical incision clean and dry. Cover the area with plastic wrap when bathing or showering.
  • Occupational Therapy will be ordered a few weeks after surgery for strengthening and stretching exercises to maximize use of the hand and forearm

Risks and complications

Most patients suffer no complications following cubital tunnel surgery, however, complications can occur following elbow surgery and include:

  • Infection
  • Nerve damage causing permanent numbness around the elbow or forearm.
  • Elbow instability
  • Elbow flexion contracture
  • Pain at site of scar
  • Symptoms unresolved even after the surgery

Tarsal Tunnel Syndrome

Tarsal tunnel is the gap that is formed between the underlying bones of the foot and the overlying tough fibrous tissue. Tarsal tunnel syndrome refers to a condition where the posterior tibial nerve that lies within the tarsal tunnel is compressed. The condition occurs when the tibial nerve is pinched.

Exact cause of the condition is not known but certain conditions such as fractures, bone spurs, ganglions, benign tumors, muscle impingement, or foot deformities are known to increase the risk of developing tarsal tunnel syndrome. Other medical conditions such arthritis can cause swelling of the joints that may compress the nerve. Scar tissue formed after an ankle injury and growth of abnormal blood vessels can press against the nerve resulting in compression.

Most children with tarsal tunnel syndrome complain of pain, numbness, and burning or tingling sensation at the bottom of the foot and heel.

Tarsal tunnel syndrome can be diagnosed by Tinel's test. Tinel's test is performed by tapping the posterior tibial nerve lightly which produces pain and other symptoms indicating tarsal tunnel syndrome.

Tarsal tunnel syndrome may be treated with conservative approaches which include:

  • Nonsteroidal anti-inflammatory medications to relieve pain and reduce swelling.
  • Corticosteroid injection that are injected into the area around the nerve to decrease the swelling.
  • Use orthotics, such as specially designed shoe inserts or change in foot wears will help to support the arch of the foot and take the tension off the tibial nerve.

Surgery is often considered a last resort only when conservative treatments fail to resolve the condition and provide symptomatic relief. Your doctor may perform tarsal tunnel release surgery to treat the condition. During this surgery, an incision is made in the tarsal tunnel and the pressure on the tibial nerve is released.