My Doctor Online The Permanente Medical Group

Symptoms

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Symptoms of carpal tunnel syndrome vary and may include:

• Numbness, tingling, electric shock-like sensation, and pain in most of the fingers
• Pain that can also be felt in the entire palm and can sometimes radiate into the arm
• Pain at night that can disturb sleep
• Muscle weakness or clumsiness of the hand

The symptoms often occur when you are involved in activities that require frequent or persistent flexing or extending of the wrists.

Other simple daily tasks that are repetitive can also bring on the symptoms. These may include cooking, driving, or holding a book. Shaking the hand may return normal feeling. Try to keep your wrists straight and avoid leaning on them.

Diagnosis

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We use a range of diagnostic tools to evaluate your wrist. Initially, we will ask you to describe your symptoms and go through a comprehensive physical examination. The exam will include some or all of the following:

• Carpal compression test. We apply direct pressure over the carpal tunnel to see if this reproduces the symptoms in the hand.
• Phalen maneuver. We ask you to flex your wrist for 30 to 60 seconds. If this movement produces numbness, tingling, or pain, you may have carpal tunnel syndrome.
• Muscle strength test. We check the strength of muscles in your thumb by asking you to try and straighten the thumb while someone else holds it back.
• Nerve conduction study. We place electrodes on the skin of your hand and wrist and pass small electric shocks through the median nerve. This shows us if the nerve is transmitting electrical impulses in the carpal tunnel at normal speed. Pressure on the median nerve can slow down these impulses.

Additional tests

X-rays or other imaging studies do not help us to diagnose carpal tunnel syndrome. If we suspect that your symptoms are caused by something other than overuse of the wrist, we may order additional tests, including blood work.

Causes

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Carpal tunnel syndrome is caused by increased pressure on the median nerve as it passes through the tight space in the wrist. This can be due to compression or inflammation. Often it is not possible to identify what causes the pressure on the median nerve to increase. However, there are many factors, including your medical and family history, that may be associated with this increase in pressure. These include:

• Obesity.
• Family history of carpal tunnel syndrome.
• Diabetes.
• Hypothyroidism, or low thyroid function. The median nerve may be more susceptible to increased pressure in people with hypothyroidism.
• Pregnancy. Swelling and fluid retention can increase pressure on the median nerve.  
• Kidney failure (end-stage renal disease). End-stage renal disease and dialysis can affect the median nerve in a number of ways. For example, the median nerve may receive a reduced flow of blood during dialysis, or the vascular access created for dialysis may press on the nerve.
• Female gender.
• Rheumatoid arthritis and other connective tissue disorders.

The kind of work you do, your behaviors, and your use of body mechanics may also exacerbate these symptoms. Here are some examples:

• Flexing the wrists while sleeping, reading, or driving.
• Clenching the steering wheel while driving.
• Repetitive activities. Certain occupations that require repetitive flexing of the wrists may increase your risk of developing carpal tunnel syndrome.
• Repeated flexing causes the tendons to swell and press on the median nerve. Construction work, nursing, and jobs that require typing and mouse use on the computer all fall into this category.

Prevention

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We recommend that you understand the activities that increase your risk of developing carpal tunnel syndrome and take steps to manage them. If you already have carpal tunnel syndrome, limiting these activities may help control your symptoms. For example:

Avoid repetitive hand motions with a bent wrist. Keep your wrist straight when you are involved in the following activities:

• Using the computer, typing, or using the mouse
• Writing
• Driving
• Using scissors, power tools, pliers, screwdrivers, or other tools
• Playing the piano
• Knitting, crocheting, and needlepoint

Take frequent breaks if you must repeat hand motions. Rest your hand for at least 5 minutes every hour. Stretch your fingers and thumb and change your grip.

Type softly on your keyboard. A gel pad may help to cushion your wrist and keep it in the right position.

Be careful with your posture. Keep your shoulders straight.

Consult an ergonomic specialist. If you are uncomfortable, ask for an ergonomic evaluation at work, if one is available to you. An ergonomic specialist may be able to improve the configuration of your workstation and improve your wrist position and posture.

Avoid sleeping on your hands. Try to keep your wrists straight while you sleep. Wearing wrist splints while sleeping may help.

Wear a wrist splint at night if you are having symptoms. You may also wear the wrist splint during the day to decrease symptoms.

Nonsurgical Treatment

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Nonsurgical treatments can be effective for people with carpal tunnel syndrome. We will discuss the preventive measures and treatments that are most appropriate for you. Sometimes we recommend a combination of treatments that may include the following:

Good posture and ergonomics

Avoid poor posture or overuse of the wrist. We can talk to you about using good ergonomics; for example, when you are using a computer workstation.

Wrist splints and ice

• We can recommend wrist splints and talk to you about using them during sleep.
• We can also tell you how to use wrist splints during the day while you are participating in activities that require you to flex your wrist.
• Icing your wrist up to 3 times each day, for 10 to 15 minutes each time, can be helpful. This is particularly important right before you go to bed. We can show you how to use ice effectively.

Anti-inflammatory pain relief

• Over-the-counter (OTC) nonsteroidal anti-inflammatory drugs (NSAIDs), such as ibuprofen, may treat the tendinitis that is causing carpal tunnel syndrome.
• Even though you do not need a prescription for OTC NSAIDs, you should still be careful to consult the package so that you take the correct dosage.
• Also, please be aware that OTC NSAIDs can interact with other medicines you may be taking and cause problems for people with various medical conditions.
• If you have a complex medical condition, or if you are pregnant or trying to get pregnant, or if you have been taking OTC NSAIDs and they do not relieve your symptoms, please let us know so that we can recommend an alternative.

Corticosteroid injections

• If your symptoms are severe, we may recommend a corticosteroid injection directly into the wrist.
• Corticosteroids, such as cortisone, decrease inflammation, which can relieve some of the pressure on the median nerve.

Surgical Treatments

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Carpal tunnel release surgery

If more conservative treatments do not relieve your symptoms, we may recommend carpal tunnel release surgery. During surgery, we cut ligaments or tissue that is pressing on the median nerve. Most commonly, we cut the transverse carpal ligament that lies directly over the median nerve. We perform the surgery in one of two ways:

• Open incision. We make a small cut in the palm of your hand to access the carpal tunnel area.
• Endoscopy. We make one or two small incisions in the wrist and/or palm. We then insert an endoscope – a lighted tube with a camera and surgical instruments attached – into the incision. This allows us to see the structures in the wrist and to treat the problem.

These are outpatient surgeries that require only local anesthetic. We will also offer you medications to help you relax during the procedure.

Your Care with Me

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If you are having symptoms that concern you, your first contact will typically be with your personal physician, who will evaluate your health and symptoms. If specialty care is needed, your personal physician will arrange an appointment for you in my department. If appropriate, she or he might call me or one of my colleagues while you are in the office so we can all discuss your care together. If we decide you need an appointment with me after that discussion, we can often schedule it the same day or soon thereafter.

During your office visit, we will discuss your medical and family history and I will examine your hand, arm and wrist. I will explain the findings of your exam and answer any questions or concerns you may have. We will discuss treatment options and develop a treatment plan that is right for you.

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If you need to talk with me after your visit or procedure, please call my office. You can also e-mail me with nonurgent issues from this website whenever it is convenient for you.

For general medical advice, our Appointment and Advice line is available 24 hours a day, 7 days a week.

If you have urgent concerns or issues while my office is closed, you can call the Appointment and Advice line. You will be connected with a nurse who can give you immediate advice.

If you are experiencing a serious problem or an emergency, call 911 or go to the nearest Emergency Room when the clinic is not open.

Coordinating Your Care

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Having all of our Kaiser Permanente departments located together or nearby, including pharmacy, laboratory, radiology, and health education, makes getting your care easier for you.

Another major benefit is our comprehensive electronic medical record system, which allows all of the doctors and clinicians involved in your care to stay connected on your health status and collaborate with each other as appropriate.

When every member of the health care team is aware of all aspects of your condition, care is safer and more effective.

If you come to an office visit

• At the beginning of your visit, you will receive information about when you are due for your next test, screening, or immunization. We can discuss and schedule any preventive tests that you need. 
• At the end of your visit, you may receive a document called the “After Visit Summary” that will summarize the issues we discussed during your visit. You can refer to it if you forget what we discussed, or if you just want to recheck your vital signs and weight. You can also view it online under Past Visits.
• To help you prepare for your visit, please see additional details under Office Visit. 

If I prescribe medications

We will work together to monitor and assess how your medications are working and make adjustments over time. Prescriptions can be filled at any Kaiser Permanente pharmacy. Just let me know which pharmacy works best for you, and I will send the prescription electronically in advance of your arrival at the pharmacy.

If refills are needed in the future, you can:

• Order them online or by phone. Order future refills from my home page or by phone using the pharmacy refill number on your prescription label.
• Have them delivered to you by mail at no extra cost. Or you can pick up your medications at the pharmacy. If no refills remain when you place your order, the pharmacy will contact me regarding your prescription.

If lab testing or imaging is needed

For lab tests, I will use our electronic medical record system to send the requisition to the Kaiser Permanente laboratory of your choice. For imaging procedures, we will schedule an appointment with the Radiology department. When the results are ready, I will contact you with your results by letter, secure e-mail message, or phone. In addition, you can view most of your laboratory results online, along with any comments that I have attached to explain them.

If I refer you to another specialty colleague

If we decide together that your condition would also benefit from the care of other types of specialists, our staff will help arrange the appointment(s) with one or more of my specialty colleagues.

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If Surgery or a Procedure is a Treatment Option

I will recommend that you review educational information and tools to help you prepare for your procedure or surgery. The information will often help you decide whether surgery is right for you. If you decide to have a surgery or procedure, the information will provide details about how to prepare and what to expect.

If we proceed with surgery, I will have my Surgery Scheduler contact you to determine a surgery date and provide you with additional instructions regarding your procedure. Once your surgery is scheduled, a medical colleague of mine will contact you to conduct a preoperative medical evaluation that will assure that you are properly prepared for your surgery.

Convenient Resources for You

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As your specialist, I have a goal to provide high-quality care and to offer you choices that make your health care convenient. I recommend that you become familiar with the many resources we offer so that you can choose the services that work best for you.

My Doctor Online is available at any time that is most convenient for you. From my home page you can:

Manage your care securely

• View and compose secure e-mail messages.
• Manage your prescriptions.
• View your past visits and test results.
• View your Preventive Services to see whether you are due for a routine screening or updated immunization.

Learn more about your condition

• Read about causes, symptoms, treatments, and procedures.
• Find interactive health tools, videos, and podcasts to help you manage your condition.
• View programs to help you decide on or prepare for a surgery or procedure.

Stay healthy

• Locate health education classes and support groups offered at every medical center.
• Explore interactive programs, videos, and podcasts that focus on helping you stay healthy.
• View your Preventive Services to see whether you are due for a routine screening or updated immunization.