Carpal tunnel syndrome (CTS), also known as median nerve compression, is a condition that can cause pain, numbness, and/or tingling in the wrist, hands, and fingers. CTS is responsible for 90% of all neuropathies (dysfunction of the nerves). The addition of massage therapy interventions can significantly reduce the pain and discomfort associated with carpal tunnel syndrome.
Massage can reduce the symptoms of carpal tunnel syndrome. It is important to determine if it’s Carpal Tunnel Syndrome or Thoracic Outlet Syndrome. CTS treatment usually requires more than one session; and a massage therapist with a comprehensive understanding of the anatomical structures involved.
Carpal Tunnel Syndrome is often misunderstood and it is important that the massage therapist is treating the cause rather than the symptoms. True CTS is treated at the hand and wrist. However, wrist pain can also be a symptom of Thoracic Outlet Syndrome, which would require treatment at the neck and shoulder. Let’s dig a little deeper. 🙂
What is the Carpal Tunnel?
The carpal tunnel is a narrow pathway located between the wrist and the palm. Several important structures pass through this limited space (median nerve, blood vessels, and the nine tendons that flex the wrist and fingers), so space for these structures to move is at a premium.
Due to the limited amount of space in this tunnel; compressive forces from other structures; inflammatory reactions; and axonal degeneration (deterioration of the portion of the nerve that transmits signals) can occur, causing symptoms to manifest throughout the arm, wrist, and hand, thereby hindering nerve movement and functionality.
The median nerve carries sensory and motor signals between the brain, forearm, and hand. When this nerve is pinched or pressed upon due to inflammation; or by surrounding bones, muscles, and fascia, it can cause significant pain and discomfort.
If this condition is not addressed early, the symptoms can significantly worsen over time and create significant damage to the median nerve.
The median nerve covers a significant amount of territory, so it is important that this condition is properly diagnosed. The nerve roots originate at the neck. The nerve continues to the pit of the arm, down the length of the forearm and arm, ending at the fingers.
To cover the scope of the symptoms associated with CTS, we need to also discuss thoracic outlet syndrome (TOS). Thoracic outlet syndrome can mimic CTS, although the root of the problem is not found in the wrist.
Let’s first take a look at the median nerve.
The Median Nerve
The Median Nerve is the only nerve that passes through the carpal tunnel; however, it does not originate there. The nerve roots are found in the spine and continue their travels to the arm by way of the brachial plexus (a bundle of nerves that begins in the back of the base of the neck and extends through the armpit). This nerve continues down through the narrow carpal tunnel of the wrist and ends at the fingers. If one area of this pathway is compromised, it can impact the entire arm, down to the wrist.
Garden Hose Analogy
Let’s use a garden hose as an example of how entrapment of the median nerve can affect various areas of the body along its course.
Imagine the median nerve as a hose that runs from the neck to the armpit, through the arm and down to the fingertips, and back to the brain. Now, imagine the muscles and surrounding structures as being the feet.
If at any point along this pathway a foot takes a step on the hose, it will inhibit the water (nerve signals) being delivered to that area, as well as the areas below. The amount of pressure the foot places on the hose will impact how much water (nerve signals) will be delivered from the brain to the hand.
The goal of massage for CTS will be to reduce pressure and friction on the nerve by relaxing the muscles, as well as attempting to release the fascia of the flexor retinaculum. This will allow the nerve to slide more freely as you flex and extend the arm, wrist, and fingers.
It also helps to use the imagery of brushing teeth. Imagine the nerve is floss and the surrounding structures are teeth. If too much plaque surrounds the teeth, the floss will have nowhere to move. A healthy nerve moves through spaces in this manner, as we move our body.
Thoracic Outlet Syndrome or Carpal Tunnel Syndrome – Can it be Both?
The symptoms associated with Thoracic Outlet Syndrome (TOS) can often mimic that of Carpal Tunnel Syndrome and should be thoroughly evaluated before treatment. CTS involves the wrist, hand, and fingers only; while TOS can impact the neck, shoulder, entire length of the arm down to the hand.
A person can have carpal tunnel syndrome and also suffer from shoulder pain, or have thoracic outlet syndrome that radiates to the hand. However, having compression of the median nerve at the carpal tunnel AND the thoracic outlet is not as common.
Phalen’s Test for Carpal Tunnel Syndrome (CTS):
Start in a seated position so that your hands are at the level of your lap. Put your wrists together so that your fingers are facing down, like an inverted prayer position. Bring your elbows and hands up with your elbows to your side and your hand at chest level. Hold this position for one minute. If you experience numbness or tingling in the wrist, hand, or fingers, CTS is likely.
Roos Test for Thoracic Outlet Syndrome (TOS):
In a seated position, outstretch the arms to the side, palms facing forward. When the arms are in line with the shoulders, flex the elbow to 90-degrees and bring the elbows slightly behind the midline. Hold this position for three minutes, while simultaneously bending and extending the fingers at a moderate pace. If at any point during this three minute period numbness or tingling occurs, TOS is likely the cause.
What is the Thoracic Outlet?
The thoracic outlet is the space located between the clavicle (collarbone) and the first rib. Much like the carpal tunnel, this narrow passage is also jam-packed with muscles, nerves, and blood vessels.
If the nerves traveling through this narrow space get compressed, it can produce pains, numbness, or tingling in the neck, shoulder, arm, hand, and/or fingers. When symptoms of TOS travel to the hand, they are usually found in the ring and little finger.
Note: The little finger is not involved with CTS. If it is exclusively CTS, you will not experience neck pain, shoulder pain, chest pain, and or upper back pain.
Carpal Tunnel Stats:
- According to a U.S. Department of Labor report, Carpal Tunnel Syndrome is the “chief occupational hazard of the 90’s”-disabling workers in epidemic proportions.
- a 1999 survey by the Safety and Health Statistics program showed the median days away from work per year due to carpal tunnel syndrome was 27 days.
- Carpal tunnel syndrome is responsible for 32.5% of repetitive motion injuries at the workplace U.S. Bureau of Labor Statistics.
- CTS is responsible for more days away from work than any other nonfatal injury U.S. Bureau of Labor Statistics
Can Massage Help Carpal Tunnel Syndrome?
Now that we have a better understanding of CTS, let’s discuss how massage can help carpal tunnel syndrome.
Massage therapy can have tremendous long-term success when managing the symptoms of carpal tunnel syndrome. However, the course of action often requires more than one treatment to resolve what took years to develop.
Massage therapy techniques target the soft tissues that surround the nerve. and can help resolve the symptoms by helping align the soft tissue structures, helping to reduce the amount of pressure in the area surrounding the carpal tunnel, and creating space for the nerve to move more freely.
An effective and thorough massage therapy intervention for CTS will likely follow a protocol similar to the one below.
Warm-Up: Several minutes will be spent warming up the tissues to prepare them for treatment.
- Begin by warming up the involved tissues with light effleurage and petrissage, followed by some techniques to assess the movement at the joints.
- The therapist will then likely focus on the regions where the median nerve has the highest likelihood of being entrapped: The neck/scapula, forearms, and the palm and fingers.
Treatment of the Hand:
Thenar Muscles: The portion of the thumb closest to the wrist is likely to be an area of soreness and a potential area where median nerve entrapment can occur. The therapist will palpate the area to find any entrapment sites and address those areas.
Transverse Carpal Ligament at the Carpal Tunnel: While not often the root cause of CTS, the Transverse Carpal Ligament should be addressed when treating CTS, as the median nerve travels beneath this structure and should be assessed. The medical massage therapist will utilize techniques to treat the transverse carpal ligament, thereby opening up the carpal tunnel to free the nerve.
Flexor Digitorum Superficialis: The flexor digitorum superficially is a large muscle that travels from the inside of the elbow, and becomes tendinous right above the wrist, continuing to the medial four fingers. If this muscle is tight and fascially restricted, it can trap the median nerve near the top of the forearm, between the radial and ulnar heads.
Pronator Teres: Repetitive “wrench-like” twisting of the forearm can put a great deal of stress on this muscle, and can lead to subsequent median nerve entrapment. This area can be quite sensitive, so the therapist should make sure to work within the client’s pain tolerance.
Struther’s Ligament: A small number of the population has this ligament; however, it is worth noting for those who do. This ligament can be found in the region of the interior side of the elbow joint. The median nerve courses under this ligament, or in the area where this ligament would ordinarily be found. Massage techniques to help move the ligament posterior/superior, while allowing the median nerve to pass freely during arm extension, are helpful.
Bonus Content: Massage Treatment Considerations for Thoracic Outlet Syndrome
The massage therapist should take great care to warm up the entire neck, shoulder, and upper back region. After the therapist has thoroughly warmed up the body for treatment, the muscles below are areas to further evaluate.
Scalenes: The area on either side of the front of the neck consists of three small muscles (anterior, middle, and posterior scalene). The nerve roots pass through the anterior and middle scalenes and ultimately form the brachial plexus. Pressure on the nerve roots at this location can impact the arms, as well as the hands.
The goal for the massage therapist is to hold the scales in place while encouraging the nerves to move distally. Manual therapy in this area requires care and precision, as some other sensitive structures lie nearby. Movement of the arm should be slow, taking great care not to overstretch the nerve.
Subscapularis: The subscapularis is an internal rotator of the rotator cuff. If this muscle is tight, it can protract (hunch) the shoulder forward and eventually entrap the chords of the brachial plexux nerves. Massage and stretching techniques to loosen the muscle and help the nerve to glide are recommended. A tight subscapularis can ultimately entrap the chords of the brachial plexus
Pectoralis minor: The pectoralis minor muscle lies directly below the clavicle, and above the brachial plexus. Tightness in this muscle can significantly impact the brachial plexus (nerves) and axillary vessels that lie beneath. Massage and stretching techniques are recommended to help relax this muscle to create space for these important structures to pass through freely.
Subclavius: This small, yet important muscle travels from the first rib upward and outward to the clavicle. This muscle may cause compression of the brachial plexus.
Massage therapy can be tremendously beneficial and have extremely successful outcomes when treating carpal tunnel syndrome and thoracic outlet syndrome. It is essential that the massage therapist has an extensive background in medical massage, and thoroughly understands the structures being treated, as there are important blood vessels and nerves in this region that must be treated with care.
Richard A. Lehman, LMT, CSCS
Compliment Your Body LLC has been providing in-home and corporate/event chair massage for New York City since 2004. You are safe in our hands!
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