Massage Therapy: Assessing Carpal Tunnel

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We’ve all heard of “Carpal Tunnel Syndrome” — that pain or numbness going down the wrist and into the fingers. However, there are many similar symptomologies. This is a quick guide to figuring out exactly which pathology may be causing pain in the arm. Many times, the median nerve is not actually being compressed by the flexor retinaculum in the carpal tunnel at all; muscles entrap the nerve before it even reaches the wrist.

To assess carpal tunnel-like syndromes, assess in order:

CERVICAL DISK PATHOLOGY

You can quickly check for the possibility of a herniated nucleus pulposus (herniated disk) or other vertebral problem by a quick compression/distraction test. Compressing the neck (cervical compression — press the head straight down) should reproduce the symptoms; pulling on the neck (cervical distraction) should relieve the symptoms. You can also check for a cervical disk pathology by having the client extend his/her neck and SLOWLY rotate the head left and right.

THORACIC OUTLET SYNDROME

Having ruled out a cervical disk pathology, check for thoracic outlet syndrome — compression of the nerves of the brachial plexus. Two muscles commonly entrap the nerves of the brachial plexus: the scalenes and the pectoralis minor.

Scalenes

To test for scalenes entrapment, examine Adson’s sign. This test is an indicator that the client may have a scalenes problem, as will a history of forward head posture or paradoxical breathing and a palpatory finding of the scalenes as ‘locked short.’

Pectoralis Minor

The pectoralis minor can entrap the brachial plexus as well. Test for it using the Wright Abduction Test (see this Youtube video), where the client moves his/her arm into maximum abduction and leaves it there for a minute. Numbness/tingling/etc. in this position is a positive sign. Also look for a history or assessment of forward (protracted) shoulders.

PRONATOR TERES SYNDROME

The median nerve passes through the two heads of the pronator teres before entering the carpal tunnel. You can quickly test for pronator teres syndrome using a manual resistive test (”don’t let me move it”) of pronation of the symptomatic arm. By having the client forcibly pronate against your attempt to supinate his/her forearm, you shorten the muscle and therefore increase the pressure on the median nerve if it is entrapped.

TINEL’S SIGN

Using Tinel’s sign helps differentiate where the nerve innervating the wrist is entrapped. Perform Tinel’s sign at each location of possible entrapment: the carpal tunnel, the pronator teres (distal to the inside of the elbow), the pectoralis minor, and the scalenes. If the compression is occurring in the carpal tunnel, you will produce pain only at the carpal tunnel. Otherwise, you will cause nerve pain at each site up to and including the actual culprit.

PHALEN’S TEST

Finally, using Phalen’s Test — forced wrist flexion with the elbows extended and hands apart — allows a final double check for carpal tunnel. This maneuver increases the pressure in the carpal tunnel. With the wrists apart, a positive Phalen’s Test is a strong indicator of carpal tunnel. With the dorsal surfaces of the wrists pressed together, as this test was originally proposed, Phalen’s test could also indicate a pronator teres problem because of the extreme pronation in this position.

MYOFASCIAL TRIGGER POINTS

Active trigger points can cause referred sensation. Refer to a trigger point book that includes pain patterns. See e.g. The Concise Book of Trigger Points By Simeon Niel-Asher from pages 130-135.

There you go!

Ten minutes and some simple tests are all you need to understand what’s likely causing “Carpal Tunnel” arm pain.

February 16, 2010 | Filed Under Massage Therapy

 

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