Clinical Pearl — Carpal Tunnel Syndrome: No Do-Overs With Surgery!!

After years of practice, I have treated numerous patients with the “diagnosis” of CTS.  Many of them even had positive nerve conduction findings and EMG’s.

We all have seen these patients.  They come in with forward head posture, internally rotated humerus, forward shoulder positioning, kyphotic T-spine, etc.

If you reverse the compensatory positioning of the above, they will likely be miserable with an increase in symptoms.  (This is without treatment of the causes of their compensation.)

Common findings in your assessment?

•    Positive upper limb neural provocation testing
•    1st and 2nd rib dysfunction (elevated or depressed with movement restriction)
•    Sternoclavicular joint dysfunction, likely restricted in arthrokinematic mobility and control
•    Dysfunction (weakness, tightness, poor control) in the following muscles, all cervical: pectoralis minor, rhomboids, serratus anterior, trapezius, subclavius, pronator teres, scalenes….  (Ask them if they get headaches and if their head is ever too heavy for their neck or if they feel like they have to hold it up after sitting at their desk for a while.)

These muscles aren’t just weak but they may be very tight.

This all leads to a double/triple/quadruple crush issue of their upper extremity nerves.

So, what do I do to treat this?  Of course I would use some Functional Dry Needling to treat all the muscles we find involved (don’t forget the cervical multifidus!).

Manually, I want to address the rib and thoracic issues.  Personally (I know this goes against much of our common views), I treat the DEPRESSED first rib and elevated 2nd rib on the most symptomatic side.  I will post another clinical pearl on the T-spine and ribs in a successive article.

Correctives are likely the most important aspect with successful treatment of this common problem.  Let’s be honest — we often don’t do well here.

The obvious correctives are strengthening the posterior musculature but I would challenge you to think a bit differently.  If you give someone more range of motion, give them correctives to control that new range.  This is likely why these patients fail rehab.  You will need to do both neuro-reeducation and specific strengthening of the muscles but please integrate it into a functional pattern as that will address so much more of the dysfunction and have greater carry over.  I have very simple principles I use in determining my corrective plan of care.  Yes, that could be an upcoming clinical pearl, too.

Please email/post/Tweet for specific questions and also consider the Functional Therapeutics course to address cases like this, as this is addressed globally and specifically in the FT.