Myofascial release of carpaltunnel syndromeBENJAMIN M. SUCHER, DO

Current treatment for carpaltunnel syndrome may be ineffective or as-sociated with complications or recurrence.In the case reported here, a myofascial re-lease by the physician combined with thepatient's self-stretch reduced pain andnumbness and improved electromyogra-phic results. The manipulative approachreleases the transverse carpal ligament, -and "opens"or dilates the canal. The pa-tient stretches the wrist, digits, and thumb,including myofascial components. An ag-gressive, conservative approach lessensthe need for surgery in mild to moderatecases. Studies with magnetic resonance im-aging may be helpful to document canalsize before and after treatment.

(Key words: Carpal tunnel syndrome,myofascial release, manipulation)

The current treatment for carpal tunnel syn-drome is often time consuming and cumber-some, involving orthoses, anti-inflammatorymedication, local steroid injection, or surgery.Clinical experience reveals a significant lackof response to conservative treatment and pa-tient unwillingness to receive injection. Sur-gery, even though considered the definitivetreatment, is associated with some degree ofcomplication and possible recurrence.1,2

This case demonstrates an alternative, ad-junctive form of treatment for carpal tunnelsyndrome. A vigorous, direct myofascial re-lease technique is described. It is administered

Reprint requests to Benjamin M. Sucher, DO, 10555 NTatum Blvd, Suite A-104, Paradise Valley, AZ 85253.

by the physician and continued to some de-gree by the patient as a modified self-stretch-ing maneuver.

Report of caseA 47-year-old female computer operator was firstseen on June 27, 1991, because of burning pain andnumbness, of recent onset, involving digits 1through 4 of the right hand. Phalen's test yieldedpositive results, and there was a 50% sensory lossto pinprick in digit 1. Carpal tunnel syndrome wasdiagnosed by a physiatrist (the author) and a re-ferring rheumatologist. Electromyography revealedprolongation of the right median distal motor la-tency (4.0 ms). Palmar stimulation produced a re-sponse of 17 mV, with a 71% decrement in ampli-tude on proximal stimulation (5 mV). The mediandistal sensory latency was 3.6 ms, with a 50 RVamplitude.

The patient had been using a wrist orthosis fortendinitis and forearm muscle strain, as well asanti-inflammatory medication and physical medi-cine modalities. While prior treatment was main-tained, a form of soft tissue release was introduced.The addition of this manipulation was combinedwith self-stretch of the carpal canal (ligament andassociated myofascial structures). The patient un-derwent manipulation on two occasions and wasstretching several times daily. By August 15, sheno longer experienced burning pain or numbness,and the distal motor latency, determined on thatdate, was 3.2 ms, with an increase in amplitudeto 8 mV (15 mV distally on palmar stimulation).The distal sensory latency had decreased to 3.2 mswith an increase in amplitude to 100 p.,V.

ManagementThe treatment involves a physician-applied ma-nipulative procedure and a patient's self-

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Figure 1. Top frame: Operator's fingers, not visible be-neath patient's hand, press upward on dorsal part of pa-tient's wrist ( centrally). Operator's thumbs apply pres-sure along attachment edges of carpal ligament at me-dial and lateral borders of carpal bones. Bottom frame:Same as in top frame, except that patient's wrist and dig-its are hyperextended, further opening or extending ca-nal, and operator's thumbs have progressed away frommidline, "stripping" ligamentous and myofascial attach-ments back.

stretch. The manipulative procedure uses athree-phase approach:

1. "Opening" of the carpal canal with stretch-ing and release of the transverse carpal liga-ment, to increase the space within the canaland thereby decrease the pressure on the me-dian nerve. Pressure is applied centrally fromthe dorsal surface of the carpal bones simulta-neously with pressure applied from the ven-tral edges of the carpal bones (Figure 1, topframe). This is a three-point opposing-pressuresystem approach. It has the effect of reversingthe natural tendency of the "working" postureto "flex" the canal and decrease or narrow the

Figure 2. Top frame: Relaxed position. Relevant struc-tures within carpal canal region, ventral part of wrist,and palm. Notice myofascial association of thenar attach-ment ventrally along transverse carpal ligament. Bottomframe: Stretch position. Carpal canal is "extended," asthe ligament and myofascial structures are maximallystretched. Notice dilation effect of thicker proximal por-tion of flexor tendons that have traveled distally throughcanal ( bougie effect).

carpal space. In effect, the canal is "extended"and opened up. Additionally, the thumbs press-ing on the edges of the wrist bones slide fur-ther medially and laterally away from the cen-ter of the canal, essentially "stripping" themyofascial tissue back and enhancing thestretch or release.

2. Release of the true myofascial componentof the carpal canal, the attachment of the ab-ductor pollicis brevis muscle. One of the op-erator's treating hands "catches" the patient'sthumb and pulls it back into hyperextension,with abduction, while simultaneously perform-ing the stretch and release previously de-

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Figure 3. Extension stretch of wrist and carpal canal.

scribed (Figure 1, top frame).3. Indirect stretch of the carpal canal dis-

tally, with distension/dilation of the canal in-ternally. The digits and wrist of the patient'sinvolved hand are hyperextended simultane-ously with the stretch and release in the firsttwo steps (Figure 1, bottom frame). This hy-perextension indirectly stretches the fasciaand ligamentous structures over the canal ven-trally and especially distally. In addition, theflexor tendons are pulled through the canalso that the more proximal, slightly thicker por-tion of the tendons (and musculotendinous re-gions) are actually pulled into the canal and

begin to distend the canal from the inside out(Figure 2).

The patient's self-stretch involves two com-ponents:

1. The carpal component (Figure 3). Thewrist and digits are simultaneously hyperex-tended.

2. The thenar/myofascial component (Fig-ure 4). The thumb is simultaneously hyperex-tended and hyperabducted.

Both self-stretches could be performed simul-taneously, by supporting the extended digitsagainst some object such as a door frame orwall, which would free the other hand tostretch the thumb.

DiscussionThe median nerve passes between the strongtransverse carpal ligament and flexor tendons,ventral to the two rigid rows of carpal bones.3,4The nerve being one of the softer structureswithin the narrow confines of the carpal canalis easily injured by compression. 5 Swelling ofthe tendon sheaths, trauma, repetitive motion,overuse, and vibration are among the more com-mon causes of damage to the nerve. 3 '4 It is gen-erally accepted that anything leading to de-creased space within the carpal canal could com-press the median nerve and thereby producecarpal tunnel syndrome . 3,5 What is not so

Figure 4. Thenar, carpal ligament stretch. Left frame: Initiation of stretch. Patient hooks hypothenar region of oppo-site hand (in this case, right hand) into thenar area of hand to be stretched (in this case, left hand), pulling laterallywhile simultaneously grasping thumb itself and extending. Right frame: Progressive phase of stretch into further exten-sion and abduction. (continued on page 100)

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widely acknowledged is the potential disten-sibility of the transverse carpal ligament 6-8 orthe thenar myofascial attachment (Figure 2)to the ligament. 9 The manipulative approachto the ligament decompresses the carpal canalwithout surgical section. The thenar attach-ment is used as a fulcrum to assist in stretch-ing the ligament and "opening" the canal.

Although generally considered strong ortough structures, ligaments have some flexi-bility and pliancy. 10 Hollinshead8 noted thatligaments did not allow much stretch, andGoodgold commented that considerable forceis needed to stretch the transverse carpal liga-ment. 6 Nevertheless, these studies reflect thatthere is potential for at least slight release ofthis structure to relieve the pressure withinthe canal. This potential would be particularlyimportant in carpal tunnel syndrome caseswhere the ligament is thickened, as someauthors5,11,12 have noted.

Computed tomographic scan analysis of thecross-sectional area through the canal has dem-onstrated that it increases after surgical treat-ment, thereby correlating with clinical improve-ment. 13 Others have assessed the canal by mag-netic resonance imaging, including volumemeasurements, to correlate improvement.14The decrease in size of the canal has been cor-related with increased pressure 16; others havenoted an "imbalance" between the size of thecanal and the volume of its contents, thus im-plying such a pressure effect. ? Johnson 16 hasobserved that the greater the "squareness" ofthe wrist, the greater the likelihood that car-pal tunnel syndrome will develop. The increasein square shape probably creates a decreasein size of the canal and thus increases the pres-sure.

Wrist and digit position appears to be sig-nificant in relation to the pressure generatedwithin the carpal canal. 17,18 Extremes of flex-ion or extension increase pressure. However,R. Werner, MD, has noted that hyperexten-sion of the digits generates the highest pres-sures (written communication, November 7,1991). The reason may be the distal movementof the flexor tendons (up to 1.5 cm) into thecanal, where the more proximal, thicker por-tion is literally "stuffed" into a narrow space.

Such an effect could be used to advantage tohelp dilate the canal, from inside out, as witha bougie.

Most persons actively using their upper ex-tremities for repetitive motion are constantlyflexing or "cupping" the wrist and carpal ca-nal region, leading to a progressive decreasein the carpal space with adaptive foreshorten-ing of the carpal ligament. This process leadsto a decrease in the canal volume and in-creased pressure, allowed to progress becausemost persons do not stretch the wrist or handinto extension to counteract or reverse this phe-nomenon.

In the case reported here, carpal tunnel syn-drome developed while the patient was under-going treatment for tendinitis and strain. Anorthosis, medication, and physical modalitieswere ineffective. Other mechanisms as de-scribed in the preceding paragraphs must havebeen involved. It is particularly relevant inthat the patient continued her regular job,which involved 6 to 8 hours per day workingat a keyboard, involving persistent wrist anddigit flexion. When those mechanisms were ad-dressed, with the myofascial release andstretch, she responded very rapidly. This re-sponse, in itself, lends credence to the theoryproposed and the usefulness of the treatment.

This case is but one example of the author'suse of a form of myofascial release manipula-tion to treat carpal tunnel syndrome. Severalpatients have been treated similarly over thepast 2 years during the development and re-finement of the procedure. However, this caseis most representative of the final multiphaseapproach, and involves documentation with lim-ited nerve conduction studies before and aftertreatment.

CommentMyofascial release of carpal tunnel syndromeshould be considered a treatment of choice formild to moderately severe cases. However, ad-vanced cases, particularly those with evidenceof denervation and atrophy, may still requiresurgical release to avoid additional or perma-nent nerve damage. Assessment of the carpalcanal by magnetic resonance imaging beforeand after treatment could further document

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the effectiveness of this technique by demon-strating an increase in canal size and greaterspace for the median nerve. Ideally, more spe-cific electrophysiologic and clinical criteria willalso be developed to help categorize the degreeof involvement and thereby direct the clini-cian to the optimal treatment regimen.

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juries and Diseases. Philadelphia, Pa, Hanley & Belfus, 1991,pp 341-352.8. Hollinshead WH: The connective tissues, in Hollinshead WH:Textbook of Anatomy, ed 2. New York, NY, Harper & Row, 1967,pp 13-36.9. Grant JC: An Atlas of Anatomy, ed 6. Baltimore, Md, Wil-liams & Wilkins, 1972, pp 59-72.10.Gray H: The articulations, in Pick TP, Howden R (eds): Anat-omy, Descriptive and Surgical, ed 15. New York, NY, BountyBooks, 1977, pp 217-293.11.Kimura J: Mononeuropathies and entrapment syndromes,in Electrodiagnosis in Diseases of Nerves and Muscle: Principlesand Practice. Philadelphia, Pa, FA Davis Co, 1983, pp 4897508.12.Posch J, Marcotte D: Carpal tunnel syndrome: An analysisof 1201 cases. Ortho Rev 1976;5:25-35.13.Dawson D, Hallett M, Millender L: Carpal tunnel syndrome,in Dawson D, Hallett M, Millender L: Entrapment Neuropa-thies. Boston, Mass, Little, Brown & Co, 1983, pp 5-59.14.Gelberman R, Rydevik B, Pess G, et al: Carpal tunnel syn-drome: A scientific basis for clinical care. Orthop Clin NorthAm 1988;19:115-124.15.Rojviroj S, Sirichativapee W, Kowsuwon W, et al: Pressuresin the carpal tunnel. J Bone Joint Surg 1990;72-B:516-518.16.Johnson E: Carpal tunnel syndrome, in Johnson E (ed): Prac-tical Electromyography, ed 2. Baltimore, Md, Williams & Wilk-ins, 1988, pp 187-205.17.Smith E, Sonstegard D, Anderson W: Carpal tunnel syn-drome: Contribution of flexor tendons. Arch Phys Med Rehab1977;58:379-385.18.Werner R, Armstrong T, Waring W, et al: Intracarpal canalpressures in selected hand tasks: A pilot study (abstract). ArchPhys Med Rehabil 1991;72:778.

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