carpal tunnel syndrome

Carpal Tunnel Syndrome

 

Definition

Carpal tunnel syndrome is a disorder caused by compression at the wrist of the median nerve supplying the hand, causing numbness and tingling.

Description

The carpal tunnel is an area in the wrist where the bones and ligaments create a small passageway for the median nerve. The median nerve is responsible for both sensation and movement in the hand, in particular the thumb and first three fingers. When the median nerve is compressed, an individual's hand will feel as if it has "gone to sleep."

Women between the ages of 30 and 60 have the highest rates of carpal tunnel syndrome. Research has demonstrated that carpal tunnel syndrome is a very significant cause of missed work days due to pain. In 1995, about $270 million was spent on sick days taken for pain from repetitive motion injuries.

Causes and symptoms

Compression of the median nerve in the wrist can occur during a number of different conditions, particularly those conditions which lead to changes in fluid accumulation throughout the body. Because the area of the wrist through which the median nerve passes is very narrow, any swelling in the area will lead to pressure on the median nerve. This pressure will ultimately interfere with the nerve's ability to function normally. Pregnancy, obesity, arthritis, certain thyroid conditions, diabetes, and certain pituitary abnormalities all predispose to carpal tunnel syndrome. Other conditions which increase the risk for carpal tunnel syndrome include some forms of arthritis and various injuries to the arm and wrist (including fractures, sprains, and dislocations). Furthermore, activities which cause an individual to repeatedly bend the wrist inward toward the forearm can predispose to carpal tunnel syndrome. Certain jobs which require repeated strong wrist motions carry a relatively high risk of carpal tunnel syndrome. Injuries of this type are referred to as "repetitive motion" injuries, and are more frequent among secretaries doing a lot of typing, people working at computer keyboards or cash registers, factory workers, and some musicians.

Symptoms of carpal tunnel syndrome include numbness, burning, tingling, and a prickly pin-like sensation over the palm surface of the hand, and into the thumb, forefinger, middle finger, and half of the ring finger. Some individuals notice a shooting pain which goes from the wrist up the arm, or down into the hand and fingers. With continued median nerve compression, an individual may begin to experience muscle weakness, making it difficult to open jars and hold objects with the affected hand. Eventually, the muscles of the hand served by the median nerve may begin to grow noticeably smaller (atrophy), especially the fleshy part of the thumb. Untreated, carpal tunnel syndrome may eventually

The most severe cases of carpal tunnel syndrome may require surgery to decrease the compression of the median nerve and restore its normal function. This procedure involves severing the ligament that crosses the wrist, thus allowing the median nerve more room and decreasing compression.

(Illustration by Electronic Illustrators Group.)

result in permanent weakness, loss of sensation, or even paralysis of the thumb and fingers of the affected hand.

Diagnosis

The diagnosis of carpal tunnel syndrome is made in part by checking to see whether the patient's symptoms can be brought on by holding his or her hand in position with wrist bent for about a minute. Wrist x rays are often taken to rule out the possibility of a tumor causing pressure on the median nerve. A physician examining a patient suspected of having carpal tunnel syndrome will perform a variety of simple tests to measure muscle strength and sensation in the affected hand and arm. Further testing might include electromyographic or nerve conduction velocity testing to determine the exact severity of nerve damage. These tests involve stimulating the median nerve with electricity and measuring the resulting speed and strength of the muscle response, as well as recording speed of nerve transmission across the carpal tunnel.

Treatment

Carpal tunnel syndrome is initially treated with splints, which support the wrist and prevent it from flexing inward into the position which exacerbates median nerve compression. Some people get significant relief by wearing such splints to sleep at night, while others will need to wear the splints all day, especially if they are performing jobs which stress the wrist. Ibuprofen or other nonsteroidal anti-inflammatory drugs may be prescribed to decrease pain and swelling. When carpal tunnel syndrome is more advanced, injection of steroids into the wrist to decrease inflammation may be necessary.

The most severe cases of carpal tunnel syndrome may require surgery to decrease the compression of the median nerve and restore its normal function. Such a repair involves cutting that ligament which crosses the wrist, thus allowing the median nerve more room and decreasing compression. This surgery is done almost exclusively on an outpatient basis and is often performed without the patient having to be made unconscious. Careful injection of numbing medicines (local anesthesia) or nerve blocks (the injection of anesthetics directly into the nerve) create sufficient numbness to allow the surgery to be performed painlessly, without the risks associated with general anesthesia. Recovery from this type of surgery is usually quick and without complications.

Prognosis

Without treatment, continued pressure on the median nerve puts an individual at risk for permanent disability in the affected hand. Most people are able to control the symptoms of carpal tunnel syndrome with splinting and anti-inflammatory agents. For those who go on to require surgery, about 95% will have complete cessation of symptoms.

Prevention

Prevention is generally aimed at becoming aware of the repetitive motions which one must make which could put the wrist into a bent position. People who must work long hours at a computer keyboard, for example, may need to take advantage of recent advances in "ergonomics," which try to position the keyboard and computer components in a way that increases efficiency and decreases stress. Early use of a splint may also be helpful for people whose jobs increase the risk of carpal tunnel syndrome.

Resources

Periodicals

Seiler, John Gray. "Carpal Tunnel Syndrome: Update on Diagnostic Testing and Treatment Options." Consultant 37, no. 5 (May 1997): 1233.

Key terms

Carpal tunnel — A passageway in the wrist, created by the bones and ligaments of the wrist, through which the median nerve passes.

Electromyography — A type of test in which a nerve's function is tested by stimulating a nerve with electricity, and then measuring the speed and strength of the corresponding muscle's response.

Median nerve — A nerve which runs through the wrist and into the hand. It provides sensation and some movement to the hand, the thumb, the index finger, the middle finger, and half of the ring finger.

carpal

 [kahr´p'l]

pertaining to the carpus, or wrist.

carpal tunnel syndrome a symptom complex resulting from compression of the median nerve in the carpal tunnel, with pain and burning or tingling paresthesias in the fingers and hand, sometimes extending to the elbow. The disorder is found most often in middle-aged women. Excessive wrist movements, arthritis, hypertrophy of the bone and connective tissue in acromegaly, and swelling of the wrist can produce the carpal tunnel syndrome. Treatment is usually conservative and consists of splinting the wrist to immobilize it for several weeks until the irritation of the median nerve has healed. In severe cases surgical resection of the carpal ligament is helpful.

 Carpal tunnel syndrome. Entrapment of the median nerve in the carpal tunnel space. From Frazier et al., 2000.

car·pal tun·nel syn·drome

[MIM*115430]

the most common nerve entrapment syndrome, characterized by paresthesias, typically nocturnal, and sometimes sensory loss and wasting in the median nerve distribution in the hand; often bilateral and affects women more than men; due to chronic entrapment of the median nerve at the wrist within the carpal tunnel.

carpal tunnel syndrome

n.

A condition characterized by pain and numbing or tingling sensations in the hand and caused by compression of a nerve in the carpal tunnel at the wrist.

carpal tunnel syndrome

a common painful disorder of the wrist and hand, caused by compression on the median nerve between the inelastic carpal ligament and other structures within the carpal tunnel. It is often seen in cumulative trauma to the wrist. Symptoms may result from trauma, synovitis, or tumor or may develop with rheumatoid arthritis, amyloidosis, acromegaly, or diabetes. The median nerve innervates the palm and the radial side of the hand; compression of the nerve causes weakness, pain with opposition of the thumb, and burning, tingling, or aching, sometimes radiating to the forearm and shoulder joint. Weakness and atrophy of muscles may increase from lack of use, as a result of pain that impairs thumb and finger dexterity. Pain may be intermittent or constant and is often most intense at night. Diagnosis can be confirmed by electromyography. Symptomatic treatment usually relieves mild symptoms of recent onset, but if the pain becomes disabling, the injection of corticosteroids often yields dramatic relief. Surgical division of the volar carpal ligament to relieve nerve pressure is usually curative.

Procedure for assessing carpal tunnel syndrome

A syndrome of painful paraesthesiae of the median nerve, affecting hands and fingers, in particular index, middle and ring fingers, 2º to fibrous adhesions in the CT; it is most common in women; if prolonged, the CTS may result in partial atrophy of the lateral half of the thenar eminence with weakness of abduction and opposition of the thumb; it is either a chronic idiopathic flexor tenosynovitis, repetitive stress syndrome, or part of systemic conditions—e.g., acromegaly, amyloidosis, diabetes, granulomatous disease, hypothyroidism, mucopolysaccharidosis I-S, myxedema, obesity, pregnancy, or local processes, including ganglion cyst, bone dislocations, lipoma, callus formation in wrist fractures—e.g., Colles or Smith fractures—gout, pseudogout, and rheumatoid arthritis causing flexor tenosynovitis
Examination Phalen sign, Tinel sign
Diagnosis EMG is ‘gold standard’ test; detects decreased conduction velocity
DiffDx Proximal sites of nerve entrapment—e.g., Pancoast tumour, pronator teres syndrome
Treatment, early Wrist splint, NSAIDs, corticosteroid injection—e.g., beta-methasone—yoga
Treatment, late Longitudinal section of epineurium and flexor retinaculum for thenar atrophy

carpal tunnel syndrome

Median nerve dysfunction, pinched nerve syndrome Occupational medicine A syndrome of painful paresthesiae of the median nerve, affecting hands and fingers, in particular index, middle and ring fingers, 2º to fibrous adhesions in the CT; it is most common in ♀; if prolonged, the CTS may result in partial atrophy of the lateral half of the thenar eminence with weakness of abduction and opposition of the thumb; it is either a chronic idiopathic flexor tenosynovitis, repetitive stress syndrome, or part of systemic conditions–eg, acromegaly, amyloidosis, DM, granulomatous disease, hypothyroidism, mucopolysaccharidosis I-S, myxedema, obesity, pregnancy, or local processes, including ganglion cyst, bone dislocations, lipoma, callus formation in wrist fractures–eg, Colles or Smith fractures, gout, pseudogout, and rheumatoid arthritis causing flexor tenosynovitis Examination Phalen sign, Tinel sign Clinical Most symptomatic at night, hypesthesia of median nerve region, paresthesias, thenar muscle atrophy, slowed nerve conduction and EMG studies; the median nerve is a 'mixed' nerve and sensory loss precedes motor dysfunction, affecting sensation in the palmar aspect of the radial 3¹⁄₂ fingers DiffDx Proximal sites of nerve entrapment–eg, Pancoast tumor, pronator teres syndrome Treatment, early Wrist splint, NSAIDs, corticosteroid injection–eg, β-methasone, yoga Treatment, late Longitudinal section of epineurium and flexor retinaculum for thenar atrophy Diagnosis EMG is the 'gold standard' test, which detects ↓ conduction velocity

car·pal tun·nel syn·drome

(kahr'păl tŭn'ĕl sin'drōm)

A common nerve entrapment syndrome, characterized by hand paresthesia and pain, and sometimes sensory loss and wasting of muscle in the median nerve distribution; caused by entrapment of the median nerve at the wrist, within the carpal tunnel.

carpal tunnel syndrome

The result of any swelling occurring within the CARPAL TUNNEL. There is compression of the median nerve causing pain, numbness and tingling in one half of the hand, on the thumb side. The condition is commonest in middle aged women and may require injections of steroids or surgical decompression. Ultrasound treatment has also been used.

carpal tunnel syndrome

nocturnal pain, numbness, weakness of the thumb and tingling in the area of distribution of the median nerve in the hand. Due to compression of the nerve as it passes under the fascial band on the front of the wrist. Most common in middle-aged women.

carpal tunnel

space deep to flexor surface of the wrist, through which median nerve and flexor tendons pass

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syndrome

aggregated objective signs, subjective symptoms and specific pathologies that typify specific conditions

• acquired immunodeficiency syndrome; AIDS severe reduction in numbers of T4 lymphocyte helper (CD4) cells (due to infection with human immunodeficiency virus [HIV]) and resultant compromise of humoral and cell-mediated immunity; patients show lymphadenopathy, opportunistic infections (e.g. tinea and verrucae) and unusual infections (e.g. histoplasmosis, gastrointestinal tract candidiasis, Pneumocystis carnii pneumonia [PCP]), unusual malignancies (e.g. Kaposi's sarcoma), wasting diseases and presenile dementia

• acute compartment syndrome; ACS increased lower-limb intracompartmental pressure on exercise (exercise expands muscles, increases intracompartmental pressures, inducing pain); treated initially by rest, immobilization, non-steroidal anti-inflammatory drugs; severe cases may require surgical decompression (fasciotomy)

• anterior tarsal syndrome; ATS deep peroneal nerve entrapment at anterior ankle/dorsal talonavicular joint, due to restriction of ankle dorsiflexion (e.g. tight boots; ski boots), or local soft-tissue trauma (e.g. dorsal tarsal exostoses); characterized by extensor hallucis longus weakness, dorsal foot paraesthesia and numbness of first intermetatarsal space (symptoms can be induced by deep peroneal nerve percussion as crosses the anterior aspect of the ankle joint, or by ankle joint plantarflexion whilst simultaneously dorsiflexing toes)

• anterior tibial compartment syndrome ischaemic necrosis of anterior compartment muscle fibres, due to local arterial compression by engorged muscles, after unaccustomed exertion

• anterior tibiotalar impingement syndrome anterior ankle pain at ankle dorsiflexion (e.g. at midstance, just before heel lift) due to inferior tibial/neck of talus exostosis

• Apert's syndrome type Ia acrocephalosyndactyly, characterized by features of Carpenter's syndrome, with lesser digital (2-5) fusion into one mass, usually with a common mega-nail

• Apert-Crouzon syndrome type IIa acrocephalosyndactyly characterized by features of Carpenter's syndrome with additional craniofacial dysostosis, maxillary hypoplasia, and 2-4 digit fusion

• Bazex syndrome; acrokeratosis paraneoplastica keratoderma (i.e. erythema, scaling and irritation) of skin of ears, nose, hands and feet and later generalized hyperkeratosis in men with underlying internal malignancy; condition regresses when underlying malignancy is resolved

• Behçet's syndrome chronic vasculitic disease of unknown cause; characterized by seronegative arthritis of knees and ankles, elbows and wrists, mouth ulcers, erythema nodosum, visual impairment and cerebrovascular accident

• benign familial joint hypermobility syndrome; BFJHS generalized joint hypermobility, diagnosed as 2 major/1 major + 2 minor/4 minor criteria (see Table 1) in the absence of Ehlers-Danlos syndrome, Marfan's syndrome and osteogenesis imperfecta

• Brocq-Lyell syndrome; toxic epidermal necrolysis severe, acute, systemic drug reaction characterized by hyperpigmented skin lesions and epidermal detachment

• Brown-Séquard syndrome hemiparaplegia and hyperaesthesia, with ipsilateral loss of stereognosis and contralateral hemianaesthesia; due to unilateral spinal cord lesion

• carpal tunnel syndrome pain, paraesthesia and loss of power of palmar muscles; associated with rheumatoid arthritis

• Carpenter's syndrome; acrocephalopolysyndactyly oxycephaly, bradysyndactyly and polydactyly of the feet, with learning difficulties

• Charcot's syndrome see intermittent claudication

• chronic compartment syndrome; CCS; chronic exertional compartment syndrome exercise-induced fascial compartment pain; caused by compromised circulation and relative ischaemia of intracompartmental tissues, with long-term muscle and nerve dysfunction and damage; recalcitrant cases require surgical decompression through fasciotomy (see syndrome, acute compartment)

• compartment syndrome see syndrome, acute compartment; syndrome, chronic compartment

• complex regional pain syndrome; CRPS; chronic regional pain syndrome neuroinflammatory dysfunction, due to ion interaction of nociceptive C-fibre nerve endings, the sympathetic nervous system and spinal cord efferent motor nerves; characterized by vasomotor instability, hyperalgesia and impaired motor function; diagnosed from clinical presentation, symptoms reduction on administration of sympathetic nerve blockade, and intense, focal periarticular uptake of contrast medium in a delayed imaging-phase bone scan; treated by early, aggressive physical therapy to prevent contracture and muscle wasting, symptomatic relief by sympathetic nerve blockade, non-steroidal anti-inflammatory drugs, tricyclic antidepressants and anticonvulsant medication; immobilization is contraindicated

• complex regional pain syndrome type 1; CRPS 1; reflex sympathetic dystrophy; Sudek's atrophy; allodynia sympathetic nervous system-mediated acute pain and vasomotor instability, triggered by minor or surgical trauma without obvious nerve injury; affects women more than men; pain is excessive and out of proportion to severity of initiating injury; diagnosis is based on clinical symptoms aided by bone scan, laser Doppler studies and thermography; patients may show anxiety, depression and disturbed sleep; condition is difficult to manage; patients suspected of CRPS 1 should have early referral to a pain clinic (see Table 2); presents in three stages:

  • stage 1 acute phase, lasting 2-3 months, with regional severe burning pain, warmth and swelling triggered by stress/light touch, bone demineralization, skin trophic changes

  • stage 2 dystrophic phase/Sudek's atrophy; lasting for several months; characterized by constant unrelenting pain, exacerbated by any stimulus, and tissue cyanosis, coolness and induration, and diffuse osteoporosis

  • stage 3 atrophic phase, characterized by reduced/absent/intractable pain, irreversible atrophy of skin/subcutaneous tissues, flexion contractures of foot, advanced osteoporosis with a 'ground-glass' appearance on X-ray of affected bone

• complex regional pain syndrome, type 2; CRPS 2; causalgia; sympathetic pain syndrome persistent and severe skin paraesthesia/burning sensations; caused by trauma to peripheral sensory nerve fibres; symptoms, progress and treatment are similar to that of CRPS 1

• Conn's syndrome primary aldosteronism; characterized by headaches, thirst, nocturia, polyuria, hypovolaemia, fatigue, hypertension, alkalosis, and potassium depletion

• constrictive band syndrome intrauterine development of deep, tight, circumferential folds around leg/foot, and compromised limb development distal to band (e.g. autoamputation; marked oedema of distal tissues); thought to relate to strands of amniotic membrane enwrapping the developing limb

• Cushing's syndrome raised blood cortisol (e.g. due to pituitary tumour; long-term steroid therapy); characterized by central obesity, moon-like facies, acne, skin striae, hypertension, decreased carbohydrate tolerance and tendency to diabetes, female amenorrhoea and hirsutism

• Down's syndrome chromosomal disorder (trisomy 21) characterized by congenital short stature, broad short hands/feet, characteristic facies (pronounced epicanthic skin folds, flat hypoplastic face, short nose, enlarged tongue), transverse palmar crease, very dry skin, learning difficulties; formerly termed mongolism

  Edwards' syndrome trisomy 18, with congenital characteristic facies (micrognathia, low-set ears), rocker-bottom feet, severe learning difficulties; affected children often die in early childhood

• Ehlers-Danlos syndrome; Ehlers-Danlos diseases I-X hereditary connective tissue disorder characterized by collagen abnormality, marked generalized skin and blood vessel laxity, and joint hypermobility; skin is readily traumatized and heals slowly; see syndrome, hypermobility

• Franconi's syndrome a form of anaemia associated with renal tubule dysfunction; adult Franconi's syndrome shows synostosis with osteomalacia, and acquired Franconi's syndrome is associated with multiple myeloma

• Giles de la Tourette syndrome motor incoordination characterized by verbal, facial or limbic tics

• Gorlin's syndrome multiple naevus-like basal cell carcinomata, causing small pits and depressions of palmar and plantar skin

• Guillain-Barré syndrome; acute inflammatory polyneuropathy; acute idiopathic polyneuritis; infectious polyneuritis; postinfective polyneuropathy sudden-onset, acute, postviral polyneuritis; presents as distal pain, muscular weakness/flaccidity, paraesthesia; spreads proximally over 14-21 days; severe cases show spinal nerve involvement, with respiratory failure and limb paralysis (patient will require life support and anticoagulation to prevent deep-vein thrombosis); spontaneous recovery occurs over several weeks/months; some residual neuromotor effects may persist

• Haglund's syndrome prominence of posterior superior lateral area of calcaneum, retrocalcaneal bursitis, Achilles tendon thickening and Achilles tendinitis; diagnostic rearfoot radiographic features include positive parallel pitch lines, loss of retrocalcaneal recess (indicating retrocalcaneal bursitis), Achilles tendon thickening, loss of distinct interface between Achilles tendon and pre-Achilles fat pad

• heel pain syndrome see heel pain

• heel spur syndrome see heel spur

• Howel-Evans syndrome familial palmoplantar keratoderma, with increased risk of oesophageal cancer

• Hurler's syndrome; lipochondrodystrophy; dysostosis multiplex autosomal-recessive inherited generalized lipid disturbance and mucopolysaccharoidosis, affecting cartilage, bone, skin, subcutaneous tissues, brain, liver and spleen; characterized by short stature, shortness of neck, trunk and digits, kyphosis, reduced joint mobility, learning difficulties, characteristic facies (so-called gargoylism) and visual impairment

• hypermobility syndrome; joint hypermobility syndrome disordered collagen (types 1 and 3) structure, with associated decreased tensile strength of skin/structural tissues; characterized by generalized joint hypermobility, easy bruising, impaired healing, increasing incidence of joint/soft-tissue pain, joint dislocation and osteoarthritis; a presenting feature of benign familial joint hypermobility syndrome (BFJHS) (see Table 3), Ehlers-Danlos syndrome, Marfan syndrome and osteogenesis imperfecta

• iliotibial band syndrome; ITBS; iliotibial band friction syndrome; ITBFS overuse-associated, friction-induced inflammation of ITB and associated bursa, where ITB moves over lateral femoral condyle (Gerdy's tubercle); due to repeated knee flexion and extension, especially in athletes/cyclists; presents as ITB pain at heel strike progressing to constant ITB pain; early-stage treatment includes a daily stretching programme (see Table 4) and application of heat (pre-exercise) and ice (postexercise) (see Table 5)

• joint hypermobility syndrome see syndrome, hypermobility

• lobster-claw syndrome extreme form of ectrodactyly; characterized by absence of third and fourth rays

• Korsakoff's syndrome confusion and severe memory impairment with confabulation and Wernicke's syndrome, associated with chronic alcoholism

• Lyell's syndrome drug-induced, acute skin sensitivity reaction; characterized by acute erythema, urticaria, vasculitis, purpura, marked exfoliation (peeling), flaccid bullae formation, subepidermal separation/detachment

• Marfan's syndrome familial, autosomal-dominant, congenital changes in mesodermal and ectodermal tissues; characterized variably by musculoskeletal changes (e.g. increased height, excessive limb length, arachnodactyly; generalized tissue laxity and joint hypermobility), visual effects, and cardiovascular effects (e.g. aortic aneurysm)

• medial tibial stress syndrome; MTSS; tibial fasciitis; shin splint muscle fatigue, reduced shock absorption, traction enthesiopathy and periostitis along anterior and posterior medial lower one-third of tibia (see Table 6) secondary to overuse/underpreparation for exercise; exacerbated by exercising on hard surfaces, especially in individuals who pronate excessively; treated by muscle-strengthening exercises, pre-exercise flexibility programme, modification of overall sports exercise programme (see Table 7), in conjunction with gait analysis, orthoses and correct shoe selection

• Morquio's syndrome; type IV mucopolysaccharoidosis severe skeletal dysplasia including spine/thorax deformity, irregular epiphyses but normal shaft length of long bones, enlarged joints, flaccid ligaments, waddling gait and urinary abnormalities, due to autosomal-recessive error of mucopolysaccharide metabolism

• Morton's syndrome congenital shortening of first metatarsal with apparent shortening of hallux and associated metatarsalgia

• Munchausen's syndrome repeated fabrication of illness/symptoms of illness

• Munchausen's syndrome by proxy repeated reporting of spurious illness/symptoms of illness by one person about another

• musculoskeletal pain syndrome see polymyalgia rheumatica

• nail-patella syndrome; hereditary arthrodysplasia autosomal-dominant abnormality of finger/toenails, absent/hypoplastic patella, defects of head of radius and iliac horns, and iris discoloration

• nephrotic syndrome peripheral oedema, albuminuria, reduced plasma albumin (hypoalbuminaemia), refractory bodies in urine and raised blood cholesterol

• nerve entrapment syndromes local nerve trunk compression (e.g. tibial, medial calcaneal lateral, first lateral branch of calcaneal, lateral plantar, high tibial, popliteal, deep peroneal, superficial, saphenous, sural or medial common hallucal nerves), as in tarsal/carpal tunnel syndromes, plantar digital neuritis, Morton's neuroma; characterized by distressing distal dermatomal sensory (e.g. pain and paraesthesia) and/or motor symptoms (e.g. muscle atrophy) (see Table 8)

• Nievergelt-Pearlman syndrome rare autosomal-dominant bone disease causing lower-limb 'rhomboidal' tibia/fibula (crura rhomboidei), joint dysplasias, genu valgum, club foot, deformed toes; more common in males

• overlap syndromes see mixed connective tissue diseases

• patellofemoral joint syndrome see syndrome, runner's-knee

• peroneal cuboid syndrome loss of rearfoot eversion due to long-standing peroneal tendon dysfunction/tendinitis; characterized by plantar pain from cuboid to first metatarsal

• polycystic ovary syndrome see syndrome, Stein-Leventhal

• Raynaud's syndrome concomitant Raynaud's disease (always affecting hands, and frequently feet) in patients with connective tissue disorders, characterized by generalized digital cyanosis, localized painful vasculitic lesions of dorsal forefoot (30% of cases) and apices of toes (20-25% of cases); subcutaneous calcinosis (20% of cases) may masquerade as a seed corn

• Reiter's syndrome urethritis, iridocyclitis, arthritis, plantar enthesiopathy and heel spur formation, often triggered by earlier gastrointestinal Escherichia coli infection or exposure to a sexually transmitted disease (e.g. Chlamydia trachomatis); more common in human leukocyte antigen (HLA) B27 tissue-type males; see keratoderma blenorrhagicum

• restless-leg syndrome overwhelming need to move the lower limbs constantly; characteristic of chronic renal failure; thought to be triggered by accumulation of metabolites and uraemia

• Reye's syndrome cerebral oedema and death (in 50% of cases, usually children), provoked by aspirin therapy; aspirin is proscribed for children less than 16 years old

• Riley-Day syndrome; familial dysautonomia autosomal-dominant complete indifference to pain; also characterized by orthostatic hypotension, hyperhidrosis and hyporeflexic/absent deep tendon reflexes, pes cavus and trophic plantar ulceration

• Roussy-Levy syndrome; hereditary areflexic dystasia; Charcot-Marie-Tooth (CMT) disease type II essential tremor, sensory ataxia, poor coordination and judgement of movement, kyphoscoliosis and distal muscle atrophy (especially peronei); autosomal-dominant inherited disease similar to CMT disease type 1, but developing in early childhood

• runner's-knee syndrome mild lateral subluxation of patella in patellar groove; due to an increase in Q angle (i.e. >15°), often in association with excessive foot pronation, tibial varum, internal tibial torsion, weakened quadriceps group, malposition of vastus medialis, hard running surfaces or faulty sports shoes, leading to uneven pressure on anterolateral surface of femoral condyle and local pain; often affects female runners; treated by prescription orthoses to reduce torque, torsion and knee joint stress

• scalded-skin syndrome scaled/peeling appearance of skin overlying areas of infection, or associated with adverse drug reactions

• 'second-class travel' syndrome pulmonary thromboembolism due to prolonged periods of inactivity, e.g. passengers (who have been static for > 4 hours during long-haul intercontinental air flights) develop deep-vein thrombosis; the clot detaches, passing through venous circulation and heart, to block the pulmonary artery; characterized by sudden collapse and death; passengers on long-haul flights are advised to undertake leg muscle exercises regularly throughout the duration of the flight, wear 'antithrombotic' elasticated hosiery and consider medication with aspirin in the weeks before long-haul flight

• sinus tarsi syndrome sensation of unsteadiness when walking on gravel/uneven ground and ongoing pain in lateral tarsal area just distal to and level with lateral malleolus, subsequent to inversion sprain/excess rearfoot pronation (e.g. as in rearfoot rheumatoid arthritis); local symptoms are exacerbated by heel inversion/eversion; treated by non-steroidal anti-inflammatory drugs, local immobilization, orthoses or steroid injection

• SjÖgren's syndrome; sicca syndrome; keratoconjunctivitis sicca oral mucous membranes dryness, loss of lacrimal secretion, facial telangiectasias (i.e. butterfly rash), bilateral parathyroiditis (in younger women), strongly associated with rheumatoid arthritis and Raynaud's phenomenon

• Stein-Leventhal syndrome; polycystic ovary syndrome multiple ovarian cyst formation, with associated menstrual abnormalities, infertility, enlarged ovaries, insulin resistance, obesity, acne, evidence of masculinization (e.g. hirsuitism) and increased tendency to type 2 diabetes mellitus; responds to treatment with oral contraceptive pill and/or metformin

• Stevens-Johnson syndrome widespread bullous erythema multiforme of skin/mucous membranes; due to hypersensitivity/drug reaction

• talar compression syndrome posterior ankle pain when foot is maximally plantarflexed at ankle joint; due to compression of posterior tubercle of talus on posterior margin of distal end of tibia; note: similar condition occurs with os trigonum, which impinges on posteroinferior margin of tibia (see Table 9)

• tarsal tunnel syndrome; TTS pain, paraesthesia and numbness in sole of foot; due to tibial nerve compression within tarsal tunnel; associated with excess foot pronation or rearfoot rheumatoid arthritis; symptoms reproduced by tapping the skin overlying distal medial malleolar area (Tinel's sign positive); conservative treatment includes valgus filler pads, cobra pads and medial heel wedges, or control of excessive rearfoot pronation with moulded cushioned orthoses worn with bespoke shoes, together with non-steroidal anti-inflammatory drugs and/or disease-modifying antirheumatic drugs; surgical treatment includes decompression procedures to free posterior tibial nerve and excise local fibrous structures (see tarsal tunnel)

• distal tarsal tunnel syndrome isolated entrapment of medial/lateral plantar nerves; medial plantar nerve is compressed between navicular tuberosity and belly of abductor hallucis longus, causing 'jogger's foot'; first branch of lateral plantar nerve (Baxter's nerve) may be entrapped as it courses laterally between bellies of abductor hallucis and quadratus plantae (flexor accessories) muscles (see Table 10)

• proximal tarsal tunnel syndrome entrapment of posterior tibial nerve/its branches deep to flexor retinaculum; due to excessive subtalar joint pronation (with narrowing of tarsal tunnel, e.g. in rheumatoid foot) due to entrapment within attachments of flexor retinaculum, compression by an enlarged abductor hallucis muscle belly, enlarged navicular tuberosity, accessory navicular, presence of os tibialis externum, ischaemic compromise of posterior tibial nerve, or varicosities within tarsal tunnel

• trisomy 21 syndrome see syndrome, Down's

• Turner's syndrome sex-chromosome (XO) abnormality affecting 1:2500 females, with characteristic morphology (web neck, short stature), infantilism and amenorrhoea, coarctation of aorta and peripheral oedema; feet are oedematous, short and broad, show excess subtalar joint pronation and hyperextended halluces; nails tend to involution, and affected subjects are prone to ingrowing nails

• Werner's syndrome autosomal-recessive condition characterized by scleroderma-like skin, cataracts, progeria (premature senility), hypogonadism and diabetes mellitus

• Wernicke's syndrome; Wernicke-Korsakoff syndrome; Wernicke's encephalopathy brainstem ischaemia causing nystagmus and other ocular effects, tremors and ataxia, mental confusion, hypothermia and hypotension; more common in chronic alcoholics

• Wolff-Parkinson-White syndrome congenital atrioventricular interconnection causing tachycardia and characteristic electrocardiogram pattern

• yellow-nail syndrome see nail, yellow

Major criteria

Current/historic Brighton score of 4/9

Arthralgia for >3/12 in four or more joints

Minor criteria

Current/historic Brighton score of 1, 2 or 3/9 (0, 1, 2, 3/9 if >50 years old)

Arthralgia for minimum of 3 months in 1-3 joints, or back pain for minimum of 3 months, or spondylosis/spondylolysis/spondylolisthesis

Dislocation/subluxation of > one joint, or one episode of simultaneous dislocation/subluxation of more than one joint

Three or more lesions of soft-tissue rheumatism (e.g. spondylitis, tenosynovitis, bursitis)

Marfanoid habitus (i.e. tall, slim physique, span:height ratio >1.3, upper:lower segment ratio <0.89, arachnodactyly [+Steinberg/wrist signs])

Abnormal skin: striae, hyperextensibility, thin skin, papyraceous scarring

Eye signs: drooping eyelids, myopia, antimongoloid slant

Varicose veins or hernia or uterine/rectal prolapse

Note: BFJHS is diagnosed in the presence of two major criteria, or one major and two minor criteria, or four minor criteria (adapted from Grahame R, Bird HA, Child A, Dolan AL, Fowler-Edwards A, Ferrell W, Gurley-Green S, Keer R, Mansi E, Murray K, Smith E. The British Society Special Interest Group on Heritable Disorders of Connective Tissue Criteria for the Benign Joint Hypermobility Syndrome. "The Revised (Brighton 1998) Criteria for the Diagnosis of the BJHS". Journal of Rheumatology 2000; 27:1777-1779).

Table 2: Features of complex regional pain syndrome

Phase	Features
Acute phase (duration: 2-3 months) Reversible	Severe burning pain, warmth, swelling and joint stiffness within a limb: not confined to a dermatome or myotome Bone demineralization Symptoms (exacerbated by limb dependence, contact or stress) persist for 2-3 months
Chronic phase (duration: several months) Reversible	Pain continues The limb becomes cool, firm and cyanotic Radiographs show diffuse osteoporosis Digits develop flexure contractures Persists for several months
Atrophic phase Irreversible	Pain diminishes or becomes intractable Skin and subcutaneous tissues become atrophic Flexion contractures in foot become fixed Osteoporosis becomes advanced; bone has a 'ground-glass' appearance

Major criteria

Current/historic Brighton score of 4/9

Arthralgia for >3/12 in four or more joints

Minor criteria

Current/historic Brighton score of 1, 2 or 3/9 (0, 1, 2, 3/9 if >50 years old)

Arthralgia for minimum of 3 months in 1-3 joints, or back pain for minimum of 3 months, or spondylosis/spondylolysis/spondylolisthesis

Dislocation/subluxation of > one joint, or one episode of simultaneous dislocation/subluxation of more than one joint

Three or more lesions of soft-tissue rheumatism (e.g. spondylitis, tenosynovitis, bursitis)

Marfanoid habitus (i.e. tall, slim physique, span:height ratio >1.3, upper:lower segment ratio <0.89, arachnodactyly [+Steinberg/wrist signs])

Abnormal skin: striae, hyperextensibility, thin skin, papyraceous scarring

Eye signs: drooping eyelids, myopia, antimongoloid slant

Varicose veins or hernia or uterine/rectal prolapse

Note: BFJHS is diagnosed in the presence of two major criteria, or one major and two minor criteria, or four minor criteria (adapted from Grahame R, Bird HA, Child A, Dolan AL, Fowler-Edwards A, Ferrell W, Gurley-Green S, Keer R, Mansi E, Murray K, Smith E. The British Society Special Interest Group on Heritable Disorders of Connective Tissue Criteria for the Benign Joint Hypermobility Syndrome. "The Revised (Brighton 1998) Criteria for the Diagnosis of the BJHS". Journal of Rheumatology 2000; 27:1777-1779).

Table 4: Iliotibial band-stretching regime

Muscle group	Action (hold for 5-10 seconds; repeat ×5, three times a day)
Hip abductor	Stand erect, legs straight, feet together; stretch trunk (on frontal plane) towards the unaffected leg
Iliotibial band	Lie on a bench on the unaffected side, with the unaffected hip and knee slightly flexed, in order to maintain balance; flex the affected hip and straighten the affected knee so that the affected leg hangs off the bench; allow the iliotibial band of the affected leg to be stretched by gravitational pull Lie on a bench on the affected side with the affected leg in line with the body and the hip and knee locked; flex the unaffected (upper) leg; place the hands on the bench immediately under the shoulder and push the trunk upwards as far as possible to apply stretch to the lateral area of the affected leg
Upper iliotibial band	Stand erect; with affected leg behind normal leg; stretch trunk (on frontal plane) towards unaffected side
Lower iliotibial band	Stand erect as above, with the knee of the affected leg slightly flexed and hips rotated (on transverse plane) towards affected leg; stretch trunk (on frontal plane) towards the unaffected side
Iliotibial band and hamstrings	Stand erect, with the affected leg behind the normal leg so that the knee of the affected leg rests on the posterior aspect of the non-affected knee; rotate the trunk (on transverse plane) away from the affected leg and attempt to touch the heel of the affected leg

Table 5: Treatment regime for iliotibial band syndrome

	Visit	Action
1	Examination Including Nobel's and Ober's tests, and excluding other causes of knee joint pain Gait analysis - walking and running	Check for presence of tibial varum, tibial torsion, uncompensated rearfoot varus and limb length discrepancy (include shoe wear pattern) Instigate the iliotibial band stretching regime (see Table 11), with a quadriceps- and adductor-strengthening programme Ice massage to painful area at lateral aspect of knee Advise reduction in athletic activity
2	Commence physical therapies, e.g. cortisone iontorphoresis or ultrasound and ice massage	Stabilizing orthoses and/or foot and ankle taping, ± heel lift Continue stretching programme ± massage Non-steroidal anti-inflammatory (10-day course of 400 mg ibuprofen qds) Stop all athletic activity if pain does not resolve
3	Magnetic resonance imaging/computed tomographic scan to knee joint area	Refer to orthopaedics
Most cases will resolve with one treatment; more severe cases will require a second visit and some will require orthopaedic referral.

Table 6: Iliotibial band-stretching regime

Muscle group	Action (hold for 5-10 seconds; repeat ×5, three times a day)
Hip abductor	Stand erect, legs straight, feet together; stretch trunk (on frontal plane) towards the unaffected leg
Iliotibial band	Lie on a bench on the unaffected side, with the unaffected hip and knee slightly flexed, in order to maintain balance; flex the affected hip and straighten the affected knee so that the affected leg hangs off the bench; allow the iliotibial band of the affected leg to be stretched by gravitational pull Lie on a bench on the affected side with the affected leg in line with the body and the hip and knee locked; flex the unaffected (upper) leg; place the hands on the bench immediately under the shoulder and push the trunk upwards as far as possible to apply stretch to the lateral area of the affected leg
Upper iliotibial band	Stand erect; with affected leg behind normal leg; stretch trunk (on frontal plane) towards unaffected side
Lower iliotibial band	Stand erect as above, with the knee of the affected leg slightly flexed and hips rotated (on transverse plane) towards affected leg; stretch trunk (on frontal plane) towards the unaffected side
Iliotibial band and hamstrings	Stand erect, with the affected leg behind the normal leg so that the knee of the affected leg rests on the posterior aspect of the non-affected knee; rotate the trunk (on transverse plane) away from the affected leg and attempt to touch the heel of the affected leg

Table 7: Grades and characteristics of medial tibial stress syndrome (MTSS)

Grade	Characteristic
1	Pain on palpation of the anteromedial (or posteromedial) area of tibial crest No pain during activity or exercise
2	Pain after activity or exercise No pain during activity or exercise
3	Pain during activity or exercise Pain after activity or exercise
4	Pain and discomfort during normal walking Continual pain during activity or exercise

Table 8: Phased treatment approach to medial tibial stress syndrome (MTSS)

Presentation	Treatment
Phase 1: acute phase	Cessation of exercise activity until all pain resolves RICE(P)
Phase 2: rehabilitation phase	Deep compartment muscle exercise to strengthen the deep fascial-bone interface and reduce tension on the deep fascial insertion, in order to decrease pain and swelling and prevent fascial scarring
Phase 3: functional phase	Use of antipronatory/functional orthoses, strapping or taping in order to strengthen the fascial-bone interphase and prevent further excessive tension on the tibia
Phase 4: return to activity	Phased and gradual return to normal levels of activity

Table 9: Presentations of nerve trunk irritation in the foot

Neuroma/lesion	Involved nerve	Location
Proximal tarsal tunnel syndrome	Branches of the posterior tibial nerve	Medial ankle area
Distal tarsal tunnel syndrome Jogger's foot	Medial plantar nerve	Between navicular tuberosity and belly of abductor hallucis
Distal tarsal tunnel syndrome Baxter's neuritis	Lateral plantar nerve	Between bellies of abductor hallucis, quadratus plantae and abductor digiti quinti minimi
Joplin's neuroma	Medial plantar nerve proper	Medial area of first metatarsal head
Houser's neuroma	First plantar intermetatarsal nerve	Between 1 and 2 metatarsals
Heuter's neuroma	Second plantar intermetatarsal nerve	Between 2 and 3 metatarsals
Morton's neuroma	Third plantar intermetatarsal nerve	Between 3 and 4 metatarsals
Islen's neuroma	Fourth plantar intermetatarsal nerve	Between 4 and 5 metatarsals

Table 10: Accessory bones in the foot

Accessory bone in the foot	Location
Os tibiale externum (accessory navicular)	Within tibialis posterior tendon, adjacent to proximal part of navicular tuberosity
Os trigonum	Posterior margin of talus
Os peroneum	Within peroneus longus tendon, adjacent to inferior lateral border of cuboid/calcaneocuboid joint
Os vesalianum	Adjacent to fifth metatarsal base
Os intermetatarseum	Between bases of first and second metatarsals
Os interphalangeus	Within insertion of flexor hallucis longus tendon, adjacent to plantar area of hallux interphalangeal joint

Table 11: Presentations of nerve trunk irritation in the foot

Neuroma/lesion	Involved nerve	Location
Proximal tarsal tunnel syndrome	Branches of the posterior tibial nerve	Medial ankle area
Distal tarsal tunnel syndrome Jogger's foot	Medial plantar nerve	Between navicular tuberosity and belly of abductor hallucis
Distal tarsal tunnel syndrome Baxter's neuritis	Lateral plantar nerve	Between bellies of abductor hallucis, quadratus plantae and abductor digiti quinti minimi
Joplin's neuroma	Medial plantar nerve proper	Medial area of first metatarsal head
Houser's neuroma	First plantar intermetatarsal nerve	Between 1 and 2 metatarsals
Heuter's neuroma	Second plantar intermetatarsal nerve	Between 2 and 3 metatarsals
Morton's neuroma	Third plantar intermetatarsal nerve	Between 3 and 4 metatarsals
Islen's neuroma	Fourth plantar intermetatarsal nerve	Between 4 and 5 metatarsals

car·pal tun·nel syn·drome

(kahr'păl tŭn'ĕl sin'drōm) [MIM*115430]

Most common nerve entrapment syndrome, characterized by sensory loss and wasting in the median nerve distribution in the hand; due to chronic entrapment of median nerve at wrist within carpal tunnel.

carpal tunnel syndrome,

n an irritation and inflammation of the synovials surrounding the tendons controlling the fingers. It is a disabling condition for persons who work with their hands, particularly those engaging in keyboard activities, data management, and instrumentation such as those in the dental office.

carpal

pertaining to the carpus.

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carpal bones

are located between the radius and ulna and metacarpals. Typically, there are six to eight bones, depending on the animal species, arranged in two rows and numbered from medial to lateral. See Table 10.

carpal canal syndrome

see carpal tunnel syndrome (below).

carpal flexion posture

at parturition the fetus is presented with the carpal joints flexed, thus increasing the diameter of initial parts entering the pelvic canal, resulting in dystocia in some patients.

carpal fracture

see chip fractures, slab fracture.

carpal instability/flexion syndrome

seen in young puppies, particularly Doberman pinschers and Shar peis; the carpi remain slightly flexed when standing and the paws are deviated inwards.

carpal organ

a group of vibrissae located on the posterior aspect of the forelimbs of cats, sensitive to touch. See also tactile hair organ.

carpal pad

see footpad.

carpal sheath

common synovial sheath in the forelimb of the horse, shared by the superficial and deep flexor tendons as they pass through the carpal canal.

carpal tunnel

the osseofibrous passage for the flexor tendons and median nerve, formed by the flexor retinaculum and the carpal bones.

carpal tunnel syndrome

a complex of signs resulting from compression of the median nerve in the carpal tunnel. In horses there is lameness with pain on extreme carpal flexion. There are no lesions on the anterior carpal bones.

Patient discussion about carpal tunnel syndrome

Q. I'm looking for natural/organic ways to deal with carpal tunnel syndrome. My Boss has Carpal Tunnel syndrome. I'm looking for some natural remedies to help her ease the pain.

A. I have found that MSM (GNC brand) 1500mg per day works for me. I talked to an Orthopedic Surgeon asking him why it works... he said "they really don't know why it works, but it works for many of my patients". When I stop taking my MSM the symptoms return so it is not a cure.

I have tried other brands of MSM and found the GNC brand works the best for me. It takes about 2 weeks to begin to see the results and several more weeks to get the full affect.

Q. what can i do to help my capentunnel without surgery?

A. a good friend of mine is a bike racer and did the surgery- it's not a bad solution as it seems...but you can try and put on a splint to stabilize the wrist. The splint is worn at night for several weeks. If this does not help, you may need to wear the splint during the day. Hot and cold compresses may also be recommended.

There are many ergonomic devices that can be used in the workplace to reduce the stress placed on the wrist. These include special keyboards, cushioned mouse pads, and keyboard drawers. Make sure the keyboard is low enough so that the wrists aren't bent upward during typing. You may also need to make changes in your work duties or recreational activities.