This article is a transcriptions of an episode of the RateFast podcast, which you can listen to by searching “RateFast” in iTunes or the iOS podcast store.
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A patient enters a doctor’s office and says, “Doctor, I believe that I have carpal tunnel!” To which the doctor replies, “My god, it appears that I have carpal tunnel too! Now let’s check and see if you’re having carpal tunnel syndrome.”
Yes, most people’s hands contain a carpal tunnel, which is a rigid ligament through which the median nerve and the tendons pass through. Carpal tunnel syndrome is the pain associated with the inflammation of the nerves and tendons within the carpal tunnel. Knowing the difference between the two can save you from a snarky conversation like the one detailed above.
We spoke with Dr. Leonard Gordon, a microsurgeon, about what causes carpal tunnel syndrome, how to avoid it, how to treat it once it begins, and what is done when it goes from bad to worse.
Carpal Tunnel (noun) – the tunnel through which a number of structures travel at the wrist. From Greek carpal, meaning wrist.
Volar (noun) – relating to the palm of the hand.
Dorsal (noun) – relating to the top of the hand.
Median Nerve (noun) – the nerve that passes through the carpal tunnel.
Motor Fibers (noun) – provides the movement in the muscles that it supplies.
Sensory Fibers (noun) – receives sensation that is returned to the brain.
Endoscopic (noun) – the procedure of the doctor looking in the body, usually with the use of a camera.
Narrator: Welcome to the California Work Comp Report, a podcast hosted by Arun Croll and Claire Williams.
Claire: Hello. Today is Thursday, the 9th of July, and we are joined on our RateFast California Work Comp Report podcast by Dr. Leonard Gordon. Hello, Doctor Gordon.
Dr. Gordon: Hi, good morning.
Claire: Good morning. I was wondering if you could start off by telling our listeners a bit about you and your background in medical practice.
Dr. Gordon: Okay. Well, I’m a practicing hand surgeon in San Francisco. Let’s see, so I finished medical school and anatomy at Stanford as a teaching assistant, and I think that’s when I fell in love with the anatomy, especially of the hand, and decided to be a hand surgeon. So from that anatomy job I did my residency in orthopaedics at UCSF, and then a fellowship at Harvard, where I did my hand surgery training. And since then, I’ve been a hand surgeon specializing for a long time in microsurgery, which is putting fingers back on, hands back on that have been cut off, and I also do general hand surgery practice, with things like carpal tunnel syndrome and arthritis and that kind of thing.
Claire: Neat. And today, we’re gonna be focusing on carpal tunnel, as it’s a common workers’ compensation injury. And so I was wondering if you could start us off with a professional definition of what carpal tunnel is.
Dr. Gordon: Okay. Well, carpal tunnel refers to the tunnel through which a number of structures travel at the wrist. Carpal comes from a Greek word meaning “wrist,” so it’s the wrist tunnel. And through that tunnel, which has a ligament on the superficial or volar side, and the bones of the wrist on the dorsal side. Through that tunnel, ten structures run from the forearm into the hand. Each finger has two tendons, the thumb has one tendon, so that’s nine structures, and then there’s the median nerve. The nerve is one of the most important nerves of the hand, and travels from the forearm through the carpal tunnel into the hand. So it’s the softest of the structures. And that’s the one, if there’s swelling, then that’s the one pressed. So the carpal tunnel is an inelastic tunnel that cannot change shape. And then you have the soft structures within the tunnel. So that’s what the carpal tunnel is. And carpal tunnel syndrome occurs when you have increased pressure in that inelastic tunnel. It cannot change shape, so there’s increased pressure and that causes problems with the structures that are within or traveling through that tunnel.
Claire: Sure. Okay, and how do people usually contract carpal tunnel syndrome at the workplace?
Dr. Gordon: So what happens is, you have all these structures going through the tunnel. Normally there’s no problem and the way nerves work is there’s a little electric current that travels all the way from the spinal cord, from the brain’s spinal cord and through the nerves and all the way to the fingertips.
Dr. Gordon: With increased pressure, then the nerve cannot function normally. And the median nerve, which is the nerve that goes through the carpal tunnel, is pressed. Now, all nerves have two types of fibers: Motor fibers, and sensory fibers. The motor fibers are the ones that provide the motor functions, the movement in the muscles that it supplies. And in the case of the median nerve, of this nerve, it’s the muscles of the thumb. The second thing it does is receive information from the fingertips, and that would be the sensory component. And the fibers travel from the fingertips through the carpal tunnel up to the spinal cord and brain, so that’s the sensation. So if you have increasing pressure in the carpal tunnel when the nerve is pressed, and these fibers do not function normally, so two things will happen: The first thing is that the sensory fibers being pressed compromises the feeling in the fingers so you have numbness and tingling, and that can be intermittent at first and then becomes constant. And the second thing that happens is that the motor fibers are affected, so the fibers traveling from the forearm into the hand are pressed, and so the muscles of the thumb become affected and you have decreased movement, ability to move the thumb away from the palm.
Claire: And what are some other medical conditions that can contribute to the likelihood of carpal tunnel syndrome?
Dr. Gordon: Any condition that causes swelling will contribute or can contribute or cause carpal tunnel syndrome, so it can be something in the workplace, such as very repetitive, forceful jobs. So a laborer who is twisting wires or cables, or somebody who’s doing computer work for 8 or 10 hours a day, or somebody who’s putting microchips together in a very repetitive way. Any of these things can cause some swelling at the wrist. Sometimes it can be other kinds of causes such as pregnancy, where you have swelling throughout the body, especially (in) the later times of pregnancy, or a wrist fracture; somebody falls on their wrist and then has swelling, and that increases the pressure in the carpal tunnel. So all of these things, some industrial, some because of work, and some non-industrial because of a fall or a fracture or pregnancy or whatever, any cause for swelling will result in carpal tunnel syndrome.
Claire: And once carpal tunnel syndrome is underway, do patients usually have to get surgery?
Dr. Gordon: Well, no. And usually they don’t need surgery. So there are different phases that this problem goes through. Initially, it’s just a little bit of swelling and it’s not serious and a little bit of tingling that comes and goes. So if one catches it at that stage, then wearing a wrist splint at night, being careful with use and that kind of thing, sometimes a cortisone injection, can alleviate the problem or prevent it from getting worse. Then it becomes a serious problem when the nerve is pressed and the fibers actually in the nerve can die. And when that happens, then the numbness or the tingling or loss of motion in the thumb becomes something that is there all the time and does not come and go, it doesn’t actually wane. One very important feature of carpal tunnel syndrome is that it’s worst at night, when the patient, the individual is sleeping. What happens is at night there’s a little bit of pooling of fluids in the hand, so you don’t have the normal pump that pumps through it back to the heart from the hand. Because of this swelling there’s increased pressure, and so often at 2 or 3 in the morning, the individual will wake up with numbness and tingling, and then will shake the hands out or exercise a little bit, that gets the fluid back out of the hand and then the problem goes away. So when it becomes a constant problem and does not wax and wane, then you really do need to have surgery. If it’s serious, every time the person uses their hand or does any excess work or anything you have a serious problem, then often you need surgery. But before that, you can do various treatments, such as stinting the wrist, making sure you rotate the jobs that you’re doing, being careful with use, and so on, to prevent the problem from getting worse.
Claire: Very good. And how often do patients need to have a follow-up surgery after initial surgery? Is usually the one surgery, it gets rid of the carpal tunnel syndrome and then they don’t need to come back?
Dr. Gordon: Well, it’s not, it’s very unusual to need further surgery. It’s a very simple procedure, it has a very high success rate. The interesting thing is that there are two ways of doing the surgery. One is by a small open incision, and the other is endoscopic. And there are some methods now to do it with just a small incision at the wrist, so I’d say that if there’s a complete relief done, and it’s more reliable to get a complete relief with an open incision, but the recovery is a little bit more, or a little bit longer, but I think it’s very unusual to have the surgery and then to need anything after that. As long as it’s caught before it’s severe.
Claire: Mhm. And how long usually is that recovery from surgery? How long do you recommend that patients remain off work?
Dr. Gordon: Well, that really depends on what kind of work. So if it’s somebody who say does computer work all day, data entry or something like that, then go back to work fairly soon, but you need to ease back to work. So maybe starting at two hours of computer work per day, but then four hours and then six hours before they get back to full, and that could be up to, gradually increasing, up to about six weeks. If an individual is doing heavy laboring kind of work it may take a little bit longer, like this really must be individualized. Every patient is a little bit different. I’ve had people go back, I had one fellow sanding floors in two weeks, but on the other hand, there are other people who take several months before they’re really back to their full activities.
Claire: And often what kind of work restrictions do you recommend? If you can think of anything in general, I understand that it’s very different for each patient.
Dr. Gordon: You mean work restrictions before surgery, like when you first start out and have to sort of avoid the problem getting worse? Or are you talking about work restrictions after surgery?
Claire: Work restrictions after surgery, but then I would also love to hear the answer to the first one too.
Dr. Gordon: Okay. Well, I think one of the important things is to listen very carefully to your symptoms. So that if you have tingling and your hands are going a little numb at night or something like that, you’re having pain at the wrist, then I think it’s important to start wearing a wrist splint at night and to avoid the wrist getting into a very flexed position while you’re sleeping. And then I think it’s important to rotate your job a little bit. So say you have four hours of typing or computer work that you have to do during the day, you do one hour or so and then do some of the other work and rotate around and then go back to the computer work. Or if you have a certain job, a laboring job, and you have to do something very intensive as far as hand use is concerned, you do half an hour or an hour of that and then you can take a break, stretch it out, maybe take five or ten minutes, do something else that you have to do and go back to it. And so if you can rotate your activities, I think that’s important. So after surgery, as far as work restrictions, I think there are two parts to it. One is in the number of hours that you do a particular activity or work, and the other is the actual hand use. So again, you’d need to limit the number of hours that you take: Two, four, six hours of computer work, or of a particular activity, maybe a weight restriction as far as lifting and gripping is concerned, and then also in addition to the restriction in time, also the restriction in weight or force or what type of activity, what is done. So each job of course is different, and one has to analyze the job and the patient and what’s going on with all of those issues.
Claire: Great. Okay, that about finishes up this podcast. Do you have any website or email where our listeners that are interested in learning more from you or possibly coming to see you with questions could go to?
Dr. Gordon: We have our work site, the Hand and Microsurgery Medical Group, in San Francisco, and Post Street Surgery Center in San Francisco, both on the web at https://www.handsurgerysf.com and https://www.poststreetsurgery.com, and certainly people can contact us at our phone number, which is (415) 923-0992. All of those are contacts.
Claire: Great, thank you so much for joining us today.
Dr. Gordon: You’re welcome, thank you.
Narrator: Thank you for joining us for this episode of the California Work Comp Report. We look forward to next week in continuing our discussion of work comp claims in California. Questions or comments? Got a great workers’ compensation story to share? Find us on Twitter at @ratefast or at rate-fast.com.