Sebastian Gonzales: I’m going to talk to you about carpal tunnel syndrome, or rather, some of the more common causes of carpal tunnel syndrome which you probably have not heard about before. Traditionally, it’s been thought that the cause of the symptoms was median nerve entrapment. That goes through the transverse carpal ligament, or through the carpal tunnel, at the base of the wrist located about right here.
However, something that’s overlooked by many healthcare providers is the fact that the median nerve can be entrapped anywhere along its course down the arm. Actually, this is the course, this is how the nerve goes, right down here into the thumb, index finger and middle finger; any spot where the nerve is entrapped can produce the same type of symptoms as carpal tunnel syndrome.
So, a few of the more common spots we’re going to talk about today is right here, this is between the anterior medial scalenes where the brachial plexus comes out (actually, the brachial plexus comes straight through these two muscles), and this can cause symptoms of carpal tunnel syndrome – the numbness in the hands. Also, radial nerve entrapment, ulnar nerve entrapment, and even thoracic outlet syndrome can all be caused through a brachial plexus entrapment in the anterior medial scalenes.
The second most common one is down here at the pronator teres. When you consider the pronator teres, it also has two heads, so again, just like this, the median nerve coming straight through, and when the median nerve gets pinched down by the two heads of the pronator, it also causes neurological symptoms. So, when you consider what the pronator teres does, it pronates the hand. With people working at a desk they’re like this a lot, and this can be a cause of median nerve entrapment for them.
There’s also the transverse carpal ligament, we just talked about that, but also the thenar muscles, so all these different spots can have the same presentation as carpal tunnel syndrome, and that just shows how difficult this situation can be when treating it through surgical methods. We get a better understanding about the median nerve, how many spots it can be entrapped, how long it actually is and how complicated the situation can be when you’re trying to perform a surgery only in one spot. Carpal tunnel surgery is one of the most prevalent surgeries performed in the United States today, and a lot of times it’s successful, sometimes it’s not, you know? But when you’re going in for surgery, you want to make sure that the carpal tunnel is the actual site of entrapment. Normally the nerve will slide freely through the soft tissue, so if it’s stuck right here, a lot of times it will also be stuck right here. When it sticks there, the relative slide is not as much, and eventually the scar tissue will build up here as well. Or you can get it here and here, or you can get it here and here; it’s known as a double crush syndrome, and for that reason I believe a lot of the surgeries are unsuccessful.
The treatment I use in my office to treat patients that come in with carpal tunnel syndrome or numbness in the hand/wrist/forearm area is called active release technique, or ART. ART has been known as an alternative to surgery in many cases of carpal tunnel syndrome, sciatica, shoulder pain, knee pain, and even low-back pain. They all respond very well to ART; let’s stick to carpal tunnel syndrome. So nerves normally slide among the soft tissues freely, without restriction; a lot of times, they get stuck. Let’s talk about the pronator; they get stuck, and it makes it so the nerve can’t slide anymore, so what sticks it is called scar tissue – it’s the body’s normal way of repairing muscles. The problem is, when you get scar tissue laid down, it just kind of lays it down everywhere, it makes everything stick together. A lot of times that’s the knot people get in their upper back, but the fact is, they get stuck and pinched off, so ART will go in and we’ll remove this scar tissue, helping the nerve slide freely through the soft tissues again, resolving the symptoms completely. ART is fairly unknown to the general population, but it’s more popular in professional sports. In fact, many NFL, NHL, NBA teams all have active release providers that they see in whatever cities they visit, and even Olympic medalists have used active release technique.
An ART provider, in the case of median nerve entrapment, will follow the nerve all the way through the arm up to the shoulder, find any sites there may be where the nerve is entrapped in the soft tissues, and release them. This can be slightly uncomfortable at the time, but many patients will respond very favorably to the treatment within about 3-4 times, and will find a significant decrease in their symptoms. A lot of times the pain or the condition can be resolved within about 8-10 treatments, but regardless, a lot of times this is better than having surgery for these kinds of conditions. For more information about different kinds of conditions, please visit my other demonstrations or visit my website.
I’ll just show you a little bit about how an ART provider will address the problem of carpal tunnel syndrome, or rather, median nerve entrapment. The median nerve starts all the way up at the neck right here, between the anterior medial scalenes or as part of the brachial plexus – that’s a major nerve entrapment site for a majority of the nerves. It goes all the way down here into the forearm (where it goes between the two heads of the pronator teres muscle), down into the wrist at the carpal tunnel itself, right underneath the transverse carpal ligament, into the thumb muscles and into the index finger and middle finger. Now, an ART provider will follow the course of the nerve all the way up into the arm, and into the neck, releasing any of the nerve entrapment sites that they may find. Many people will find a significant decrease in their pain, or in their symptoms, within about 3-4 visits or so; however, some people have come back reporting that they found a significant change after one treatment. It’s not uncommon to find that you have a different kind of soreness for about 48 hours or so after the treatment.
Erica Gerlach: ART, or active release technique, is a soft-tissue manual therapy that is provided by certified healthcare providers. This technique is used to treat a variety of diagnoses, including back pain, rotator cuff tendonitis, shin splints, knee pain and tennis elbow. All of these diagnoses have something in common, which is an overuse injury. An overuse injury can lead to scar tissue. A certified ART provider will find adhesions within the tissue, as with someone dealing with tennis elbow. Once the ART provider finds the adhesion or restriction within the soft tissue, they will provide a direct, precise tension to that soft tissue, and then instruct the patient in moving their joint through a range of motion to apply tension to that tissue, and help break up any adhesions. To find an ART provider, you can come to Excel physical therapy and fitness, who is the largest ART provider on the East Coast.