Avin Patel

Carpal Tunnel Syndrome

The carpal tunnel is a narrow space in the wrist. Nerves and tendons pass through here on their way to or from the hand.

The carpal tunnel

The median nerve runs through the tunnel, and it can be irritated in this small space. This nerve supplies some of the palm with sensation and movement.

When the nerve is irritated, it can cause pain, weakness, numbness, and pins and needles in the area it supplies. These are symptoms of Carpal Tunnel Syndrome (CTS). These symptoms are often worse at night, potentially due to compression of the wrist while sleeping. Bending the wrist is an aggravating factor in itself.

How Carpal Tunnel Syndrome Occurs

The nerve can be irritated in two ways: from pressure from within the tunnel, or from outside.

Internal Pressure

Overuse of the muscles whose tendons run through the tunnel can cause CTS. This is generally agreed to be the most common cause of CTS. Previously known as “repetitive strain injury” or RSI, this can be associated with excessive computer work. The effect on the carpal tunnel is more apparent with poor ergonomics- resting the wrists on a hard desk while typing adds more pressure to the nerve.

Anything that reduces space within the tunnel can predispose CTS. One common factor is fluid retention, as may occur with:

  • pregnancy
  • kidney disease
  • heart failure
  • some medications

As cells become more full of fluid, they take up more space and can lead to compression.

External Pressure

Positional problems can cause unnecessary pressure on the nerve from outside the tunnel. One reason that symptoms may be worse overnight is that we commonly sleep with a flexed wrist. This causes compression through the tunnel, and can encourage symptoms to develop overnight.

As discussed previously, direct pressure to the wrist at work will also apply external pressure.

Persistent Symptoms of Carpal Tunnel Syndrome

Occasionally we see patients who still have symptoms after CT release surgery. This is a procedure to make space in the tunnel by cutting the band of tissue near the surface. Persistent symptoms tell us that either there is something in the wrist that continues to cause irritation, or it’s not the wrist at all.

The median nerve can also be irritated further up the arm, causing similar symptoms but having nothing to do with the wrist. One of the muscles that turns the hand over is another point at which the nerve can be compressed. Alternatively, other nerves could be irritated as far up as the neck, causing discomfort, weakness, or numbness into the hand. However, this latter alternative is unlikely to mimic CTS so closely.

Persistent symptoms without surgery do not necessarily mean that surgery is the answer. As overuse of the wrist muscles is considered the most likely cause on average, it makes sense that symptoms may remain as long as the wrist is overused. Your osteopath may be able to help here.

Treatment

Osteopathy is built on the principle that the body can heal itself. As mentioned above, this may be as simple as changing a movement to remove an aggravating factor. Whether this means strengthening one muscle group to take the load off another, or advising the use of a splint overnight,

In the case of wearing a splint, it may be possible to work on other factors at play in order to avoid reliance. Advice such as using ice, or self massage to reduce the impact of overstrained muscles can help here. Techniques from the treatment room that may be adapted for exercise at home could include gentle “flushing” techniques. These aim to reduce any inflammation or fluid build up in the wrist.

For help managing symptoms of carpal tunnel syndrome, book now.

Thoracic Outlet Syndrome

The thoracic outlet is the area between the arm and ribs where nerves and blood vessels leave the thorax (rib cage). There is not a lot of space here, so sometimes those nerves and vessels can be compressed. This causes symptoms into the arm, and is known as Thoracic Outlet Syndrome (TOS).

Thoracic Outlet Syndrome

The Thoracic Outlet

There are a few small spaces in the outlet where nerves and vessels pass through. They become even smaller in certain movements, such as taking your arm out to the side or rotating out. As a result, people who do these movements in daily life may be more prone to developing TOS. They may also notice that their symptoms are worse when moving through these positions.

However, the two most common causes of TOS are traumatic or anatomical. It may be the case that you were already predisposed to TOS because of your anatomy, but it took an injury on top of that to initiate it.

Symptoms of TOS

With both kinds of TOS, symptoms affect the arm. Symptoms may be mild a lot of the time with an increase during activity. There may also be a pattern associated with things like desk work. Tight pectoral muscles can play a role in TOS, and modern life encourages this tightness.

Neurological TOS

The symptoms of TOS caused by nerve compression are similar to those of compressed nerves elsewhere. They can include:

  • Weakness
  • Wasting of hand muscles
  • Numbness
  • Pins and needles

When a nerve is repeatedly irritated, it can become hyper sensitive. This means that longer-standing problems typically take longer to resolve.

Vascular TOS

If a blood vessel is compressed, this is more urgent. This form of TOS is usually related to a cervical rib: where the lowest vertebra in the neck has ribs. This in itself is not too rare or significant, but when it compresses a blood vessel it can have major complications. Treatment may be surgical to remove or reduce the side of the rib.

There are tests we can use to determine whether your TOS is caused by a trapped nerve or vessel. It may also be evident which type you have from the case history. Vascular TOS can cause:

  • Arm swelling
  • Pain in the arm or hand in a less defined area
  • Changes to skin colour in the arm (looking more red or blue)
  • Pain when using the affected arm

Managing Thoracic Outlet Syndrome

In cases where conservative treatment is appropriate, your osteopath will devise a plan for you. Treatment might involve relaxing of the muscles around the thoracic outlet. As mentioned above, modern life can easily lead to tight pectoral muscles. This is further exacerbated by weakness in the upper back, allowing shoulders to round further and compress the outlet more.

In response to this, your osteopath might give you exercises to do between sessions. A stretch for the chest and strengthening for the upper back complement each other well.

As with any presentation, your osteopath will also look further afield to identify other predisposing factors. Treatment to the neck, upper back, or around the shoulder blade could be appropriate depending on your case.

If these sound like your symptoms, you can make an appointment online.

Neuralgia

Neuralgia literally just means “nerve pain”, but it is used to mean something more specific.

Examples of neuralgia

The basics

Technically any pain, like a mild trapped nerve, could be called neuralgia. But the term is actually used to describe significant sensitivity, not just irritation.

It is often associated with other conditions, such as diabetes or multiple sclerosis. It can also be post-viral, as with postherpetic neuralgia. In all of these cases, a nerve is irritated or damaged, which leads to its sensitisation.

Symptoms

Sensitisation makes painful sensations more painful, and some non-painful sensations surprisingly uncomfortable. This could mean that the feeling of bedsheets on skin is unbearable, for example.

Pain in neuralgia can be described as burning, electric, sharp, or stabbing. In contrast, it can also feel like more of an ache. Typically this pain will follow quite a defined line, which is a clear sign to your osteopath that the pain is following a specific nerve.

Trigeminal Neuralgia

One of the nerves that supplies the face is the trigeminal nerve. It branches into three smaller nerves:

  • Occipital (upper) branch: supplying the top of the face
  • Maxillary (middle) branch: supplying the middle of the face
  • Mandibular (lower) branch: supplying the bottom jaw

Usually it is the middle or lower branch that is affected, and very rarely does it affect both sides. Pain can come out of nowhere, or follow exposure to cold air, touch, or eating. Pain is severe but usually quick to pass. However it might come and go throughout the day.

In addition to the possible causes mentioned above, trigeminal neuralgia can be caused by pressure from a blood vessel. Your GP may want to send you for a scan or further to make sure nothing serious is causing the irritation.

Evidence suggests that osteopathy can be beneficial for pain relief in trigeminal neuralgia. Although it is unlikely that we would be able to affect the root cause of the pain, we may be able to help to calm the nerve down. Your GP may offer painkillers and suggest you keep a pain diary to better understand your triggers.

Postherpetic Neuralgia

Shingles is caused by the same virus as chicken pox: herpes zoster. It can become symptomatic years after recovering from chicken pox because it stays dormant in the nervous system. The rash from shingles tends to follow the course of a nerve, so it’s not too surprising that there might be neurological symptoms.

After the rash fades, you may find symptoms of neuralgia in its place. These can include the sharp pains and increased sensitivity mentioned above. Symptoms typically self resolve within a year, but the process may be sped up with treatment. Osteopaths work with nerve pain frequently, and can use techniques to try and desensitise the nerve.

Shingles is highly contagious, and you should not see your osteopath before the rash has cleared. You can get in contact to discuss your symptoms if you’re not sure whether you’re safe to come in yet.

If you suffer from neuralgia, make an appointment and see what we can do for you.

Sciatica

The sciatic nerve runs from the lower back down the back of the thigh and outside of the calf. Sciatica is a symptom of irritation of this nerve.

Scatica and its causes

Symptoms

When the nerve is irritated, symptoms can develop anywhere along the length of it. For some people this means pain from the back to the foot, and for others it can be a lot more focal. A sharp, shooting pain in a defined line is a typical symptom of sciatica. This is rarely constant but might be somewhat unpredictable. Pins and needles in the same area, or numbness or weakness are also common.

If the cause is a disc bulge, movements that stress the disc can aggravate symptoms. Examples of this are heavy lifting, twisting, and straining on the toilet. It is important to note that symptoms are not indicators of damage. Nor does intensity of symptoms predict how long an episode will last. Sometimes people with the most debilitating pain are the quickest to recover.

Causes of sciatica

The basic cause of sciatica is irritation of the nerve in the back or upper leg. There are a number of ways this can happen, and sometimes there are multiple causes. Two of the most common are:

  • Nerve compression in the back due to a bulging disc (diagram C)
  • Nerve compression in the buttock due to a tight gluteal muscle (piriformis syndrome)

When is Sciatica not Sciatica?

Not all pains in the back of the leg are down to the sciatic nerve.

Hamstrings

The sciatic nerve runs through the same area as the hamstrings, so pain can be mistaken for sciatica when it’s not a nerve at all. A simple pulled muscle can imitate the symptoms without any sciatic involvement.

Referred pain

Sometimes the brain misinterprets pain signals and detects pain where it shouldn’t be. You may have heard of people having heart attacks but experiencing jaw pain: this is the same mechanism. Nerves cover a broad area, so when a nerve brings a pain signal to the brain, the brain has to work out where exactly the pain is coming from. Heart pain isn’t a usual sensation, so the brain thinks the pain must be coming from somewhere else in that nerve’s area. One nerve that supplies the heart also supplies the jaw, so the brain makes an educated guess.

The same can happen in the back and leg. Irritated joints in the lower back and pelvis can cause pain in the back of the thigh. This doesn’t necessarily mean that anything is wrong with your leg! Your osteopath can work out what’s happening and what needs to be done.

Plantar fasciitis

Pain and pins and needles in the foot can be symptoms of sciatica, but when they’re isolated to the sole of the foot alone they could be something else. Plantar fasciitis is inflammation of the soft tissues on the sole, unrelated to the sciatic nerve.

Book an appointment today to get on top of your sciatica