June 17

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Carpal Tunnel Syndrome with Iyad Salloum

By Wil Seto

June 17, 2022

carpal tunnel syndrome

Mark: Hi, it's Mark from Remarkable Speaking. I'm here with Iyad Salloum. He's the clinical director at Insync Physio in North Burnaby. And we're going to talk about something fairly common, something that I have just learned that I had thought I had, but I didn't have, carpal tunnel syndrome. How are you doing Iyad?

Iyad: Good, how are you doing Mark? 

Mark: Good. So what is it? What is this thing? Carpal tunnel. 

Iyad: Yeah, that's a good question. Probably a good place to start. So most people with carpal tunnel syndrome or people who have been told or think they have carpal tunnel syndrome will present with symptoms along their hand, tends to be a little more kind of towards above the wrist and it'll effect, usually the palm area towards the thumb side.

So usually they'll tell you these three fingers and to go a little fuzzy or numb on occasion and it'll present for different reasons. So people tend to have like different jobs, maybe that involve a lot of wrist work or repetitive work, and they could present that way. We see it in the pregnant population actually, just because of the overall swelling that happens in the body.

So if you have a bit of swelling at the wrist, for example, you could have that. And there are potential also trauma. If you have an impact on that area where it affects the nerve that passes through the carpal tunnel, you can also get that. What it is is it tends to affect the nerve structures most of the time. 

You have a thing called the transverse carpal ligament that goes right through here, and it's really like, not stretchy. So the tissue tends to be very strong and you need it to be strong and rigid and right under there, you have your, your finger tendons that help you do all kinds of stuff with your hands. And then also you have like, you know, your blood supply and your nerve. And then the nerve kind of feeds this fleshy part in your thumb that helps you control your thumb.

So if somebody has had carpal tunnel for awhile, usually we'll see a bit of wasting here. If it's been a long, long time and it's gotten progressively worse. So that's one way we can kind of figure that out if it's been awhile. But in the kind of early onset, acute phase tends to be numbness or burning along this kind of distribution where the thumb, the index and the middle finger are affected.

And sometimes it goes to the ring as well, because there are people, people's differences. Now what it is, and sometimes where people really confuse it. And this is kind of, I guess, to go back to your point, because they say, oh, I have it in the backside of my hand that doesn't tend to be carpal tunnel. It doesn't really go there.

You know, we tend to look at something else because there are other tissue and nerves that can get affected. Or sometimes they'll tell you, yeah, it starts with the elbow and it goes all the way down, you know, where we're starting to probably suspect that there's something else. Even though it feels exactly like carpal tunnel, which is like, all my hand eventually goes numb.

But if it's not a little more restricted to the hand and the assessment will be like only positive on the hands assessment, I would tend to look elsewhere and try to see if there's another area where that nerve is getting sensitized and then giving the people symptom scenarios. 

Mark: So we've talked about the shoulder being a really complex joint, but the wrist is probably right up there with being in terms of all the bones. That even just in the wrist itself, let alone in your hand, et cetera. So there's a lot of stuff trying to glue that all together. 

Iyad: Yeah. Yeah, absolutely. So we have eight bones just in the wrist alone. They're very small called the carpals. And then we have our metacarpals, which are kind of these bones here. And then we have the phalanges which are the fingers. So, yeah, there's layers of muscles. So we have multiple layers. And that kind of layering systems, kind of get to know if you're trying to think of treatment and also trying to think of the movements that the person needs to be able to do with their hand and wrist.

So, yeah, it is complicated, but it also doesn't need to be, as far as treatment goes, like, you know, we will usually try to simplify it as much as possible. We need to make sure the person's able to move safely and normally as possible through that hand and wrist complex. 

Yeah, you're right in that sense, but we don't complicate it. You don't need to be as a patient wants to seek treatment, you don't need to be an expert on how the wrist biomechanics move to actually get that better. 

Mark: So when we're talking about causes, is it generally, or can we almost infer that it's almost always an overuse injury that causes metacarpal tunnel syndrome?

Iyad: I think so. For carpal tunnel syndrome, there are overuse based stuff. There are other things too. So I'd say there's different subsets. So there's the kind of, let's call it the more mechanical irritation group, where it would tend to be from overuse or impact or prolonged positioning in certain areas.

You have other causes, other things that could just sensitize your nerves. Like, so we talked about just, if you have overall swelling in your body, like usually we see this in a pregnancy, especially after second, third trimester, you know, times we'll see that. It doesn't mean it's gonna affect everybody. But if it does happen, you know, not to be too, too alarmed because we could do some treatment for that. 

And then like, obviously there are some conditions that will predispose you to having more nerve related issues. So think about like if you have somebody with diabetes, with diabetic neuropathy, it might present with these symptoms and they tend to start at the fingertips, work their way up and it affects the hands and feet primarily. But that's more of a systemic issue. 

So yeah, I think if we simplify it and say, it's just overuse, I think that's also being a little unfair because sometimes you get people coming in, they're like, I did nothing. I work like, I'm on the phone all day or I'm on this and I'm on that.

So this is where it's kind to useful for us to get a good, detailed history on how it started when they started noticing it. And also the pain pattern, because some people will just tell you, I get got at night. I don't get it any other time except at night. 

Like I had a patient to only got it when she falls, go to sleep and she would sleep like this on her wrist. So she imagined being here for six to eight hours without moving. So you could get that. But then there's the others who, again, look like they have carpal tunnel, but you assess everything. And you're like, there's a little more going on here. So most common one would be potentially an issue in the neck. Where you have sensitized nerves through here, but they feel it in the hand. So if we can change it from the neck, it's probably not carpal tunnel syndrome, even though it's carpal tunnel like.

Mark: So just a point of interest, the carpal tunnel really is that ligament around your wrist? 

Iyad: So there's a cavity under that ligament is the canal. But once you cover with the ligament, it's called the tunnel and you have the structures through it. So that's what it's referring to. And you know, usually people will tell you, yeah whenever I put any pressure here, I start to get symptoms. Again, that's not enough for us to just say, oh, it's only due to this because in some cases we don't have a lot of evidence on this but it happens. But if you have a nerve that's sensitive somewhere else, it could become a little easier for it to get irritated further down. 

So imagine if you have a neck issue at the beginning, that's contributing to this nerve. I'm going to be probably, based on just like our, some studies on animals, we don't have a lot of human data, that it could spread to other areas and it could make it easier for you to develop an issue further down the same line. 

But usually what we do with somebody like that is we will tend to treat both areas together, instead of just saying, oh, we're only going to do the wrist. We'll splint your wrist and we'll do all kinds of mobilizations to that and tendon sliding exercises and stuff. No, we'll tend to treat neck, shoulder, and wrist at the same time.

Mark: So diagnosis is fairly critical. Like always. 

Iyad: It is. It's just good to know, because I mean, I've had two patients now who have had confirmed electric conduction studies, when they actually study if the nerves conducting properly and they've confirmed carpal tunnel syndrome because of reduction in the conduction in the wrist, but they've never had anything else assessed.

They have the surgical release and yes, it helps potentially reduce their symptoms, but they're like, why is it not gone? And it tends to be because that nerve is probably sensitive somewhere else. So, you know, with those two people, we ended up, one of them, it was more somewhere in the neck. So we treat the neck, we gave them a neck and kind of a shoulder rehab program and it eliminated it completely. 

And the other person was a little more persistent. So we needed to do a lot more kind of overall change, I guess. So we had to change just the way they did things and teach them different movement strategies, and treat the neck, treat the shoulder with the mix of therapy and exercise and IMS and different kind of strategies to help them get out of that kind of vortex that they kind of get stuck in sometimes. 

So yeah, you would want to know what you're treating first, instead of here's the three thing to do for carpal tunnel syndrome, because you might have something that looks like it feels like it but probably isn't it.

Mark: And I'm sure there's a range of treatment. So what is that what's included in the range of treatment options that you provide people? 

Iyad: So most important is we try to identify, this is usually what I do in the first days. We'll try to identify what's actually provoking the symptoms. And we try to see if we can modify those stresses. So if it's with changing the way they do things, if it's basically with a mix of maybe bracing and some other exercises, we could do that. So I'll give you an example. I had a tennis player who had it, so we just had to teach them to hit the racket a little more like a tennis racket and a little less like a badminton racket where they would do an extra wrist flick at the end.

So that was a lot of what we did with them. And then there's other people where we would tend to so for example, my client who would sleep on their wrist. We're like, okay, how do we make them not sleep that way? We put them in an overnight brace to prevent that bending. So you got to just identify what's the potential trigger and maybe figure out ways to modify the stress on it.

So that's, I guess, what you could do from a, let's call it a reduction of stress, on the area. The other thing we could do, obviously there's tons of exercises that tend to help a lot here. So the exercise doesn't have to just hand specific. Let's say the tennis player, we'd work a lot on shoulder and upper back, so they can actually learn to swing through their body.

If you have somebody who has a stiff hand, the tendons don't move so well, so we mobilized those, in the planes that they need to move. So it tends to be a mix of that. And then obviously, we have our hands-on techniques where we can do sometimes some mobilizations in their just within their tolerance. And it tends to kind of help with pain relief and with improved range of motion. We just try to match the treatment to what's actually missing because whenever you hear the word syndrome after a condition, it doesn't mean that it's a specific singular contributor, just to kind of like a cluster of symptoms that get presented. So we try to figure out what's causing this here and kind of match the treatment to that. 

Mark: And treatment time range? 

Iyad: It all depends from, I guess, how long you've had it. Whether we can actually stop temporarily or modify the provocative factors, it'll depend on, for example, overall health. So if this person potentially has multiple co-morbidities, and then diabetes and these other things, obviously the recovery tends to be a bit slower, even if they're doing everything right.

So there's a lot of that goes into it. And then if you find it early and you intervene early, you're probably able to move on pretty quick versus if you wait, wait, wait. Until that sensitivity builds up to the point, we probably are looking at longer. So we've seen in clinic anywhere from four weeks to six months to a year, even sometimes. It just depends on the job.

So I'll give you an example of one person. We had a cashier who had this issue, so constantly scanning things. And we just had to change the way they did it, so it would be like move the whole shoulder instead of moving just the wrist. So it's really tough to throw a number on it.

But yeah, some people do really well without anything, which is also the funny part. And some people just persist even six months after the ground zero first day when they experienced symptoms. 

Mark: If you're experiencing any kind of numbness, pain in your hands, the guys to see are Insync Physio. Get experts diagnosing exactly what's going on so you can get it back on the path to recovery and health and feeling better. Insyncphysio.com is where you can book to see them. They have two offices, one in Vancouver at (604) 566-9716 or in North Burnaby, (604) 298-4878. Get, get in there. Get feeling better. Thanks Iyad. 

Iyad: Thanks Mark.

Wil Seto

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