Myofascial Release Helps Ease Carpal Tunnel Syndrome
By Christine McLaughlin
Myofascial release can be extremely effective in alleviating mild to moderate symptoms of carpal tunnel syndrome, according to Benjamin M. Sucher, DO, medical director at the Center for Carpal Tunnel Studies in Paradise Valley, AZ.
"Approximately 70 percent of CTS cases have at least some kind of improvement with a decrease in symptoms," he said, noting that the more severe cases of the syndrome can't claim similar outcomes.
The myofascial technique involves a vigorous controlled release of myofascial structures that uses some stretching, but also a lot of direct pressure and control, explained Dr. Sucher. "It should be guided along the muscle and the ligaments where they attach to the edges of the bone and the carpal tunnel."
The rigorous procedure stretches out ligaments and tendons in and around the carpal tunnel and temporarily increases pressure, which for more severe cases, can be too extreme. In this case, surgery is usually a better solution. "The reason is that you don't want to add any temporary increase in pressure to the nerve because it could be too irritating. Instead, it would be better to immediately cut the ligament and get the pressure off the nerve, which is what surgery would do," detailed Dr. Sucher.
But for mild to moderate cases of CTS, myofascial release could be effective in easing the symptoms.
In December 1993, Dr. Sucher used magnetic resonance imaging to document the results of myofascial release and self-stretching in four patients with CTS who failed to respond to routine conservative measures.
All of the patients had experienced symptoms consistent with carpal tunnel syndrome for two weeks or longer, and electrodiagnostic studies had confirmed abnormal distal motor latency or distal sensory latency.
The myofascial treatment took five to 10 minutes, and worked the thenar muscle attachments called the abductor pollicis--a superficial muscle. It involved holding the arm out in front with the palm facing up and taking the thumb into abduction by pulling it back toward the body. Also, the thumb was pulled and extended down toward the floor. "The thumb muscle attaches directly to the carpal ligament. So this way you can use the thumb as a lever or fulcrum to tug on the ligament and stretch it out," added Dr. Sucher.
Patients were asked to perform a self-stretch maneuver (Fig. 1 and Fig. 2) five to 10 times a day. When clinical improvement was noted, a limited nerve conduction study was performed. And when electrophysiologic improvement was documented, the MRI was repeated.
Among all four patients, the nerve conduction studies showed resulting reduction in distal latencies or increase in motor response amplitudes. The MRI also showed progress.
"Magnetic resonance imaging in all four patients reported demonstrates increases in both the anteroposterior and transverse dimensions of the canal after osteopathic manipulative treatment," (Journal of the American Osteopathic Association, vol. 93, No. 12).
While there was no cross-sectional measurement calculated, the modifications in the carpal canal could be considered significant because they indicate additional space in the carpal tunnel. "As a result, pressure on the nerve is decreased and symptoms associated with carpal tunnel syndrome are alleviated," the report stated.
Said Dr. Sucher, "Because the size of the canal increased, there probably was increased space for the nerve and thereby less pressure on the nerve, which would explain why the patients' symptoms improved."
While the ultimate goal in myofascial release for CTS is to stretch and release the transverse carpal ligament, there are times when myofascial release is not enough and the use of modalities is necessary, said Tom Brooks, MS, PT, ATC.
He explained that if he sees a patient with acute CTS, he will perform an aggressive 10-day treatment program that includes other modalities. "In addition to the myofascial release, I use any modality I can to get relief and softening in the area to make room in the carpal canal," elaborated Brooks, who is the owner and chief therapist of Tom Brooks Sports Therapy in Las Vegas.
Some modalities Brooks uses are iontophoresis, paraffin, heat and ice.
DR. SUCHER noted that he, too, will combat the irritability and inflammation associated with CTS by using iontophoresis. "I find it calms down the swelling and allows the manipulation to be more tolerated. Moreover, ultrasound used along the edges of the ligament can help loosen up the ligamentous structures and enable the area to be released with the myofascial technique."
Another technique that can be used in conjunction with myofascial release and self-stretching is a relatively new procedure called the "opponens roll." According to Dr. Sucher, the opponens roll can enhance the effectiveness of myofascial release and may be useful in more severe cases of CTS.
This process involves rotating the thumb along the axis of the thumb bone, which reaches the deeper opponens muscle. "This is not just pulling the thumb back or down, but kind of twisting it. The technique not only stretches the ligament out, but the rotation elevates the muscle and the ligament right up off of the nerve."
Nevertheless, some patients with CTS who don't improve with myofascial release and self-stretches directed at the carpal tunnel may actually have thoracic outlet syndrome as well--also known as "double crush" syndrome.
In fact, Brooks said that now that he is more aware of what to look for in his patients with CTS, he has found cases of double crush syndrome. "Usually, the symptom they complain of least is the one that is causing the most trouble. For example, if a patient says, 'My wrist was never my first problem, I always had this neck trouble,' that sends a red flag to me."
Yet, myofascial release can be beneficial in treating double crush syndrome because it can be directed at the thoracic outlet and the carpal canal.
Dr. Sucher said that for clinicians who are interested in learning more about myofascial techniques to treat CTS and double crush syndrome, the Center for Carpal Tunnel Studies offers training seminars twice a year. At the seminars, three sets of self-stretching exercises are disseminated that are designed for patient use. Each exercise gets progressively more intense and effective. He added that there is even a one-handed myofascial technique for patients with bilateral CTS.
"With proper instruction and patient monitoring, noninvasive myofascial release can be an effective means to relieve symptoms and control CTS, and possibly prevent the need for surgery," concluded Dr. Sucher.
* For more information, contact the Center for Carpal Tunnel Studies, 10555 N. Tatum, Ste. A-104, Paradise Valley, AZ 85253; (602) 483-7387.
Sucher, B. M. (1993). Myofascial manipulative release of carpal tunnel syndrome: Documentation with magnetic resonance imaging. Journal of the American Osteopathic Association , 93(12), 1273-1278.