People with diabetes are prone to carpal tunnel syndrome
People with diabetes know that their disease may cause foot problems and are constantly on the alert for “danger” symptoms. But virtually nobody knows that diabetes is also a common element in hand problems. Do you have numbness or tingling in your fingers? This may be a complication of diabetes. Frequently, hand problems associated with diabetes are not severe, and hence are not brought to the attention of the doctor.
Numbness or tingling in the fingers, often ignored until it becomes persistent or painful, may be caused by carpal tunnel syndrome, which is a nerve compression at the wrist. This is actually caused more by inflammation of the surrounding tendons – tendinitis – rather than a problem with the nerve itself. High blood sugar can cause tendinitis. Therefore, people with diabetes are prone to carpal tunnel syndrome.
Patients typically complain that their symptoms grow worse at night. Compression of the nerve also may lead to weakness of the thumb, which poses difficulty in many daily tasks.
The diagnosis of carpal tunnel syndrome
The diagnosis of carpal tunnel syndrome is usually made through a careful history and physical exam of the hand and wrist, and confirmed by studies that measure the electrical conduction of the median nerve through the wrist.
Treatment initially consists of sleeping with a wrist splint and high doses of vitamin B6. Anti-inflammatories may help as well, as might a corticosteroid injection in the wrist. These treatments, however, help the symptoms, but do not cure the problem. Those with significant or persistent symptoms will require a minor surgical procedure to decompress the carpal canal and take pressure off of the median nerve. A new technique allows this to be done endoscopically through a tiny incision with local anesthesia and mild sedation. Patients can use their hand immediately after the outpatient procedure, miss only a minimal amount of work, and usually don’t need any follow-up therapy.
Another tendinitis problem that people with diabetes are prone to is called trigger finger, and is where the tendon going to the finger catches in its sheath as the person tries to extend the finger after flexing. With this condition, it can be difficult to make a tight fist, particularly upon wakening. Occasionally, triggering is severe enough that the finger locks and must be pried open with the other hand, which can cause considerable pain that radiates up the arm.
The treatment of trigger finger is simple, ranging from a corticosteroid injection to a minor surgical procedure to release the tight sheath.
People with diabetes may also notice tendinitis in the shoulder or elbow. If you have any hand, elbow, or shoulder problems, discusses them with your doctor or diabetes educator.
Weightlifting and fitness sport injuries in the hand and wrist are often misdiagnosed and undertreated for a variety of reasons. Chronic and overuse injuries often go untreated due to the athlete’s reluctance to seek medical attention. This is because in many sports, the athlete can compensate with some of these injuries while this may be more difficult in weight bearing joints such as the knee and ankle. However, a more preventable issue may be the inaccurate diagnoses and inadequate treatment often afforded the hand and upper extremity in athletes. This is particularly true in weightlifters, Cross fit athletes and bodybuilders since these athletes often rely upon allied health professionals such as chiropractic physicians, physical therapists and athletic trainers to make the diagnosis and recommend treatment. This is where the physician and ancillary health specialist can improve their management of these challenging and often obscure injuries. In many instances, the hand surgeon should be involved at an early stage of treatment and to ensure an accurate diagnosis. Common athletic injuries in the hand and wrist are often sports specific and appropriately named. For example, jersey finger is an avulsion of the flexor profundus tendon that occurs when the athlete grabs the opponents jersey as they pull away. In unusual cases, this can be seen in doing very heavy wrist curls where a great stress is placed on the insertion of the tendon on the distal phalanx at the tip of the finger. This leads to a sudden and resisted hyperextension force that avulses the tendon at its insertion site. A strong surgical repair is necessary followed by appropriate therapy to maximize the passive range of motion and later the active flexion. Subsequent strengthening is of obvious particular importance in the competitive athlete and weightlifter. Blunt injuries can occur to the extensor mechanism as well and the wide range of complex joints in the hand and wrist. Much more common, however, is the chronic and overuse injury in the weightlifter. Repetitive heavy strain on a muscle/tendon unit can lead to microtears in this tissue and lead to the common entity known as tendonitis. This is a very general term and it is important to understand the specifics and severity of the particular lesion. Injuries as common as finger injuries, elbow epicondylitis (tennis and golfers elbow), wrist tendonitis and rotator cuff strain must all be evaluated by a specialist so that the more severe injury can be recognized early and treatment instituted by appropriate health care professional. Only after point, the therapist, chiropractor or athletic trainer may then be the most apt person to bring the gym buff back to full weightlifting potential !! Dr. Alejandro Badia Miami, Florida
Bahamian patients often travel to Miami to undergo endoscopic release of the median nerve since in the Caribbean nations, the procedure is currently done via an open incision with is much more painful, takes longer to recover and may require rehabilitation. We have good relationships with therapists in Nassau, Freeport etc but fortunately, most patients with carpal tunnel release require no formal therapy and have complete relief of their painful numbness. Procedure is done with local anesthesia requires only a 3 day stay in Miami (Doral) and patients can use the hand immediately.
Diabetes is a systemic disease with wide ranging manifestations due to defects in insulin production or organ receptor sensitivity to this critical hormone. It has profound effects on the cells comprising the circulatory, nervous and connective tissue systems. This widespread involvement of systems is expressed in the hand and diabetes patients often have symptoms that are due to these problems but go unrecognized. Numbness or tingling in the fingers is often ignored until it becomes persistent or painful. This if often interpreted as neuropathy which occurs commonly in the foot. In the hand, this tingling, or “paresthesias”, is more often due to a nerve compression in the upper extremity. Most commonly, carpal tunnel syndrome is present, which is a median nerve compression at the wrist level. It is actually due more to inflammation of the surrounding flexor tendons, rather than direct pathology of the nerve itself. Patients typically complain of numbness or tingling in the thumb or central fingers which is often worse at night and can cause difficulty sleeping. Chronic and severe compression of the nerve leads to weakness of the thumb with subsequent difficulty in many daily tasks. The cause of carpal tunnel syndrome is really a thickening and inflammation of the tendons that pass in the tunnel along with the delicate nerve. This same tendonitis deep in the wrist causes mechanical problems and pain farther along in the palm. Inflammation of these flexor tendons as they travel to the finger leads to pain in the palm of the hand with occasional “triggering” or catching of the tendon in the tunnel as the patient attempts to extend the finger after flexing. The treatment of tendonitis is quite simple, involving either reducing the tendon inflammation or opening the tunnel through which it passes. A corticosteroid injection along the tendon sheath is very effective, unless the patient experiences locking where the mechanical problem is more profound and requires a mechanical solution. A trigger finger release is done by a small incision in the palm and opening the tight sheath containing the tendon allowing it to glide once again. In isolated cases of trigger finger, we can even do this percutaneously, without making an incision. This is also done under local anesthesia, and the dressing is removed the very next morning by the patient themselves. Similar releases are done at the wrist level for DeQuervain’s tendonitis. There is a common misconception that cortisone injections are harmful to patients, particularly diabetics. This is not the case when the injections are limited to several low dose injections spanned out over time and in different locations. This treatment is also used in other locations such as lateral epicondylitis (tennis elbow) or bursitis of the shoulder, where an arthroscopic excision of bursa can be done to alleviate and usually cure the problem. It is important that the patient as well as the primary physician have a good understanding of these conditions and to involve the hand surgeon at an early stage. ALEJANDRO Badia dORAL, MIAMI fLORIDA
Carpal Tunnel Syndrome (CTS) is a common, but misunderstood condition. In recent years, it has received much coverage in the press, yet it remains puzzling even to the scientific community. The media has branded CTS as an occupational disease because workers have linked the pain in their hands to repetitive activities such as typing or assembly work. Despite popular opinion, using a keyboard does not cause this condition. However, if one has a predisposition to this condition, repetitive activity such as typing can aggravate it. Carpal Tunnel Syndrome simply means that there is a compression of the median nerve in the hand. This nerve sits inside a tunnel in the hand, of which the floor and walls consist of bones known as carpal bones. Besides the nerve, there are nine tendons that run through the canal that flex the fingers and thumb. When the lining around these tendons becomes inflamed, there is less space for the nerve and it becomes compressed. This compression of the median nerve leads to the symptoms of CTS. The most frequently reported symptoms of CTS are nighttime numbness and tingling in the hand. There can also be pain and weakness in the hand, particularly in the thumb. If these symptoms are allowed to progress untreated, they can lead to atrophy of the muscles in the base of the thumb. Besides the physical symptoms of CTS, the diagnosis is easily confirmed by a simple nerve conduction study. This study, which measures the velocity and the latency of the nerve impulse across the median nerve at the wrist, will show the physician if there is a compression of the median nerve. CTS most commonly occurs in middle-aged women, often perimenopausal, or in women who are in the third trimester of pregnancy. It can also be caused by chronic conditions such as diabetes, gout or thyroid disease. It often coincides with related conditions such as tendonitis in the fingers, (trigger finger) or tendonitis in the wrist. DeQuervain’s tendonitis, for example, leads to pain in the wrist at the base of the thumb. The treatment for CTS is directed at decreasing the inflammation of the tendons. Injections of steroids, such as cortisone, can lead to a decrease in the swelling. This will allow the median nerve more room in the carpal tunnel and relieve the pain. The most common treatment, without the use of drugs or injections, is a night splint. This splint prevents the patient from flexing their wrist at night, which often occurs during dreaming. This relieves some of the pressure within the canal. Symptoms are usually magnified at night because the position of the hand is at the same level of the heart, which leads to pooling of the fluid in the soft tissues within the canal . There are also complicated hormonal changes that can lead to increased nighttime fluid retention. As a remedy to this, some researchers recommend high doses of Vitamin B-6 as a diuretic to decrease the fluid in the carpal canal, leading to the relief of symptoms. If the compression is severe and the patient does not respond to conservative treatment, the next step is surgery. The public, as well as some physicians, misunderstand surgery for Carpal Tunnel Syndrome. There are many false beliefs about the outcome of this procedure. Some patients are even fearful of losing the function of their hand if they undergo surgery. The truth is, the surgery is extremely successful. Surgery for CTS entails a very simple procedure. A division is made in the ligament which serves as the roof of the carpal tunnel. This division gives an increase of space in the carpal tunnel, which allows the median nerve to function as it should. The most recent breakthrough in treatment of CTS, which is commonly used at our practice, is called endoscopic release. In this procedure, an incision of less than one centimeter is made in the crease of the wrist and an endoscopic, a tiny camera, is inserted. This allows the surgeon to literally see inside of the hand in order to make the division of the ligament. This is not a laser surgery, but rather surgery using fiber optic technology, which allows a surgeon to operate “from inside out”. The use of this procedure means that tender tissue is not violated and there is minimal pain, if any. The advantages to this technique are less scarring and decreased recovery time, which allows the patient to return to work quickly. The long-term result of endoscopic release for treatment of CTS is excellent, and benefits the patient more than the traditional means. Patients occasionally complain of some soreness in the palm when resting their hand upon a hard object, otherwise, there are fewer complications, and less pain following this type of procedure. The key to understanding Carpal Tunnel Syndrome is to think of it as a pinched nerve in the wrist that leads to symptoms such as numbness or tingling. These are painful conditions that need to be evaluated by a surgeon or specialist in this field. Either a rehab medicine specialist or a neurologist can confirm the condition by conducting nerve conduction studie