Carpal Tunnel Syndrome

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Carpal tunnel syndrome (CTS) constitutes the most common, recognizable, and frequently agonizing peripheral neuropathy worldwide, as well as one of the most usual conditions of the upper limbs in the modern orthopedic clinic. This specific condition is characterized as a gradually progressive and highly painful state, which, if left without medical management, can lead to permanent neurological damage and loss of hand functionality.

It is the direct result of mechanical pressure (entrapment) exerted on the median nerve, which constitutes one of the main nerves of the hand, as it passes through a narrow anatomical “tunnel” in the wrist, the so-called carpal tunnel. As our daily routine requires the continuous and uninterrupted use of our hands —from typing on computers and using smartphones to manual labor— understanding the condition, early diagnosis, and the correct therapeutic approach are critical for maintaining quality of life.

What is Carpal Tunnel Syndrome and the Anatomy of the Wrist

To fully understand the mechanism by which the condition is caused, it is necessary to take a look at the anatomy of the region.

The carpal tunnel is a real, narrow tunnel located at the base of the palm (on the palmar side of the wrist). The “floor” and the side walls of this tunnel are formed by the small bones of the wrist (the carpal bones). The “roof” of the tunnel is covered by an exceptionally strong, thick, and inelastic band of connective tissue, which is called the transverse carpal ligament (flexor retinaculum).

Through this narrow and non-expandable space pass ten (10) vital structures from the forearm to the palm and fingers:

Nine (9) tendons: These are the flexor tendons, which function like durable ropes and allow us to bend our fingers and make a fist.
One (1) nerve: The median nerve, which is located exactly under the transverse ligament.

The median nerve is responsible for providing sensation (sensitivity) to the palmar surface of the thumb, the index, the middle, and half of the ring finger. At the same time, it provides the motor signals (the strength) to the small muscles located at the base of the thumb (the thenar eminence), allowing us to grasp, squeeze, and execute delicate movements (such as picking up a needle or buttoning a shirt).

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How pressure is created (The Mechanism)

Because the transverse ligament is rigid, the boundaries of the carpal tunnel are absolutely fixed. Any condition causing enlargement, edema, or inflammation in the tissues located inside the tunnel (usually the swelling of the sheaths surrounding the 9 tendons) automatically increases the pressure in this restricted space. Given that tendons are tough and durable, the increased pressure “crushes” the most sensitive structure: the median nerve. This pressure interrupts the smooth flow of blood to the nerve (ischemia), resulting in the onset of pain and numbness symptoms.

Carpal Tunnel Syndrome – Frequency of Appearance and Risk Factors

Carpal Tunnel Syndrome is a global phenomenon; however, epidemiological studies prove that it does not affect all people the same. The condition seems to appear with greater frequency and be influenced by specific factors:

Women

In women, the probability of the disease appearing is strikingly higher, reaching up to 3 times greater compared to that of men. The main reason behind this statistical difference is anatomical: the carpal tunnel in women is naturally narrower and smaller in diameter than that of men. Therefore, even a minimal increase in tissue volume (e.g., a slight swelling) suffices to press the median nerve.

Older Individuals

In older ages, the syndrome is observed with much greater frequency compared to younger ages. Usually, the condition peaks in individuals aged between 40 and 60 years old. As we age, the tendons and tissues around the joints undergo gradual degeneration, lose their elasticity, become more prone to inflammation (tendinopathy), and the wrist joints may present osteoarthritis, which further restricts the space.

Heredity

Many patients ignore the fact that wrist anatomy is inherited. If your parents have a history of carpal tunnel syndrome due to a congenitally narrow tunnel, it is very likely that you will face the same problem during your lifetime.

What are the causes of appearance of Carpal Tunnel Syndrome?

Rarely is carpal tunnel syndrome caused by a single clear cause. Most of the time, it is the result of a combination of factors leading to increased pressure on the median nerve. The causes from which pressure on the median nerve in the carpal tunnel can arise vary and are analyzed thoroughly below:

Occupational Strain and Repetitive Movements

Utilizing the hands very intensely and continuous movements of flexion (bending) or extension (straightening) of the wrist constitute the number one extrinsic risk factor.

Working long hours at the computer (typing, mouse use at the wrong angle), working on production lines, sewing, knitting, using vibrating tools (such as drills or jackhammers by technicians), and occupations such as those of hairdressers, musicians, butchers, or supermarket cashiers cause constant micro-injury. The tendons moving the fingers rub incessantly, become inflamed (tenosynovitis), and enlarge, strangling the nerve.

Systemic and Inflammatory Conditions

Various inflammatory conditions, such as for example rheumatoid arthritis, play a catalytic role. In these autoimmune diseases, the lining surrounding the tendons (the synovium) presents chronic, intense inflammation and hypertrophy. The thickness of the tendons increases dramatically, occupying all available space in the carpal tunnel.

Diseases of a Metabolic Character

Diabetes mellitus is inextricably linked with neuropathies. Increased blood glucose causes alterations in the small blood vessels feeding the nerves. The median nerve of a diabetic patient is already exceptionally vulnerable to damage, and consequently, even the slightest mechanical pressure on the wrist is enough to cause intense symptoms (diabetic neuropathy).

Endocrine Character Disorders

Disorders such as hypothyroidism or hyperthyroidism affect tissue metabolism and can cause edema. Equally significant are hormone disorders, particularly during menopause but also throughout a pregnancy.

During pregnancy, the female body has a tendency to retain fluids (pregnancy edema). This fluid retention occurs inside the narrow space of the carpal tunnel as well. Fortunately, carpal tunnel syndrome related to pregnancy frequently subsides on its own a few weeks or months after delivery, as body fluids return to normal levels.

Injuries and Anatomical Variations

A fracture of the wrist (such as a Colles fracture after a fall), a dislocation, or a severe strain can deform the bony structure of the small wrist bones. Even when the fracture heals, the tunnel space can remain narrower than before or a bony callus (calcium deposits) can develop, exerting direct pressure on the nerve. Additionally, some rare cases include the existence of cysts (ganglions) or tumors inside the tunnel.

Symptoms of Carpal Tunnel Syndrome: How will I know I suffer?

The manifestation of carpal tunnel syndrome is rarely sudden. Symptoms start gradually, often passing unnoticed in the first stages, but worsen progressively as pressure on the nerve increases and becomes established. The most usual symptoms appearing during this specific condition take the form of:

Sensory Symptoms (The first indications)

Numbness of the fingers innervated by the median nerve: This is the most classic and recognizable symptom. The patient feels that their fingers are “dead” or frozen. This concerns exclusively the thumb, the index, the middle, and half the side of the ring finger. Note: The little finger is never affected, as it is innervated by another nerve (the ulnar).
Tingling of the first three fingers: A sensation as if hundreds of small “pins and needles” are piercing you (paresthesia).
Pain and Burning: Intense pain, which is sometimes described as an electric current or burning, starting from the wrist and can radiate upward along the forearm, frequently reaching up to the elbow or even the shoulder.

The Nightmare of Night Pain

Research has shown, and clinical experience confirms, that symptoms become more intense during the night hours. For this reason, the plethora of patients state that they find it difficult to sleep, their sleep quality downgrades rapidly, and they wake up several times during the night from sharp pain and unbearable numbness.

Why does this happen? This occurs because most people sleep bending (flexing) their hands and wrists unconsciously close to the chest, in a fetal position. Extreme flexion of the wrist reduces the already restricted space of the carpal tunnel to a minimum, completely strangling the blood supply to the median nerve. The characteristic reaction of the patient is waking up and shaking their hand vigorously (“flick sign”), trying to restore blood circulation and be relieved of the numbness.

Motor Symptoms (The advanced stages)

Weakness and clumsiness of the hand: As pressure on the nerve is prolonged, the transmission of motor signals toward the muscles weakens. The hand loses its gripping power and fine motor skills.
Dropping objects: The patient discovers with surprise that objects drop from their hands (a coffee cup, keys, a plate) without an obvious reason and without realizing it, as the sensation of how tightly they must hold the object is lost (reduced proprioception).
Muscle Atrophy: In the most advanced, chronic, and dangerous stage, the muscle at the base of the thumb (the thenar eminence) begins to “melt” and shrink visually. When atrophy comes upon it, nerve damage is often very difficult to reverse fully, making immediate medical intervention imperative.

How is the diagnosis of Carpal Tunnel Syndrome performed?

The diagnosis of Carpal Tunnel Syndrome is not based on assumptions, but on a structured and strict medical methodology.

Clinical Examination

The first and perhaps most decisive step is performed with the correct clinical examination of the patient by the specialized orthopedic surgeon. Once a detailed medical history is taken, the doctor will check the sensitivity and strength of the fingers and examine the thumb for any signs of muscle atrophy. During the clinical examination, specific diagnostic pain provocation tests are applied, such as:

Tinel’s Test (Tinel’s Sign): The doctor percusses (taps lightly with his finger or a special hammer) over the median nerve, on the inner side of the wrist. If this tapping causes a sensation of “electric current” or numbness extending toward the fingers, the test is positive.
Phalen’s Test (Wrist flexion test): The patient presses the backs of their hands together, maintaining the wrists in maximal flexion for approximately 60 seconds. If within this time interval the numbness or pain is reproduced, nerve compression is confirmed.

Laboratory and Imaging Check

For greater certainty regarding the diagnosis results, and in order to determine the exact severity of the lesion, it may be required for the individual to proceed to a laboratory check via an electromyogram (EMG) and nerve conduction velocity study. This neurophysiological examination measures the speed with which electrical signals travel through the nerve. If pressure exists in the carpal tunnel, the transmission speed of the signal decreases noticeably.

It is worth mentioning that cases of patients exist (a percentage of 10-15%) where the electromyogram does not yield the same result as the clinical examination (it can come out falsely negative in initial stages), which ultimately is also more significant for decision-making.

In very specific cases (e.g., in a history of trauma or suspicion of a mass), some further tests might be needed, such as Plain X-ray, Diagnostic Ultrasound to measure the enlargement (edema) of the nerve itself, or Magnetic Resonance Imaging (MRI) to be able to determine the etiology of the disease more correctly.

Treatment of Carpal Tunnel Syndrome

As applies in most conditions of modern orthopedics, so in Carpal Tunnel Syndrome, treatment is adjusted depending on the severity of symptoms, the duration of the condition, and the response of the body. Treatment can take either a conservative or a surgical form. In more detail:

Conservative Management (For Initial and Mild Stages)

Mild forms of the disease, or cases where the condition developed recently (e.g., during pregnancy), have the capability to be treated effectively without surgery. The plan usually includes:

Use of Special Splints: Placing a rigid immobilization splint (wrist splint) during the night hours is perhaps the simplest and most effective intervention. The splint holds the wrist in absolute straightness (neutral position) during sleep, preventing unconscious flexion, thus maintaining the carpal tunnel at its maximum possible opening. This frequently vanishes night pain.
Ergonomic Changes: The avoidance of movements causing flexion or hyperextension of the wrist during the day. Using an ergonomic keyboard, wrist support cushions (mousepads), and changing posture regularly help in offloading. Additionally, resting the hand (with regular breaks from manual work) soothes the irritation that might appear in that area.
Medication: All the above, combined with the simultaneous administration of drugs of anti-inflammatory action (Non-Steroidal Anti-Inflammatory – NSAIDs), enhance to a quite significant degree the effectiveness of conservative treatment, reducing local edema. In certain cases, vitamins of the B complex (B6, B12) are also administered for feeding the nerve.
Corticosteroid Injections: In more persistent cases, the doctor can administer a local cortisone injection directly into the carpal tunnel (usually under ultrasound guidance for absolute safety). This offers a powerful and immediate reduction of tendon inflammation, “emptying” space for the nerve. Relief is immediate, but it can be temporary if the deeper causes are not eliminated.

Surgical Management (Definitive Solution)

Surgical treatment refers primarily to individuals who did not have the appropriate results from conservative treatment for a period exceeding 3-6 months, to patients presenting muscle weakness/atrophy, or to those whose electromyogram indicates severe and chronic entrapment of the nerve.

The goal of surgery is the absolute and permanent decompression of the median nerve, and this is achieved through the division (cutting) of the transverse carpal ligament, thus releasing the trapped space. The operation performed is exceptionally safe, fast, and is done as a day case (Day Clinic) using local anesthesia in the wrist region, without needing general anesthesia.

There are two main surgical approaches:

Classic Open Release: The surgeon makes an incision of approximately 3-5 centimeters in the palm and directly divides the ligament. Although exceptionally effective, the larger incision in the palm can require slightly more time for skin healing.
Endoscopic Release & Microsurgery MIS: In recent years, with the progress of medical technology, through the technique of endoscopic release (with the use of a microscopic camera) but also the use of special knives and tools (Minimally Invasive Surgery), the size of the incision created has decreased significantly. Frequently, a microscopic incision of just 1-1.5 centimeters in the folds of the wrist suffices.

Advantages of modern techniques: The minimally invasive approach offers immense benefits. Minimal postoperative pain exists, no muscles of the palm are cut, no ugly scars remain, and the patient’s return to daily activities (such as writing or driving) happens rapidly, frequently within just a few days. Nerve pain (and particularly night pain) literally vanishes from the very first night after the surgery. The full restoration of numbness, however, depends on the degree of pre-existing damage to the nerve and can need a few weeks.

A Few Words About the Doctor (Dr. Polyzois)

Surgery of the peripheral nerves of the upper limb and especially of the Carpal Tunnel requires high specialization, millimeter precision, and deep knowledge of microsurgical anatomy.

Ioannis Polyzois is a highly specialized Orthopedic Surgeon, having worked and distinguished himself for 10 consecutive years in the ultra-modern and demanding National Health System (NHS) of Great Britain as a permanent Director of Orthopedics (Substantive Consultant) in Surrey, London. He constitutes the only Orthopedic surgeon in Greece with this certified prior service at such a level of specialization (Fellowship trained) in shoulder and upper limb surgery.

The field in which he specializes includes the implementation of the most modern, safe, and minimally invasive (MIS) surgical techniques for the definitive management of Carpal Tunnel Syndrome. Having performed thousands of successful releases in his career, his approach focuses on rapid recovery, minimizing pain, an excellent aesthetic result (without visible scars), and honest, human communication with the patient. Do not hesitate to contact the doctor to give an answer to all your concerns and find the definitive solution to your problem!

Cost and Prices for the Management of the Syndrome

One of the most frequent questions of patients, when they decide to proceed to the definitive treatment of carpal tunnel syndrome, concerns the financial cost. The philosophy of our clinic is based on providing top medical services with absolute transparency, keeping the cost affordable and reasonable for everyone.

The final cost of treatment depends on the type of approach (conservative treatment in the clinic with injections or surgical management). In the case of surgery (the release of the ligament), the fact that it is performed exclusively with local anesthesia and does not require general anesthesia, an anesthesiologist, or an overnight stay in the hospital (since the patient returns home the very same hour) drastically reduces private clinic expenses.

In addition, our clinic cooperates seamlessly with all private insurance companies, while the use of the state insurance body (EOPYY) is also supported to further cover a significant part of the expenses (medical tests, hospitalization). Following your full clinical evaluation, you will receive a clear, detailed, and completely personalized financial brief, ensuring that no “hidden” charges exist.

Movement is life! Contact the doctor for specialized orthopedic care, tailored to your needs.

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Συχνές ερωτήσεις

Can carpal tunnel syndrome appear in both hands?

Yes, it is extremely common. In reality, carpal tunnel syndrome appears bilaterally (in both hands simultaneously or with a small time difference) in more than 50% of cases. This occurs because the factors causing the condition —such as anatomical predisposition (narrow tunnel), hormonal changes, diabetes, or repetitive movements at work (such as typing)— usually affect both upper limbs equally. Frequently, however, symptoms start first or are more intense in the dominant hand (e.g., in the right, if you are right-handed).

Is carpal tunnel syndrome permanent?

If the syndrome is diagnosed and treated timely (in initial or middle stages) with conservative or surgical treatment, symptoms subside fully and the damage is completely reversible. Surgery secures a permanent solution. However, if the condition is neglected for years, the constant “suffocation” of the median nerve causes the death of nerve fibers. In these extreme cases of delayed treatment, permanent (irreversible) muscle atrophy can come upon the thumb and permanent loss of sensation, rendering the damage unrepairable. That is why early intervention saves the nerve.

Can it be related to office work?

Naturally. Long hours of office work (desk jobs) constitute today one of the main causes of appearance or worsening of the condition. Continuous use of the keyboard and, primarily, prolonged use of the mouse forces the wrist to be at an unnatural angle of slight extension for hours. This posture increases pressure inside the tunnel, while the repetitive movement of fingers causes inflammation (tendinitis) in the tendons located around the nerve. Correct ergonomics (e.g., ergonomic keyboards and wrist supports) is decisive.

Can it be caused by an injury?

Yes, carpal tunnel syndrome can have a traumatic etiology (Post-traumatic CTS). A powerful fall onto the hand can cause a dislocation of the wrist, a very severe strain leading to acute bleeding and huge swelling inside the tunnel, or —more frequently— a fracture in the bones (such as a fracture of the distal radius). When the bone breaks, it can compress the nerve directly. Additionally, during the callus formation (healing) phase of the fracture, extra bone tissue or deformity can be created, permanently reducing the space for the median nerve.

How much time is needed to recover after the operation?

Recovery from surgery (especially with modern minimally invasive techniques) is strikingly fast. Intense night pain and “burning” usually vanish from the very first night. You can use your hand for light, basic daily activities (such as eating, dressing) already from the next day. Returning to office work can happen in approximately 1 to 2 weeks (as soon as sutures are removed). However, you should avoid heavy manual labor and weight lifting for approximately 4 to 6 weeks, so that full healing of the deep tissues of the palm is allowed.

What alternatives exist if I fear the surgery?

For those who are not ready for surgical operation, a cycle of “aggressive” conservative treatment is always recommended. This includes strict every-night use of a special immobilization splint, physiotherapy protocols with ultrasounds and stretches (nerve gliding exercises), adjusting ergonomics at work, and —as a more powerful step— targeted infiltration (injection) of cortisone into the carpal tunnel. Although cortisone can offer dramatic relief lasting months, it is important to know that if the problem is strictly anatomical (very narrow tunnel), symptoms sooner or later tend to return, rendering surgery inevitable for a definitive solution.

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