Acute Compartment Pain: Carpal Tunnel Syndrome!

If you are experiencing any numbness, tingling, and inability to make a fist or are frequently dropping things, then the time to have it looked at is now. Nerve compression is an extremely unforgiving condition...

For most people, the words compartment syndrome, get mixed up with apartment syndrome. Most apartments are nothing more than dinky compartments anyway and subject to many common syndromes we have all experienced.

One syndrome is that you can never pay your rent on time. This is most prevalent in San Francisco and San José where your rent goes up every three weeks or so. Syndrome number two is where there's always some overly amorous couple upstairs overdosing on androstenedione, while seemingly, constantly auditioning for a porn movie.

In syndrome three, a group of bowlers must live upstairs, and they seem to enjoy rolling their 16 lb. ball across their wood floor from midnight to 3 a.m. nightly. And finally - syndrome four. Here, there's a couple upstairs who seem to have about six one year olds trying out for the USA Olympic crying and screaming team (and frankly, doing a pretty damn good job). Sign those toddlers up for the drug tests.

But that's just a few of the more commonly known apartment syndromes that we all have mixed up with compartment syndromes. Unfortunately, bodybuilders and athletes may suffer from both compartment and apartment syndromes. (do bodybuilders ever pay rent on time?) and this article is about one of the worst compartment syndromes known to man, carpal tunnel!

You can think of a compartment syndrome, which usually causes a lot of pain as an inflamed area, or possibly, an area of overly hypertrophied muscle, connective or scar tissue, in a minimalist area, where there is resulting nerve compression.

Sometimes a runner gets severe shin splints so unresponsive to treatment, that this compartment pain actually has to be relieved or released through surgical incision intervention. Sometimes, in some individuals, there's a syndrome called "thoracic outlet syndrome." Here, inflamed or compressed tissue contact nerve root offshoots rising out from the spine brachial plexus (and sometimes the pain is even structural, due to a misplaced or even abnormal rib). This one-sided arm/neck/shoulder nerve irritation in the thoracic cavity area, results in numbness, pain, atrophy and even the complete inability to use your hands or fingers.

Much more common to bodybuilders these days, besides lack of rent control, is a compartment syndrome known as carpal tunnel (and boy, this is not a fun ride at DisneyLand). I therefore asked our resident Doctor of Chiropractic, Gary Gagliardi, D.C., who was a former competitive bodybuilder and lifter, to comment on the dreaded carpal tunnel compartment syndrome. Even though Gary has always considered me somewhat of a mental syndrome, who should be locked in a compartment, he graciously agreed.

Here are some questions for the day. When you wake up in the morning, or after your workouts, do you have an unusual heaviness, ache or tingling in your hands, wrists and forearms? Do you have any numbness or uncomfortable pain in these areas, and do you always find yourself unconsciously shaking-out and massaging your wrists and forearms?

Does it seem like your forearms are not getting their usual pump and have a feeling of always being over-trained? Finally, can you make a tight fist; can you open any jar cap (of protein powder), like a bodybuilder should be able to? Can you hold your fanned-out hand of cards steadily after 3-4 hours of poker? Is your grip strength after a high-rep set of dead lifts strong or do you lose the barbell from your hands before your back fatigues?

Well, if some of these symptoms occur on a rather regular basis, you may have an injury commonly assocaited with certain industrial and repetitive manufacturing jobs, like computer workers, typists, garment workers and assembly-line workers, called carpal tunnel syndrome. Or, as is most common with iron-pumpers, it could be a related condition known as compression syndrome, or pseudo carpal tunnel syndrome, as it were.

No Old Roman Aqueaduct

Not an ancient artifact of Romanesque architecture, your sophomore class of Latin should remind you that the carpal tunnel has something to do with your finger and hand bones. But, more precisely, the carpal tunnel is actually a narrow passageway at the junction point where your wrist meets your hand. It's bordered on the topside (where your watch is) by the carpal bones and on the under side (where you feel your pulse) by a ligament called the flexor retinaculum.

The tendons that flex the fingers and the median nerve, (the stars of our story), traverse through this narrow space, wouldn't you know. The median nerve is the only nerve that runs within the carpal tunnel. The rest are tendon tenants (nine to be exact). This lonely median nerve performs double duty. It not only carries information to the brain about touch (sensory information), but it also carries messages from the brain to move the fingers (motor function).

Unfortunately there is limited space in the tunnel and if anything causes swelling of any of the tissues, the median nerve can get crunched as in compressed. You may be asking yourself, "So what if it's compressed?" Well, this nerve is responsible for the sensations of your thumb, index and middle fingers and it controls the muscles of the thumb side of the hand. Call that big-time delicate functioning.

Unfortunately there is limited space in the tunnel and if anything causes swelling of any of the tissues, the median nerve can get crunched as in compressed. You may be asking yourself, "So what if it's compressed?" Well, this nerve is responsible for the sensations of your thumb, index and middle fingers and it controls the muscles of the thumb side of the hand. Call that big-time delicate functioning.

Typically, CTS (carpal tunnel syndrome) is found in those who perform repetitive motions with their hands and wrists.

    Note: Ok, it's now time for one of Jeff Everson's perverse, but realistic notes. All you lonely single guys can relax. Excessive and repetitive hand motion induced secondary to testosterone and growth hormone, and after looking at swimwear layouts in Bob Kennedy's MMI, probably does not qualify. That is, except to say, that the use of excessive steroids and GH can cause tissue proliferation inappropriate to the space that contains the tissue, and in and of itself, could lead to carpal tunnel syndrome. This has been documented in at least three professional bodybuilders.

Back to normality. Examples of job risks include: secretaries, computer workers with bad technique, court stenographers, industrial workers, hair stylists and yes, even bodybuilders. Bodybuilders, over a lifetime, perform thousands of repetitive motions with their fingers, hands and forearms. Many of the exercises that you may be doing could actually be causing gradual damage or irritation and you may not even be aware of it. Certain exercise technique and the work that you do are the main culprits for your being at a higher risk of developing CTS.

Let's say you work as a software computer programmer for 8-10 hours a day, six days a week and every night after a long day of typing in information, you go to the gym and train your arms. While, in your mind, you think you haven't hit arms for days, your body knows you just used your arms and hands for eight hours! Ouch.

You don't necessarily have to do the "wrong" exercise to get hurt; you only have to overuse certain muscles.

Bad Exercises?

Over the years, as a chiropractic physician, I have seen many cases of CTS brought on by high-risk exercises, overuse, improper form and systemic disease.

In my professional opinion, the worst barbell/dumbbell exercises include: upright rows, close-grip bench presses, wrist curls off the end of a bench with a barbell or dumbbell and power cleans, in that order. All of these exercises load or strain the wrist in a very unstable position. If one of your favorites is mentioned and you don't want to give it up, then at least take a closer look at how you are doing the exercise and determine if you are confusing the pain of destruction with the pain of growth.

First, let's look at the least offensive, the power clean.

Power cleans are a very difficult exercise and if performed improperly, such as catching the weight too high and banging the bar into the chest, can jam the wrists and cause a great deal of compression. Thankfully, not too many bodybuilders are interested and patient enough to try to perfect this exercise, so that is good. But, they do the other ones, that I mentioned, too often.

Upright rows can place a tremendous amount of stress on the wrist and hands. In order to lift the barbell up, you must flex your hands and wrists into an awkward position to complete the movement, not to mention the big weights "hanging" on your wrist tendons. The supposed goal of this exercise is to build deltoids and traps. Well, why do an exercise that can lead to injury quicker than other exercises that are even more effective?

If you want bigger deltoids, do lateral raises and dumbbell presses. If you want bigger traps, do all the numerous variants of shrugs.

Besides, usually the amount of weight needed to maximize development in the deltoids and traps is too much for the wrists and hands to support. Yet they are doing most of the initial work. And for any of you who either never took physics or did take it and have forgotten about Newton's laws of motion, it's harder to initiate movement than it is to continue it. Drop upright rows.

Close-grip bench presses, while excellent for mass building in the triceps, can be very detrimental to the wrist/hand area. While your hand position leads to pumped triceps, it can also load the wrist region in a way that is very biomechanically unsound. Depending upon style, the exercise can produce radial or ulnar deviation, sometimes both. Ulnar deviation is most common and this is where the wrists have a relative bend towards the ulna (bone) side of your forearm, towards your pinky finger.

This position (it would be best to keep your wrists straight), places your muscles, tendons and ligaments under a significant load in a cramped position.

What about wrist or forearm curls off the end of a bench? Yes, there's nothing as impressive as a pair of Popeye forearms hanging out of a shirt, but forearm curls are not the way to achieve this. The problem with this exercise is that the main support structures, namely the ulna and radius bones are connected to your hand and wrist by a criss-cross network of ligaments. When you hang your hands off a bench with a barbell, the two forearm bones are supported by the bench, but the weight is directly shearing through the joint at the exact spot the ligaments of the wrist join to these bones, just like the hanging upright rows. In other words, you are placing a tremendous amount of pressure on the retinaculum structures, which encompass the carpal tunnel.

The foregoing are reasons for CTS caused by exercise, however, sometimes CTS can result from systemic causes. These include diabetes, hypothyroidism, pituitary disease, where there is excess growth hormone production, menopause, pregnancy, obesity and various forms of tissue-proliferating diseases.

The common denominator is that they all can result in some type of increase in tissue mass or fluid retention. This can lead to a compression of the median nerve within the carpal tunnel. Taking reams of artificial GH might actually imitate a pituitary tumor and GH, at high amounts, is well established as causing hypertrophy of internal organs and subcutaneous tissue! With limited space in the tunnel, excess tissue can quickly lead to compression syndromes.

For the diabetic, the complexity of the problem can go way beyond nerve compression from fluid retention. Diabetes can also cause peripheral neuropathies. When the body's glucose levels are not regulated properly, the increased sugar in the blood stream can cause damage to the transmitting structures of the nerves, eventually leading to muscle wasting and atrophy due to the nerve.

Avoidance Is The Name Of The Game!

So how do we avoid CTS and what can you do if you have developed it? The first step is to evaluate the type of work you do and the environment in which it takes place. I have seen cases of CTS that could have been avoided if the proper ergonomic work environment had been supplied.

The most important element these days with computers is correct keyboard placement. The keyboard should be almost at lap level so that both arms are bent at 90 degrees at the elbows. The hands and wrists should be in a straight neutral position.

Under no circumstances should the wrists be bent while typing. This causes a tremendous amount of friction and irritation within the carpal tunnel, irritation to those nine tendons in the carpal tunnel - almost all of them are used in typing.

If the wrists are bent during typing, those tendons move back and forth. They rub against the surrounding tissue. The longer this occurs, the more irritation and inflammation develops. So, add bodybuilding with heavy weights every day to this typing irritation and you start to get the picture.

Is There Any Complete Cure?

The cure for CTS is pretty simple; relieve the pressure on the median nerve. Unfortunately, the most effective way for rough cases is surgery. Good news though, today's technology has made this once dreadful condition a little easier to deal with.

In the past the surgical procedure for CTS decompression involved a large broad incision from the base of where your wrist meets your hand up your forearm about 4 inches. The recovery time was slow and the rehabilitation even worse. But thanks to the advent of new forms of surgery, the incision is barely three quarters of an inch long and the recovery is only 2 to 4 weeks.

Again, surgery is typically the only solution for those more severe cases where there is decreased nerve function on electrical diagnostic testing. It is imperative at this point to reduce the compression or risk permanent nerve damage and muscle atrophy. The nice thing about the surgical approach is that the decompression is immediate and healing usually begins rapidly.

For those less severe cases alternative therapies apply. These include massage of the affected muscles, splinting of the hands to open the tunnel up, proper biomechanical positioning while working and anti-inflammatory medications in both oral and local injection form. I have good treatment success with ice massage and manipulation of the wrist and hand combined with an initial 7-14 day rest period.

Real Carpal Tunnel Or Is It Memorex?

There are conditions that can mimic the symptoms of CTS and a thorough work up is required to rule out pseudocarpal tunnel syndrome or a C7 (seventh cervical bone level nerve problems). Both conditions cause some wrist and hand pain, which can cause the less experienced practitioner or the layperson to immediately assume it's CTS.

C7 nerve problems (radiculopathy) causes numbness and tingling into the hand, the same as CTS. The first clue that the problem is not CTS is found during the orthopedic examination. True CTS produces pain during diagnostic tests called Phalen's and reverse Phalen's tests. If you place your hands together as if praying close to your body with your thumbs against your chest, does this cause specific pain and tingling in the areas I described earlier?

If you place the back of the hands together in the opposite direction, does this cause the pain? Usually true CTS will immediately intensify the symptoms if they are constant and reproduce them if they are transient, with these tests. A second clue is found during a neurological examination.

A specific test is performed called Tinel's sign. This involves tapping on the median nerve and getting a reproduction of symptoms of tingling along the course of the nerve.

If both of these tests are negative, then most likely the source of the problem is elsewhere. If treatment of the cervical area relieves the problem, then it was not truly carpal tunnel syndrome but a cervical radiculopathy, maybe caused by a neck muscle strain or pull. Needless to say, do not attempt self-diagnosis.

The Real Problem With Bodybuilders!

As a chiropractor and bodybuilder, the most frequent problem I encounter is pseudocarpal tunnel syndrome. As the name implies, this is a false syndrome.

The root of the problem seems to be in one specific muscle in the upper, outer forearm region. The Pronator Teres is the main muscle that pronates or rotates the hand inward. Anyone who has done dumbbell curls is familiar with supination or the outward turning of your hand as you curl the weight; this muscle allows your body to do the opposite movement.

The Pronator Teres lies over the median nerve as it traverses down the forearm. If myofascial trigger points from repetitive overuse develop within the belly of the muscle, this can, in turn, apply pressure to the median nerve below. Suddenly, we have the illusion of CTS!

The trick to diagnosing pseudocarpal tunnel syndrome is to begin with a thorough history. It is imperative to ask many questions regarding the patient's work habits, their sleep position, (i.e. do they lie on the affected arm at night) and most importantly their exercise routine. If the physician is not familiar with bodybuilding it is highly likely he or she may just suggest the patient stop all exercise to avoid further injury. This is synonymous with the expression, "throwing the baby out with the bath water."

In most of the cases of pseudo-CTS I have treated, even if the patient is an avid bodybuilder, a successful resolution of symptoms can be reached. This can be accomplished by altering the order of the exercises, grouping of body parts, or by taking an additional day off following a workout or busy workday. Most patients respond well to this approach.

With CTS, where muscle damage is implicated, my treatments of choice are manipulation with associated deep tissue muscle-scar release. To do this, you must understand anatomy, as well as the diagnosis of pseudo-CTS. Additional modalities include the use of ice following training and either deep moist heat or ultrasound, both prior to training and during off times.

Bodybuilders whom I have worked with have all responded well to Sportscare Deep Relief too (advertised in this magazine). This cream applies to muscular problems not tissue inflammation. Many patients have had success with acupuncture and I myself have referred acupuncture as an adjunct to physical therapy, in the quest to relieve pain.

Like most things, the most important part of treatment is rehabilitation. Once the proper diagnosis has been made and treatment is instituted, strengthening becomes key. If afflicted persons have no alternative but to stay in their particular profession, even though it is causing injury to their bodies, then strength training is the solution.

Unfortunately, we use our hands and arms too many times to count in a day. Sometimes this can lead to a simple overuse muscle injury. And other times it can cause a potentially debilitating nervous disease. Weight training though, is by far, the best all around exercise movement anyone could choose. But many times the trauma of weight lifting following a long workday is not always a positive thing.

So, if you are experiencing any numbness, tingling, and inability to make a fist or are frequently dropping things, then the time to have it looked at is now. Nerve compression is an extremely unforgiving condition. And CTS ranks up there with the best of them.

About The Author

Gary Gagliardi, D.C., Chiropractic Physician. Member The American College of Chiropractic Orthopedists. Member The American Association of Spine Physicians. Dr. Gagliardi is a Chiropractic Physician with a postgraduate fellowship in orthopedics. He has treated Ms. Olympia, Cory Everson, and Mr. Olympia, Dorian Yates, Hollywood celebrities, stunt men and many amateur and professional lifters and bodybuilders. This includes Jeff Everson, (who Gary calls pretty much a hopeless case).

Gary has contributed to Muscle & Fitness and Flex magazines in the past and now writes for Planet Muscle. You can reach Gary by faxing questions to (561) 642-9626.