Stingray-Induced Tarsal Tunnel Syndrome.

This case report involves a 17-year-old male referred for electrodiagnostic (EDX) evaluation with symptoms of tarsal tunnel syndrome after being stung by a stingray. EDX testing revealed moderate axonal injury localized to the tarsal tunnel. Subsequent exploratory surgery removed a stingray barb from the tarsal tunnel. The patient's symptoms nearly completely resolved at five weeks postoperative follow-up. EDX evaluation of this patient with delayed recovery proved to be a valuable component of management.

Suction Decompression of the Carpal Tunnel.

Carpal tunnel syndrome (CTS) is a common nerve compression syndrome that includes symptoms of numbness and tingling in the median nerve distribution. Medical cupping therapy has been used for managing a variety of medical conditions, but, to the author's knowledge, the cupping device has not been directly applied over the carpal tunnel as a form of treatment. This case report involves a 27-year-old woman who presented with symptoms of CTS in the right hand and palpatory restriction over the right carpal canal. Electrodiagnostic testing confirmed mild CTS, and neuromuscular ultrasonography revealed a mildly enlarged median nerve at the wrist, which was also consistent with CTS. The patient was taught to use a cupping device that would allow her to apply suction over the ventral wrist daily. The patient noted improvement over several weeks and was asymptomatic at her 3-month follow-up visit. Repeated testing revealed that initial abnormalities in the wrist had resolved. Suction decompression of the carpal tunnel may be a viable alternative treatment for patients with mild CTS.

Carpal tunnel syndrome diagnosis.

Carpal tunnel syndrome (CTS) is a common median nerve compression syndrome and the most common peripheral mononeuropathy. The clinical syndrome is diagnosed by history and physical examination. Electrodiagnostic testing is the objective method used to measure median nerve dysfunction at the wrist and confirm the clinical diagnosis of CTS. Neuromuscular ultrasound imaging of the carpal tunnel provides supportive diagnostic information by revealing pathologic nerve swelling in CTS, and other anatomic anomalies that compress the median nerve. These tests cannot be used to make the diagnosis in the absence of history that includes CTS symptom criteria and excludes other causes.

Two novel nonsurgical treatments of carpal tunnel syndrome.

This article describes 2 nonsurgical approaches to the treatment of carpal tunnel syndrome that are not routinely offered, probably due to a lack of awareness. Osteopathic manipulative treatment (OMT) is commonly used for many medical problems, including musculoskeletal issues. OMT of the carpal tunnel is well described and researched, and can be clinically used by a skilled practitioner. The second treatment strategy is a more recent development. The use of ultrasound for guidance of injection is established, but a newer technique using sonographically guided percutaneous needle release of the transverse carpal ligament has shown promising results.

Grading severity of carpal tunnel syndrome in electrodiagnostic reports: why grading is recommended.

Carpal tunnel syndrome (CTS) is not difficult to confirm by electrodiagnosis (EDx), but the challenge lies in whether to grade the severity and the method for doing so. The arguments about grading are discussed, with an emphasis in favor, using a method that relies on the EDx data, but qualifies that it is the median neuropathy being graded and not the syndrome of CTS. Although use of latencies can be arbitrary and misleading, it is possible to apply other criteria, such as low amplitudes or conduction block and denervation, to develop a grading scale that could be applied widely. Several previously published grading schemes are reviewed, and a new method is described that combines the prior ranking criteria into 3 basic categories. Application of a grading system identifies the degree of nerve injury and thus allows the referring physician to utilize optimally the EDx report to manage the patient.

Ultrasonography-guided osteopathic manipulative treatment for a patient with thoracic outlet syndrome.

Patients with thoracic outlet syndrome can be treated with osteopathic manipulative treatment (OMT) to alleviate dysfunction and restriction of the pectoralis minor muscle (PMM) and the resulting compression of the brachial plexus. Neuromuscular ultrasonography (US) can demonstrate abnormalities in the thoracic outlet that are amenable to OMT and can be used to monitor intervention. The present report identifies PMM deformation and brachial plexus compression in a 32-year-old woman with thoracic outlet syndrome who was treated successfully with OMT. Neuromuscular US results were used to measure the degree of PMM deformation with the pectoral bowing ratio and confirm the diagnosis. Osteopathic manipulative treatment was applied and monitored using neuromuscular US to confirm that the operator's manipulating hand had direct contact with the PMM. Symptoms abated immediately after treatment. Results of a second neuromuscular US examination showed that the pectoral bowing ratio decreased into the normal range and thus confirmed that PMM deformation had resolved.

Ultrasound imaging of the carpal tunnel during median nerve compression.

Median nerve (MN) compression is a recognized component of carpal tunnel syndrome (CTS). In order to document compressive changes in the MN during hand activity, the carpal tunnel was imaged with neuromuscular ultrasound (NMUS). Ten patients with CTS and five normal controls underwent NMUS of the MN at rest and during dynamic stress testing (DST). DST maneuvers involve sustained isometric flexion of the distal phalanges of the first three digits. During DST in the CTS patients, NMUS demonstrated MN compression between the contracting thenar muscles ventrally and the taut flexor tendons dorsally. The mean MN diameter decreased nearly 40%, with focal narrowing in the mid-distal carpal canal. Normal controls demonstrated no MN compression and a tendency towards MN enlargement, with an average diameter increase of 17%. Observing the pathologic mechanism of MN injury during common prehensile hand movements could help better understand how to treat and prevent CTS.

Carpal tunnel syndrome: ultrasonographic imaging and pathologic mechanisms of median nerve compression.

Median nerve compression is a well-known cause of carpal tunnel syndrome (CTS). Yet, reasons why the most common idiopathic form of CTS develops in certain individuals are not well understood. To further understand the compressive mechanisms at work in CTS development, the authors used ultrasonographic imaging of the median nerve to evaluate 2 patients with CTS. Findings were compared to those of 2 control subjects who did not have CTS. In the patients who had CTS, the transverse carpal ligament was pulled taut by thenar muscle contraction as the flexor tendons tightened, compressing the median nerve between the ligament and tendons. No such compression was observed with the control subjects. Thus, a pathologic mechanism of median nerve compression was confirmed in the patients with CTS. Demonstration of such pathologic mechanisms during prehensile hand movement may improve understanding of how to treat patients with CTS and prevent nerve injury.

Manipulative treatment of carpal tunnel syndrome: biomechanical and osteopathic intervention to increase the length of the transverse carpal ligament: part 2. Effect of sex differences and manipulative "priming".

As a theoretical basis for treatment of carpal tunnel syndrome (CTS) and expanding upon part 1 of this study, the authors investigated the effects of static loading (weights) and dynamic loading (osteopathic manipulation [OM]) on 20 cadaver limbs (10 male, 10 female). This larger study group allowed for comparative analysis of results by sex and reversal of sequencing for testing protocols. In static loading, 10-newton loads were applied to metal pins inserted into carpal bones. In dynamic loading, the OM maneuvers used were those currently used in clinical settings to treat patients with CTS. Transverse carpal ligament (TCL) response was observed by measuring changes in the width of the transverse carpal arch (TCA) with three-dimensional video analysis and precision calipers. Results demonstrated maximal TCL elongation of 13% (3.7 mm) with a residual elongation after recovery of 9% (2.6 mm) from weight loads in the female cadaver limbs, compared to less than 1 mm as noted in part 1, which used lower weight loads and combined results from both sexes. Favorable responses to all interventions were more significant among female cadaver limbs. Higher weight loads also caused more linear translatory motion through the metal pins, resulting in TCA widening equal to 63% of the increases occurring at skin level, compared to only 38% with lower loads. When OM was performed first, it led to greater widening of the TCA and lengthening of the TCL during the weight loading that followed. Both methods hold promise to favorably impact the course of management of CTS, particularly in women.