Description
Carpal tunnel syndrome is a common source of hand numbness and pain. It is more common in women than men and affects up to 10 percent of the population. It is caused by increased pressure on a nerve entering the hand through the confined space of the carpal tunnel.

The median nerve travels from the forearm into your hand through a tunnel in your wrist. The bottom and sides of this tunnel are formed by wrist bones and the top of the tunnel is covered by a strong band of connective tissue called a ligament.

Your doctor may make the diagnosis by discussing your symptoms and examining you. If symptoms continue to bother you, electrical testing of the nerve function is often performed to help confirm the diagnosis and clarify the best treatment option in your case.

Symptoms
Symptoms usually begin gradually without a specific injury. Numbness, tingling and pain in the hand are common. You may experience an electric-like shocking feeling. The thumb side of the hand is usually most involved. Symptoms at night are common and may awaken you from sleep.

During the day symptoms frequently occur with holding a phone, reading or driving. Symptoms may occur at any time. Moving or shaking the hands often helps decrease symptoms. Sometimes strange feelings and pain will travel up the arm.

Initially symptoms come and go, but over time they may become constant. A feeling of clumsiness or weakness can make delicate motions like buttoning buttons difficult and may cause you to drop things. If the condition is very severe, muscles in the palm may become visibly wasted.

Risk Factors
The actual cause is unknown in most people. Carpal tunnel syndrome is more common in women. In women, the swelling that occurs during pregnancy may cause symptoms, but those will frequently go away after delivery. Carpal tunnel syndrome becomes more common as we grow older and seems to affect people with certain medical conditions such as diabetes, thyroid conditions and rheumatoid arthritis more frequently.

Treatment Options
Symptoms can often be relieved without surgery. Treatment often begins with a brace or splint worn at night to keep the wrist in a natural position. Splints can also be worn during activities that aggravate symptoms. Simple medications such as Tylenol® or Advil® can help decrease pain. Changing patterns of hand use to avoid aggravating positions and activities may be helpful. A corticosteroid injection will often provide temporary relief, but symptoms may come back.

If your carpal tunnel syndrome continues to bother you and you do not gain relief from non-surgical treatments, surgery can be effective in diminishing symptoms. Because carpal tunnel syndrome is not a dangerous problem, the decision whether to have surgery is based mostly on the severity of your symptoms.

• If your symptoms are severe and won’t go away you may want to consider surgery.
• In more severe cases, surgery is considered sooner because other treatment options are less helpful.
• In very severe cases, surgery may be recommended to prevent irreversible damage.

Treatment Options: Surgical
The strong roof of the carpal tunnel is cut during carpal tunnel surgery to increase the size of the tunnel and decrease pressure on the nerve. This is done through an incision in the palm or wrist. A small camera may be used to allow the surgery to be performed through a smaller incision.

Risks of the surgery include bleeding, infection and nerve injury. Some pain, swelling and stiffness are expected, but severe problems are rare.

After surgery, elevating the hand and moving the fingers helps minimize swelling and stiffness. Minor soreness in the palm is common for several months after surgery. Most patients have improvement following surgery, but recovery may be gradual.

When carpal tunnel syndrome has been present longer and the nerve is more severely affected, recovery is slower and less complete.

Carpal Tunnel Syndrome is a common condition that occurs when the median nerve is compressed at the wrist, resulting in pain, numbness, and tingling of the hand and fingers. The carpal tunnel is a tight area of the wrist that many important tendons and nerves pass through. It has a floor, walls, a ceiling, an entrance, and an exit. The floor and walls of the tunnel are made up of the bones.

The ceiling is the transverse carpal ligament. The median nerve runs from the forearm to the hand and directly through the carpal tunnel. This nerve controls some of your hand muscles and also allows sensation of your thumb, index, middle, and half of your ring finger. When this nerve is pressed and squeezed, carpal tunnel syndrome develops.

What are the symptoms of Carpal Tunnel Syndrome?

There are nine tendons that pass through the carpal tunnel and these attach muscles of this area to bones to allow your your thumb and fingers to flex. Each of these tendons has a slippery covering called the synovium. This covering allows the tendons to slide easily as the fingers are moved.

When the synovium becomes inflamed or thickened, pressure develops on the median nerve, adversely affecting its function. With a compromised median nerve, there is less blood and nutrients available, leading to numbness, weakness, and pain of the fingers and thumb. These symptoms are considerably worse at night or while driving. … read more

Hallux Rigidus

Big toe arthritis, also called 1st metatarsophalangeal (MTP) arthritis or hallux rigidus, is a common condition affecting the foot and ankle. It is the most common site for arthritis in the foot. Patients typically develop symptoms between age 30 and 60, and females are more commonly affected than men.

Presentation
Patients typically develop stiffness and decreased range of motion at the big toe, which affects walking, running, and other athletic activities. Some patients develop large bone spurs on the top of the foot, which can cause pain with shoe wear and discomfort when going up on the toes.

Causes
Sometimes trauma (a fracture or crush injury) can lead to this condition, but for most patients there is no specific inciting event. Some patients are more likely than others to develop big toe arthritis, either because of some anatomic abnormality or because of genetic predisposition.

Diagnosis
A clinical exam and x-rays can confirm the diagnosis. Generally, advanced imaging like MRI or CT scan is not required.

Treatment
Non-surgical options include anti-inflammatories, shoe wear modifications, and over-the-counter or custom inserts (orthotics). Physical therapy can be helpful to maintain range of motion. Occasionally cortisone injections into the joint can decrease inflammation for a period of time.

Surgery can be used to treat cases that fail non-operative treatment. Traditionally, a procedure called a cheilectomy can be used to remove bone spurs from the top of the big toe joint. This is recommended for mild to moderate cases of hallux rigidus. This is a joint-sparing procedure. Recovery involves walking in a surgical sandal for about 3-4 weeks after the surgery.

For moderate to severe arthritis, a fusion has until recently been the only proven surgical option. This is a joint-sacrificing procedure, in which the bones on either side of the joint are fused together with screws and possibly a plate.

This reliably addresses pain symptoms but eliminates all motion at the joint. Recovery involves a period of non- or heel- weight bearing followed by fully weight bearing in a surgical sandal for 8 weeks or more after the surgery.

Cartiva

A New Surgical Treatment Option

A new option is Cartiva, which can be an alternative to the aforementioned procedures. Cartiva is an organic polymer engineered to match the properties of human cartilage, which is what wears out as arthritis progresses. Your surgeon implants the polymer into the head of the 1st metatarsal, to act as a new joint surface. This is a joint-sparing procedure which retains, and in many cases increases, range of motion.

Recent literature shows greater than 90% patient satisfaction after 5 years of implantation. Recovery is similar to that of cheilectomy, and involves fully weight bearing in a surgical sandal for about 3-4 weeks after the surgery. If the procedure does not resolve pain, a fusion is still a surgical option for you.

Summary

Hallux rigidus is a common condition that involves pain, swelling, stiffness and decreased range of motion of the big toe. Diagnosis is often straightforward and involves a clinical examination and x-ray. Several non-operative treatments exist, including NSAIDs, shoe wear modifications, shoe inserts, and injections.

When non-operative treatment fails, surgery is an appropriate option. Cartiva may be an appropriate treatment option to avoid fusion of the big toe. Please see a qualified foot and ankle orthopedic surgeon if you believe you may be a candidate.

Mark Reed, MD is a fellowship-trained foot and ankle orthopedic surgeon who has undergone training on the Cartiva procedure and has incorporated it in his practice. Please contact OSS to schedule an appointment for an in-depth evaluation.