The onset of CTS can be classified into two categories: (1) acute and (2) chronic. Acute CTS is associated with a traumatic event, such as blunt trauma to the wrist, wrist fracture, infections, vascular disorders, rheumatologic disorders, hemorrhagic problems, burns, and high pressure injection injuries.1 These traumas produce a sudden and sustained increase in interstitial pressure within the carpal tunnel, resulting in a median nerve conduction block from intracompartmental and intraneural ischemia. This form of CTS is a medical emergency and requires immediate carpal tunnel decompression.

Chronic CTS is the result of an insidious rise of the interstitial pressure in the carpal tunnel and is classified as early, intermediate, or advanced. Patients with early CTS experience mild, intermittent symptoms that have been present less than 1 year. Intermediate CTS is characterized by more constant symptoms, including numbness and paresthesia, usually worse at night, with little or no atrophy of the thenar muscles. Surgery performed at this time uncovers a nerve that has undergone chronic changes, including epineural and intrafascicular edema. If decompression is performed at this time, then the neural changes are frequently reversible, although night symptoms may take a year to resolve. Advanced CTS is characterized by progressive paresthesia, atrophy of the thenar muscles, and pinch and grip weakness. Even after a successful surgical decompression, the chronic changes in the median nerve may be permanent.⁹

CTS can affect anyone, although females tend to have a higher incidence. Medical and ergonomic histories have been identified as independent risk factors in developing CTS, although controversy exists as to the contribution of work activities to the development of CTS.^10–12 Recent studies have looked at obesity as defined by body mass index; other biologic factors, such as genetics or structural make-up; and wrist anthropometrics as possible contributing factors.^13–18 There are some strong associations between CTS and age, gender, and female hormonal status as seen, for instance, during menopause or pregnancy.¹² Pregnancy can precipitate CTS by causing edema around the structures traversing the carpal canal. During pregnancy the symptoms of CTS tend to occur in the last trimester, secondary to fluid retention. The condition usually resolves within 6 to 12 weeks after delivery.⁹

CTS can also be associated with a number of other disease processes, including thyroid disease, rheumatoid arthritis, and diabetes, as well as with various anatomic anomalies such as a persistent median artery, median nerve variations, extramuscle bellies, and extratendinous slips.^15,18–20 Tumors and ganglions of the wrist, although rare, can precipitate CTS as the lesion occupies space within the carpal canal.²¹ Wrist trauma can cause CTS because of the resulting edema and hematoma surrounding the median nerve. Variations in lumbrical origin, length, or width can increase carpal tunnel pressure as dynamic lumbrical incursion into the CT can occur during finger flexion movements.²²

From the ergonomic side, CTS is often seen in patients who perform repetitive activities in their work or hobbies. One study of computer workers demonstrated that the angle of wrist extension (more than 20°) was associated with developing CTS.²³

The diagnosis of CTS can usually be made based on a thorough history and careful physical examination. In cases in which the diagnosis is uncertain, electrodiagnostic studies can be helpful in either confirming or ruling out the disorder.²⁴

In general, patients who are diagnosed with early stage CTS are initially treated without surgery. Nonsteroidal antiinflammatory drugs, although often prescribed, have not been shown to be effective in any controlled study to date^25,26 In some patients with recently developed CTS (less than 1 year), local injection of steroid medication into the carpal canal or oral steroids can significantly, although temporarily, reduce the symptoms of median nerve compression (Fig. 12-1). It has not been shown that a steroid injection can actually alter the progression of the disorder.^5,27

The best evidence-based conservative physical therapy treatments for CTS include splinting, deep pulsed ultrasound (US), nerve-gliding exercises, carpal bone mobilization, and yoga.^26,28 Splinting the patient’s wrist can be very helpful in controlling nighttime pain symptoms.²⁹ The wrist is splinted in a neutral position that maximizes the carpal tunnel space³⁰ and minimizes the carpal tunnel pressure.³¹ The splint is chosen based on the patient’s needs and comfort. The metal stay of a prefabricated wrist splint is easily replaced with a custom-molded thermoplastic stay to position the wrist in neutral. A positive Berger test (the patient holds a full fist position for 30 to 40 seconds, with a positive test reproducing paresthesia) result would suggest that the metacarpal phalangeal joints should also be immobilized in the splint, as the lumbricals can descend into the carpal tunnel with active finger flexion and cause further space compromise of the carpal tunnel contents.^10,32 All patients should sleep in their splints. Patients who have constant or activity-induced paresthesia may also wear their splints during the day.³⁰ When such conservative measures fail to resolve symptoms, surgery is indicated.

Classic CTS symptoms include the following⁵:

Sensory changes are commonly the first symptoms noted. The patient typically reports paresthesia and numbness of the digits served by the sensory branches of the median nerve and in the tips of the thumb, index finger, middle finger, and radial half of the ring finger, although both sides of the ring finger can be affected. Sensory symptoms may also be restricted to a single digit, or even involve the entire hand.¹ Sensibility in the thenar eminence is usually unaffected as this area is innervated by the palmar cutaneous branch of the median nerve, which branches proximal to the carpal tunnel, entering the hand volar to the TCL.

The onset of pain is most often the primary reason a person with chronic CTS seeks medical attention. The pain associated with CTS tends to begin in the latter aspects of the early and then into the intermediate stages. The patient complains of an intermittent, vague, dull aching in the wrist or forearm. Less common is pain radiating to the elbow and even the shoulder. Night pain is a common complaint most likely caused by congestion of the venous system during sleep.³³ Neurologic muscle weakness associated with CTS occurs late in the disease process. In advanced cases, atrophy of the thenar musculature can be seen. The unlucky patient with symptoms progressed to this state is at high risk for permanent nerve damage and may require a tendon transfer to substitute for the loss of palmar abduction.

The clinician must be able to visualize the anatomic structures that make up the carpal tunnel. The carpal canal is bounded by the TCL volarly, the scaphoid tuberosity and the trapezium radially, the hook of the hamate and the pisiform ulnarly, and the volar radiocarpal ligament and volar ligamentous extensions between the carpal bones dorsally.^19,34 The carpal canal is traversed by the median nerve, the four flexor digitorum profundus tendons, the four flexor digitorum superficialis tendons, the flexor pollicis longus tendon, and the surrounding synovial membranes. Any condition that causes enlargement of the contents of the carpal canal (such as inflammation or edema) or occupies space within the canal (such as a tumor or hematoma) compresses the median nerve. This occurs because the structures that make up the carpal canal are relatively inelastic and do not expand as the contents of the canal enlarge. The resulting pressure compromises circulation within the substance of the nerve, leading to nerve ischemia, which in turn leads to the symptoms and signs seen in CTS.

Residual symptoms following carpal tunnel surgery are common, but in one of the author’s experience, true recurrences and failed surgeries are very rare. Although symptoms of CTS vary depending on the individual, age, and duration of symptoms, the most common symptom of carpal tunnel is numbness in the distribution of the median nerve, which is worse at night. This is usually confirmed by evidence of significant slowing of the nerve conduction through the carpal canal. When patients with residual symptoms are properly questioned, they usually recall that they did in fact have relief of their nocturnal numbness following release of the TCL. This indicates a successful treatment of their CTS; however, they may still be dissatisfied with the result if they still have symptoms that brought them to the physician in the first place. These symptoms might include arm pain, arm numbness and tingling, shooting pains into various parts of the arm and hands, and weakness. The symptoms might be reproducible when attempting to perform specific activities, giving rise to the notion that their condition is a repetitive motion injury. In the experience of the authors of this chapter, the vast majority of these patients are no longer suffering from CTS but rather have a more proximal nerve entrapment. There are several potential points of entrapment of the median nerve at the elbow, including pronator syndrome. If cervical radiculopathy can be ruled out, the problem may be attributed to compression at the level of the brachial plexus, the so-called thoracic outlet syndrome. This diagnosis is often made by exclusion and then treated with a trial of therapy to address the thoracic outlet. Within a few weeks the patient will often notice a significant decrease in pain and an increase in strength.46,47

The frequency and duration of treatment is highly variable after a carpal tunnel release. In most cases minimal therapy is required, with key contributions to postoperative care being wound/scar management and proper instructions in exercises to enhance tendon gliding, obtain full active range of motion (AROM), and minimize edema. The patient may need guidance on ergonomics and other principles to facilitate full return to work or other activities.10 All patients referred to therapy are instructed in a home exercise program appropriate to the phase of recovery and their individual needs.

In general, patients tend to do quite well after carpal tunnel release. However, because the extent of the damage to the median nerve cannot fully be known before surgery, predicting the exact outcome of carpal tunnel release is difficult. Patients with mild to moderate symptoms can expect full recovery of sensation and resolution of the numbness and tingling caused by entrapment of the nerve. Patients with more advanced disease who have significant sensibility loss and muscle weakness usually achieve significant improvement of their condition. Patients with muscle atrophy can expect a halt to progression of muscle wasting and in some cases can regain muscle mass.

The recovery of the median nerve directly relates to the success of the surgery. Ultrasonography postoperatively may be helpful in identifying the initial beneficial morphologic changes. Nerve conduction studies could take as long as 3 to 6 months to change.⁴⁸ Patients must understand that they may have some element of incisional pain after surgery, which can last as long as 3 to 6 months. They must also be informed that they will temporarily lose some strength in the hand, which usually improves after 3 to 6 months.

In general, patients may be referred to therapy anywhere from 1 to 3 weeks postoperatively. The timing of the first visit will dictate which tests are appropriate to perform and which should be deferred until a later time. The initial evaluation after carpal tunnel release includes the following:

After 3 weeks postoperatively, in addition to the above measurements, the evaluation can include:

The patient’s history is obtained by patient interview. Information to be noted in the history includes age, gender, hand dominance, cause of CTS, type and date of the carpal tunnel release, occupation, avocational interests, onset and description of symptoms before surgery, and notes regarding whether symptoms were unilateral or bilateral. The patient should be screened for medical or systemic problems that might contribute to the persistence of symptoms.

The patient is asked to quantify the pain on a scale from 0 (representing no pain) to 10 (indicating severe pain requiring medical attention). The patient is asked to rate the pain both at rest and with use. The quality of the patient’s pain is obtained by documenting the descriptive terms the patient uses when discussing the symptoms.⁴⁹

Edema of the hand is recorded either by volumetric circumferential or figure of eight measurements. If edema is profuse throughout the hand, then volumetric measurements can be taken provided that stitches have been removed and the patient has no open wounds. The volumetric assessment should be administered following the American Society of Hand Therapists (ASHT) guidelines. If edema is minimal or the stitches have not yet been removed, then circumferential measurements recorded in centimeters should be obtained at the distal wrist crease and the distal palmar crease (DPC). The figure of eight method for assessing hand edema has been shown to be as reliable and valid as the volumetric method, and may be easier to perform in a busy clinic than the volumetric method.⁵⁰

AROM measurements are obtained using a goniometer for the wrist and forearm. Individual finger AROM measurements may not be necessary when motion limitations are minimal. A global measurement of finger flexibility is obtained by measuring composite finger flexion to the DPC. The distance from the middle of the pulp of a finger to the DPC is measured in centimeters for each finger. Functional thumb opposition is recorded as the ability to oppose the thumb to each fingertip, and full composite flexion/opposition as the ability to touch the thumb to the DPC of the small finger. Full motion is recorded as “zero,” and lack of full motion as a negative number.

To prevent bowstringing (i.e., subluxing, or anterior displacement, of the flexor tendons through the healing TCL), simultaneous wrist/finger flexion measurements should be deferred until 3 weeks after an open incision surgery. As mentioned, bowstringing may be more of a concern with open procedures than with endoscopic procedures.⁵¹

“Sensibility testing is the evaluation of the ability to feel or perceive a stimulus applied to an area.”⁵² Sensibility assessment is completed using the Semmes-Weinstein pressure aesthesiometer kit (a five filament kit is adequate). This type of sensory test is a pressure threshold test. The patient is seated comfortably for testing with the forearm supinated and the hand supported on a towel roll. The therapist should occlude the patient’s vision during the test and instruct the patient to report when a finger is stimulated and which finger feels the stimulus. The volar fingertips and thumb pulp are tested starting with the 2.83 monofilament. “Each monofilament is applied perpendicular to the skin for 1.5 seconds and lifted for 1.5 seconds.”⁵² The therapist should apply monofilaments 2.83 and 3.61 three times to the same spot, and apply monofilaments 4.31 through 6.65 once. The lowest-numbered monofilament felt for each digit should be recorded on the evaluation form.⁵² Full hand mapping is rarely required after a carpal tunnel release.

“Two point discrimination values are most often normal in CTS, and if they are abnormal it indicates advanced disease.”^53,54 The therapist should complete two-point discrimination testing only if the patient demonstrates significant deficits on the Semmes-Weinstein Monofilament Test. Two point discrimination is an innervation density test.⁵³ The difference between the pressure threshold test and an innervation density test is the sensitivity of the pressure threshold test to gradual loss or improvement in nerve function versus an all-or-none response on an innervation density test.

The surgical incision or scar is evaluated for its stage of healing. The therapist should document whether the scar is raised or flat, tough or soft, mobile or adherent. The color of the scar also is noted. Some authors have written that one of the principle predictors of good outcomes and successful back to work status is minimal scar tenderness.^44,55 Therapeutic interventions by physical therapists that include scar assessment and management techniques are necessary, therefore, to ensure a flat, nonadherent, nonpainful scar.

The patient’s present functional status can be documented in the areas of grooming, dressing, bathing, cooking, home care, work, avocational activities, and driving. Standardized self-administered outcome measurement tools that can be employed include the DASH, the Michigan Hand Outcomes Questionnaire, and the Boston Carpal Tunnel Scales, which includes the symptoms severity scale and functional status scale. Each of these scales takes only about 5 minutes to complete. These scales have been validated for use in CTS and even reported as more responsive to clinical improvements than grip, MMT, or sensory testing by monofilaments or two-point discrimination (Fig. 12-6).^56–58

If the patient is 3 weeks postoperation, grip strength is recorded using a dynamometer with the handle positioned at the second setting^59,60 per American Society of Surgery of the Hand (ASSH) and ASHT guidelines.

To perform a grip test, the patient should be “seated with the shoulder adducted and neutrally rotated, elbow flexed to 90°, forearm in neutral position” and unsupported.^61,62 The therapist may support the dynamometer to prevent dropping; however, the dynamometer should not be allowed to rest on the table. The therapist should document three grip measurements, alternating the right and left hands,⁶³ unless repetitive grasping of the dynamometer would increase the discomfort in the patient’s hand. Several authors have published normal values for grip strength but because of the high standard deviation¹¹ and inconsistencies in the studies, “comparison of grip scores to the contralateral extremity or longitudinal comparison to earlier values for each patient is recommended by ASSH and ASHT.”^60,62,64

Three types of pinch can be recorded using a pinch meter. Finger positioning for a three-point pinch is performed with the index and middle finger on the top of the pinch meter and the thumb on the bottom. Lateral pinch positioning is performed with the pinch meter held between the radial side of the index finger and the thumb on the top of the meter. Tip pinch is thumb pulp against index finger pulp. Tip pinch has been reported as a better outcome measure of strength for postoperative carpal tunnel release than grip or lateral pinch.⁶⁵ Early forceful pinch, however, is not recommended until 3 weeks after surgery.

Finger dexterity can be evaluated with various instruments such as the nine hole peg test, Jebsen-Taylor hand function test, O’Connor finger dexterity test, modified Moberg pick-up test, or the Minnesota rate of manipulation test. These tests have been standardized and normative data have been established for comparison purposes.

Upper-limb tension testing of the median nerve is appropriate to determine whether the patient has restrictions in nerve gliding. Limited studies have shown a decrease in the symptoms during conservative treatment of CTS,^66,67 and neural gliding is recommended not only to minimize the potential of adhesions on the nerve, but to increase range of motion (ROM) and decrease pain.⁶⁸ Local median nerve gliding at the wrist can be addressed as well (Fig. 12-7). Readers are referred to other authors such as Butler, Coppieter, and Elvey for more detailed information on neural tensioning principles and techniques.

The hand can be assessed for any atrophy of the thenar eminence, after which MMT of the upper quarter can be performed. As mentioned previously, care is taken to avoid undue stress on the flexor tendons until at least 3 weeks after surgery. In assessing the function of the median nerve, the “abductor pollicis brevis is the muscle of choice for clinical assessment because it is superficial, and is solely innervated by the median nerve.”^69,70

The value of postoperative splinting has been debated, and physical therapists should engage the patient in a decision on the need for splint use.43,71 Neutral wrist splinting^31,72 can be helpful for controlling tension at the wound site/scar, helping the patient to avoid simultaneous wrist/finger flexion, as well as functioning as a simple reminder for the patient to minimize use of the operative hand. However, according to one study,⁴³ there was less pain and scar tenderness but a greater delay in return to full activity level and less strength in patients who wore a splint postoperatively for 2 weeks compared with those who did not wear a splint.

GOALS: Promote wound healing, maintain tendon excursion, and prevent median nerve from adhering to tendon, increase digit ROM to within normal limits (WNL) and maintain proximal ROM, decrease pain, decrease edema, independence with ADL, independence with home program (Table 12-1)

A light postoperative dressing is usually worn for 7 to 10 days after surgery. The patient should be instructed to elevate the hand and move fingers frequently to help decrease edema. Exercises during phase I consist of AROM to the shoulder, elbow, and digits. The patient is instructed in tendon-gliding exercises (Fig. 12-8) to prevent adhesion of the tendons through the carpal tunnel and to help decrease edema.⁷³ The patient is also instructed in nerve glides, which include gentle wrist flexion and extension with the UE held in a relaxed position at side of body. Many patients are not referred to formal therapy and, after instruction, can perform exercises as a home program and are instructed to use the hand as tolerated.

GOALS: Promote scar remodeling, decrease hypersensitivity and pain, increase wrist ROM to WNL, begin to increase hand strength, independence in home exercise program (Table 12-2)

Within 48 hours of suture removal, scar mobilization techniques may be initiated. Begin with a light scar massage with lotion and progress to a more vigorous soft tissue mobilization as tolerated.

AROM should include composite flexion and extension of the digits, isolated blocking to the FDS and FDP, full median nerve glides, and continued tendon-gliding exercises. Seven to 10 repetitions are performed three to four times per day. At this time, composite flexion of the wrist and fingers is generally avoided until 21 days postoperation to prevent bowstringing of the tendons through the healing carpal ligament. Some patients may be referred for formal hand therapy for pain relief, scar desensitization, hand strengthening, and to help facilitate return to maximum activity (see Table 12-2). Modalities may be used to decrease pain and edema, to increase elasticity of tissues, and to promote tissue healing.⁷⁴ Moist heat may be used for pain control before exercise and to prepare tissues for soft tissue mobilization. The modalities of pulsed US, iontophoresis,⁷⁴ and high-voltage galvanic stimulation⁷⁴ are helpful in reducing the local swelling and pain experienced by patients after carpal tunnel release. Phonophoresis has not been shown to be any more effective than US alone for pain relief.⁵⁶

Iontophoresis with dexamethasone sodium phosphate may be used for decreasing local edema about the incision site. However, the incision must be completely healed and able to tolerate the stimulation.

Cryotherapy, if tolerated, may be administered after exercises for 10 minutes to help in managing edema and pain. Light retrograde massage also may facilitate lymphatic return. Patients with persistent edema may benefit from wearing a compression glove in conjunction with other edema-controlling modalities. The compression glove should be worn almost continuously at first, and then worn only at night as edema decreases. As discussed, splinting is declining in favor during postoperative treatment because of the deleterious effects of immobilization on joint mobility and muscle length. Splinting may be appropriate for patients who experience nighttime pain associated with flexed postures of the wrist and may also be used to provide rest to inflamed tissues.

The therapist should initiate scar desensitization when the surgical incision is closed. The desensitization process is initiated gently and can be performed in many ways. These methods include manual self-massage of the scar, immersion in tubs of textured particles, and rubbing the scar with different textures. When performing scar desensitization, the scar is initially rubbed lightly with soft fabrics; treatment progresses by using deeper pressure and coarser textures. Scar massage is initiated with minimal force, and the force is increased as the incision increases in tensile strength (Fig. 12-9). Scar massage can be done for 1 to 3 minutes, five times per day.

Limiting the development of scar adhesion to tendons, skin, and nerves is another important aspect of scar management after carpal tunnel release surgery. Tendon-gliding exercises are continued to move the flexor tendons differentially in the carpal tunnel. Nerve-gliding techniques are helpful in maintaining mobility of the median nerve after a carpal tunnel release.⁷⁵ The home program for median nerve gliding begins with the arm held at the side of the body, the elbow extended, and the forearm and wrist in a neutral position. The patient is instructed to extend the wrist from a neutral position in a gliding motion. The patient should be cautioned not to be overzealous with these exercises and to inform the therapist if symptoms increase.

When the incision is fully closed, a scar conformer can be fabricated from silicone elastomers or cut from silicone gel sheets (Fig. 12-10). Because the scar conformer works by applying pressure over the scar, it needs to be held firmly in place. Silicone sheeting does not need pressure wrapping, because the intervention is simply direct contact with scar tissue. Silicone gel sheeting is recommended for nightly application, for 8 to 10 hours per day. The therapist can use a self-adherent wrap such as Coban to secure the conformer or gel sheeting over the scar. The patient should be instructed not to wrap the scar conformer or sheeting too tightly with the Coban because tight wrapping will cause edema and pain in the hand. An explanation should be given to the patient regarding the purpose and importance of scar management techniques for at least 3 months. The patient should wash the scar conformer or silicone sheeting as needed to prevent skin irritation and replace the scar conformer/sheeting if it becomes worn or soiled. The patient should observe the skin closely for signs of skin maceration or heat rash. If these problems occur, then the patient should stop using the scar conformer or silicone and inform the therapist. Decreasing the amount of wear time or placing a light gauze or tissue between the scar elastomer pad and the skin may control skin maceration and heat rash.

After 3 weeks, the therapist can also initiate isometric strengthening exercises for wrist extension and flexion. Wrist isometrics are performed in a neutral wrist position.⁷⁶ The patient applies enough resistance with the opposite hand to create a muscle contraction, which is held for 5 seconds without increasing pain. The exercises can be progressed by increasing resistance and repetitions. Instruction on ways to maintain a neutral wrist position during functional use of the hand is emphasized with paper crunch activity and isometric strengthening exercises. This education is further emphasized with ergonomic instruction in phase II.

The patient should be encouraged to use the affected hand for self-care while avoiding wrist flexion, forceful repetitive grip, and lifting more than 3 lb. Tasks that require forceful grip, such as vacuuming, handling wet laundry, putting fitted sheets on the bed, yard work, tool use, lifting, and pushing, should be avoided for 6 to 8 weeks to allow complete healing.

GOALS: Improve strength and endurance in hand and UE for independence in ADL, progress strength and endurance in hand to prepare for return to work, return to full-time work activities (Table 12-3)

Phase II focuses primarily on strengthening and education (see Table 12-3). It begins on day 22 after surgery and continues until day 42 (6 weeks after surgery). Phase I modalities are continued for edema and pain control. Moist heat may be continued before exercises. Scar desensitization is continued with scar massage and soft tissue mobilization. Texture desensitization techniques are continued, especially as part of the home program. Use of a gel sheeting to pad the sensitive palm may increase comfort for performing self-care and light home care. Tendon-gliding and nerve-gliding exercises and scar massage are continued to prevent or decrease scar adhesions. The pressure used for scar massage is increased in intensity for manual massage. Use of the scar conformer or gel sheeting is continued at night to soften and flatten the scar.

The patient can add active wrist flexion exercises after 21 days with the expectation of full wrist flexion by the end of the sixth week after surgery.

Full UE stretching exercises and neural-gliding exercises are added at this time. UE stretches include composite motions of (1) wrist flexion, forearm pronation, and elbow extension; (2) wrist extension, forearm pronation, and elbow extension; and (3) wrist extension, forearm supination, and elbow extension.⁷⁷

Resistive gripping and pinching exercises with light resistive putty may be started 28 days after surgery. Putty exercises must be comfortably tolerated before moving to more resistive putty; however, if patients begin to complain of pillar pain, this should be discontinued for another week or two. Pillar pain is described in the literature as pain in the thenar or hypothenar areas, and should be distinguished from incisional or local scar tenderness.^44,78,79 Pillar pain occurs at the bony attachments of the TCL (the hook of the hamate, pisiform, scaphoid tubercle, and the ridge of the trapezium). Patients with pillar pain may have difficulty with gripping and palmar weight-bearing activities. Modalities may be used to decrease the inflammation and symptoms of pillar pain. Low-intensity continuous US⁸⁰ (0.5 W/cm², 3 MHz) has been noted to help decrease this type of pain. The therapist should instruct the patient that the maximum use of putty is two times a day for 5 minutes, and tell him or her to stop using the putty and notify the therapist if the pain increases significantly. Wrist isometric exercises can be continued along with the initiation of grip isometric exercises. The patient can perform grip isometric exercises by squeezing a towel roll in the hand. Light progressive resistance exercises (PREs) are added when pain is controlled. PREs are added for both wrist extension and flexion (Fig. 12-11).⁷⁶ Resistance should begin at to 1 lb and progressed to 3 lb as the patient tolerates it.

Wrist and grip strengthening are progressed to using a weight well or computerized work simulator (Fig. 12-12). The patient starts on the weight well with no weight or on the work simulator at minimal torque and progresses as tolerated.

Proximal muscle strengthening of the forearm, elbow, shoulder, and shoulder girdle can be started on day 28 after surgery. Forearm rotation strength can be achieved using a hammer held with the elbow flexed at 90° and stabilized against the side of the body. The therapist should ask the patient to rotate the forearm from the neutral position into supination and pronation. Simply moving the hammerhead away from the hand to increase the lever arm, or toward the hand to decrease the lever arm, can change the resistance of the exercise. Bicep curls and elbow extension exercises can be performed with dumbbells beginning at 1 or 2 lb and progressing as the patient tolerates. Shoulder and shoulder girdle exercises beginning with 1 to 2 lb are important and are performed for flexion, abduction, internal and external rotation, and scapular retraction. The patient should be monitored closely during the advancement of the proximal strengthening program to prevent the development of other cumulative trauma disorders, such as shoulder impingement syndrome, lateral epicondylitis, de Quervain’s syndrome, or trigger finger symptoms.

Treatment of the patient after carpal tunnel release surgery may also include instruction on ergonomic principles, proper posture, and body mechanics to prevent recurrence of CTS or the development of other repetitive stress injuries. Instruction should include general topics for all patients and job-specific teaching for those returning to highly repetitive or heavy-labor jobs.

GOALS: Adequate strength to return to full-time work activities, independent home exercise program, self-management of symptoms (Table 12-4)

The types of patients who progress to phase III are heavy laborers, construction workers, mechanics, and assembly workers. These patients should be able to progress to aerobic exercise using a bicycle, treadmill, or UE ergometer. The stretching program and scar management program from phase II is continued. Scar massage also continues, with the patient wearing the scar conformer or gel sheeting until the scar color is no longer reddened. Scar maturation can take as long as 1 year. Phase II strengthening exercises should be continued and progressed as tolerated. Large muscle group exercises using gym equipment or free weights are appropriate at this time for general body conditioning.

Work activity simulation is an important aspect of the phase III therapy protocol. These activities can include using a pipe tree or assembly boards and learning proper lifting and carrying techniques. The use of work simulation equipment can be helpful for strengthening and simulation of specific work activities (see Fig. 12-12). Full return of presurgical grip and pinch strengths often does not occur until 3 to 6 months following surgery.

Clearly, CTS affects patients physically, financially, and psychologically. Comprehensive management of the patient recovering from surgery for CTS optimizes the potential to return to ADL, work, and avocational activities.