Journal of Hand Therapy
Volume 18, Issue 2 , Pages 259-269 , April 2005

Pathomechanics of Peripheral Nerve Loading: Evidence in Carpal Tunnel Syndrome

  • Peter J. Keir, PhD

      Affiliations

    • Corresponding Author InformationCorrespondence and reprint requests to Peter J. Keir, PhD, School of Kinesiology and Health Science, York University, 4700 Keele Street, Toronto, ON M3J 1P3, Canada

References 

  1. Sunderland S. The nerve lesion in the carpal tunnel syndrome. J Neurol Neurosurg Psychiatry. 1976;39:615–626
  2. Lundborg G. Structure and function of the intraneural microvessels as related to trauma, edema formation, and nerve function. J Bone Joint Surg Am. 1975;57:938–948
  3. Lundborg G, Dahlin LB. Anatomy, function, and pathophysiology of peripheral nerves and nerve compression. Hand Clin. 1996;12:185–193
  4. Ochoa J, Fowler TJ, Gilliatt RW. Anatomical changes in peripheral nerves compressed by a pneumatic tourniquet. J Anat. 1972;113:433–455
  5. Rydevik B, Lundborg G. Permeability of intraneural microvessels and perineurium following acute, graded experimental nerve compression. Scand J Plast Reconstr Surg. 1977;11:179–187
  6. Rydevik B, Lundborg G, Bagge U. Effects of graded compression on intraneural blood flow. An in vivo study on rabbit tibial nerve. J Hand Surg [Am]. 1981;6:3–12
  7. Szabo RM, Sharkey NA. Response of peripheral nerve to cyclic compression in a laboratory rat model. J Orthop Res. 1993;11:828–833
  8. Lundborg GN, Gelberman RH, Minteer-Convery M, Lee YF, Hargens AR. Median nerve compression in the carpal tunnel- Functional response to experimentally induced controlled pressure. J Hand Surg [Am]. 1982;7:252–259
  9. Gelberman RH, Szabo RM, Williamson RV, Dimick MP. Sensibility testing in peripheral-nerve compression syndromes. An experimental study in humans. J Bone Joint Surg Am. 1983;65:632–638
  10. Gelberman RH, Szabo RM, Williamson RV, Hargens AR, Yaru NC, Minteer-Convery MA. Tissue pressure threshold for peripheral nerve viability. Clin Orthop. 1983;178:285–291
  11. Lundborg G, Myers R, Powell H. Nerve compression injury and increased endoneurial fluid pressure: a “miniature compartment syndrome”. J Neurol Neurosurg Psychiatry. 1983;46:1119–1124
  12. Dyck PJ, Lais LC, Giannini C, Engelstad JK. Structural alterations of nerve during cuff compression. Proc Natl Acad Sci U S A. 1990;87:9828–9832
  13. Dahlin LB, Nordborg C, Lundborg G. Morphologic changes in nerve cell bodies induced by experimental graded compression. Exp Neurol. 1987;95:611–621
  14. Dahlin LB, Archer DR, McLean WG. Axonal transport and morphological changes following nerve compression. An experimental study in the rabbit vagus nerve. J Hand Surg [Br]. 1993;18:106–110
  15. Dahlin LB, Kanje M. Conditional effect induced by chronic nerve compression. An experimental study of the sciatic and tibial nerves of rats. Scand J Plast Reconstr Surg. 1992;26:37–41
  16. Dahlin LB, Thambert C. Acute nerve compression at low pressures has a conditioning lesion effect on rat sciatic nerves. Acta Orthop Scand. 1993;64:479–481
  17. Dahlin LB, Lundborg G. The neurone and its response to peripheral nerve compression. J Hand Surg [Br]. 1990;15:5–10
  18. Mosconi T, Kruger L. Fixed-diameter polyethylene cuffs applied to the rat sciatic nerve induce a painful neuropathy: ultrastructural morphometric analysis of axonal alterations. Pain. 1996;64:37–57
  19. Cornefjord M, Sato K, Olmarker K, Rydevik B, Nordborg C. A model for chronic nerve root compression studies. Presentation of a porcine model for controlled, slow-onset compression with analyses of anatomic aspects, compression onset rate, and morphologic and neurophysiologic effects. Spine. 1997;22:946–957
  20. Konno S, Olmarker K, Byröd G, Rydevik B, Kikuchi S. Intermittent cauda equina compression. An experimental study of the porcine cauda equina with analyses of nerve impulse conduction properties. Spine. 1995;20:1223–1226
  21. Mackinnon SE, Dellon AL, Hudson AR, Hunter DA. Chronic nerve compression: an experimental model in the rat. Ann Plast Surg. 1984;13:112–120
  22. Thomas PK. The connective tissue of peripheral nerve: an electron microscope study. J Anat. 1963;97:35–44
  23. Mackinnon SE, Dellon AL, Hudson AR, Hunter DA. Chronic human nerve compression: a histological assessment. Neuropath Appl Neurobiol. 1986;12:547–565
  24. Faithfull DK, Moir DH, Ireland J. The micropathology of the typical carpal tunnel syndrome. J Hand Surg [Br]. 1986;11:131–132
  25. Yamaguchi DM, Lipscomb PR, Soule EH. Carpal tunnel syndrome. Minn Med. 1965;48:22–33
  26. Freeland AE, Tucci MA, Barbieri RA, Angel MF, Nick TG. Biochemical evaluation of serum and flexor tenosynovium in carpal tunnel syndrome. Microsurgery. 2002;22:378–385
  27. Fuchs PC, Nathan PA, Myers LD. Synovial histology in carpal tunnel syndrome. J Hand Surg [Am]. 1991;16:753–758
  28. Kerr CD, Sybert DR, Albarracin NS. An analysis of the flexor synovium in idiopathic carpal tunnel syndrome: report of 625 cases. J Hand Surg [Am]. 1992;17:1028–1030
  29. Neal NC, McManners J, Stirling GA. Pathology of the flexor tendon sheath in spontaneous carpal tunnel syndrome. J Hand Surg [Br]. 1987;12:229–232
  30. Schuind F, Ventura M, Pasteels JL. Idiopathic carpal tunnel syndrome: histologic study of flexor tendon synovium. J Hand Surg [Am]. 1990;15:497–503
  31. Armstrong TJ, Castelli WA, Evans FG, Diaz-Perez R. Some histological changes in the carpal tunnel contents and their biomechanical implications. J Occup Med. 1984;26:197–201
  32. Clark BD, Barr AE, Safadi FF, et al. Median nerve trauma in a rat model of work-related musculoskeletal disorder. J Neurotrauma. 2003;20:681–695
  33. Clark BD, Al-Shatti TA, Barr AE, Amin M, Barbe MF. Performance of a high-repetition, high-force task induces carpal tunnel syndrome in rats. J Orthop Sports Phys Ther. 2004;34:244–253
  34. Lundborg G, Dahlin LB, Hansson HA, Kanje M, Necking LE. Vibration exposure and peripheral nerfve fiber damage. J Hand Surg [Am]. 1990;15:346–351
  35. Chang KW, Ho ST, Yu HS. Vibration induced neurophysiological and electron microscopical changes in rat peripheral nerves. Occup Environ Med. 1994;51:130–135
  36. Strömberg T, Dahlin LB, Brun A, Lundborg G. Structural nerve changes at wrist level in workers exposed to vibration. Occup Environ Med. 1997;54:307–311
  37. McLellan DL, Swash M. Longitudinal sliding of the median nerve during movements of the upper limb. J Neurol Neurosurg Psychiatry. 1976;39:566–570
  38. Nakamichi K, Tachibana S. Transverse sliding of the median nerve beneath the flexor retinaculum. J Hand Surg [Br]. 1992;17:213–216
  39. Szabo RM, Bay BK, Sharkey NA, Gaut C. Median nerve displacement through the carpal canal. J Hand Surg [Am]. 1994;19:901–906
  40. Wright TW, Glowczewskie F, Wheeler D, Miller G, Cowin D. Excursion and strain of the median nerve. J Bone Joint Surg Am. 1996;78:1897–1903
  41. Nakamichi K, Tachibana S. Restricted motion of the median nerve in carpal tunnel syndrome. J Hand Surg [Br]. 1995;20:460–464
  42. Greening J, Smart S, Leary R, Hall-Craggs M, O'Higgins P, Lynn B. Reduced movement of median nerve in carpal tunnel during wrist flexion in patients with non-specific arm pain. Lancet. 1999;354:217–218
  43. Valls-Solé J, Alvarez R, Nunez M. Limited longitudinal sliding of the median nerve in patients with carpal tunnel syndrome. Muscle Nerve. 1995;18:761–767
  44. Watanabe M, Yamaga M, Kato T, Ide J, Kitamura T, Takagi K. The implication of repeated versus continuous strain on nerve function in a rat forelimb model. J Hand Surg [Am]. 2001;26:663–669
  45. Lundborg G, Rydevik B. Effects of stretching the tibial nerve of the rabbit. A preliminary study of the intraneural circulation and the barrier function of the perineurium. J Bone Joint Surg Br. 1973;55:390–401
  46. LaBan MM, Friedman NA, Zemenick GA. “Tethered” median nerve stress test in chronic carpal tunnel syndrome. Arch Phys Med Rehabil. 1986;67:803–804
  47. Rojviroj S, Sirirchativapee W, Kowsuwon W, Wongwiwattananon J, Tamnanthong N, Jeeravipoolvarn P. Pressures in the carpal tunnel. A comparison between patients with carpal tunnel syndrome and normal subjects. J Bone Joint Surg Br. 1990;72:516–518
  48. Brain WR, Wright AD, Wilkinson M. Spontaneous compression of both median nerves in the carpal tunnel. Six cases treated surgically. Lancet. 1947;1:277–282
  49. Gelberman RH, Hergenroeder PT, Hargens AR, Lundborg GN, Akeson WH. The carpal tunnel syndrome: A study of carpal canal pressures. J Bone Joint Surg Am. 1981;63:380–383
  50. Okutsu I, Ninomiya S, Hamanaka I, Kuroshima N, Inanami H. Measurement of pressure in the carpal canal before and after endoscopic management of carpal tunnel syndrome. J Bone Joint Surg Am. 1989;71:679–683
  51. Seradge H, Jia YC, Owens W. In vivo measurement of carpal tunnel pressure in the functioning hand. J Hand Surg [Am]. 1995;20:855–859
  52. Szabo RM, Chidgey LK. Stress carpal tunnel pressures in patients with carpal tunnel syndrome and normal patients. J Hand Surg [Am]. 1989;14:624–627
  53. Hamanaka I, Okutsu I, Shimizu K, Takatori Y, Ninomiya S. Evaluation of carpal canal pressure in carpal tunnel syndrome. J Hand Surg [Am]. 1995;20:848–854
  54. Weiss ND, Gordon L, Bloom T, So Y, Rempel DM. Position of the wrist associated with the lowest carpal-tunnel pressure: Implications for splint design. J Bone Joint Surg Am. 1995;77:1695–1699
  55. Keir PJ, Wells RP, Ranney DA, Lavery W. The effects of tendon load and posture on carpal tunnel pressure. J Hand Surg [Am]. 1997;22:628–634
  56. Keir PJ, Bach JM, Rempel DM. Effects of finger posture on carpal tunnel pressure during wrist motion. J Hand Surg [Am]. 1998;23:1004–1009
  57. Keir PJ, Bach JM, Engstrom JW, Rempel DM. Carpal tunnel pressure: effects of wrist flexion/extension. In: Proceedings of the Twentieth Annual Meeting of the American Society of Biomechanics, Georgia Tech, Atlanta, Georgia, October 17-19, 1996, pp 169–70.
  58. Werner R, Armstrong TJ, Bir C, Aylard MK. Intracarpal canal pressures: the role of finger, hand, wrist and forearm position. Clin Biomech. 1997;12:44–51
  59. Rempel D, Bach JM, Gordon L, So Y. Effects of forearm pronation/supination on carpal tunnel pressure. J Hand Surg [Am]. 1998;23:38–42
  60. Luchetti R, Schoenhuber R, Nathan P. correlation of segmental carpal tunnel pressures with changes in hand and wrist positions in patients with carpal tunnel syndrome and controls. J Hand Surg [Br]. 1998;23:598–602
  61. Rempel D, Manojlovic R, Levinsohn DG, Bloom T, Gordon L. The effect of wearing a flexible wrist splint on carpal tunnel pressure during repetitive hand activity. J Hand Surg [Am]. 1994;19:106–110
  62. Luchetti R, Schoenhuber R, DeCicco G, Alfarano M, Deluca S, Landi A. Carpal tunnel pressure. Acta Orthop Scand. 1989;60:397–399
  63. Rempel D, Keir PJ, Smutz WP, Hargens AR. The effects of static fingertip loading on carpal tunnel pressure. J Orthop Res. 1997;15:422–426
  64. Keir PJ, Bach JM, Rempel DM. Fingertip loading and carpal tunnel pressure: differences between a pinching and pressing task. J Orthop Res. 1998;16:112–115
  65. Silverstein BA, Fine LJ, Armstrong TJ. Occupational factors and carpal tunnel syndrome. Am J Ind Med. 1987;11:343–358
  66. Leclerc A, Landre MF, Chastang JF, Niedhammer I, Roquelaure Y. Upper-limb disorders in repetitive work. Scand J Work Environ Health. 2001;27:268–278
  67. Tanzer RC. The carpal-tunnel syndrome. A clinical and anatomical study. J Bone Joint Surg Am. 1959;41:626–634
  68. Smith EM, Sonstegard DA, Anderson WH. Carpal tunnel syndrome: contribution of flexor tendons. Arch Phys Med Rehabil. 1977;58:379–385
  69. Armstrong TJ, Chaffin DB. Some biomechanical aspects of the carpal tunnel. J Biomech. 1979;12:567–570
  70. Keir PJ, Wells RP. Changes in geometry of the finger flexor tendons in the carpal tunnel with wrist posture and tendon load: An MRI study on normal wrists. Clin Biomech. 1999;14:635–645
  71. Uchiyama S, Coert JH, Berglund L, Amadio PC, An K-N. Method for the measurement of friction between tendon and pulley. J Orthop Res. 1995;13:83–89
  72. Uchiyama S, Amadio PC, Coert JH, Berglund LJ, An KN. Gliding resistance of extrasynovial an dintrasynovial tendons through the A2 pulley. J Bone Joint Surg Am. 1997;79:219–223
  73. Uchiyama S, Amadio PC, Ishikawa J-I, An K-N. Boundary Lubrication between the Tendon and the Pulley in the Finger. J Bone Joint Surg Am. 1997;79:213–217
  74. Dekel S, Papaioannou T, Rushworth G, Coates R. Idiopathic carpal tunnel syndrome caused by carpal stenosis. BMJ. 1980;280:1297–1299
  75. Merhar GL, Clark RA, Schneider HJ, Stern PJ. High-resolution computed tomography of the wrist in patients with carpal tunnel syndrome. Skeletal Radiol. 1986;15:549–552
  76. Papaioannou T, Rushworth G, Atar D, Dekel S. Carpal canal stenosis in men with idiopathic carpal tunnel syndrome. Clin Orthop. 1992;285:210–213
  77. Winn FJ, Habes DJ. Carpal tunnel area as a risk factor for carpal tunnel syndrome. Muscle Nerve. 1991;13:254–258
  78. Skie M, Zeiss J, Ebraheim NA, Jackson WT. Carpal tunnel changes and median nerve compression during wrist flexion and extension seen by magnetic resonance imaging. J Hand Surg [Am]. 1990;15:934–939
  79. Yoshioka S, Okuda Y, Tamai K, Hirasawa Y, Koda Y. Changes in carpal tunnel shape during wrist joint motion. MRI evaluation of normal volunteers. J Hand Surg [Br]. 1993;18:620–623
  80. Ham SJ, Kolkman WFA, Heeres J, den Boer JA, Vierhout PAM. Changes in the carpal tunnel due to action of the flexor tendons: Visualization with magnetic resonance imaging. J Hand Surg [Am]. 1996;21:997–1003
  81. Cobb TK, Dalley BK, Posteraro RH, Lewis RC. Establishment of carpal contents / canal ratio by means of magnetic resonance imaging. J Hand Surg [Am]. 1992;17:843–849
  82. Robbins H. Anatomical study of the median nerve in the carpal tunnel and etiologies of the carpal-tunnel syndrome. J Bone Joint Surg Am. 1963;45:953–966
  83. Bleecker ML. Medical surveillance for carpal tunnel syndrome in workers. J Hand Surg [Am]. 1987;12(2 Pt 2):845–848
  84. Cobb TK, Bond JR, Cooney WP, Metcalf BJ. Assessment of the ratio of carpal contents to carpal tunnel volume in patients with carpal tunnel syndrome: a preliminary report. J Hand Surg [Am]. 1997;22:635–639
  85. Bower JA. An MRI evaluation of carpal tunnel dimensions in healthy wrists: Implications for carpal tunnel syndrome [master's thesis]. School of Kinesiology and Health Science, York University, 2004.
  86. Horch R, Allmann KH, Laubenberger J, Langer M, Stark GB. Median nerve compression can be detected by magnetic resonance imaging of the carpal tunnel. Neurosurgery. 1997;41:76–82
  87. Allmann KH, Horch R, Uhl M, et al. MR imaging of the carpal tunnel. Eur J Radiol. 1997;25:141–145
  88. Richman JA, Gelberman RH, Rydevik BL, Gylys-Morin VM, Hajek PC, Sartoris DJ. Carpal tunnel volume determination by magnetic resonance imaging three-dimensional reconstruction. J Hand Surg [Am]. 1987;12:712–717
  89. Pierre-Jerome C, Bekkelund SI, Mellgren SI, Torbergsen T. Quantitative magnetic resonance imaging and the electrophysiology of the carpal tunnel region in floor cleaners. Scand J Work Environ Health. 1996;22:119–123
  90. Pierre-Jerome C, Bekkelund SI, Nordstrom R. Quantitative MRI analysis of anatomic dimensions of the carpal tunnel in women. Surg Radiol Anat. 1997;19:31–34
  91. Pierre-Jerome C, Bekkelund SI, Mellgren SI, Nordstrom R. Quantitative MRI and electrophysiology of preoperative carpal tunnel syndrome in a female population. Ergonomics. 1997;40:642–649
  92. Schultz RJ, Endler PM, Huddleston HD. Anomalous median nerve and an anomalous muscle belly of the first lumbrical associated with carpal-tunnel syndrome. J Bone Joint Surg Am. 1973;55:1744–1746
  93. Zeiss J, Guilliam-Haidet L. MR demonstration of anomalous muscles about the volar aspect of the wrist and forearm. Clin Imaging. 1996;20:219–224
  94. Cobb TK, An K-N, Cooney WP, Berger RA. Lumbrical muscle incursion into the carpal tunnel during finger flexion. J Hand Surg [Br]. 1994;19:434–438
  95. Cobb TK, An K-N, Cooney WP. Effect of lumbrical muscle incursion within the carpal tunnel on carpal tunnel pressure: A cadaveric study. J Hand Surg [Am]. 1995;20:186–192
  96. Yii NW, Elliot D. A study of the dynamic relationship of the lumbrical muscles and the carpal tunnel. J Hand Surg [Br]. 1994;19:439–443
  97. Keir PJ, Bach JM. Flexor muscle incursion into the carpal tunnel: a mechanism for increased carpal tunnel pressure?. Clin Biomech (Bristol, Avon). 2000;15:301–305
  98. Holtzhausen L-M, Constant D, de Jager W. The prevalence of flexor digitorum superficialis and profundus muscle bellies beyond the proximal limit of the carpal tunnel: A cadaveric study. J Hand Surg [Am]. 1998;23:32–37
  99. An KN, Ueba Y, Chao EY, Cooney WP, Linscheid RL. Tendon excursion and moment arm of index finger muscles. J Biomech. 1983;16:419–425
  100. Armstrong TJ, Chaffin DB. An investigation of the relationship between displacements of the finger and wrist joints and the extrinsic finger flexor tendons. J Biomech. 1978;11:119–128
  101. Zeiss J, Jakab E. MR demonstration of an anomalous muscle in a patient with coexistent carpal and ulnar tunnel syndrome. Case report and literature summary. Clin Imaging. 1995;19:102–105
  102. Luchetti R, Schoenhuber R, Alfarano M, Deluca S, DeCicca G, Landi A. Carpal tunnel syndrome: Correlations between pressure measurement and intraoperative electrophysiological nerve study. Muscle Nerve. 1990;13:1164–1168
  103. Thurston AJ, Krause BL. The possible role of vascular congestion in carpal tunnel syndrome. J Hand Surg [Br]. 1988;13:397–399
  104. Werner C-O, Elmqvist D, Ohlin P. Pressure and nerve lesion in the carpal tunnel. Acta Orthop Scand. 1983;54:312–316
  105. Jarvik JG, Yuen E, Haynor DR, et al. MR Nerve Imaging in a prospective cohort of patients with suspected carpal tunnel syndrome. Neurology. 2002;58:1597–1602
  106. Monagle K, Dai G, Chu A, Burnham RS, Snyder RE. Quantitative MR imaging of carpal tunnel syndrome. AJR Am J Roentgenol. 1999;172:1581–1586
  107. Bleecker ML, Bohlman M, Moreland R, Tipton A. Carpal tunnel syndrome: role of carpal canal size. Neurology. 1985;35:1599–1604

PII: S0894-1130(05)00041-4

doi: 10.1197/j.jht.2005.02.001

Journal of Hand Therapy
Volume 18, Issue 2 , Pages 259-269 , April 2005