One of the most common clinical problems I see in my orthopedic practice is carpal tunnel syndrome (CTS). I’m sure you or someone you know has suffered from CTS. In the United States alone, well over 100,000 people a year undergo carpal tunnel surgery. For such a common disorder, it’s amazing that doctors have so little understanding about what actually causes carpal tunnel syndrome.
We do know that carpal tunnel syndrome is associated with certain medical conditions, such as diabetes, thyroid disease, and gout. Furthermore, it is widely believed that repetitive use of the hands and wrists causes CTS. However, no scientific study has ever proven a direct link between any specific job activity and carpal tunnel syndrome.
The truth is that the causes of CTS are what we doctors call multifactorial. That is, multiple factors, including occupational and recreational overuse, underlying medical conditions, genetics, and who knows what else, all contribute to this very common syndrome.
Although playing golf has not been identified as a direct cause of carpal tunnel syndrome, the repetitive use of the hands and wrists seen in golf could certainly contribute. But to say that playing a few rounds of golf a month is a major factor in the development of your CTS is probably stretching the point. The same may not be true for the serious amateur or pro, for whom the countless hours of practice and play could take its toll. For one, Ken Venturi has noted that he developed such severe carpal tunnel syndrome in both hands that his touring career was ended.
Carpal tunnel syndrome occurs as a result of injury to the median nerve. As this nerve travels from the forearm to the wrist, it passes through a structure called the carpal tunnel. The wrist (carpal) bones form the floor of the carpal tunnel, and a thick ligament forms the roof. Packed into the tunnel, along with the median nerve, are most of the flexor tendons en route to the fingers. When inflammation and swelling of the tendons cause crowding and increased pressure on the median nerve, CTS is the result. The increased pressure on the nerve causes it to malfunction, resulting in the symptoms of carpal tunnel syndrome.
Patients with carpal tunnel syndrome describe several classic symptoms. Numbness and tingling involving the thumb and the index and middle fingers (and sometimes the whole hand) are the hallmark of CTS. Annoying numbness can occur both during the day (while doing things such as driving, holding a telephone, or using hand tools) and at night (patients are frequently awakened from sleep by numbness in the hands). Clumsiness and weakness when trying to grip things are also common complaints. There may be pain as well.
A course of rest, wrist splinting (especially at night), and anti-inflammatory medication are frequently the initial treatments for carpal tunnel syndrome. Identifying work-related or recreational activities that may be aggravating the situation is also helpful. Looking for ways to get the job done using less force, less repetition, and /or less wrist motion may help. For the golfer, simple measures—such as easing up on grip pressure during the address phase of the golf swing and making sure that worn golf grips are replaced regularly—may reduce the stress on the wrists/hands and help minimize the severity of CTS. Also, wearing a glove on each hand may provide extra cushioning. Finally, simply cutting back on the rounds of golf played or the number of balls hit at the range each week may help an injured nerve to recover.
The nonoperative measures listed above are most successful for early and mild cases of CTS. Studies show that only about one-third of patients will respond to these simple measures. For the rest, surgery may be the only answer—or, as one of my former co-residents used to say, the only cure left is hot lights and cold steel!
The concept behind CTS surgery is quite simple—the tunnel is “unroofed” by cutting the ligament overlying the nerve. This gives the nerve extra breathing space that is usually sufficient to allow the injured nerve to recover and for symptoms to resolve. In the early 1900s, surgeons mistakenly believed that CTS was caused by pressure on the nerves at the base of the neck and that the treatment was rib resection. Ouch! For those of you who constantly long for the “good old days”, I recommend that you stick to reminiscing about five-cent Hershey bars and leave out the early days of medicine.
Surgery can be performed either through an open incision or through tiny incisions with the aid of a camera (endoscopic technique). Either way, the success rate of CTS surgery is very high. Postoperatively, patients can return to golf once the incision has healed and wrist strength and range of motion have returned to normal.
If you or someone you know is experiencing the symptoms of carpal tunnel syndrome, make sure to see an orthopedic doctor. Delaying treatment not only results in unnecessary suffering, it can lead to irreversible nerve damage with permanent numbness and weakness. One the other hand (bad pun intended), prompt treatment can get you back on the golf course in no time.
By Larry Foster, M.D., F.A.A.O.S. (Dr. Divot)
Larry Foster, M.D., F.A.A.O.S., is a board-certified orthopedic surgeon and self-described golf nut. Trained at Columbia University and the Hospital for Joint Diseases in New York, Dr. Foster is the author of Dr. Divot’s Guide to Golf Injuries—A Handbook for Golf Injury Prevention and Treatment. Written in a humorous “plain-English” style, Dr. Divot’s Guide teaches the reader how to prevent and treat the most common golf injuries. Visit Dr. Divot’s website at: www.doctordivotmd.com.