The Median Nerve

The Median Nerve runs down the arm and into the hand on the underside of the wrist via the Carpal Tunnel.   It supplies sensation tothe thumb, first, second and part of the ring finger on either hand, it also supplies the thenar muscles of the thumb that allow you to touch the thumb against the other fingers and thereby grip the sticks.

CTS arises from a one-off or repeated action that causes tendon irritation or inflammation which may result in swelling and thickening of the covering (tenosynovium) of the tendons which share the tunnel with the Median nerve. 

"As the tenosynovium covering all of the tendons begins to swell and thicken, the pressure begins to increase in the carpal tunnel - because the bones and ligaments that make up the tunnel are not able to stretch in response to the swelling.  Increased pressure in the carpal tunnel begins to squeeze the median nerve against the transverse carpal ligament - because the nerve is the softest structure in the carpal tunnel.  Eventually, the pressure reaches a point when the nerve can no longer function normally.  Pain and numbness in the hand begins.

"There are many conditions which can result in irritation and inflammation of the tenosynovium, and eventually cause carpal tunnel syndrome.  Different types of arthritis can cause inflammation of the tenosynovium directly.  A fracture of the wrist bones may later cause carpal tunnel syndrome if the healed fragments result in abnormal irritation of the flexor tendons.  The key concept to remember is that anything which causes abnormal pressure on the median nerve will result in the symptoms of pain, numbness and weakness". (Courtesy Medical Multimedia Group )  

In the case of drummers, CTS is thought to be caused by inflammation and swelling of the tenosynovium due to overuse.

How do I know if I have CTS?

Commonly, your first signs of potential CTS are numbness and pain in the hand excepting the little finger (which is not served by the median nerve).  You may also find that you waken in the middle of the night with pain and a feeling that the whole hand is asleep, you should check immediately if your little finger is affected, if it is numb then it may not be CTS, if it is not numb I urge you to have it checked out as soon as you can. The pain may be carried up the nerve to the shoulder and even the neck.  If untreated, the muscles of the thumb will be affected and the ability to grip is affected

What can I do about it?

Non-surgical Treatments

A wrist support or brace is standard initial practise for CTS sufferers.  This maintains the wrist in a stable neutral position which keeps the tunnel as wide as possible, it should give some relief.  It may not be practical to wear this all the time but it should certainly be worn at night .

Anti inflammatory medication may also help to reduce the pressure caused by swelling of the tendons, over-the-counter medcines such as brufen or neurofen are widely available. As usual, check with your doctor before taking any medication .

Preventative exercises may also be recommended to control or reduce the condition (Paul get link to site with exercises) Paul R. Martin from Neuro Diagnostics McHenry, Illinois says

"It seems to me that any therapy offered to treat CTS must focus on the wrist and associated intrinsic hand muscles and forearm flexors and must relieve pressure on the median nerve while increasing circulation. Furthermore, a person must be retrained in proper hand posture and biomechanical stress reduction to prevent exacerbation of the problem. Medical massage therapy is uniquely positioned to offer this therapy without the side effects of NSAIDS, local injections, or surgery.

He continues..." I am inclined to believe that a thorough and frequent massage of the hand and anterior musculature, the wrist, and the forearm flexors combined with self-massage between treatments and proper use of splints and retraining should bring a variety of solutions directly to bear on the locus of injury. I would suspect that if this approach is going to work, the patient should experience reduction of pain in a few weeks, and clinical restoration of function within a few months. But this approach has yet to be demonstrated in any controlled trial."

One further treatment is that of injecting cortisone directly into the carpal tunnel to reduce the swelling of the tendon covering material, and to give relief from symptoms.  It is said that it serves to aid in diagnosis 

"If you don't get even temporary relief from the injection, it may be a sign that other problems exist that are causing the carpal tunnel symptoms.    There is also a newer way to get cortisone medications down into the carpal tunnel.  Iontophresis is a technique where an electrical current is used to move the molecules of the medication through the skin down into the carpal tunnel.  It is less painful than an injection, but is probably not as effective".

I have read concerns from doctors about the use of acupuncture to treat CTS, those concerns are based on the premise that Acupuncture masks pain without treating the source, thereby actually allowing the condition to deteriorate.  I have no anecdotal or other evidence for this, perhaps some of the readers may care to share their experiences

Surgical Treatment

If all other treatments fail then the last resort is that of surgery. 

Paul Martin states

"Prolonged nerve compression with attendant muscle wasting due to axonal damage and denervation may become irreversable resulting in permanent damage to vital hand muscles. The one positive thing about surgery in these cases is that relief of the compression is immediate and recovery begins within hours of the surgery. But in early stages, or even moderately advanced stages, I would personally try anything other than surgery to reverse the problem, and I am comfortable in suggesting the same to others However, for all these reasons, it is best to have information on all aspects with attendant risks and to make an informed choice, including the risk of any surgical procedure/anesthesia/infection/hospital stay, etc., along with the risk of delay in decompressing the nerve with any non-invasive aproach."

There are two different types that I am aware of, the first is the traditional open incision through the carpal ligament and the second is keyhole surgery using fibreoptic cameras called 'Endoscopic Carpal Tunnel Release'

The basic steps for the traditional open surgery are as follows (Courtesy of Medical Multimedia Group) More information, video and images are available

•  "A small incision, usually less than 2 inches, is made in the palm of the hand. In some severe cases, the incision needs to be extended into the forearm another 1/2 inch or so.
• "After the incision is made through the skin, a structure called the palmar fascia is visible. An incision is made through this material as well, so that the constricting element, the transverse carpal ligament, can be seen.
• "Once the transverse carpal ligament is visible, it is cut with either a scalpel or scissors, while making sure that the median nerve is out of the way and protected.
• "Once the transverse carpal ligament is cut, the pressure is relieved on the median nerve.
• "Finally, the skin incision is sutured. At the end of the procedure, only the skin incision is repaired. The transverse carpal ligament remains open and the gap is slowly filled by scar tissue".

Stitches are normally removed within 2 weeks of surgery and you are advised to avoid any playing or other aggravating action for at least 4 weeks after the procedure.   The Pain and numbness caused by CTS should be immediately relieved after the ligament is released however you will have pain in the area of the incision.  Take your doctor's advice on when and in what manner playing should resume.

Paul

I received the following additional suggestion from Roger Clipsham. Thank you Roger

In relation to your (2002) article on drumdojo.com, there is a useful set of exercises to be found at eatonhand which is also good on the syndrome generally, as well as related problems such as tendonitis - which I also got - mainly from using the mouse although I think drumming has aggravated both.


It also has a link to the Professional Association's site which has a set of information brochures.

I would endorse your advice to seek medical attention - from Doctor or Physiotherapist - they can deal with the problems rapidly effectively

Roger Clipsham

CTS links

Orthodoc site

Surgery encyclopaedia CTS entry

Detailed page discussing CTS and invasive remedial actions

The Carpal Glove - invented by drummer Roger Williams

"...a completely new approach in splinting that has been found clinically effective in relieving symptoms, yet encouraging hand use and mobility. The splint is really an “Orthotic” meaning, to effect a therapeutic change and is named the “Carpal Glove Orthosis”

I am seeking further links on CTS, drop me a line if you can help, thanks  - Paul