vibration . 15 Overuse of the flexor muscles of the forearm is associated with thickening of its synovial sheaths and tenosynovitis , with consequent reduction of intra-tunnel area . A dose response relationship is described , which correlates the duration and frequency of wrist flexion / extension movements with the degree of nerve dysfunction . The pressure within the CT increases by 8-10 times when movements of hyperflexion or hyperextension of the wrist are performed . 14 The limit for the compromise of axonal transmission is an intracanal pressure of 30mmHg . Between the 30-40 mmHg paresthesia begins . Axonal blockade occurs at 50 mmHg . At 60 mmHg complete neural ischemia could occurs , with consequent sensory and motor blockade . 19 It is important to know the athlete ’ s history , namely bone fractures of the distal portion of the upper limb that required surgical treatment and prolonged immobilization . The appearance of osteoarthritis after resolution of a radial fracture is a risk factor for the development of CTS . 10 CTS is not a frequent sports injury . However , in sports such as archery , wheelchair basketball , golf , weightlifting , cycling and motorcycling CTS are increasingly referred . In archery it is suggested that finger flexion and repeated fisting promote compression of the digital nerves in the distal portion of RF . 10 In wheelchair basketball 30 % of elite players have CTS symptoms , with 70 % of positive electrophysiological studies . Both technical gesture and repeated movements made to mobilize the chair involve forced palmar grip and frequent wrist flexion / extension . 20 , 21 In weightlifting and bodybuilding , forced wrist postures and weight lifting , may compromise the regional anatomy . The intensity and frequency of the developed force defines the synovial thickening and muscular hypertrophy of the CT region . Intake of anabolic agents , such as growth hormone or anabolic steroids may precipitate the pathology . 9 , 22 Golf swinging requires a forced palmar grip of the club and hyperextension followed by hyperflexion of the wrist . The impingement often arises at the pronator teres or at the sublimis bridge in the superficial flexor of the fingers . Therefore , in addition to the symptoms of CTS , there is often a change in sensitivity in the region enervated by the palmar cutaneous nerve . 23 Other sports such as cycling and motorcycling , may also compromise the MN path . Venue compression on the steering wheel , hyperextension and vibratory movements in the palmar region of the hand are also risk factors for tenosynovitis and FR
24 , 25
thickening . Treatment – Although surgical intervention is common , conservative therapy should be initially considered . The use of positioning orthoses , non-steroidal antiinflammatory drugs , Venue steroid injection and physical agents ( laser , transcutaneous electric neurosensory stimulation ) are usually therapeutic options to be consider . The use of vitamin supplements ( B6 , B12 ) the use of vitamin supplements did not demonstrate clinical evidence . The use of positioning orthoses is often used in clinical practice . The aim is to place the wrist in a neutral position , with consequent decrease in intracanal pressure and decompression of MN . 26 Corticosteroid injection is effective in symptomatic relief , although often very temporary . The use of physical agents is described with variable results . 27 Most studies show that surgical decompression of CT is more effective in relieving symptoms compared to corticosteroid injection , improving nerve conduction and electrophysiological pattern . 28 After surgery 92 % of patients report clinical improvement ( about paresthesia and dysesthesias ), 82 % refer a decreased of pain and 42 % improved muscle strength at the intrinsic muscles of the hand . Complications and the need for re-intervention are reduced and reported between 2.6 and 6 %, variable with the type of technique . 29 Currently two surgical techniques are most commonly used . The classical technique or endoscopic approach . The latter has a shorter recovery period , less postoperative pain and surgical wound complications are reduced . However , the poor visibility of structures may result in incomplete retinaculotomie , usually at the distal level , and an increased risk of injury in vascular and nerve structures . It is suggested that the option should be based particularly on the experience of the surgeon and also in the patient ’ s choice . 30 After surgical intervention the rehabilitation program is mandatory and will allow a gradual recovery of the sport activity . It is important to adapt the training requirements and to promote a close dialogue between athlete and medical team . The right moment for a save return to sports activity after surgical intervention is not well defined . 33 It is suggested an average of 6 to 8 weeks for returning and 12 weeks for competition . Athlete should not present any symptoms and the muscular strength of the upper limb must be completely recovered . The onset of pain and / or inflammatory signs requires regression of load training and medical reassessment . Psychological factors should be taken into account according the needs for a save returning to sports . Evidence shows that rehabilitation facilitates a faster and safer recovery of exercise .
The authors declare no conflicts of interest .
Contact : João L Pinheiro jpascoapinheiro @ gmail . com
References
1 . Paget J . ( 1854 ). Lectures on surgical pathology . Philadelphia : Lindsay and Blakiston .
2 . Omer GE . Median nerve compression at the wrist . Hand Clin . 1992 ; 8 ( 2 ): 317-324 .
3 . Krom MC , Knipschild PG , Kester D , Thijs CT , Boekkooi PF , Spaans F . Carpal tunnel syndrome : prevalence in the general population . Journal of Clinical Epidemiology . 1992 ; 45 ( 4 ): 373-376 .
4 . Seddon HJ . A Classification of nerve injuries . Br Med J . 1942 ; 2 ( 4260 ): 237-239 .
5 . Sunderland . A classification of peripheral nerve injuries producing loss of function . Brain . 1951 ; 74 ( 4 ): 491-516 .
6 . Padua L , Coraci D , Erra C , Pazzaglia C , Paolasso I , Loreti C , Hobson-Webb LD . Carpal tunnel syndrome : clinical features , diagnosis , and management . The Lancet Neurology . 2016 ; 15 ( 12 ): 1273-1284 .
7 . Dada S , Burger MC , Massij F , Wet H , Collins M . Carpal tunnel syndrome : The role of collagen gene variants . Gene . 2016 ; 587 ( 1 ): 53-58 .
8 . Osterman M , Ilyas AM , Matzon JL . Carpal tunnel syndrome in pregnancy . The Orthopedic Clinics of North America . 2012 ; 43 ( 4 ): 515-520 .
9 . Caliandro P , Padua L , Aprile I , Conti V , Pazzaglia C , Pavone A , Tonali P . Adverse
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