Revista de Medicina Desportiva (English) March 2018 - Page 16

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
14 march 2018 www . revdesportiva . pt
vibration. 15 Overuse of the flexor muscles of the forearm is associ- ated with thickening of its synovial sheaths and tenosynovitis, with consequent reduction of intra-tun- nel area. A dose response relation- ship 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 pres- sure 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 motorcy- cling 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 wheel- chair 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 / exten- sion. 20,21 In weightlifting and body- building, 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 ana- bolic steroids may precipitate the pathology. 9,22 Golf swinging requires a forced palmar grip of the club and hyperextension followed by hyper- flexion of the wrist. The impinge- ment often arises at the pronator teres or at the sublimis bridge in the 14 march 2018 www.revdesportiva.pt superficial flexor of the fingers. Therefore, in addition to the symp- toms 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 thickening. 24,25 Treatment – Although surgi- cal intervention is common, con- servative therapy should be initially considered. The use of position- ing orthoses, non-steroidal anti- inflammatory drugs, Venue steroid injection and physical agents (laser, transcutaneous electric neurosen- sory stimulation) are usually thera- peutic 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 decom- pression of MN. 26 Corticosteroid injection is effective in symptomatic relief, although often very tempo- rary. The use of physical agents is described with variable results. 27 Most studies show that surgical decompression of CT is more effec- tive in relieving symptoms compared to corticosteroid injection, improving nerve conduction and electrophysi- ological pattern. 28 After surgery 92% of patients report clinical improve- ment (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 complica- tions 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. 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