Written by Edo Zylstra PT, DPT, re-released from previous publication.

After years of practice, I have treated numerous patients with the “diagnosis” of Carpal Tunnel Syndrome (CTS). Many of them even had positive nerve conduction findings and EMG’s.

As physical therapists, we have all seen these patients. They come in a combination of observable issues including:  forward head posture, internally rotated humerus, forward shoulder positioning, kyphotic T-spine, etc.

If you reverse the compensatory positioning of the above, they likely will be miserable with an increase in symptoms. (This is without treatment of the causes of their compensation.)

Common findings in your assessment?

• Positive upper limb neural provocation testing
• 1^st and 2^nd rib dysfunction (elevated or depressed with movement restriction)
• Sternoclavicular joint dysfunction, likely restricted in arthrokinematic mobility and orthokinematic control
• Dysfunction (weakness, tightness, poor control) in the following muscles: cervical extensors (particularly from C3-C7), pectoralis major (clavicular head), pectoralis minor, rhomboids, serratus anterior, trapezius, subclavius, pronator teres, sternocleidomastoid, scalenes…. (Ask them if they get headaches and if their head is ever too heavy for their neck or if they feel like they have to hold it up after sitting at their desk for a while.)

These muscles aren’t just tight and symptomatic, but are likely very weak, which is likely the main contributor to their tightness.

This all leads to a double/triple/quadruple crush issue of their upper extremity nerves and vasculature.

So, what do we do to treat this? Of course, we will likely use Intramuscular Stimulation (Functional Dry Needling) to treat the muscles we find involved, but that is just the beginning.

If we do a great job resetting the muscle function and symptoms, we have to do a good job reinforcing that change (more below).

Manually, I’d want to address the rib and thoracic issues. Personally (I know this goes against much of our common views), I treat the DEPRESSED first rib and elevated 2^nd rib on the most symptomatic side. I will post another clinical pearl on the T-spine and ribs in the future.

Correctives are likely the most important aspect with successful treatment of this common problem. Let’s be honest — we often don’t do well here.

The obvious correctives are strengthening the posterior musculature but I would challenge you to think a bit differently. If you give someone more range of motion, give them correctives to control that new range. This is likely why these patients fail rehab. You will need to do both neuro-reeducation and specific strengthening of the muscles, but please integrate it into a functional pattern as that will address so much more of the dysfunction and have greater carry over. I have very simple principles I use in determining my corrective plan of care.  Yes, that will be an upcoming article as well.