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Why is Carpal Tunnel Syndrome Associated with Hypothyroidism?

Written by Kieran Macphail on . Posted in Uncategorized

Carpal tunnel syndrome (CTS) is a result of compression of the median nerve and has a 10% lifetime risk with known occupational associations (Olney 2001). Hypothyroidism is an accepted risk factor for CTS (Solomon 1998). However, what is the mechanism for this? Does the hypothyroidism cause the carpal tunnel symptoms? Or do both conditions share a similar potential aetiology?

Palumbo et al (2000) state that no study clearly defines the nature of the association between hypothyroidism and CTS. In their study Palumbo et al (2000) compared 26 patients (45 hands) with a diagnosis of primary hypothyroidism and CTS. 24 healthy controls (47 hands) were used.  They tested sensation, muscle atrophy and weakness, Phalen’s, Tinel’s test and manual compression tests and conducted electrodiagnostic tests on the median nerve.  In the control group only clinical tests produced two false positives. In the test subjects 19 patients (31 hands) had CTS symptoms, 16 (25 hands) patients had clinical signs and only 6 patients (7 hands) had electodiagnostic changes. All these patients were biochemically euthyroid, normal function following thyroid treatment. In these patients CTS symptoms and a positive physical examination are more common than expected by the reported sensitivity of electrodiagnostic testing.

Other studies suggest a mechanism for musculoskeletal pain in other areas of the body. Interestingly Schwartz et al (1983) discuss the frequency of the tarsal tunnel syndrome in hypothyroid patients. Although not as frequent the frequency suggests a similar mechanism driving the incidence of both conditions. Similarly, Golding (1970) discusses 9 case histories of hypothyroid patients with complex pain patterns in a combination of the back and, or the upper and, or lower limbs. Notably in one case the pain relieving medication phenylbutazone aggravated symptoms which was attributed to it’s anti-thyroid effect. This weakly suggests that hypothyroidism may be the cause of these distal symptoms.

Furthermore, 75% of hypothyroid patients have a delayed ankle jerk and indicating pseudo-myotonia is common in many of these patients. In addition muscle aches are commonly accepted symptoms of hypothyroidism (Golding 1970). This defect in the reflex arc is not due to the neural components but is thought to be due to defects in contractile mechanism it’s self (Lambert et al 1951).

These musculoskeletal symptoms may all potentially be explained by one common mechanism, the effects of untreated hypothyroidism, myxedema. Myxedema produces a cutaneous and dermal odema caused by excess deposition of glycosaminoglycans, hyalauronic acid and some mucopolyssacharides in subcutaneous tissues (Mansourian 2010). CTS was commonly attributed to deposition of pseudo mucinous substances on the median nerve sheath (Golding 1970). This process is described similarly to that of myxedema.

It may be that this deposition alters the contractile properties of muscles leading to the delayed ankle jerk reflex. The deposition on the median nerves would reduce carpal tunnel space and when more severe could lead to lesions capable of effecting the conductivity of the nerve. However, initially it’s feasible it would not significantly alter the conductivity of the nerve but in functional tasks and mechanical tests the nerve has insufficient space in the carpal tunnel and signs are present. Therefore explaining results of Palumbo et al (2000).

Clinically it’s important to consider the effects of untreated hypothyroidism in patients with neural and musculoskeletal symptoms. This should form part of the thought process for patients with diagnosed and undiagnosed hypothyroidism. Clinicians should familiarise themselves with common symptoms of hypothyroidism to help them screen for potential hypothyroidism contributing to musculoskeletal symptoms.

As always if you have any questions feel free to email me at kieran@kieranmacphail.com or comment below to discuss anything!

References

Golding, D.N., 1970. Hypothyroidism presenting with musculoskeletal symptomsAnn. rheum. Disease, 29, 10.

Lambert, E.H., Underdahl, L.O., Beckett, S. and Mederos, L.0., 1951. A study of the ankle jerk in myxedema. Journal clinical endocrinology, 11, 1186.

Mansourian, A.R., 2010. A review on post puberty hypothyroidism: A glance at myxedema. Pakistan journal of biological sciences, 13 (8), 866-878.

Olney, R.K., 2001. Carpal tunnel syndrome. Neurology, 56 (11), 1431-1432.

Palumbo, C.F., Szabo, R.M. and Olmsted, S.L., 2000. The effects of hypothyroidism and thyroid replacement on the development of carpal tunnel syndromeJournal of Hand Surgery, 25 (4), 734-739.

Schwartz, M.S.  Mackworth-Young, C.G. and McKeran, R.O., 1983. The tarsal tunnel syndrome in hypothyroidism. Journal of Neurology, Neurosurgery, and Psychiatry, 46, 440-442

Solomon, D.H., Katz, J.N., Bohn, R., Mogun, H. and Avorn, J., 1999. Nonoccupational Risk Factors for Carpal Tunnel Syndrome. Journal of General Internal Medicine, 14 (5), 310–314.

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Comments (12)

    • Kieran Macphail

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      Thanks Tom. It’s just my analysis and undoubtedly there’s more to it.

      Reply

  • Chris

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    Wow. I was diagnosed with hypothyroidism about a month ago after my carpal tunnel like symptoms had been progressing for over two years. Never imagined there could be a connection since I am a software developer and had that occupational risk. Wish my doctor had made the connection two years ago when my high TSH levels were considered something to worry about down the road.

    Reply

    • Kieran Macphail

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      Often these factors impact each other. Having the occupational risk factors may decrease space in the carpal tunnel meaning the effects of the uncontrolled hyperthyroidism may produce symptoms quicker. Having your thyroid correctly managed is essential. The key being to measure what the dysfunction is in the thyroid, as the term “hypo”thyroid does not give any indication as to what specifically is dysfunctional.

      Reply

  • Jenn

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    I have been in such pain with my left wrist for over three years, and for the past year my right wrist is throbbing. Unable to brush teeth, hair, bathe without pain.
    Washing dishes is arduous, and basic chores are difficult. I am hypothyroid and have been on Bio identical meds for the past 8 years along with menopause for the past six years. Level’s are spot on. after years of adjusting chemicals. So, I do not know where to turn. I have tried yoga and the pain it send through me is really tough.

    Thanks for the article you posted….this is the first time I am online talking about this.

    Reply

    • Kieran Macphail

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      Hi Jenn,
      It is a really difficult condition to manage. You have already done a lot of the right things in my opinion. Bio-identical hormones are the optimum choice based on the reading I’ve done and patient’s usually have better outcomes when using them in my experience. Obviously they are doing the job as your hormone levels are “spot on”.
      The question then is why have you still got the pain?
      Although, in this article I’m talking about the connection between hypothyroidism and carpal tunnel you may have a mechanical carpal tunnel?
      The keys being,
      1. Ensure you have an excellent consultant overseeing your case.
      2. Have your cervical spine and upper limbs cleared for any possible cause. I see this far to often in people that have had bilateral carpal tunnel surgeries.
      3. Clean up your diet. Switch a more anti-inflammatory diet, organic foods where possible and adjust the ratios of foods to suit your genetic and environmental needs.
      4. Consider nerve conduction tests. These probably would have been done if you have an 8 year history and you should be guided hear by your excellent consultant.
      5. Get a specialist hand therapist assessment
      6. Consider consulting a nutritional therapist
      7. If no cause can be established then pain management under a pain specialist and a nutritional therapist is the way forward. This can be as simple as learning to breathe diaphragmatically and doing some regular relaxation. It may also involve appropriate medication from a pain specialist. These symptoms can respond well to medication that targets the nervous tissue in some case where anti-inflammatoriess have little effect.

      These are my thoughts and hopefully they may give you a little direction.
      Don’t give up! There is a reason you are getting the pain, once that is established it will be much easier to manage your symptoms.

      Reply

      • Jenn

        |

        I am very much appreciative of your detailed input for my problem. How wonderful that you are the professional that you are. I will take your advise and go forth. It is not a mechanical carpel symptom, it is hypothyroidism. And I have changed my diet, to see how that goes. But, alas all the research at my finger tips has me more confused and disappointed. I have Hashimoto’s, from the hypothyroidism, and was a celiac infant! I have looked into the Paleo diet, and the autoimmune Paleao diet…..I have come to the conclusion that my life as a foodie ~ my life is over!
        Combing the two diets, I am starving….I am miserable, and I am hungry.

        Reply

    • Kieran Macphail

      |

      Hi Jenn,
      It is a really difficult condition to manage. You have already done a lot of the right things in my opinion. Bio-identical hormones are the optimum choice based on the reading I’ve done and patient’s usually have better outcomes when using them in my experience. Obviously they are doing the job as your hormone levels are “spot on”.
      The question then is why have you still got the pain?
      Although, in this article I’m talking about the connection between hypothyroidism and carpal tunnel you may have a mechanical carpal tunnel?
      The keys being,
      1. Ensure you have an excellent consultant overseeing your case.
      2. Have your cervical spine and upper limbs cleared for any possible cause. I see this far to often in people that have had bilateral carpal tunnel surgeries.
      3. Clean up your diet. Switch a more anti-inflammatory diet, organic foods where possible and adjust the ratios of foods to suit your genetic and environmental needs.
      4. Consider nerve conduction tests. These probably would have been done if you have an 8 year history and you should be guided hear by your excellent consultant.
      5. Get a specialist hand therapist assessment
      6. Consider consulting a nutritional therapist
      7. If no cause can be established then pain management under a pain specialist and a nutritional therapist is the way forward. This can be as simple as learning to breathe diaphragmatically and doing some regular relaxation. It may also involve appropriate medication from a pain specialist. These symptoms can respond well to medication that targets the nervous tissue in some case where anti-inflammatories have little effect.

      These are my thoughts and hopefully they may give you a little direction.
      Don’t give up! There is a reason you are getting the pain, once that is established it will be much easier to manage your symptoms.

      Reply

  • Katie

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    I’m a PT student, and this was helpful for a case study. I just read your background…wow! I’m so jealous! It was definitely some inspiration for my upcoming exams. Thank you!

    Reply

  • Caroline

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    I have just come across this website and it all sounds so familiar to me. I have been treated with thyroxine for hashimotos thyroiditis for many years and suspect it may have been responsible for me having 3 miscarriages when untreated. I am now in the menopause and have been suffering with back pain, numbness, pain and tingling in my fingers( now confirmed by nerve conduction tests as being carpel tunnel syndrome). I have tried to persuade my gp to increase my thyroxine, but as my levels are within the labs reference ranges(but not those recommended by Nice) he is very reluctant to do this. I understand that he is concerned regarding litigation for prescribing outside the guidelines, however this does not adress my current health problems. I do not want to face surgery and years of painkillers if an increase in thyroxine may improve my health. I currently take 75mcg of thyroxine and my TSH is 5.2 and serum T4 is 17.9. I have also experienced tenderness to the side of my knees and thought I may have fibromyalgia. I am considering showing my gp this article in the hope that he may reconsider and increase my thyroxine. Thanks for the information.

    Reply

    • Kieran Macphail

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      I’m really sorry to hear that.
      Let me know if you want to be put in touch with an excellent London based endocrinologist or if you would like to arrange some private testing that goes in to more depth than is done on the NHS.
      Best wishes

      Reply

  • mary

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    I am currently havin test on my thyroid but didn’t realise until a read this site that the pins and needles in my left elbow would have anything to do with your thyroid

    Reply

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