Exposed: The Carpal Tunnel Misdiagnosis Epidemic

Carpal Tunnel Rabbithole

You’ve been feeling that burning aching pain in your forearms for a while now and it’s really starting to impact your ability to work or play. You can’t type without feeling it, it bothers you at night, it feels like a knife stabbing into your arm. The internet didn’t have any helpful advice and if you’ve been to the doctor you found that even less useful with the short evaluation and unhelpful advice like “Wear a brace” or my favorite “just stop doing that.”

We are a team of doctors working in the esports industry, treating professional gamers but we’ve helped 1000s of tech workers, artists, and musicians overcome the same issues. A lot of people think we mainly treat carpal tunnel syndrome, but it actually makes up less than 1% of our cases.

With tons of misinformation on the internet and even more misinformed doctors this issue has gotten completely out of hand (BAD PUN).

I’m hoping by the end of this article you understand:

• What carpal tunnel is

• What the difference is between carpal tunnel and tendonitis

• Which issue you are likely dealing with

• The best approach for solving each issue

Quick Note About Anatomy

The muscles and nerves that go through the wrist where people often associate carpal tunnel pain start at the elbow and travel through the wrist all the way to the fingers. So when we discuss symptoms at the wrist we are also talking about the hand and elbow!

The muscles that control the hand start all the way up at the elbow.

The Bad News & Good News about Carpal Tunnel Syndrome

Let me help you understand the bad news and good news about carpal tunnel…but before then what is considered true Carpal Tunnel Syndrome?

Carpal tunnel syndrome happens when the carpal tunnel ligament thickens and compresses the nerves in the carpal tunnel space. This causes numbness, tingling, and pain in the hand, especially in the thumb, index, and middle fingers. Carpal tunnel usually develops after years of repetitive stress.

THE BAD NEWS:

If the entrapment of the median nerve is truly caused by the carpal tunnel ligament, a surgical release of the ligament is often necessary! However…

Distal Median Nerve Entrapment By the Tendons is *MUCH MORE COMMON*

The carpal tunnel contains 9 flexor tendons and the median nerve. When the tendons swell, they compress the nerve.

Tendonitis, on the other hand, is inflammation of the tendons passing through the carpal tunnel. Think of the carpal tunnel like a sandwich with the carpal tunnel ligament above and the tendons below. Swelling of the bottom half of the sandwich in the tendons can mimic carpal tunnel syndrome.

But surgery on the ligament won’t help reduce tendon swelling!

Many doctors don’t thoroughly screen for tendonitis versus carpal tunnel syndrome, leading to unnecessary injections, surgeries, and failed healing. So even if a doctor has diagnosed you with carpal tunnel it may not be accurate unless they did the following tests to see if the carpal tunnel ligament is actually thickened and compressing the nerve, or if the tendons are just irritated and swollen:

• MRI

• Diagnostic Ultrasound

• EMG Testing

• Endurance Testing for your wrist muscles

Tendonitis occurs due to overuse and low endurance. (The capacity of your muscles to perform light contractions over time or repeatedly).

THE GOOD NEWS:

Fixing tendonitis is actually quite simple with some rehab exercises and you can do it successfully from home (it just takes 6-8 weeks). Tendonitis is caused by overuse and low endurance of the tendons. Even if you do a lot of strength training of your arms you can still have low endurance for the same reasons bodybuilders can’t run marathons.

Here are some signs you probably DON’T have carpal tunnel:

• Burning pain, numbness, or tingling in places other than the thumb, index, or middle fingers.

• Pain, numbness, or tingling above the wrist.

• Hand or wrist pain without numbness or tingling.

I’ve seen many cases where people think they have carpal tunnel based on pain alone. To reiterate, if you don’t have numbness, tingling, or burning you likely do not have true carpal tunnel syndrome. Instead the focus should be on the tendons.

Why it’s worth treating the tendons first

Tendons heal. You can effectively reduce the space in that carpal tunnel by reducing the inflammation in your tendons.

If the problem is the tendons and not the carpal tunnel ligament (if you’re under 45 it likely is the tendons), I strongly recommend trying rehab exercises for at least 6 weeks before considering surgery or injections. This was something I had recently worked on with a digital artist who had received carpal tunnel surgery on his right wrist, yet continued to feel pain upon returning to drawing and computer use. He reached out because he started to feel some pain on his left side and didn’t want to pursue the same route.

By understanding the RSI equation, in only 3 weeks he was able to notice some positive changes with his function and significantly reduce his pain with use.

RSI is a Simple Equation

When: Load > Endurance = Inflammation (Pain)

Injuries occur when load exceeds capacity. Endurance training balances the scale.

This simple equation means that when we overload our underprepared tendons it causes microtears, inflammation, and pain. This turns into a vicious cycle of pain and inflammation that can eventually lead to tendon degeneration that requires surgery to fix.

This means there are 2 major ways we can address fixing this equation:

1. Reduce load – When load matches muscle / tendon endurance the tissues are adequately prepared to handle the repetitive strain.

• Reducing load means things like reducing play / work time, changing your ergonomics, peripheral / dpi, bracing, etc.

• This method is often less efficient at eliminating the pain because as soon as you increase the load again the problem comes back.

2. Increase Endurance – when endurance equals or is greater than load your tissues are prepared to handle the repetitive strain.

• Increasing the endurance of your tendon / muscles will allow you to perform more actions per minute without fatiguing your tendons which causes microtears and inflammation.

• This method is more effective at solving RSI issues because you are training the muscles to handle much higher volumes of actions per minute and can accommodate to almost any load (people train to climb mountains and run marathons, you can train to type at a computer for 8 hours a day).

Most Doctors Don’t Take The Time To Properly Diagnose You

If any of you have been to the doctor recently you probably know they talked to you for a few minutes and recommended that you get an injection, take some anti-inflammatories or wear a brace and stop using the hand.

Not only are these methods useless at worst and bandaid fixes at best, they don’t address the underlying endurance issue that is causing the overuse / under-preparation injury in the first place.

Carpal Tunnel? Not the Usual Culprit!

Many people jump to carpal tunnel syndrome (CTS) for any wrist pain. But surprise! True CTS is actually pretty rare, making up less than 1% of RSI (repetitive strain injury) cases.

The real culprit for most wrist pain is likely tendonitis. Tendons are the hardworking heroes that connect your muscles to bones. When you overuse them, they get inflamed and irritated, leading to that burning / aching pain.

How to Spot the Difference:

• Carpal Tunnel: This one focuses on your thumb, middle, and index finger. Expect numbness and tingling, like your fingers fell asleep on the keyboard.

• Tendinopathy: More of a general pain / achiness / stiffness in your wrist or hand. You might feel burning, aching, or stiffness anywhere in the area of your hand, wrist, or even forearm all the way up to the elbow.

Tendinopathy Spectrum Disorders

The management of tendon pain has shifted toward the "tendinopathy" framework. Proposed by Cook and Purdam, the Tendon Continuum suggests that tendon pathology is not a binary state but a spectrum. Tendons can move back and forth along this continuum based on the loads placed upon them.

The Three Stages of Tendinopathy

Reactive Tendinopathy

A non-inflammatory proliferative response in the cell matrix caused by acute tensile or compressive overload. Cells thicken the tendon to reduce stress.

This stage is relatively short-term and has the potential to revert back to a normal tendon if the load is reduced.

Tendon Disrepair

Occurs if the tendon is not offloaded. Results in collagen separation and matrix disorganization. Increased vascularity and neural ingrowth may be present.

Visible on MRI and ultrasound. It is an attempt at healing that has become more physiologically complex and difficult to diagnose without imaging.

Degenerative Tendinopathy

The final stage is characterized by cell death, tenocyte exhaustion, and large areas of matrix disorganization.

Clinically presents in chronic cases or older individuals with ongoing overload.

Load Management and Reversibility

The hallmark of the continuum model is its dynamic nature. By adding or removing load, clinicians and patients can influence the tendon's progression:

• Early Intervention: In the Reactive and Disrepair phases, reducing load allows the tendon the opportunity to return to a previous, healthier stage on the continuum.

• Adaptation: The "Reactive" phase is actually a functional adaptation intended to increase stiffness and reduce stress, but it requires appropriate recovery time to prevent progression to disrepair.

• The "Donut" Philosophy Connection: In the Degenerative stage, the tendon often contains "islands" of degeneration scattered among healthy sections. This supports the treatment philosophy of "treating the donut, not the hole"—focusing on strengthening the healthy, viable sections of the tendon (the donut) rather than trying to reverse the necrotic or dead areas (the hole).

The "Treat the Donut, Not the Hole" philosophy is a paradigm shift in the management of chronic tendinopathy and repetitive strain injuries (RSI). Traditional medical models often focus on the "hole", the area of tissue degeneration seen on imaging, leading to unsuccessful treatments like complete rest or passive modalities. Modern evidence suggests that by focusing on the "donut", the healthy surrounding tissue, we can build sufficient capacity to restore 100% function, regardless of the structural appearance of the tendon core.

What happens if you don’t deal with this?

What will happen if you only focus on the symptoms… instead of the actual cause of your injury?

The longer you have inflammation in your tendons the more likely they are to break down and become degenerate. Once tendons become degenerate they may thicken, reducing the overall amount of space in the carpal tunnel. This increases the likelihood that the carpal tunnel ligament will irritate the nerve and surgery becomes a more necessary solution.

Surgery can easily be prevented by increasing the tendon endurance to deal with the inflammation while the tendons are still in the reactive stage.

You Don’t Have to Suffer! Here’s the best part: Unlike CTS, tendonitis doesn’t require surgery or scary injections. There’s a non-invasive, safe and effective method called Tendon Neuroplastic Training to help you heal.

Tendon Neuroplastic Training: Retraining Your Brain to Heal Your Wrist with Exercise

Tendon Neuroplastic Training retrains your brain to recruit more muscle fibers, reducing strain on the tendons.

How it works: according to the latest tendon research, the motor cortex of the brain is responsible for controlling the muscle fibers that you use to control your fingers. This research shows when you use a metronome to retrain your brain to control your muscles more efficiently.

This normalizes stress on your tendons by recruiting more muscle fibers (Think about 100 ropes pulling a weight vs 50 ropes) allowing the strained tendon fibers to heal. As physical therapists who work with pro gamers and high performing software engineers we swear by it, and we usually see a 95% success rate in just 3 months of treatment.

How do I Incorporate This Into My Routine? 

Our programs at 1HP utilize these principles of tendon neuroplastic training to give you the most optimized rehab and recovery routine. We have built this program to take you through the diagnostic process and give you the most specific routine for your pain pattern for either carpal tunnel or tendonitis. Check out the information below for more info! 

I’m Elliot, and I've helped many people like you.

I’m a Physical Therapist who has been worked professionally with desk workers, musicians, artists and gamers for the past 10+ years. 

I realized what a huge problem repetitive strain injuries were when I was working with musicians at Marshall University and I took that experience with me into the esports industry here in Los Angeles. 

I never understood why there was such a disconnect from the mainstream medical systems for people suffering from this easily treatable condition. 

This is why my team built the 1HP Power Leveling Program, which aims to help people learn how they can get back to 100% without surgery, injections or medication. Our passion is to help people learn that there are doctors that understand them and they don’t have to stop doing what they love. They don’t need surgery and that they can actually fix their wrist pain right in the comfort of their own home if they just follow our simple frameworks and personalized programs.

If wrist, hand, or arm pain is holding you back, book a free 60-minute consultation with our team. We'll review your pain history and tell you whether our coaching program is the right fit to get you back to full activity.

1. Cook JL, Rio E, Purdam CR, Docking SI. Revisiting the continuum model of tendon pathology: what is its merit in clinical practice and research? British Journal of Sports Medicine. 2016;50:1187-91.

2. Cook JL, Purdam CR. Is tendon pathology a continuum? A pathology model to explain the clinical presentation of load-induced tendinopathy. British Journal of Sports Medicine 2009;43:409–416

3. Rio E, Kidgell D, Moseley GL, et al. Tendon neuroplastic training: changing the way we think about tendon rehabilitation: a narrative review. British Journal of Sports Medicine 2016;50:209-215.

   
   Medical Disclaimer: The information provided in this article is for educational purposes only and is not intended as a substitute for professional medical advice, diagnosis, or treatment. Always seek the advice of your physician or other qualified health provider with any questions you may have regarding a medical condition.