Protect the nerve
• Splint wrist in neutral
• Protect areas in decreased sensitivity

Modify activity and educate the patient
• Teach patient about provoking activities and how to modify them
• Teach safe exercises for home exercise program
• Teach patient how to protect areas of decreased sensitivity in the hand

Mobilize restricted joints, connective tissue, and muscle/tendon
• Mobilize carpals if restricted
• Tendon gliding exercises
• Median nerve mobilization exercises

Improve muscle performance
• Gentle multi-angle muscle setting
• Progress to resistance and endurance
• Fine-finger dexterity

Progress functional independence
• Involve patient in all aspects of program
• Self monitoring of symptoms
Pain in the thenar and hypothenar eminences may result from the release and flattening of the palmar arch (pillar pain). Immediately after surgery there is loss of the wrist pulley in the long finger flexor system due to release of the flexor retinaculum. Therefore, time must be allowed for healing to prevent bowstringing of the flexor tendons at the wrist. The wrist may be immobilized 7 to 10 days postoperatively in slight extension with the fingers free to move

Maximum Protection Phase

Usually a bulky dressing or splint is used following surgery. When allowed, remove the protective splinting during therapy.
• Patient education. Educate the patient on expectations for recovery. The impairments of decreased strength in grip and pinch as well as pillar pain should resolve within 3 to 6 months. This is related to the changed length-tension relationship of the thenar muscles due to cutting the transverse carpal ligament. Neurological symptoms should resolve with time, with light touch returning first.
• Wound management, control of edema and pain.
• Active tendon-gliding and nerve-gliding exercises. Tendon-gliding and nerve-gliding exercises are important to prevent adhesion formation from restricting motion in the carpal tunnel. Include forearm supination and elbow extension as nerve symptoms allow.

• Exercises
  • Active finger and thumb flexion/extension, abduction/adduction, and thumb opposition with the wrist stabilized in moderate wrist extension
  • Active wrist extension; this may be combined with passive wrist flexion with the splint removed.
  • Active radial and ulnar deviation of the wrist (with the splint removed and the wrist supported in slight extension), pronation and supination of the forearm, and all shoulder and elbow motions.

Moderate and Minimum Protection Phases
The sutures are usually removed around the 10th to 12th postoperative day, and more active treatment is allowed. The patient should be able to return to full activity by 6 to 12 weeks. Impairments may include residual weakness and sensory deficits, persistent edema, limited motion, hypersensitivity, and pain.
Suggested interventions include:
• Scar tissue mobilization. Use soft tissue mobilization to the palmar fascia and scar.
• Progressive stretching and joint mobilization of restricted tissue. If restricted, lengthen the abductor pollicis brevis and opponens pollicis. Mobilize restricted tendons or nerve tissue (same techniques as described previously except with a stretch force).
• Muscle performance. Begin strengthening exercises 4 weeks after surgery with isometric exercises. Progress to grip and pinch exercises by 6 weeks. Emphasize strength, coordination, and endurance toward functional goals.
• Dexterity exercises. Begin as soon as signs of motor recovery occur. Suggestions include picking up small objects using pad-to-pad, tip-to-tip, and tip-to pad prehension patterns, turning over cards, stacking checkers, writing, and holding the perimeter of a jar lid and having the thumb move around the edge in a circumduction motion.
• Sensory stimulation and discriminative sensory reeducation. Desensitization of hypersensitive skin is a priority. As the nerve recovers, help desensitize and reprogram awareness. These techniques were described earlier in the chapter. Educate the patient about the progression of nerve recovery such that an area that had absence of sensation will have increased sensitivity and pain as it recovers. Symptoms usually subside within 1 to 6 months.

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