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R E S E A R C H A R T I C L E Open Access
Changes in carpal tunnel compliance with
incremental flexor retinaculum release
Rubina Ratnaparkhi, Kaihua Xiu, Xin Guo and Zong-Ming Li
*
Abstract
Background: Flexor retinaculum transection is a routine surgical treatment for carpal tunnel syndrome, yet
the biomechanical and clinical sequelae of the procedure remain unclear. We investigated the effects of flexor
retinaculum release on carpal tunnel structural compliance using cadaveric hands.
Methods: The flexor retinaculum was incrementally and sequentially released with transections of 25, 50, 75,
and 100 % of the transverse carpal ligament, followed by the distal aponeurosis and then the antebrachial fascia.
Paired outward 10 N forces were applied to the insertion sites of the transverse carpal ligament at the distal
(hamate-trapezium) and proximal (pisiform-scaphoid) levels of the carpal tunnel. Carpal tunnel compliance was
defined as the change in carpal arch width normalized to the constant 10 N force.
Results: With the flexor retinaculum intact, carpal tunnel compliance at the proximal level, 0.696 ± 0.128 mm/N,
was 13.6 times greater than that at the distal level, 0.056 ± 0.020 mm/N. Complete release of the transverse carpal
ligament was required to achieve a significant gain in compliance at the distal level (p< 0.05). Subsequent release
of the distal aponeurosis resulted in an appreciable additional increase in compliance (43.0 %, p= 0.052) at the
distal level, but a minimal increase (1.7 %, p= 0.987) at the proximal level. Complete flexor retinaculum release
provided a significant gain in compliance relative to transverse carpal ligament release alone at both proximal and
distal levels (p< 0.05).
Conclusions: Overall, complete flexor retinaculum release increased proximal compliance by 52 % and distal
compliance by 332 %. The increase in carpal tunnel compliance with complete flexor retinaculum release helps
explain the benefit of carpal tunnel release surgery for patients with carpal tunnel syndrome.
Keywords: Carpal tunnel release, Transverse carpal ligament, Distal aponeurosis, Antebrachial fascia, Compliance
Background
The flexor retinaculum (FR) consists of three continuous
but distinct segments from the proximal to distal: the
antebrachial fascia (AF), transverse carpal ligament
(TCL), and distal aponeurosis (DA) [1, 2]. The AF is a
membranous tissue that provides distal reinforcement of
the volar antebrachial fascia [3]. The TCL is a dense
transverse fibrous lamina defined by its attachments to
the pisiform and the hook of the hamate medially and
the tubercles of the scaphoid and the trapezium laterally.
The DA is a fibrous septum between the bases of the
thenar and hypothenar muscles [3].
Carpal tunnel release represents the gold-standard
surgical treatment for carpal tunnel syndrome, a painful
entrapment neuropathy caused by compression of the
median nerve within the carpal tunnel. Historically, the
terms FR and TCL have both been used in reference to
the ligamentous structure transected in carpal tunnel re-
lease surgery. However, most commonly, it is primarily
the TCL that is released, with varying extents of the AF
and DA transection, depending on the surgical tech-
nique, the surgeon’s preference, and the wrist involved
[2]. Surgical release decompresses the median nerve by
increasing the tunnel size and reducing tunnel pressure
[4]. Although surgical treatment is considered effective
in relieving symptoms in a majority of carpal tunnel syn-
drome cases, post-operative complications and symptom
* Correspondence: liz4@ccf.org
Hand Research Laboratory, Departments of Biomedical Engineering,
Orthopaedic Surgery, and Physical Medicine and Rehabilitation, Cleveland
Clinic, 9500 Euclid Avenue, Cleveland 44195 OH, USA
© 2016 Ratnaparkhi et al. Open Access This article is distributed under the terms of the Creative Commons Attribution 4.0
International License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and
reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to
the Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver
(http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated.
Ratnaparkhi et al. Journal of Orthopaedic Surgery and Research (2016) 11:43
DOI 10.1186/s13018-016-0380-3
Content courtesy of Springer Nature, terms of use apply. Rights reserved.
recurrence are reported in 25 % or more cases [5–7]. In-
complete FR release has been considered a causative
mechanism for new, persistent, or recurrent symptoms
that may require later revision surgery to improve
inadequate median nerve decompression stemming
from residual focal mechanical restraints [4, 8]. How-
ever, the FR plays an important role in carpal tunnel
mechanics, and carpal tunnel release unavoidably
affects the structural integrity and flexibility of the
carpal tunnel [9]. There is lingering debate about
whether transection of all three FR segments is re-
quired to adequately release the median nerve, given
the potential for undesirable complications with either
incomplete or excessive FR release.
Previous research has examined the morphological
changes associated with FR release as a means of under-
standing the procedure’s effects on the structural integ-
rity and flexibility of the carpal arch. In vivo and in vitro
studies have demonstrated that carpal tunnel release
leads to increases in carpal tunnel volume and in the
cross-sectional and carpal arch areas [10–14]. In con-
trast, the effect of FR release on carpal arch width re-
mains inconclusive, as both an increase and no change
in carpal arch width have been reported in previous
studies evaluating FR release depending on the hand po-
sitioning and imaging modality used [10, 11, 15]. In vitro
studies completed under well-controlled experimental
conditions have shown that carpal tunnel release drastic-
ally affects the biomechanical properties of the carpal
tunnel [13, 16, 17]. For example, Tengrootenhuysen
et al. [17], who applied constant loads to the carpal
tunnel, demonstrated that the carpal arch was in-
creasingly extensible with incremental release of the
TCL. Xiu et al. [16] showed that complete TCL re-
lease led to a location-dependent increase in carpal
arch compliance, with a greater relative increase in
compliance at the distal than at the proximal carpal
tunnel. Kim et al. [14] reported that complete TCL
release caused a ninefold increase in the compliance
of the carpal arch, as quantified by the pressure-area
relationship. However, it remains unclear how differ-
ent degrees of FR release, including both intermedi-
ate transection of increasing percentages of the TCL
and complete transections of the DA and AF, alter
the compliance of the carpal arch at both the prox-
imal and distal levels.
The purpose of this study was to investigate the effect
of incremental FR release on the structural mechanics of
the carpal tunnel, focusing on the compliance related to
carpal arch width at multiple locations in the carpal tun-
nel. We hypothesized that carpal tunnel compliance
would progressively increase with incremental FR release
and that the impact of FR release would differ between
the proximal and distal levels.
Methods
Specimens and preparation
Nine fresh frozen cadaver hands (five men and four
women; mean age, 50 ± 11 years) were used in this study.
The cadaveric hands were obtained from Anatomy Gifts
Registry (Hanover, MD), and the experimental use of the
cadaveric specimens was approved by Cleveland Clinic
Institutional Review Board. All specimens were screened
by review of medical records and by X-ray examinations
to exclude any specimens with musculoskeletal disor-
ders, traumatic injuries, or arthritic changes in the hands
or wrists. The specimens were thawed overnight at room
temperature. Dissection was then performed to expose
the FR by removing the skin and palmar fascia. The
three portions (AF, TCL, and DA) of the FR were identi-
fied. Then, cortical screws (Synthes, Inc., West Chester,
PA), 2.0 mm in diameter, were drilled into the hamate,
trapezium, pisiform, and scaphoid at the sites of TCL in-
sertion until the screw head was flush with the bony sur-
face (Fig. 1). A thin wire was attached to each screw
head to assist in force application.
Apparatus design and specimen alignment
A custom apparatus was developed in our laboratory to
affix each hand specimen and apply the prescribed force
[16]. The apparatus included a platform with a wedge-
shaped plywood block to stabilize the specimen, with ad-
justable pulley systems for aligning applied forces. The
wrist of each specimen was positioned in a 20° extension
by aligning the dorsal side of the hand specimen with
the surface of the wedge-shaped plywood block on the
platform. The specimen was then affixed by drilling a
screw through the middle shaft of the third metacarpal
Fig. 1 Lateral X-ray image showing intra-experimental cortical screw
insertion onto the carpal bones of a cadaver hand. These screws
served as the points of application of the paired outward loading
forces (10 N) at the proximal and distal levels of the carpal tunnel
Ratnaparkhi et al. Journal of Orthopaedic Surgery and Research (2016) 11:43 Page 2 of 7
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into the block. Velcro strips were used to strap the
forearm to the base block for further stabilization. A
T-slotted track with two sliders was configured at each of
the two parallel edges of the platform along the proximal-
distal direction of the hand. Each slider was attached to a
pulley, which was adjustable in both horizontal and verti-
cal directions for force alignment.
Experimental procedures
Two pairs of 10 N forces were applied to the bones in the
outward direction via the screw and wire system. One
force pair was aligned along the line connecting the ham-
ate and trapezium at the distal level of the carpal tunnel,
and the other was aligned along the line connecting the
pisiform and scaphoid at the proximal level (Fig. 2).
The coordinates of the center of each screw head sur-
face were digitized using a MicroScribe 3D digitizer
(Immersion Corp., San Jose, CA) during unloaded and
loaded conditions with the FR intact and at each step of
FR release. The FR was incrementally released in the
following steps: (1) 25 % TCL, (2) 50 % TCL, (3) 75 %
TCL, (4) 100 % TCL, (5) 100 % TCL + DA, and (6)
100 % TCL + DA + AF (i.e., complete release of the FR).
Incremental FR release started from the center of the
TCL, progressed symmetrically to the distal and prox-
imal edge of the TCL, and then the DA and AF were se-
quentially transected (Fig. 3). After each release step,
there was a 1-min unloading period to allow the carpal
tunnel structure to recover and stabilize.
Data analysis
Carpal tunnel compliance was used to quantify struc-
tural flexibility and was calculated as the ratio of the
load-induced change in carpal arch width to the applied
load (i.e., a constant 10 N at each level). Compliance was
individually defined for the distal and proximal tunnel
for each of the intact and released conditions. Digitized
coordinates from the bony landmarks were used to
calculate carpal arch width at the distal tunnel between
the hamate and trapezium and at the proximal tunnel
between the pisiform and scaphoid. Carpal tunnel com-
pliance was defined as (W−W
0
)/Load, where Wis the
distal or proximal carpal arch width under loading, and
W
0
is the initial distal or proximal carpal arch width
without loading. Two-way repeated-measures ANOVA
(6 × 2) was performed to investigate the effects of the FR
release steps and carpal tunnel levels on the carpal
tunnel compliance. Post hoc Tukey’s tests were used for
pairwise comparisons. All statistical analyses were
performed using SigmaStat 3.4 (Systat Software, Inc.,
San Jose, CA), and results were considered significant
for pvalues <0.05.
Results
With an intact FR, carpal tunnel compliance was 0.056±
0.020 mm/N at the distal level and 0.696 ± 0.128 mm/N at
the proximal level. There was no significant change in
compliance observed with 25 % TCL transection at either
the distal or proximal carpal tunnel (Fig. 4). The first re-
lease step that significantly increased compliance relative
to compliance with the FR intact was 100 % TCL release
at the distal level and 50 % TCL release at the proximal
level (p< 0.05). Complete TCL transection led to com-
pliance values of 0.149 ± 0.024 mm/N (distal) and 0.966 ±
0.213 mm/N (proximal). Complete FR release increased
compliance relative to the intact condition by 0.166 ±
0.041 mm/N (332 %) at the distal and 0.365 ± 0.137 mm/
N (52 %) at the proximal level. The distal tunnel exhibited
significantly smaller compliance than the proximal tunnel
at every step of FR release (p< 0.01). However, FR release
progressively reduced the difference in compliance be-
tween the proximal and distal levels, from a factor of 13.6
with the FR intact, to a factor of 6.6 with 100 % TCL re-
lease, and to a factor of 4.9 with complete FR release.
The impact of incomplete FR release differed between
the proximal and distal levels (Fig. 5). At the distal level,
a minimum of 100 % TCL release was required to in-
crease compliance significantly relative to compliance
with the FR intact (p< 0.001). Subsequent DA release
further increased compliance an additional 116 %
although this increase did not represent a statistically
significant gain relative to compliance with 100 % TCL
release (p= 0.052). The compliance increase with AF
transection was significantly greater than compliance
with 100 % TCL release (p< 0.05) but not meaningfully
different from the compliance with TCL and DA release
(p> 0.05). At the proximal level, releasing 50 % of the
TCL significantly increased compliance relative to com-
pliance with the FR intact (p< 0.001). A 75 % TCL re-
lease increased compliance beyond the gain seen with
50 % TCL release (p< 0.05), and 100 % TCL release
Fig. 2 Experimental setup used to simultaneously apply two pairs of
outward 10 N loading forces to the carpal bones at the proximal
and distal levels
Ratnaparkhi et al. Journal of Orthopaedic Surgery and Research (2016) 11:43 Page 3 of 7
Content courtesy of Springer Nature, terms of use apply. Rights reserved.
further increased CTC relative to CTC with 75 % TCL
release (p< 0.05). DA release had only a minimal effect
on CTC compared with 100 % TCL release at the prox-
imal level (p= 0.987). However, complete FR release
yielded a significant additional gain in compliance be-
yond that obtained with either 100 % TCL release or
TCL + DA release (p< 0.05).
Discussion
In this cadaver hand study, we investigated changes in
the mechanical properties of the carpal tunnel with vari-
ous degrees of FR release. We concluded that incremen-
tal FR release altered carpal tunnel structural mechanics
as a function of compliance as calculated from the
changes in carpal arch width. More specifically, the im-
pact of FR release on carpal tunnel compliance was
dependent on both the location within the carpal tunnel
and the extent of FR release.
We found that complete FR transection significantly
increased compliance by a factor of 4.3 at the distal level
and 1.5 at the proximal level. This finding aligns with
those of previous investigations [14, 16]. Previous studies
have used different methodologies and outcome mea-
sures to evaluate the compliance features of the carpal
tunnel, which limits our ability to directly compare the
magnitude of compliance increase across studies. For ex-
ample, Xiu et al. [16] defined compliance as the slope of
the linear regression of the carpal arch width change as
a function of outwardly applied forces of 2–10 N. Kim
et al. [14] calculated compliance as the rate of change in
the carpal arch area per change in carpal tunnel pressure
applied via water infusion. In the current study, we used
a constant 10 N force to stretch the carpal arch width as
Fig. 3 Stepwise release of the FR. (1) 25 % TCL release, (2) 50 % TCL release, (3) 75 % TCL release, (4) 100 % TCL release, (5) 100 % TCL release + DA
release and (6) 100 % TCL release + DA + AF release. Note that all release steps were completed in the same plane of sectioning. FR flexor retinaculum;
TCL transverse carpal ligament; DA distal aponeurosis; AF antebrachial fascia
Fig. 4 Carpal tunnel compliance as a function of stepwise flexor retinaculum transection at the proximal and distal levels of the carpal tunnel
Ratnaparkhi et al. Journal of Orthopaedic Surgery and Research (2016) 11:43 Page 4 of 7
Content courtesy of Springer Nature, terms of use apply. Rights reserved.
a means of evaluating the compliance changes of the car-
pal tunnel due to FR release. The compliance increase
achieved by FR transection is one potential mechanism by
which carpal tunnel release surgery can achieve median
nerve decompression and symptom alleviation for patients
whohavecarpaltunnelsyndrome.
Our results show that complete TCL transection was re-
quired to significantly increase compliance at the distal
level and to augment compliance relative to 50 or 75 %
TCL release at the proximal level. This finding suggests
that incomplete TCL release limits potential gains in
structural flexibility of the carpal tunnel. Our findings
differ somewhat from a prior study [17] that showed a
gradual increase of bony carpal arch stretchability with
progressive TCL sectioning. More specifically, the data re-
ported in that study showed that 30 N loading led to a car-
pal arch distance change of 2.3 mm with the TCL intact,
and distance changes of 2.7, 3.2, and 3.7 mm, respectively,
when the TCL was progressively sectioned by 1/3, 2/3,
and completely. The different pattern observed may be at-
tributable to the differences in experimental protocols.
Tengrootenhuysen et al. [17] used a threefold greater
loading force and measured the change in carpal arch
distance along an oblique orientation from the scaphoid
tubercle at the proximal level to the hook of the hamate at
the distal level. In contrast, in the present study, we mea-
sured along transverse axes at the proximal and distal
levels. Our previous studies [16] have shown that the dis-
tal carpal tunnel at the hook of the hamate is relatively
rigid, whereas the proximal carpal tunnel has greater flexi-
bility. Mobility along the oblique axis is greater than that
on the transverse axis at the proximal level but less than
that at the distal level [18]. The greater distance changes
along the oblique axis may be a function of the complex,
three-dimensional motion of individual carpal bones [18].
TCL + DA release at the proximal level only minimally
increased carpal tunnel compliance beyond the gain
achieved with 100 % TCL release alone. In contrast, re-
lease of the TCL and DA at the distal level tripled com-
pliance relative to the intact condition, whereas 100 %
TCL release only doubled compliance. The small sample
size may have contributed to the borderline significance
of this result. This result points toward a trend that dis-
tal aponeurosis release has a greater effect on carpal tun-
nel compliance more distally within the carpal tunnel.
Previous studies have demonstrated that DA release is
required to decrease carpal tunnel pressure to below
pathologic levels [19–22]. It is possible that the additive
gains in compliance at the distal tunnel with DA release
might explain the benefit of reduced carpal tunnel pres-
sure after DA release. A previous study [23] did not report
changes in carpal arch width after DA release; however,
that study measured changes in carpal arch width without
application of a loading force. Such a static measurement
of carpal arch width captures only the resting state of the
carpal tunnel structure rather than the intrinsic structural
compliance of the carpal tunnel.
We observed a significant additional increase in com-
pliance with AF release. At the proximal level, AF tran-
section significantly increased compliance relative to
both TCL + DA release and 100 % TCL release alone,
whereas compliance at the distal level with complete FR
(i.e., TCL + DA + AF) release was significantly greater
than compliance with 100 % TCL release but only min-
imally greater than compliance with TCL + DA release.
This difference suggests that AF release contributes to
compliance gains to a greater extent at the proximal car-
pal tunnel than at the distal level. This additional gain in
compliance with AF release helps explain previous find-
ings that complete FR release, including AF release,
Fig. 5 Ratio of carpal tunnel compliance after each step of flexor retinaculum release to the compliance with the FR intact at the proximal and
distal levels of the carpal tunnel
Ratnaparkhi et al. Journal of Orthopaedic Surgery and Research (2016) 11:43 Page 5 of 7
Content courtesy of Springer Nature, terms of use apply. Rights reserved.
significantly reduced carpal tunnel pressure beyond the
level achieved with TCL + DA release alone [22]. That
study also showed that AF release more robustly re-
duced pressure in the proximal carpal tunnel relative to
more distal levels, which parallels our observation that
AF release had a greater effect on compliance at the
proximal level.
We found that incomplete TCL or FR release can mech-
anically constrain the carpal tunnel, causing residual focal
compression that could contribute to median nerve ische-
mia. Clinically, incomplete FR release either proximally or
distally is associated with persistent symptoms, including
numbness, paresthesia, and difficulty manipulating small
objects [4]. However, several clinical studies have sug-
gested that release of the proximal FR may contribute to
other postoperative complications that can delay return to
work and resumption of activities of daily living [2]. These
include pillar pain due to changes in carpal arch morph-
ology that disrupt intercarpal articulations and grip weak-
ness due to the FR’s reduced capacity to anchor the thenar
and hypothenar muscles [24, 25]. Further research is
needed to evaluate the pros and cons of DA and AF re-
lease. Our results suggest that DA release may be particu-
larly beneficial for reducing mechanical constraints at the
distal carpal tunnel.
We demonstrated that FR release increases local com-
pliance more at the distal level of the carpal tunnel than
at the proximal level. The carpal tunnel was found to be
more rigid at the distal than the proximal level, irre-
spective of FR status, and a greater extent of FR release
was required to effect a significant compliance change at
the distal level than was needed at the proximal level.
The relative inflexibility of the distal tunnel is a function
of the differences in its structure compared with the
proximal tunnel. The bones of the distal carpal arch
form a rigid unit held in place by sturdy intercarpal liga-
ments that severely restrict movement [26]. In contrast,
the proximal carpal arch is an intercalated segment with
limitations on movement of its bones arising only from
mechanical forces from their surrounding articulations
[18]. Furthermore, the distal TCL has been shown to
have a greater elastic modulus [27] and a lesser amount
of strain [28] than the proximal TCL region. Clinically,
the distal level of the carpal tunnel has been reported as
a common site of median nerve entrapment [29, 30].
Complete FR release including the distal TCL + DA thus
is particularly important for increasing compliance at
this location.
There are several limitations to this study. First, a fixed
FR release sequence was implemented. However, for
each release step, there was no significant difference in
the carpal arch width in the unloaded condition before
and after loading, which suggests that there was no re-
sidual deformation of the carpal arches as a result of any
specific transection or serial loading. Second, we had to
use an artificial outward loading force applied to the car-
pal tunnel to investigate the structural properties of the
carpal tunnel in the cadaveric specimens due to their
lack of inherent physiologic or pathologic carpal tunnel
pressure. Structural compliance is defined in the current
study as the change in carpal arch width with respect to
the 10 N loading force, which is different from the
changes derived from the pressure-area relationship
[14]. Finally, soft tissue around the FR, including the
skin, muscles, and fascia, were dissected in the cadaveric
specimens to allow digitization of the carpal bones and
calculation of the carpal arch width. The effects of this
soft tissue on carpal tunnel compliance are therefore not
reflected in our results.
Conclusions
In conclusion, we investigated changes in carpal tunnel
compliance with incremental FR release and found that
FR release increased the compliance of the carpal tunnel
and had the greatest effect at the more rigid distal tunnel.
Incomplete flexor retinaculum release without full tran-
section of all three segments limits potential gains in
carpal tunnel structural flexibility. Our study supports the
benefit of complete flexor retinaculum release to
maximize the effect of carpal tunnel release surgery to
increase carpal tunnel compliance and thereby reduce car-
pal tunnel pressure and decompress the median nerve.
Abbreviations
AF: antebrachial fascia; DA: distal aponeurosis; FR: flexor retinaculum;
TCL: transverse carpal ligament.
Competing interests
The authors declare that they have no competing interests.
Authors’contributions
KX, XG, and ZML designed the experiment; XG completed data collection;
RR, KX, XG, and ZML participated in data analysis. All authors (RR, KX, XG, and
ZML) participated in data interpretation and manuscript writing. All authors
have read and approved the final submitted manuscript.
Acknowledgements
The authors thank Tamara L. Marquardt and Christine Kassuba, Biomedical
Engineering, Cleveland Clinic, and Christine Kassuba for their comments
and edits on this manuscript. Research reported in this publication was
supported by the National Institute of Arthritis and Musculoskeletal and Skin
Diseases of the National Institutes of Health under grants R21AR062753 and
R01AR068278 (both to ZM Li). The content is solely the responsibility of the
authors and does not necessarily represent the official views of the National
Institutes of Health.
Received: 19 January 2016 Accepted: 4 April 2016
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