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Annals of Internal Medicine

In the Clinic

Carpal Tunnel
Syndrome Screening and Prevention

Diagnosis

C
ompressive median neuropathy at the
wrist, also known as carpal tunnel syn-
drome (CTS), is the most common en- Treatment
trapment neuropathy, accounting for about 90%
of all such disorders. It is estimated to occur in
up to 3.8% of the general population with a Tool Kit
yearly incidence rate of 276:100 000 (1, 2). Vari-
ous occupational and personal factors predis-
pose to CTS, including age, sex, and obesity. In Patient Information
the working population, it is a disabling and
costly condition, representing a major cause of
lost workdays and workers compensation costs
in the United States (3). Tingling, numbness,
and pain in the median nerve distribution in the
hand is the typical presentation.

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Physician Writer CME Objective: To review current evidence for screening and prevention, diagnosis,
Kleopas A. Kleopa, MD treatment, and patient information of carpal tunnel syndrome.
Funding Source: American College of Physicians.
Disclosures: Dr. Kleopa, ACP Contributing Author, has disclosed no conicts of interest.
Disclosures can also be viewed at www.acponline.org/authors/icmje/ConictOfInterestForms
.do?msNum=M15-0576.
In the Clinic does not necessarily represent ofcial ACP clinical policy. For ACP clinical
guidelines, please go to https://www.acponline.org/clinical_information/guidelines/.
With the assistance of additional physician writers, the editors of Annals of Internal
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Clinical examination and electrodi- compression and compromising
agnostic testing conrm the diag- nerve circulation. Surgical section-
nosis. Given the considerable so- ing of the transverse carpal liga-
1. Mondelli M, Giannini F, cioeconomic impact of CTS, it is ment reduces the pressure in the
Giacchi M. Carpal tunnel
syndrome incidence in a important to identify risk factors tunnel and can be curative. It
general population. Neu- and introduce potentially effective should be offered when conserva-
rology. 2002;58:289-94.
[PMID: 11805259] measures for primary prevention tive treatment fails to provide ade-
2. Atroshi I, Gummesson C, when possible. The presumed un- quate relief and when clinical ex-
Johnsson R, et al. Preva-
lence of carpal tunnel derlying mechanism of CTS is in- amination or electrodiagnostic
syndrome in a general
population. JAMA. 1999; creased pressure within the carpal changes suggest the possibility of
282:153-8. [PMID: tunnel, causing median nerve irreversible nerve damage.
10411196]
3. Dawson DM. Entrapment
neuropathies of the upper
extremities. N Engl J Med.
1993;329:2013-8. [PMID:
8247077]
Screening and Prevention
4. Barcenilla A, March LM, Who is at risk for CTS? Nonoccupational risk factors may
Chen JS, Sambrook PN.
Carpal tunnel syndrome Numerous occupational as well also predispose to CTS (Table 1).
and its relationship to
as nonoccupational risk factors Increased body mass index (BMI)
occupation: a meta-
analysis. Rheumatology for CTS have been recognized. is an independent risk factor, es-
(Oxford). 2012;51:250-61.
[PMID: 21586523] Therefore, screening and preven- pecially in patients younger than
5. Herbert R, Gerr F, Dropkin
tion may be possible for some 63 years (7). Moreover, increased
J. Clinical evaluation and
management of work- at-risk individuals. Occupational serum low-density lipoprotein
related carpal tunnel syn-
risk factors have long been rec- (LDL) levels was found to be a
drome. Am J Ind Med.
2000;37:62-74. [PMID:
ognized and primarily include risk factor in a Japanese popula-
10573597]
6. Harris-Adamson C, Eisen repetitive, forceful hand work tion, probably related to LDL-
EA, et al. Biomechanical induced brinogenesis and me-
risk factors for carpal tun- with wrist extension as well as
nel syndrome: a pooled dian nerve enlargement (8).
vibration, cold environment, and
study of 2474 workers. However, this association has not
Occup Environ Med. combinations thereof (4). Work-
2015;72:33-41. [PMID: been entirely replicated in other
25324489] ers with increased risk for CTS
7. Bland JD. The relationship
populations (9, 10). Genetic pre-
include workers in the construc-
of obesity, age, and carpal disposition to CTS has also been
tunnel syndrome: more tion, electronic and forestry, sh found in prospective (11) as well
complex than was
thought? Muscle Nerve. processing and cannery, frozen as twin studies, regardless of en-
2005;32:527-32. [PMID:
16025527]
food/meat, furniture factory, vironmental risk factors (concor-
8. Nakamichi K, Tachibana S. garment and textile, and metal dance for monozygotic twins,
Hypercholesterolemia as a
risk factor for idiopathic casting industries; aircraft me- 0.35; for dizygotic twins, 0.24)
carpal tunnel syndrome.
Muscle Nerve. 2005;32:
chanics; appliance and automo- (12). Familial predisposition is
364-7. [PMID: 15937877] bile manufacturers; and dental more common in patients with
9. Shiri R, Heliovaara M,
Moilanen L, et al. Associa- hygienists (5). bilateral CTS (13). More rare enti-
tions of cardiovascular risk
factors, carotid intima- ties include autosomal dominant
media thickness and man- There is evidence that biomechanical occupa- CTS (14) and early childhood fa-
ifest atherosclerotic vascu- tional risk factors contribute to CTS. A recent,
lar disease with carpal milial forms that may be associ-
tunnel syndrome. BMC large, multicenter, prospective study of 2474 ated with systemic genetic disor-
Musculoskelet Disord.
2011;12:80. [PMID:
workers from various industries documenting ders, such as amyloidosis (15).
21521493] workplace exposures of the dominant hand
10. Bischoff C, Isenberg C, Perhaps related to genetic pre-
found, after adjustment of covariates, that esti-
Conrad B. Lack of hyper- disposition, there seems to be an
lipidemia in carpal tun- mated peak hand force (hazard ratio [HR],
nel syndrome. Eur Neu- anatomical risk factor for CTS:
rol. 1991;31:33-5. 2.08 2.17; 95% CI, 1.313.43), forceful repe-
[PMID: 2015834] tition rate (HR, 1.84; CI,1.19 2.86), and the Wider palm and more squared
11. Radecki P. The familial
percentage of time spent in forceful hand ex- carpal tunnel and wrist measured
occurrence of carpal
tunnel syndrome. Mus- ertions (HR, 2.05; CI, 1.34 3.15) were associ- as higher wrist ratio (anterior-
cle Nerve. 1994;17:325-
30. [PMID: 8107710] ated with increased risk for incident CTS. Asso- to-posterior wrist dimension/
12. Hakim AJ, Cherkas L, El ciations were not observed between total hand medial-to-lateral wrist dimension)
Zayat S, MacGregor AJ,
Spector TD. The genetic repetition rate, percentage of duration of all and wrist-to-palm ratio (anterior-
contribution to carpal hand exertions, or wrist posture and incident to-posterior wrist dimension/
tunnel syndrome in
women: a twin study. CTS (6). Accordingly, improvements in the de- palm length) were signicantly
Arthritis Rheum. 2002; sign of workplace safety programs may help to associated with idiopathic CTS
47:275-9. [PMID:
12115157] prevent work-related CTS. (16). This association may be par-

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Table 1. Nonoccupational Risk Factors for Carpal Tunnel Syndrome
Female sex
Age
Pregnancy
Obesity
Wrist ratio*
Family history
Renal failure/dialysis (possibly mediated through amyloid)
Amyloidosis (various forms)
Drug treatment with aromatase inhibitors (exemestane, tamoxifen)
Diabetes (with or without overt polyneuropathy)
Hypothyroidism
Acromegaly
Previous wrist fracture
Collagen vascular disease
Osteoarthritis of the wrist 13. Alford JW, Weiss AP,
Lipid abnormalities Akelman E. The familial
incidence of carpal tun-
nel syndrome in patients
* Anterior to posterior wrist dimension divided by medial to lateral wrist dimension. with unilateral and bilat-
Studies conict with regard to the association between lipid abnormalities and eral disease. Am J Or-
carpal tunnel syndrome. thop (Belle Mead NJ).
2004;33:397-400.
[PMID: 15379235]
14. Stoll C, Maitrot D. Auto-
tially due to differences in BMI. vibration gloves. In general, somal dominant carpal
Anatomical variations of the hook modifying the work environment tunnel syndrome. Clin
Genet. 1998;54:345-8.
of hamate may also predispose to and alternating tasks to reduce [PMID: 9831348]
CTS (17). Finally, several systemic high-repetition work, vibration, 15. Murakami T, Tachibana
S, Endo Y, et al. Familial
disorders may be associated with and forceful hand exertion, when carpal tunnel syndrome
due to amyloidogenic
increased risk (Table 1). possible, may be recommended. transthyretin His 114
variant. Neurology.
Are there measures that can Occupational and nonoccupa- 1994;44:315-8. [PMID:
8309582]
prevent CTS? tional risk factors may coexist. 16. Lim PG, Tan S, Ahmad
TS. The role of wrist an-
The evidence for the utility of Studies in industrial workers thropometric measure-
preventive measures for CTS, showed that, in addition to ment in idiopathic carpal
tunnel syndrome.
such as engineering, personal, vibrations associated with job J Hand Surg Eur Vol.
and multiple component inter- tasks, greater age, female sex, 2008;33:645-7. [PMID:
18662961]
ventions, is insufcient, and no relative overweight, and ciga- 17. Chow JC, Weiss MA, Gu
Y. Anatomic variations of
specic guidelines have been rette smoking signicantly in- the hook of hamate and
established for primary preven- creased the risk for dominant- the relationship to carpal
tunnel syndrome.
tion. However, at least one study hand CTS (19). Specically, BMI J Hand Surg Am. 2005;
showed that among workers ex- and age were associated with 30:1242-7. [PMID:
16344183]
posed to upper extremity vibra- higher prevalence of CTS 18. Jetzer T, Haydon P, Reyn-
olds D. Effective interven-
tion, which is a signicant risk among construction workers tion with ergonomics,
factor for CTS, ergonomic inter- (20), suggesting that weight antivibration gloves, and
medical surveillance to
vention was effective in prevent- loss may be a preventive mea- minimize hand-arm
ing progression of symptoms sure for at-risk industrial work- vibration hazards in the
workplace. J Occup Envi-
and ndings attributable to CTS ers. Finally, among hemodialy- ron Med. 2003;45:
1312-7. [PMID:
(18). Such preventive measures sis patients, such measures as 14665818]
included the introduction of new switching from conventional to 19. Nathan PA, Meadows
KD, Istvan JA. Predictors
tools with lower vibration levels a high-ux membrane as well as of carpal tunnel syn-
and use of International Stan- use of ultrapure dialysate, may drome: an 11-year study
of industrial workers.
dards Organization 10819 anti- reduce the risk for CTS. J Hand Surg Am. 2002;
27:644-51. [PMID:
12132090]
20. Rosecrance JC, Cook TM,
Anton DC, Merlino LA.
Carpal tunnel syndrome
among apprentice con-
struction workers. Am J
Ind Med. 2002;42:107-
16. [PMID: 12125086]

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Table 2. History and Physical Examination for Carpal Tunnel Syndrome
History
Dull, aching discomfort in the hand, forearm, or upper arm
Paresthesias in the hand
Weakness or clumsiness of the hand
Dry skin, swelling, or color changes in the hand
Provocation of symptoms by sleep
Provocation of symptoms by sustained hand or arm positions
Provocation of symptoms by repetitive actions of the hand or wrist
Mitigation of symptoms by changing hand posture or shaking the wrist
Hand-symptom questionnaire diagram (sensitivity 64%93%, specicity 39%80%);
extramedian spread of sensory symptoms in up to 40% of patients
Age >40 y (sensitivity 80%, specicity 41%)
Nocturnal paresthesias (sensitivity 51%84%, specicity 27%68%)

Examination
Hypalgesia in the median nerve territory (sensitivity 15%51%, specicity
85%93%); comparing index nger to little nger
Two-point discrimination (sensitivity 6%32%, specicity 64%99%); using calibers
whose points are set 46 mm apart
Atrophy restricted to thenar (sensitivity 4%28%, specicity 82%99%)
Weak thumb abduction (sensitivity 63%, specicity 66%); abductor pollicis brevis
muscle
Decreased vibratory sensation (sensitivity 20%61%, specicity 71%81%);
comparing index nger to little nger
Tinel sign (sensitivity 23%60%, specicity 64%87%); pain and paresthesias in
median nerve distribution when taping the wrist
Phalen sign (sensitivity 10%91%, specicity 33%86%); pain and paresthesias after
exing wrists 90 degrees for 1 min
Hand elevation test (sensitivity 88%, specicity 99%); tingling/numbness in median
ngers after elevating hand above head for 1 min

Screening and Prevention... Several occupational and nonoccupa-


tional risk factors may predispose to CTS. Although there are no
evidence-based guidelines on the choice, usefulness, indications, or
cost-effectiveness of screening tools, knowing the most important risk
factors, such as high-force, repetitive tasks with vibrating tools, may be
useful to implement preventive measures when possible.

CLINICAL BOTTOM LINE


21. Buch-Jaeger N, Foucher
G. Correlation of clinical
signs with nerve conduc-
tion tests in the diagno-
sis of carpal tunnel syn-
drome. J Hand Surg Br.
1994;19:720-4. [PMID:
Diagnosis
7706873] What symptoms suggest CTS? poorly localized to median terri-
22. DArcy CA, McGee S. The
rational clinical examina- CTS should be considered in any tory; a few patients may have
tion. Does this patient
have carpal tunnel syn- patient with a history of pain in only daytime symptoms; and
drome? JAMA. 2000; the hand and arm; numbness some may not report any pain.
283:3110-7. [PMID:
10865306] and paresthesias in the hand; or Typical provocative factors in-
23. Stevens JC, Smith BE,
Weaver AL, Bosch EP, weakness or clumsiness in the clude worsening symptoms at
Deen HG Jr, Wilkens JA. hand, especially in the median night, with sustained hand
Symptoms of 100 pa-
tients with electromyo- nerve distribution. However, and/or arm positions, or with
graphically veried car-
pal tunnel syndrome. many patients in the early stages repetitive hand and wrist move-
Muscle Nerve. 1999;22: present only with nocturnal par- ments and improvement with
1448-56. [PMID:
10487914] esthesias, which may be rather changing position or shaking the

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Figure. Median nerve sensory territory and location of paresthesias in
patients with CTS.

The median nerve territory in the palm is supplied by the median palmar cutaneous branch,
which does not pass through the carpal tunnel; therefore, sensory decits in CTS are usually
restricted to the median-innervated ngers. CTS = carpal tunnel syndrome.

hand (Table 2). A hand diagram should be aware that CTS symp-
(Figure) may help the patient toms may be most commonly
localize the symptoms. reported in both median and
What physical examination ulnar digits, followed by median
digits only and a glove distribu-
ndings are helpful in
tion. Furthermore, paresthesias
diagnosing CTS?
or pain may be felt proximal to
Several clinical ndings or pro-
the wrist in 36.5% of hands (23).
vocative tests have been tradi-
tionally used to diagnose CTS, The clinician should be aware
including nocturnal paresthesias, that CTS may progress through
Phalen and Tinel signs, thenar different stages of severity with
atrophy, 2-point discrimination, changing symptoms: In mild CTS,
and vibratory and neurolament nocturnal paresthesias as well as
sensory testing (21) (Table 2). swelling and pain relieved by
Although the sensitivity of iso- shaking the hands or changing
lated symptoms may be limited
hand position are characteristic.
in predicting the disease, a com-
In moderate CTS, symptoms per-
bination of typical neurologic
sist during the day and decreas-
symptoms, exacerbating and re-
ing sensation results in nger
lieving factors, and the epidemio-
clumsiness and dropping ob-
logic prole of the patient are
essential in establishing the diag- jects. In severe CTS, numbness
nosis. A review of multiple stud- without pain and atrophy of the
ies focusing on the diagnostic thenar eminence may occur.
utility of isolated history and However, patients can have vari-
physical examination ndings ous clinical courses, including
and maneuvers showed that use monophasic, self-limited symp-
of a hand symptom diagram, toms; relapsingremitting symp-
hypoalgesia in the median nerve toms over many years; stable but
territory, and weakness of thumb tolerable symptoms for long peri-
abduction are most consistent ods; and rapid or slow progres-
with electrodiagnostically con- sion of symptoms. Progression is
rmed CTS (22). Physicians not inevitable, and some patients

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may improve spontaneously cion of CTS have a different diag-
without surgical treatment (24). nosis, most commonly musculo-
skeletal disorders (25). Therefore,
Given the large differential diag- NCSs and EMG are considered
nosis of CTS (Table 3), at a mini- to be the gold standard, not only
mum, physical examination in for conrming the diagnosis of
patients with suspected CTS CTS with high a degree of accu-
should include detailed neuro- racy (sensitivity >85% and speci-
logic assessment of the hand and city >95%), but also for deter-
arm, including motor and sen- mining the degree of severity
sory testing, with emphasis on based on nerve function and to
the motor and sensory territory of exclude other neuromuscular
the median nerve distal to the conditions. NCSs also provide
wrist, and comparison of strength insight into the degree of func-
of the abductor pollicis brevis tional impairment of the median
with the other hand muscles not nerve, which does not always
innervated by the median nerve correlate with clinical symptoms,
(e.g., the ulnar-innervated rst depending on the stage and se-
dorsal interosseous and abduc- verity, thus offering a better basis
tor digiti minimi) and to more for planning appropriate treat-
proximal median-innervated ment (Table 4).
muscles. Pain, temperature, and
vibration should be tested on the However, when the diagnosis of
24. Padua L, Padua R, Aprile median innervated compared CTS is either clinically certain or
I, Pasqualetti P, Tonali P; with the ulnar innervated ngers. highly unlikely, then EMG may
Italian CTS Study Group.
Carpal tunnel syndrome. not change the overall probabil-
Multiperspective What other conditions should ity of diagnosing CTS to a clini-
follow-up of untreated
carpal tunnel syndrome:
be considered when evaluating cally meaningful extent (26). Ac-
a multicenter study. a patient with possible CTS? cording to guidelines from the
Neurology. 2001;56:
1459-66. [PMID: Several conditions can cause American Association of Electro-
11402101]
25. Lo JK, Finestone HM, symptoms and ndings similar to diagnostic Medicine (27), conr-
Gilbert K, Woodbury MG. those caused by CTS (Table 3). A matory testing with NCS and
Community-based refer-
rals for electrodiagnostic careful history and clinical exami- EMG are recommended when
studies in patients with
possible carpal tunnel
nation may help to exclude most clinical diagnosis is uncertain;
syndrome: what is the of them. However, denite exclu- when only a few or atypical clini-
diagnosis? Arch Phys
Med Rehabil. 2002;83: sion of some other neurologic cal features are present; and
598-603. [PMID: conditions will require laboratory when other neurologic diagno-
11994797]
26. Graham B. The value testing with a nerve conduction ses, in addition to or instead of
added by electrodiagnos-
tic testing in the diagno-
study (NCS) and electromyogra- CTS, are suspected. Electrodiag-
sis of carpal tunnel syn- phy (EMG). nostic evaluation should also be
drome. J Bone Joint
Surg Am. 2008;90: done in patients who do not re-
2587-93. [PMID:
What is the role of NCS and
spond to conservative therapy, in
19047703] EMG?
27. Jablecki CK, Andary MT, the presence of thenar atrophy
Floeter MK, et al; Ameri- Although certain clinical ndings, and/or persistent numbness, or
can Association of Elec-
trodiagnostic Medicine. as discussed here, are moder- when invasive treatment is con-
Practice parameter: Elec- ately accurate in establishing the sidered (28).
trodiagnostic studies in
carpal tunnel syndrome. diagnosis of CTS, other isolated
Report of the American
ndings in referred patients have What is the role of imaging
Association of Electrodi-
agnostic Medicine, Amer- limited diagnostic accuracy. No studies?
ican Academy of Neurol-
ogy, and the American data exist on the value of physical Imaging studies in patients with
Academy of Physical diagnosis in patients presenting CTS may be useful if there is sus-
Medicine and Rehabilita-
tion. Neurology. 2002; to a primary care physician with picion of local structural disease,
58:1589-92. [PMID:
12058083]
symptoms suggesting CTS (22). such as deformity after previous
28. Keith MW, Masear V, A community-based study wrist fractures, primary bone or
Chung K, et al. Diagnosis
of carpal tunnel syn- showed that many patients re- joint disease, or local tumor.
drome. J Am Acad Or- ferred to an electrodiagnostic Wrist lms or computed tomog-
thop Surg. 2009;17:389-
96. [PMID: 19474448] laboratory with a clinical suspi- raphy are indicated only for eval-

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Table 3. Differential Diagnosis of Carpal Tunnel Syndrome
Disease Characteristics
Cervical radiculopathy Neck pain radiating into the corresponding dermatome and paresthesias and/or sensory loss;
(common) decreased reexes; and in severe cases, weakness in the corresponding myotome
C6C7 radiculopathies may mimic sensory symptoms of CTS while C8T1 radiculopathies may
cause thenar muscle atrophy
Usually improves at night (as opposed to CTS)
Sensory abnormalities in the forearm, beyond the distribution of the distal median nerve
Reex abnormalities (biceps, brachioradialis, triceps) and weakness of proximal muscles
(C6C7) or nonmedian innervated hand muscles (C8T1) (normal in CTS)
CTS and cervical radiculopathy may coexist ("double crush syndrome")
Can be denitely evaluated with NCS/EMG
Polyneuropathy (diabetic, Sensory and/or motor decits in a length-dependent pattern, affecting many nerves
other acquired, or Examine lower extremities for decreased reexes, sensory loss, and weakness
hereditary) or multiple NCS critical to fully characterize
mononeuropathies Multiple mononeuropathies affect more than one nerve at different sites, but if the initial
(common) presentation is with a median neuropathy, it may be difcult to distinguish from CTS before
further nerves are affected
Brachial plexopathy All trunks, and the medial and lateral cord of the brachial plexus, contribute bers to the median nerve
Upper trunk lesions cause symptoms and decits in the C5C6 dermatomes and myotomes, with sensory
loss extending to the lateral arm and weakness affecting the deltoid, biceps, brachioradialis, and
supraspinatus
Middle trunk lesions mimic C7 radiculopathy (weakness of triceps, pronator teres and exor carpi radialis,
diminished triceps reex) and rarely occur in isolation
Lower trunk and medial cord lesions cause almost identical presentations (C8 portion of the radial nerve
is involved in lower trunk but not medial cord lesion) with C8T1 myotome weakness and sensory loss
in digits 4 and 5
Lateral cord lesion affects the musculocutaneous nerve with biceps weakness and proximal (C6C7)
median-innervated muscle weakness
EMG and NCS show abnormalities of motor and sensory nerves affected by the plexopathy, with
denervation in the corresponding muscles
Vascular disorders Cold-induced vasoconstriction and pain in the hands, also affecting nonmedian territory
(Raynaud syndrome) (all ngers)
Ischemia may cause paresthesias, but there are no constant neurologic decits
Cervical myelopathy Extra- or intramedullary lesions (compressive, syringomyelia, neoplastic, inammatory) in the
(common) cervical area (C6T1) may cause symptoms and signs in one or both hands, which can be
mistaken for CTS
Distribution of neurologic abnormalities extends beyond the median nerve territory
Associated features, including upper motor neuron signs in the lower extremities (spasticity,
hyperreexia) and bladder dysfunction, are common
NCS ndings are normal
Other CNS disorders Transient paresthesias or motor/sensory decits in one hand may be attributed to CTS, but other
signs of CNS involvement (increased reexes, mental or other higher cortical dysfunction,
nonmedian territory involvement) and absence of pain make a diagnosis of CTS unlikely
Other painful articular and Mechanically induced and exacerbated pain syndromes without sensory loss or muscle weakness
soft tissue disorders Motor dysfunction may result from tendinitis or arthritis, with decreased passive range of motion
In many patients with CTS, swelling and brosis of the exor tendons within the carpal tunnel are
present, which may worsen median nerve compression
NCS ndings are normal
Proximal median Compression under the ligament of Struthers (rare): anatomical variant of ligament spanning
neuropathy between the supracondylar process and the medial epicondyle, which may be compressing
the median nerve
Diagnosis supported by the presence of a supracondylar process in x-rays
Pain in the elbow area and volar forearm with paresthesias in the median-innervated digits,
exacerbated by supination of the forearm and extension of the elbow; the radial pulse may
also be attenuated with these maneuvers
Other causes include compressive casting, trauma, venipuncture, mass lesion, hematoma
Sensory loss over the thenar eminence and weakness of median-innervated muscles proximal to
the carpal tunnel (exor pollicis longus, pronator teres and quadratus, exor carpi radialis)
differentiate proximal median neuropathy from CTS
Pronator teres syndrome Compression of the nerve by a thickened band connecting the biceps muscle to the forearm,
(rare) hypertrophy of the pronator teres, or a tight brous arch of the exor digitorum supercialis
Presents with pain at the elbow area associated with paresthesias and numbness; worsens with
repetitive elbow movement but improves at night, in contrast to CTS; proximal forearm area is
usually tender to pressure
Anterior interosseus Motor decits affecting the forearm muscles innervated by this branch of the median nerve
syndrome (rare) result in the typical weakness of distal phalanx exion of the thumb and index nger (tested
with the attempt to make the "OK" sign)
Anterior interosseus neuropathy is often a variant presentation of (idiopathic) brachial neuritis

CNS = central nervous system; CTS = carpal tunnel syndrome; EMG = electromyelography; NCS = nerve conduction studies.

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Table 4. Laboratory and Other Tests for Carpal Tunnel Syndrome
Test Sensitivity (%) Specicity (%) Notes
NCS and electromyography >85 >95 NCS sensitivity based on the use of recommended
elements of NCS for carpal tunnel syndrome
A >90% sensitivity may be achieved when motor
conduction techniques are used
High-resolution sonography of the 5789 6597 When local structural disease is suspected (lower cost
carpal tunnel and time requirement favor sonography over MRI)
For the diagnosis of CTS (quantitative measurement of
median nerve cross-sectional area) sensitivity up to
89% and specicity of 97% reported among selected
patients with CTS conrmed by electrodiagnosis,
lower among unselected patients with clinically
suspected CTS
High-resolution CT of the wrist When local structural disease is suspected, evaluation of
bony lesions or calcications
MRI of the wrist 96 33-38 When local structural disease is suspected
Wrist x-ray Detects bony but not soft tissue abnormalities; should
be considered only with history of wrist trauma or
restricted wrist movement
Cervical spine MRI When cervical radiculopathy is suspected
Chest x-ray and/or MRI of brachial When brachial plexopathy or thoracic outlet syndrome
plexus is suspected
Blood studies When CTS is associated with systemic disease (diabetes,
hypothyroidism, acromegaly, gout) is suspected
Polyneuropathy evaluation Depending on the type of neuropathy, inammatory
markers and assessment for connective tissue disease,
protein electrophoresis, genetic testing for
amyloidosis or other inherited neuropathies, spinal
uid examination, tissue biopsy for amyloid

CT = computed tomography; CTS = carpal tunnel syndrome; MRI = magnetic resonance imaging; NCS = nerve conduction
studies.

uation of osseous carpal stenosis tunnel inlet, at the carpal tunnel


or bony tumors. Magnetic reso- inlet, and at the carpal tunnel
nance imaging (MRI) or ultra- outlet) using similar discrimina-
sonography is useful for direct tory criteria (cutoff point around
visualization of the median nerve 10 mm2, depending on the level
and other soft tissues (tenosyno- and site in the arm) showed sen-
vium) when there is suspicion of sitivity ranging from 83% to 94%
a soft tissue space-occupying and specicity ranging from 65%
lesion, such as a tumor, ganglion to 73%. The sensitivity of ultra-
cyst, muscle hypertrophy, or pal- sonography in diagnosing mild
mar lipoma. The specicity of CTS is much lower (30%55%).
MRI for diagnosing CTS is rather However, ultrasound assessment
low (Table 4). was found to be useful diagnosti-
29. Kwon BC, Jung KI, Baek
In contrast, there is an emerging cally in a group of patients with
GH. Comparison of
sonography and electro- role for high-frequency ultra- clinical CTS ndings and nega-
diagnostic testing in the
diagnosis of carpal tun- sound examination of the median tive electrodiagnostic test results.
nel syndrome. J Hand
nerve in the diagnosis of CTS. Several studies showed that elec-
Surg Am. 2008;33:65-
71. [PMID: 18261667] Abnormalities identied by trophysiologic measurements
30. Kaymak B, Ozcakar L, have consistently higher specic-
Cetin A, et al. A compari- sonography include swelling of
son of the benets of the median nerve, attening of ity and sensitivity than sonogra-
sonography and electro-
physiologic measure- the nerve in the distal carpal tun- phy (29) and are better predic-
ments as predictors of tors of symptom severity and
symptom severity and
nel, or increased palmar exion
functional status in pa- of the transverse ligament. Mea- functional status in patients with
tients with carpal tunnel
syndrome. Arch Phys surement of the median nerve idiopathic CTS (30). This has
Med Rehabil. 2008;89:
743-8. [PMID:
cross-section in up to 3 areas (im- been reproduced by a prospec-
18374007] mediately proximal to the carpal tive, blinded study conrming

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the higher diagnostic value of CTS are usually clinically evident
electrodiagnostic testing than a and have been diagnosed long
new ultrasound approach (31). before presentation. Fasting
Thus, sonography may be useful plasma glucose for suspected
but is not accurate enough to diabetes; thyroid function tests
supplant NCS for CTS diagnosis for suspected hypothyroidism;
(32). However, this is an evolving renal function and uric acid test-
eld and a correlation between ing for suspected renal failure or
3-dimensional ultrasono- gout; measurement of rheuma-
graphic ndings and electrodiag- toid factor, erythrocyte sedimen-
nostic severity of CTS is increas- tation rate, and antinuclear anti-
ingly being reported (33). bodies for suspected rheumatoid
arthritis or other connective tis-
To determine whether electrodiagnostic exam-
ination can be replaced by ultrasonography to
sue disorders; somatomedin-C,
conrm CTS, Claes and colleagues (31) used a prolactin and phosphate levels,
new set of normal values taking wrist circum- and growth hormone suppres-
ference of patients into account and prospec- sion testing for suspected acro-
tively examined 156 patients with idiopathic megaly; serum protein immuno-
CTS with both ultrasonography and NCSs. Of xation for paraproteinemia; and
the selected patients, 83.3% met the electrodi- tissue biopsy for amyloid may be
agnostic criteria for CTS. Ultrasonography nd- considered in patients with sec-
ings were normal in 67 (42.9%) of 156 pa- ondary CTS in the appropriate
tients, and within this group, NCS ndings
clinical setting.
were abnormal in 44 patients (65.7%). Of 89
patients with abnormal ultrasonography nd- When should clinicians refer
ings, only 3 patients had normal ndings from patients to a specialist for
electrodiagnosis. The authors concluded that
diagnosis?
ultrasonography does not have the same diag-
nostic value and cannot replace NCSs for con- Most clinical signs and symp-
rmation of clinical diagnosis of CTS. However, toms of CTS are not diagnostic,
abnormal ultrasound results are highly predic- and many other conditions can
tive that electrodiagnostic results in clinically mimic it. A specialist with exper-
dened CTS will also be abnormal. Ultrasonog- tise in electrodiagnostic studies
raphy might reveal relevant anatomical infor- (neurologist, physiatrist) should 31. Claes F, Kasius KM,
mation before surgery; however, it seldom di- be consulted to assist with con- Meulstee J, Verhagen
rectly inuences patient management. WI. Comparing a new
rmatory NCS/EMG. Increas- ultrasound approach
with electrodiagnostic
What other laboratory studies ingly, there is also the option to studies to conrm clini-
may be useful? consult radiologists with exper- cally dened carpal tun-
nel syndrome: a prospec-
Although the diagnosis of CTS tise in ultrasonographic diagno- tive, blinded study. Am J
Phys Med Rehabil.
does not require laboratory stud- sis of CTS. Consultation for di- 2013;92:1005-11.
ies, there is evidence for associa- agnosis should be considered [PMID: 23811615]
32. Descatha A, Huard L,
tion of CTS with certain systemic when the diagnosis is in doubt, Aubert F, et al. Meta-
disorders. Therefore, further di- when conservative treatment analysis on the perfor-
mance of sonography for
agnostic testing should be con- has failed, and when surgery or the diagnosis of carpal
tunnel syndrome. Semin
sidered when symptoms of con- other invasive treatment is be- Arthritis Rheum. 2012;
ditions associated with increased ing considered. The NCS pro- 41:914-22. [PMID:
22244369]
incidence of secondary CTS are vides the denitive diagnosis 33. Kwon HK, Kang HJ,
for most patients and helps to Byun CW, et al. Correla-
present (34). Consensus guide- tion between Ultrasonog-
lines are available from the exclude other neuropathic or raphy Findings and Elec-
trodiagnostic Severity in
American Academy of Neurology neuromuscular conditions that Carpal Tunnel Syndrome:
and the American Society of Plas- mimic CTS. Even in patients 3D Ultrasonography.
J Clin Neurol. 2014;10:
tic and Reconstructive Surgeons whose clinical diagnosis is con- 348-53. [PMID:
25324885]
on the indications for specic sidered denitive, preoperative 34. Solomon DH, Katz JN,
diagnostic tests in patients pre- electrodiagnostic assessment Bohn R, Mogun H, Avorn
J. Nonoccupational risk
senting with CTS and suspected provides a baseline for postop- factors for carpal tunnel
underlying systemic disorders. erative assessment in patients syndrome. J Gen Intern
Med. 1999;14:310-4.
Conditions that predispose to with unsatisfactory surgical re- [PMID: 10337041]

1 September 2015 Annals of Internal Medicine In the Clinic ITC9 2015 American College of Physicians

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sults. Presurgical electrodiag- by several professional societies
nostic assessment is endorsed (35).

Diagnosis... Pain in the hand and arm; numbness and paresthesias in


the hand; and weakness or clumsiness in the hand, occurring in the me-
dian nerve distribution, are highly suggestive of CTS. However, clinical
ndings are limited in their diagnostic accuracy, and several conditions
can cause similar symptoms and ndings. Patients should be carefully
examined with this in mind, but consultation for electrodiagnostic NCS/
EMG conrmation and, increasingly, ultrasonographic evaluation will be
needed in most cases, especially when initial treatments fail and surgi-
cal decompression is planned. Imaging studies are useful for detecting
rare structural anomalies, and further laboratory studies may conrm
suspected secondary CTS due to a systemic condition.

CLINICAL BOTTOM LINE

Treatment
How should clinicians manage trials with 1190 participants;
patients with CTS? studies were generally of poor
Optimal and cost-effective CTS quality. A few trials found that
management should be patient- splinting at night was better than
oriented and tailored to the stage no splinting, and side effects
of the median neuropathy. Con- were minimal across studies (36).
servative nondrug treatments are Splinting is inexpensive and asso-
widely accepted rst-line therapies ciated with few complications
and should be the rst treatment
for mild CTS; however, evidence
option, especially in mild to mod-
for some of these treatments is not
erate cases. Splints may also pro-
compelling, and their effects are
vide some immediate symptom-
usually temporary. Drug therapy,
atic relief for patients awaiting
including steroid injection, may
surgery for more severe disease.
also be effective only temporarily.
Splints should be used for at
The patient should be offered
least 4 weeks, and improvement
surgical decompression if these
usually occurs within the rst 2
methods fail or as early as possible
weeks. Full-time splinting may be
in advanced stages of nerve com-
more effective than night-only
pression indicated by progressive splinting, and neutral position
35. Keith MW, Masear V,
motor decit, severe sensory de- splints relieve symptoms better
Amadio PC, et al. Treat- cit, or a severe electrodiagnostic than cock-up (extension) splints
ment of carpal tunnel
syndrome. J Am Acad abnormality to avoid further nerve (37). Immobilization of the wrist
Orthop Surg. 2009;17:
397-405. [PMID: damage. In patients with second- in neutral position decreases
19474449] ary CTS associated with a systemic pressure in the carpal tunnel and
36. Page MJ, Massy-
Westropp N, OConnor D, disease, treatment should be improves circulation and median
Pitt V. Splinting for carpal
tunnel syndrome. Co- targeted at the primary disease. nerve function. To achieve a neu-
chrane Database Syst tral wrist position, a thermoplas-
Rev. 2012;7:CD010003. What is the role of conservative tic custom insert is easier to mold
[PMID: 22786532]
37. Burke DT, Burke MM, measures, such as wrist than a prefabricated metal one;
Stewart GW, Cambre A.
Splinting for carpal tun- splinting and activity however, the latter is more cost-
nel syndrome: in search
of the optimal angle.
modication? effective. It is important to ob-
Arch Phys Med Rehabil.
1994;75:1241-4. [PMID:
A 2012 Cochrane review of serve the wrist position when t-
7979936] splinting for CTS included 19 ting a prefabricated off-the-shelf

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wrist splint, as they tend to be after 8 weeks (42). However,
more rigid and less comfortable studies addressing chiropractic
than custom splints and are typi- or biobehavioral interventions,
cally made to have 10 to 30 de- magnet therapy, low-level laser
grees of extension. CTS patients therapy, and laser acupuncture
prescribed prefabricated splints yielded no conclusive evidence for
should be followed up with the the use of these methods in CTS.
splint to adjust to the neutral posi-
Which medications should
tion for better results (38).
clinicians prescribe rst?
A 2012 Cochrane review of exer- In general, treatment with oral
cise and mobilization therapy for medications for CTS is not well
CTS included 16 studies with 741 supported by experimental
participants, but only 3 studies evidence. Nonsteroidal anti-
addressed the primary outcome inammatory drugs (NSAIDs) 38. Gravlee JR, Van Durme
DJ. Braces and splints for
of short-term improvement and may be tried rst, especially in musculoskeletal condi-
presented enough data for inclu- patients with inammatory joint tions. Am Fam Physician.
2007;75:342-8. [PMID:
sion; all 3 were of low quality. conditions (arthritis) or exor ten- 17304865]
39. Page MJ, OConnor D,
One study showed that exercise dinitis, although oral corticoste- Pitt V, Massy-Westropp
led to more overall improvement, roids may be more effective. N. Exercise and mobilisa-
tion interventions for
a second showed that it led to Two-week treatment with oral carpal tunnel syndrome.
greater satisfaction with care, and steroids led to symptom im- Cochrane Database Syst
Rev. 2012;6:CD009899.
a third showed no effect on mea- provement compared with pla- [PMID: 22696387]
40. Page MJ, OConnor D,
sures of nerve function (39). Aer- cebo for as long as 4 weeks (43). Pitt V, Massy-Westropp
obic exercise for reduction of The latter may also cause more N. Therapeutic ultra-
sound for carpal tunnel
body weight in overweight side effects. Lidocaine patch 5% syndrome. Cochrane
individuals may also be may offer temporary pain relief. Database Syst Rev. 2012;
1:CD009601. [PMID:
recommended. Diuretics can theoretically be 22259004]
41. Incebiyik S, Boyaci A,
useful in CTS patients with wrist Tutoglu A. Short-term
What is the role of physical
edema, but their use is not sup- effectiveness of short-
therapy? ported by substantial evidence.
wave diathermy treat-
ment on pain, clinical
A 2013 Cochrane review of ultra- Age older than 50 years, disease symptoms, and hand
function in patients with
sound for CTS included 11 stud- duration exceeding 10 months, mild or moderate idio-
ies with 414 participants. Overall, and constant paresthesias are pathic carpal tunnel
syndrome. J Back Mus-
the evidence was of low quality. indicators that conservative man- culoskelet Rehabil.
Only one study reported short- agement is unlikely to succeed
2015;28:221-8. [PMID:
25061038]
term improvement as an out- (44). Overall, there is no satisfac- 42. Garnkel MS, Singhal A,
Katz WA, Allan DA,
come; it also found that patients tory evidence from randomized, Reshetar R, Schumacher
receiving ultrasound were more controlled clinical trials support- HR Jr. Yoga-based inter-
vention for carpal tunnel
likely to improve after 7 weeks. ing the use of diuretics, NSAIDs, syndrome: a randomized
There was no evidence to sug- gabapentin, or amitriptyline.
trial. JAMA. 1998;280:
1601-3. [PMID:
gest which ultrasound protocol 9820263]
was most benecial (40). Short- When should clinicians 43. OConnor D, Marshall S,
Massy-Westropp N. Non-
wave diathermy treatment for consider corticosteroid surgical treatment (other
than steroid injection) for
mild and moderate idiopathic injections? carpal tunnel syndrome.
CTS was studied in a prospective, Local steroid injection into the Cochrane Database Syst
Rev. 2003:CD003219.
randomized, double-blind study carpal canal should be consid- [PMID: 12535461]
44. Kaplan SJ, Glickel SZ,
and was benecial in relieving ered for temporary relief in se- Eaton RG. Predictive
symptoms and improving clinical lected patients with signicant factors in the non-
surgical treatment of
scales after 3 weeks of treatment pain and mild to moderate CTS. carpal tunnel syndrome.
(41). A randomized, single-blind For milder cases, steroid injec- J Hand Surg Br. 1990;
15:106-8. [PMID:
study of a yoga-based interven- tion may be sufcient to provide 2307866]
45. Jenkins PJ, Duckworth
tion showed that, compared with lasting effect, although this out- AD, Watts AC, McEachan
patients treated only with a wrist come is less likely in women, pa- JE. Corticosteroid injec-
tion for carpal tunnel
splint, those in the yoga-treated tients with diabetes, and those syndrome: a 5-year survi-
group had signicantly improved with nerve conduction abnormal- vorship analysis. Hand
(N Y). 2012;7:151-6.
grip strength and reduced pain ities (45). Several clinical trials [PMID: 23730233]

1 September 2015 Annals of Internal Medicine In the Clinic ITC11 2015 American College of Physicians

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have shown the efcacy of corti- Patients should be referred for
costeroid injection in providing surgical management if they do
at least temporary relief of CTS- not respond to conservative treat-
related pain. Injection is relatively ment for pain or have progressive
contraindicated in patients with sensory or motor decits or
thenar muscle weakness and at- moderate-to-severe electrodiag-
rophy, advanced sensory loss nostic abnormalities according to
indicating severe CTS, or acute widely accepted grading (49, 50).
CTS and/or wrist edema. Patients Patients with clinically or electro-
with severe CTS of more than 1 diagnostically severe CTS at initial
year in duration with these clini- diagnosis should have surgical
cal ndings and severe electro- decompression as rst-line treat-
physiologic abnormalities have a ment to avoid further nerve dam-
poor response to steroid injec- age. In patients with bilateral CTS,
tions and a high rate of relapse simultaneous carpal tunnel release
(45, 46). Multiple injections are may be more cost-effective and
not recommended because they cause less disability than consecu-
46. Graham RG, Hudson DA,
Solomons M, Singer M.
can cause tendon rupture and tive bilateral release (51).
A prospective study to median nerve injury. The number
assess the outcome of
steroid injections and of injections should not exceed 3 Surgical treatment of CTS is
wrist splinting for the or 4, and usually, if pain recurs based on the evidence that in-
treatment of carpal tun-
nel syndrome. Plast after a second injection, patients creased pressure in the carpal
Reconstr Surg. 2004; tunnel causes compression of the
113:550-6. [PMID:
should be advised to proceed
14758217] with surgical release. median nerve. Carpal tunnel re-
47. Marshall S, Tardif G,
Ashworth N. Local corti- lease consists of division of the
costeroid injection for A 2007 Cochrane review of local transverse carpal ligament, which
carpal tunnel syndrome. corticosteroid injection for CTS
Cochrane Database Syst increases the space in the carpal
Rev. 2007:CD001554. included 12 studies with 671 par- tunnel, thereby reducing the
[PMID: 17443508].
48. Racasan O, Dubert T. The ticipants. Two randomized trials pressure on the median nerve.
safest location for steroid of high quality found that injec- Surgical literature on the utility of
injection in the treat-
ment of carpal tunnel tion was superior to placebo for carpal tunnel release consists of
syndrome. J Hand Surg clinical improvement at 1 month
Br. 2005;30:412-4. several retrospective and uncon-
[PMID: 15950338] (relative risk, 2.58 [CI, 1.72 to trolled studies, showing excellent
49. Padua L, Lo Monaco M,
Padua R, Gregori B, 3.87]). Two studies found that outcomes in 90% to 100% of pa-
Tonali P. Neurophysio- steroid injection was superior to tients (52). However, referring
logical classication of
carpal tunnel syndrome: oral steroids, and another study
assessment of 600 symp-
physicians should be aware that
found that steroid injection was
tomatic hands. Ital J these high success rates are usu-
Neurol Sci. 1997;18: not superior to splinting plus
145-50. [PMID: ally reported from specialized
9241561] anti-inammatory medication
hand surgery centers and that a
50. Bland JD. A neurophysio- (47). The safest location for injec-
logical grading scale for higher percentage of patients
carpal tunnel syndrome. tion is proximal to the carpal tun-
Muscle Nerve. 2000;23: having this procedure in general
nel through the exor carpi radia-
1280-3. [PMID: practice may have an unsatisfac-
10918269] lis tendon to avoid injury to the
51. Weber RA, Boyer KM. tory outcome. A randomized,
Consecutive versus si- median nerve. Complications of
parallel-group trial also con-
multaneous bilateral local steroid injection, aside from
carpal tunnel release. rmed that surgical treatment led
Ann Plast Surg. 2005;54: median nerve injury, include lo-
15-9. [PMID: 15613876] to better outcomes than did non-
52. Cseuz KA, Thomas JE,
cal infection; tendon rupture; re-
surgical treatment (53). Either
Lambert EH, Love JG, ex sympathetic dystrophy; and,
Lipscomb PR. Long-term open release or endoscopic car-
results of operation for rarely, digital ischemia (48). Ion-
pal tunnel release can be used. A
carpal tunnel syndrome. tophoresis may be an alternative,
Mayo Clin Proc. 1966;
low-risk method of local steroid mini-open release is a newer ver-
41:232-41. [PMID:
5907222]
delivery to the carpal tunnel and sion with a smaller incision, and
53. Jarvik JG, Comstock BA,
Kliot M, et al. Surgery deserves further study. single-portal or dual-portal tech-
versus non-surgical ther- niques may be used for endo-
apy for carpal tunnel
syndrome: a randomised
When should clinicians scopic release. Numerous studies
parallel-group trial. Lan- consider referral to a surgical have compared the benets and
cet. 2009;374:1074-81.
[PMID: 19782873] or nonsurgical specialist? drawbacks of these surgical ap-

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proaches. Although outcome A recent study examining the benet of carpal
measures and results vary, no tunnel release in patients with electrophysiologi-
signicant differences were cally moderate (n = 47) compared with severe
found in terms of efcacy. Sev- (n = 48) disease showed that at 1 year or longer
eral randomized, controlled stud- after surgery, 1 (2%) patient with moderate CTS
and 9 (19%) patients with severe CTS reported
ies comparing various surgical
continued symptoms. Although symptoms di-
techniques for CTS treatment
minished in both groups from the preoperative
failed to demonstrate any strong assessment to the 2-week postoperative assess-
evidence supporting the use of ment, patients with severe CTS had compara-
one technique over the other. tively more severe symptoms at all time points,
with the exception of pain at 2 weeks and 1
A recent meta-analysis of 21 randomized, con-
year or longer after surgery. At those times
trolled trials comparing open versus endoscopic
there was no signicant difference. Preoper-
carpal tunnel release indicated that endoscopic
ative electrodiagnostic severity was the fac-
release allows earlier return to work and im-
tor most predictive of symptom scores. Thus,
proved strength during the early postoperative
patients with severe CTS have considerable
period. Results at 6 months or later were similar,
reduction in symptoms after surgery but
except that patients undergoing endoscopic re-
should be informed that recovery may be
lease were at greater risk for nerve injury and less
more prolonged and in some cases may be
risk for scar tenderness than those having open
release. The authors concluded that additional re- incomplete 1 year after carpal tunnel re-
search is required to dene the learning curve of lease, particularly with regard to numbness
54. Sayegh ET, Strauch RJ.
endoscopic release and to clarify the inuence of (58). Open versus endoscopic
carpal tunnel release: a
surgeon volume on safety (54). Postsurgical care includes eleva- meta-analysis of random-
ized controlled trials. Clin
Most surgeons agree on a general tion of the hand, gradual exercise Orthop Relat Res. 2015;
473:1120-32. [PMID:
list of absolute and relative contra- of the hand and forearm, and wrist 25135849]
indications for endoscopic ap- splinting in a neutral or slightly ex- 55. Arle JE, Zager EL. Surgi-
cal treatment of common
proaches, including suspected tended position for 2 to 3 weeks. entrapment neuropa-
thies in the upper limbs.
mass lesion within the carpal tun- Early mobilization, as opposed to Muscle Nerve. 2000;23:
nel, rheumatoid arthritis, prior sur- splinting, may result in shorter time 1160-74. [PMID:
10918251]
gery, severe tenosynovitis, or con- to return to activities of daily living 56. Benson LS, Bare AA,
or work (59). If a patient does not Nagle DJ, et al. Compli-
comitant ulnar neuropathy at the cations of endoscopic
wrist (55). Signicant, lasting respond to carpal tunnel release, it and open carpal tunnel
release. Arthroscopy.
complications after carpal tunnel is important to verify that the distal 2006;22:919-24,
release include damage to the ligament has been properly sec- 924.e1-2. [PMID:
16952718]
median or ulnar nerve and devel- tioned. Release is found to be in- 57. Manktelow RT, Binham-
mer P, Tomat LR, Bril V,
opment of reex sympathetic dys- complete in nearly half of patients Szalai JP. Carpal
trophy. However, complication in whom surgery has failed (60). tunnel syndrome: cross-
sectional and outcome
rates are low, both with endo- Other causes of failure to improve study in Ontario workers.
J Hand Surg Am. 2004;
scopic and open carpal tunnel after surgery include brous prolif- 29:307-17. [PMID:
release (56). With appropriate eration, circumferential brosis, 15043907]
58. Kronlage SC, Menendez
patient selection and technical ex- incorrect diagnosis, iatrogenic in- ME. The benet of carpal
tunnel release in patients
pertise, carpal tunnel release is jury, or recurrent tenosynovitis. A with electrophysiologi-
considered one of the most fre- more recent study that classied cally moderate and se-
vere disease. J Hand
quently successful interventions selected patients having revision Surg Am. 2015;40:438-
44.e1. [PMID:
in medicine. In a large, cross- carpal tunnel release into those 25708432]
sectional study, poor outcome was with persistent, recurrent, or new 59. Cook AC, Szabo RM,
Birkholz SW, King EF.
associated with repeated surgeries symptoms showed that diabetes Early mobilization follow-
ing carpal tunnel release.
or surgical complications, as well and a longer interval from primary A prospective random-
as with concurrent diagnoses of carpal tunnel release were more ized study. J Hand Surg
Br. 1995;20:228-30.
either tendonitis or epicondylitis. common in the recurrent group, [PMID: 7797977]
whereas nerve injury was more 60. OMalley MJ, Evanoff M,
In contrast, better outcome was Terrono AL, Millender LH.
associated with abnormal NCS common in the group with new Factors that determine
reexploration treatment
ndings, emphasizing the impor- symptoms. Incomplete release of of carpal tunnel syn-
tance of this diagnostic test for pa- the exor retinaculum and scarring drome. J Hand Surg Am.
1992;17:638-41. [PMID:
tient selection before surgery (57). of the median nerve were com- 1629542]

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mon intraoperative ndings in all neurologic function. Return visits
groups (61). at 2- to 6-week intervals for up to
6 months after invasive therapy
How should clinicians follow
or surgery are recommended to
patients with CTS? ensure timely reevaluation and
Patients treated conservatively possible revision in cases of
who do not improve or who have failed carpal tunnel release
progression of symptoms and (63).
neurologic decits require re-
evaluation and consideration of How should clinicians educate
surgical treatment. Moreover, patients about CTS?
improvement after most conser- Patients should be educated
vative treatments may be tempo- about the nature of CTS, its known
rary, and symptoms may recur causes and risk factors, exacerbat-
after initial amelioration (62). ing activities, diagnostic methods,
Therefore, patients receiving and therapeutic options. Patients
conservative treatment should be who have good information about
followed for at least 6 months to their disease will be more likely to
ensure clinical improvement and exercise secondary prevention
response to therapy, including and to adhere to therapeutic inter-
pain relief and sensory and mo- ventions and follow-up care. Many
tor function. After invasive ther- patients feel reassured by learning
apy (injection or surgery), pa- about their disease, particularly if
tients should be followed more they had suspected a more serious
closely, with emphasis on vascu- neurologic problem or other
lar status, wound healing, and condition.

Treatment... CTS treatment should be individualized and tailored to the


severity of median nerve compression. In mild to moderate cases,
evidence-supported nonsurgical therapies include splinting in neutral
wrist position, mobilization therapy, and steroid injection. Secondary
CTS should be recognized and the associated systemic disease treated.
Lack of lasting response or ndings consistent with advanced stages of
median nerve compression and injury should prompt early decompres-
sive surgery to avoid lasting nerve damage. Surgical decompression of
the carpal tunnel, either open or endoscopically, is generally well-
tolerated and highly successful in the hands of an expert.

61. Zieske L, Ebersole GC,


Davidge K, Fox I, Mackin-
non SE. Revision carpal
CLINICAL BOTTOM LINE
tunnel surgery: a 10-year
review of intraoperative
ndings and outcomes.
J Hand Surg Am. 2013;
38:1530-9. [PMID:
23809470]
62. Girlanda P, Dattola R,
Venuto C, et al. Local
steroid treatment in
idiopathic carpal tunnel
syndrome: short- and
long-term efcacy. J
Neurol. 1993;240:187-
90. [PMID: 8482993]
63. Jones NF, Ahn HC, Eo S.
Revision surgery for
persistent and recurrent
carpal tunnel syndrome
and for failed carpal
tunnel release. Plast
Reconstr Surg. 2012;
129:683-92. [PMID:
22090245]

2015 American College of Physicians ITC14 In the Clinic Annals of Internal Medicine 1 September 2015

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http://familydoctor.org/familydoctor/en/diseases

Tool Kit
-conditions/carpal-tunnel-syndrome.html
Information on carpal tunnel syndrome from the Ameri-
can Academy of Family Physicians.
www.ninds.nih.gov/disorders/carpal_tunnel/detail
_carpal_tunnel.htm
Carpal tunnel syndrome fact sheet from the National In-
Carpal Tunnel stitute of Neurological Disorders and Stroke (NINDS).
www.ninds.nih.gov/disorders/carpal_tunnel/carpal
Syndrome _tunnel.htm
Information on carpal tunnel syndrome from the NINDS.
http://tools.aan.com/apps/disorders/index.cfm?event
=database:disorder.view&disorder_id=872
Information on carpal tunnel syndrome from the Ameri-
can Academy of Neurology.
www.aanem.org/Education/Patient-Resources
/Disorders/Carpal-Tunnel-Syndrome.aspx
Information on carpal tunnel syndrome from the Ameri-
can Association of Neuromuscular and Electrodiagnos-
tic Medicine.
http://orthoinfo.aaos.org/topic.cfm?topic=A00005
Information on carpal tunnel syndrome from the Ameri-
can Academy of Orthopaedic Surgeons in English.
http://orthoinfo.aaos.org/topic.cfm?topic=A00621

IntheClinic
Information on carpal tunnel syndrome from the Ameri-
can Academy of Orthopaedic Surgeons in Spanish.
www.nhs.uk/conditions/carpal-tunnel-syndrome
/pages/whatisit.aspx
Information on carpal tunnel syndrome from the National
Health Service.

Clinical Guidelines
http://onlinelibrary.wiley.com/cochranelibrary/search
Guideline on carpal tunnel syndrome from The Cochrane
Library Database of Systematic Reviews.
www.aaos.org/research/guidelines/CTStreatmentguide
.asp
www.aaos.org/research/guidelines/CTSTreatment
Guideline.pdf
Guideline on carpal tunnel syndrome from the American
Academy of Orthopaedic Surgeons.
www.aanem.org/Practice/Practice-Guidelines.aspx
www.aanem.org/getmedia/3836fd0d-11c1-461b-8f45
-5ef59dcf604b/NMUS-for-DX-of-CTS-for-web.pdf
.aspx
www.aanem.org/getmedia/7ddc9ef9-ee91-4b48-9c1a
-53454313001e/CTS.pdf.aspx
Guidelines on the treatment of carpal tunnel syndrome
from the American Association of Neuromuscular and
Electrodiagnostic Medicine.

1 September 2015 Annals of Internal Medicine In the Clinic ITC15 2015 American College of Physicians

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WHAT YOU SHOULD In the Clinic
Annals of Internal Medicine
KNOW ABOUT CARPAL
TUNNEL SYNDROME
What Is Carpal Tunnel Syndrome?
Carpal tunnel syndrome is a condition caused by
pinched nerves in the wrist. These nerves help
your wrist and hand move and feel. When they
become pinched, it can cause pain and discom-
fort. Risk factors for carpal tunnel syndrome are:
A job that requires using your hand or wrist in
the same way every day (such as using power
tools that vibrate) or put stress on the hands
(such as typing or working on an assembly
line)
Family history of carpal tunnel syndrome
Past wrist injury
Being overweight or obese
Being pregnant
Having certain health conditions like arthritis,
diabetes, or underactive thyroid called a steroid, which is injected into your wrist.
In some cases, surgery may be needed. If not
What Are the Warning Signs of treated, carpal tunnel syndrome can cause per-
Carpal Tunnel Syndrome? manent nerve damage.
Symptoms can develop slowly and become more Questions for My Doctor
noticeable over time. These can include:
Should I change any of my daily activities?
Numbness, tingling, or pain in the ngers,
Am I at risk for permanent nerve damage?
hand, or forearm. Symptoms often are worse
Do I need any further testing?
at night.
Which treatment option is best for me?
Feeling like you are unable to make a st or
When can I expect my discomfort to go away?
hold objects.
How can I prevent any further damage?
Weakness in your hand and wrist.
How can I change my work activities?

Patient Information
How Is Carpal Tunnel Syndrome Bottom Line
Diagnosed? Carpal tunnel syndrome is a condition that
Your doctor will ask about your symptoms. He or develops when the nerves in your wrist
she may also physically examine your arm, wrist, become pinched.
and ngers. In some cases, your doctor may do Symptoms include numbness, pain and
a test to check for muscle and nerve function. tingling in your forearm, wrist, and hand. They
Further testing may be needed, including an may also include feeling like you are unable to
ultrasound of your wrist or forearm, especially if make a st, or feeling weak in your hands and
the nerve and muscle tests are negative. ngers.
To diagnose carpal tunnel syndrome, your
How Is Carpal Tunnel Syndrome doctor will ask about your symptoms and may
perform a physical examination of your arm,
Treated? wrist, and ngers. Some people may need
There are several treatment options for carpal tun- additional tests, like tests of nerve and muscle
nel syndrome. Your doctor may suggest using a function.
splint to support your wrist. A splint will hold Treatment includes using a splint to stabilize
your wrist in place and help the nerves in your your wrist and prevent more damage. Your
arm heal. Over-the-counter pain medicines can doctor may also suggest over-the-counter
help with swelling or pain. If the pain is severe, pain medicines or steroid injections. In some
your doctor may suggest a stronger medicine, cases, surgery may be needed.

For More Information


National Institute of Neurological Disorders and Stroke
www.ninds.nih.gov/disorders/carpal_tunnel/detail_carpal_tunnel
.htm
American Academy of Family Physicians
http://familydoctor.org/familydoctor/en/diseases-conditions
/carpal-tunnel-syndrome.html
American College of Rheumatology
https://www.rheumatology.org/Practice/Clinical/Patients
/Diseases_And_Conditions/Carpal_Tunnel_Syndrome/

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