Carpal Tunnel Syndrome

Background
Carpal tunnel syndrome (CTS) is a collection of characteristic symptoms and signs that occurs following
entrapment of the median nerve within the carpal tunnel. Usual symptoms include numbness, paresthesias,
and pain in the median nerve distribution. These symptoms may or may not be accompanied by objective
changes in sensation and strength of median-innervated structures in the hand. See image below.

The hands of an 80-year-old woman with a several-year history of numbness and weakness are shown in
this photo. Note severe thenar muscle (abductor pollicis brevis, opponens pollicis) wasting of the right
hand, with preservation of hypothenar eminence.
Pathophysiology
Until the advent of electrophysiologic testing in the 1940s, carpal tunnel syndrome (CTS) commonly was
thought to be the result of compression of the brachial plexus by cervical ribs and other structures in the
anterior neck region. It is now known that the median nerve is damaged within the rigid confines of the
carpal tunnel, initially undergoing demyelination followed by axonal degeneration. Sensory fibers often are
affected first, followed by motor fibers. Autonomic nerve fibers carried in the median nerve also may be
affected.
The cause of the damage is subject to some debate; however, it seems likely that abnormally high carpal
tunnel pressures exist in patients with CTS. This pressure causes obstruction to venous outflow, back
pressure, edema formation, and ultimately, ischemia in the nerve.
The risk of development of CTS appears to be associated, at least in part, with a number of different
epidemiologic factors, including genetic, medical, social, vocational, avocational, and demographic.[1] A
complex interaction probably exists between some or all these factors, eventually leading to the
development of CTS. Definite causative factors, however, are far from clear.
Epidemiology
Frequency
United States
The incidence of carpal tunnel syndrome is 1-3 cases per 1000 subjects per year; prevalence is
approximately 50 cases per 1000 subjects in the general population. Incidence may rise as high as 150
cases per 1000 subjects per year, with prevalence rates greater than 500 cases per 1000 subjects in
certain high-risk groups.
International
A paucity of population-based studies of carpal tunnel syndrome (CTS) exists; however, the incidence and
prevalence in developed countries seems similar to the United States (eg, incidence in the Netherlands is
approximately 2.5 cases per 1000 subjects per year; prevalence in the United Kingdom is 70-160 cases per
1000 subjects).[2, 3, 4] CTS is almost unheard of in some developing countries (eg, among nonwhite South
Africans).

Mortality/Morbidity
Carpal tunnel syndrome is not fatal, but it can lead to complete, irreversible median nerve damage, with
consequent severe loss of hand function, if left untreated.
Race
Whites are probably at highest risk of developing carpal tunnel syndrome (CTS). The syndrome appears to
be very rare in some racial groups (eg, nonwhite South Africans).[4] In North America, white US Navy
personnel have CTS at a rate 2-3 times that of black personnel.[5]
Sex
The female-to-male ratio for carpal tunnel syndrome is 3-10:1.
Age
The peak age range for development of carpal tunnel syndrome (CTS) is 45-60 years. Only 10% of patients
with CTS are younger than 31 years
History
The patient's history often is more important than the physical examination in making the diagnosis of
carpal tunnel syndrome (CTS).

Numbness and tingling

Among the most common complaints, patients will reveal that their hands fall asleep or that
things slip from their fingers without their noticing (loss of grip, dropping things); numbness and tingling
also are commonly described.
Symptoms are usually intermittent and are associated with certain activities (eg, driving, reading
the newspaper, crocheting, painting). Nighttime symptoms that wake the individual are more specific to
CTS, especially if the patient relieves symptoms by shaking the hand/wrist. Bilateral CTS is common,
although the dominant hand is usually affected first and more severely than the other hand.
Complaints should be localized to the palmar aspect of the first to the fourth fingers and the
distal palm (ie, the sensory distribution of the median nerve at the wrist). Numbness existing
predominantly in the fifth finger or extending to the thenar eminence or dorsum of the hand should
suggest other diagnoses. A surprising number of CTS patients are unable to localize their symptoms
further (eg, whole hand/arm feeling dead). This generalized numbness may indicate autonomic fiber
involvement and does not exclude CTS from the diagnosis.
Pain
The sensory symptoms above commonly are accompanied by an aching sensation over the
ventral aspect of the wrist. This pain can radiate distally to the palm and fingers or, more commonly,
extend proximally along the ventral forearm.
Pain in the epicondylar region of the elbow, upper arm, shoulder, or neck is more likely to be due
to other musculoskeletal diagnoses (eg, epicondylitis) with which CTS commonly is associated. This
more proximal pain also should prompt a careful search for other neurologic diagnoses (eg, cervical
radiculopathy).
Autonomic symptoms
Not infrequently, patients report symptoms in the whole hand. Many patients with CTS also
complain of a tight or swollen feeling in the hands and/or temperature changes (eg, hands being cold/hot
all the time).
Many patients also report sensitivity to changes in temperature (particularly cold) and a
difference in skin color. In rare cases, there are complaints of changes in sweating. In all likelihood,
these symptoms are due to autonomic nerve fiber involvement (the median nerve carries most
autonomic fibers to the whole hand).
Weakness/clumsiness - Loss of power in the hand (particularly for precision grips involving the thumb)
does occur; in practice, however, loss of sensory feedback and pain is often a more important cause of
weakness and clumsiness than is loss of motor power per se.

Physical
Clinical examination is important to rule out other neurologic and musculoskeletal diagnoses; however, the
examination often contributes little to the confirmation of the diagnosis of carpal tunnel syndrome (CTS).

Sensory examination

Abnormalities in sensory modalities may be present on the palmar aspect of the first 3 digits
and radial one half of the fourth digit. Semmes-Weinstein monofilament testing or 2-point discrimination
may be more sensitive in picking this up; however, in the author's experience, pinprick sensation is as
good as any test.
o
Sensory examination is most useful in confirming that areas outside the distal median nerve
territory are normal (eg, thenar eminence, hypothenar eminence, dorsum of first web space).

Motor examination - Wasting and weakness of the median-innervated hand muscles (LOAF
muscles) may be detectable.
o
L - First and second lumbricals
o
O - Opponens pollicis
o
A - Abductor pollicis brevis
o
F - Flexor pollicis brevis

Special tests - No good clinical test exists to support the diagnosis of CTS.
o
Hoffmann-Tinel sign

Gentle tapping over the median nerve in the carpal tunnel region elicits tingling in the
nerve's distribution.

This sign still is commonly looked for, despite the low sensitivity and specificity.
o
Phalen sign

Tingling in the median nerve distribution is induced by full flexion (or full extension for
reverse Phalen) of the wrists for up to 60 seconds

This test has 80% specificity but lower sensitivity.

o
The carpal compression test[6]

This test involves applying firm pressure directly over the carpal tunnel, usually with
the thumbs, for up to 30 seconds to reproduce symptoms.

Reports indicate that this test has a sensitivity of up to 89% and a specificity of 96%.
o
Palpatory diagnosis

This test involves examining the soft tissues directly overlying the median nerve at
the wrist for mechanical restriction.

This palpatory test has been noted to have a sensitivity of over 90% and a specificity
of 75% or greater.
o
The square wrist sign

The ratio of the wrist thickness to the wrist width is greater than 0.7.

This test has a modest sensitivity/specificity of 70%.

Several other tests have been advocated, but they rarely provide additional information beyond that
which the Phalen and square wrist signs provide.
o

Causes
Note that carpal tunnel syndrome (CTS) is associated with many different factors.[7] In particular, the more
the hand and wrist are used, the greater the symptoms. This observation does not necessarily mean that
using the hand and wrist causes the syndrome or that more median nerve damage ensues. Association
should not be assumed to signify causation.

Demographics
o
o
o
o
o
o
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Increasing age
Female sex
Increased body mass index (BMI), especially a recent increase
Square-shaped wrist
Short stature
Dominant hand
Race (white)

Genetics
o
o

Medical conditions
o
o
o
o
o
o
o
o
o
o

o
o
o
o

o
o
o

A strong family susceptibility exists and is probably related to multiple inherited

characteristics (eg, square wrist, thickened transverse ligament, stature).
A number of inherited medical conditions also are associated with CTS (eg, diabetes, thyroid
disease, hereditary neuropathy with liability to pressure palsies).

Wrist fracture (Colles)

Acute, severe flexion/extension injury of wrist
Space-occupying lesions within the carpal tunnel (eg, flexor tenosynovitis, ganglions,
hemorrhage, aneurysms, anomalous muscles, various tumors, edema)
Diabetes
Thyroid disorders (usually myxedema)
Rheumatoid arthritis and other inflammatory arthritides of the wrist
Recent menopause (including post-oophorectomy)[1]
Renal dialysis
Acromegaly
Amyloidosis
Vocational/avocational[7, 8, 9] - Activities that may be associated with CTS (particularly in
combination) involve the following:
Prolonged, severe force through the wrist
Prolonged, extreme posture of the wrist
High amounts of repetitive movements
Exposure to vibration and/or cold
Other factors
Lack of aerobic exercise
Pregnancy and breastfeeding
Use of wheelchairs and/or walking aids

Differentials
Cervical Disc Disease
Cervical Myofascial Pain
Cervical Spondylosis
Compartment Syndrome
Diabetic Neuropathy
Ischemic Monomelic Neuropathy
Lateral Epicondylitis
Leprosy
Lyme Disease
Medial Epicondylitis
Mononeuritis Multiplex
Multiple Sclerosis
Myofascial Pain
Neoplastic Brachial Plexopathy
Overuse Injury
Posttraumatic Syringomyelia
Radiation-Induced Brachial Plexopathy
Reflex Sympathetic Dystrophy
Thoracic Outlet Syndrome
Traumatic Brachial Plexopathy

Laboratory Studies
No blood tests exist for the diagnosis of carpal tunnel syndrome; however, laboratory testing for associated
conditions (eg, diabetes) may be performed when clinically indicated.
Imaging Studies
No imaging studies are considered routine in the diagnosis of carpal tunnel syndrome (CTS).
Magnetic resonance imaging (MRI) of the carpal tunnel is particularly useful preoperatively if a spaceoccupying lesion in the carpal tunnel is suggested. Signal abnormality can be detected in the median nerve
in some cases of CTS, but how these abnormalities correlate to diagnosis and physiologic severity is not
clear. MRI does not rule out the multitude of other differential diagnoses and is time consuming and
resource intensive.[10]
Ultrasonography potentially can pick up some space-occupying lesions in the carpal tunnel. Problems
differentiating the median nerve from surrounding soft tissue (particularly distally) severely limit its role in
diagnosis at present.[11]
Other Tests
Electrophysiologic studies,[12, 13, 14] including electromyography (EMG) and nerve conductions studies (NCS),
are the first-line investigations in suggested carpal tunnel syndrome (CTS).[15] Abnormalities on
electrophysiologic testing, in association with specific symptoms and signs, are considered the criterion
standard for CTS diagnosis. In addition, other neurologic diagnoses can be excluded with these test
results. NCS in a patient with CTS are seen in the images below.

Sensory nerve conduction studies from the left hand of a patient with a several-year history of numbness and
weakness (responses from the median nerve in the right hand were completely absent). Note marked slowing of the
conduction velocity (CV) to 29.8 and 25.5 m/s for digits 3 and 1, respectively (normal >50 m/s). The amplitude for both
also is reduced markedly (normal >10). These findings are consistent with carpal tunnel syndrome.

Motor nerve conduction studies from the left hand of a patient with a several-year history of numbness and weakness
(responses from the median nerve in the right hand were completely absent). Note that the conduction velocity (CV)
across the carpal tunnel segment slows severely to 18.3 m/s (normal >50 m/s) and that the distal motor latency is
prolonged at 6.3 ms (normal < 4.2 ms). Amplitudes are low for the wrist and elbow stimulus sites at 4.7 mV (normal >5
mV), but amplitudes are 31% higher distal to the carpal tunnel (at the palm). This discrepancy may represent

conduction block (neurapraxia) at the level of the carpal tunnel or coactivation of the ulnar branch to adductor pollicis.
Needle electromyography is required to determine whether axonal loss is present .

Electrophysiologic testing also can provide an accurate assessment of how severe the damage to the
nerve is, thereby directing management and providing objective criteria for the determination of prognosis.
CTS is usually divided into mild, moderate, and severe; however, criteria for this assessment usually vary
from lab to lab. In general, patients with mild CTS have sensory abnormalities alone on electrophysiologic
testing, and patients with sensory plus motor abnormalities have moderate CTS. However, any evidence of
axonal loss (eg, decreased or absent sensory or motor responses distal to the carpal tunnel or neuropathic
abnormalities on needle EMG) is classified as severe CTS.
Changes in electrophysiologic results over time can be used to assess the success of various treatment
modalities.
The American Association of Electrodiagnostic Medicine has published standards and guidelines that
govern the minimum number of studies that should be performed to diagnose CTS.[13]
Other quantitative tests, such as thermography and vibrometry, have been shown to be inferior to
electrophysiologic examination and, because they have not been supported by controlled studies, are not
recommended
Rehabilitation Program
Physical Therapy
Given that carpal tunnel syndrome (CTS) is associated with low aerobic fitness (and increased BMI), it
makes inherent sense to provide the patient with an aerobic fitness program. Stationary biking, cycling, or
any other exercise that puts strain on the wrists probably should be avoided.
The use of modalities (eg, ultrasonography, phonophoresis, iontophoresis) may provide relief in some
patients.[16, 17] Interestingly, it may be possible to enlarge the carpal tunnel by specific stretching techniques.
Such an exercise program may provide a new noninvasive treatment for CTS in the future.
Occupational Therapy
Work-site ergonomic assessment may help to reduce potentially exacerbating factors (eg, poor posture,
excessive force).[18] Manufacture of a wrist-hand orthosis with the wrist joint in neutral (to be worn at
nighttime for a minimum of 3-4 weeks) is one of the best evidence-based conservative treatments for carpal
tunnel syndrome (CTS). A specific stretching/strengthening program for the hand and wrist may be useful in
improving strength and dexterity (particularly following surgical treatment), although it can exacerbate
symptoms. Massage and/or nerve glide techniques offer no proven benefit.[17]
Medical Issues/Complications
Most individuals with mild-to-moderate carpal tunnel syndrome (CTS; according to electrophysiologic data)
respond to conservative management, usually consisting of splinting the wrist at nighttime for a minimum of
3 weeks. Many off-the-shelf wrist splints seem to work well, although theoretically, a custom-made splint in
neutral is probably the best choice.[16, 19]
Steroid injection into the carpal tunnel has been shown to be of long-term benefit and can be tried if more
conservative treatments have failed[20] . Injections may also be worthwhile prior to surgical management or
in cases in which surgery is relatively contraindicated (eg, because of pregnancy).[20, 21] Ultrasound
measurements of the median nerve can help predict response to steroid injection.[22] .

Nonsteroidal anti-inflammatory drugs (NSAIDs) and/or diuretics may be of benefit. Vitamin B-6 or B-12
supplements are of no proven benefit.
Lack of aerobic exercise (along with increased body mass index [BMI]) is a risk factor for the development
of CTS and should be addressed.
Overuse of legal drugs (eg, caffeine, nicotine, alcohol) can contribute to CTS and should therefore be
reduced.[17]
Surgical Intervention
Patients whose condition does not improve following conservative treatment and patients who initially are in
the severe carpal tunnel syndrome (CTS) category (as defined by electrophysiologic testing) should be
considered for surgery. Surgical release of the transverse ligament provides high initial success rates
(greater than 90%), with low rates of complication; however, it has been suggested that the long-term
success rate may be much lower than previously thought (approximately 60% at 5 y). Success rates also
are considerably lower for individuals with normal electrophysiologic studies.[23, 24, 25]
Consultations
Refer patients with suggested carpal tunnel syndrome to a specialist trained in clinical neurophysiology
(usually a neurologist, physiatrist, or physical medicine and rehabilitation specialist) for possible
electrophysiologic studies. These test results are important for diagnosis, instigation of appropriate
treatment, determination of prognosis, and long-term follow-up.
Other Treatment
Techniques and devices to stretch or manipulate the carpal tunnel have shown some promise but still are
not accepted widely. Laser therapy also has shown some early promise.

Medication Summary
Short (1-2 wk) courses of regular NSAIDs can be of benefit, particularly if there is any suggestion of
inflammation in the wrist region (eg, flexor tenosynovitis, rheumatoid arthritis). Likewise, if edema is thought
to be prominent, then a short course of a mild diuretic may be of benefit.
Nonsteroidal anti-inflammatory drugs
Class Summary
NSAIDs provide pain relief and reduction of inflammation. Reducing inflammation in the structures passing
through the carpal tunnel decreases pressure and provides some relief to the compressed nerve.
Ibuprofen (Ibuprin, Motrin)
DOC for patients with mild to moderate pain. Inhibits inflammatory reactions and pain by decreasing
prostaglandin synthesis.
Cyclooxygenase-2 inhibitors
Class Summary
Although increased cost can be a negative factor, the incidence of costly and potentially fatal GI bleeds is
clearly less with COX-2 inhibitors than with traditional NSAIDs. Ongoing analysis of cost avoidance of GI
bleeds will further define the populations that will find COX-2 inhibitors the most beneficial.
View full drug information
Celecoxib (Celebrex)

Inhibits primarily COX-2. Considered an inducible isoenzyme, COX-2 is induced during pain and
inflammatory stimuli. Inhibition of COX-1 may contribute to NSAID GI toxicity. At therapeutic concentrations,
COX-1 isoenzyme is not inhibited; thus, GI toxicity may be decreased. Seek lowest dose of celecoxib for
each patient.
Diuretic agents
Class Summary
Conditions that cause edema may increase pressure in the carpal tunnel. Diuretics may be beneficial in
reducing edema.
View full drug information
Hydrochlorothiazide (Esidrix, HydroDIURIL, Microzide)
Inhibits reabsorption of sodium in distal tubules, causing increased excretion of sodium and water, as well
as potassium and hydrogen ion

Further Outpatient Care

Individuals treated conservatively for carpal tunnel syndrome should undergo a follow-up in 4-6
weeks so that the success of treatment interventions can be assessed. Patients who do not achieve the
desired results from conservative treatment should be referred for a surgical opinion.
Continued symptoms following carpal tunnel release should prompt referral for repeat
electrophysiologic studies.
Deterrence
No conclusive evidence exists of any intervention that can prevent carpal tunnel syndrome.
Complications
Carpal tunnel syndrome may continue to increase median nerve damage, leading to permanent
impairment and disability.
Some individuals can develop chronic wrist and hand pain (with or without reflex sympathetic
dystrophy).
Prognosis
Carpal tunnel syndrome (CTS) appears to be progressive over time (although with considerable
fluctuations from week to week) and can lead to permanent median nerve damage. Whether any
conservative management can prevent progression is unclear. Even with surgical release, it appears that
the syndrome recurs to some degree in a significant number of cases (possibly in up to one third after 5
years).[24]
Initially, approximately 90% of mild to moderate CTS cases respond to conservative management.
Over time, however, a number of patients progress to requiring surgery.
Patients with CTS secondary to underlying pathology (eg, diabetes, wrist fracture) tend to have a
less favorable prognosis than do those with no apparent underlying cause.
Patients with normal electrophysiologic studies consistently have much less favorable operative
outcomes (and more complications) than do individuals with abnormalities on these tests. Axonal loss on
electrophysiologic testing also indicates a less favorable prognosis.
Patient Education
Association versus cause - The association of 2 phenomena does not imply a causal relationship.
Using the hands frequently brings on symptoms of carpal tunnel syndrome (CTS), in the same way that
exercise brings on angina in patients with coronary artery disease. This association, however, does not
necessarily mean that the median nerve damage is caused by use or that it will get worse. (Exercise, in
fact, is good for coronary artery disease.)
Avoidance of extremes - If a patient's vocation/avocation involves extreme
force/repetition/posture/vibration through the wrist, then it seems prudent to seek ways of avoiding factors
that cause or aggravate CTS.
Reduction of caffeine, alcohol, and/or nicotine intake - All of these substances are associated with
the development of CTS.
Exercise - BMI and poor fitness levels do appear to be related to the development of CTS.
For patient education resources, see the Hand, Wrist, Elbow, and Shoulder Center and Arthritis Center, as
well as Carpal Tunnel Syndrome.