Carpal Tunnel Syndrome: Diagnosis and Management

 

Am Fam Physician. 2016 Dec 15;94(12):993-999.

  Patient information: See related handout on carpal tunnel syndrome.

Author disclosure: No relevant financial affiliations.

Carpal tunnel syndrome, the most common entrapment neuropathy of the upper extremity, is caused by compression of the median nerve as it travels through the carpal tunnel. Classically, patients with the condition experience pain and paresthesias in the distribution of the median nerve, which includes the palmar aspect of the thumb, index and middle fingers, and radial half of the ring finger. Additional clues include positive physical examination findings, such as the flick sign, Phalen maneuver, and median nerve compression test. Although patients with typical symptoms and signs of carpal tunnel syndrome do not need additional testing, ultrasonography and electrodiagnostic studies are useful to confirm the diagnosis in atypical cases and rule out other causes. If surgical decompression is planned, electrodiagnostic studies should be obtained to determine severity and surgical prognosis. Conservative treatment may be offered initially to patients with mild to moderate carpal tunnel syndrome. Options include splinting, corticosteroids, physical therapy, therapeutic ultrasound, and yoga. Nonsteroidal anti-inflammatory drugs, diuretics, and vitamin B6 are not effective therapies. Local corticosteroid injection can provide relief for more than one month and delay the need for surgery at one year. Patients with severe carpal tunnel syndrome or whose symptoms have not improved after four to six months of conservative therapy should be offered surgical decompression. Endoscopic and open techniques are equally effective, but patients return to work an average of one week earlier with endoscopic repair.

Carpal tunnel syndrome (CTS) is often a debilitating disorder that is commonly encountered in primary care. It is the most common entrapment neuropathy of the upper extremity, affecting approximately 3% of the general adult population.1 Women are three times more likely to have CTS than men, and the prevalence and severity increase with age. Work-related activities that require a high degree of repetition and force or use of hand-operated vibratory tools significantly increase the risk of CTS.2 A large prospective cohort study found that forceful hand exertion was the most important factor in the development of CTS in workers.3 Additional risk factors include family history and a personal history of diabetes mellitus, obesity, hypothyroidism, pregnancy, and rheumatoid arthritis.

 Enlarge     Print

SORT: KEY RECOMMENDATIONS FOR PRACTICE

Clinical recommendationEvidence ratingReferences

Ultrasound measurement of a cross-sectional area of the median nerve by an experienced clinician may be used as a diagnostic test for carpal tunnel syndrome.

C

14, 15

Local corticosteroid injection is effective for more than one month in patients with mild to moderate carpal tunnel syndrome and delays the need for surgery at one year.

A

2024

Splinting, therapeutic ultrasound, carpal bone mobilization, and nerve glide exercises are effective short-term treatments for carpal tunnel syndrome.

B

2527

Endoscopic and open carpal tunnel release are equally effective, long-lasting treatments for carpal tunnel syndrome.

A

30


A = consistent, good-quality patient-oriented evidence; B = inconsistent or limited-quality patient-oriented evidence; C = consensus, disease-oriented evidence, usual practice, expert opinion, or case series. For information about the SORT evidence rating system, go to http://www.aafp.org/afpsort.

SORT: KEY RECOMMENDATIONS FOR PRACTICE

Clinical recommendationEvidence ratingReferences

Ultrasound measurement of a cross-sectional area of the median nerve by an experienced clinician may be used as a diagnostic test for carpal tunnel syndrome.

C

14, 15

Local corticosteroid injection is effective for more than one month in patients with mild to moderate carpal tunnel syndrome and delays the need for surgery at one year.

A

2024

Splinting, therapeutic ultrasound, carpal bone mobilization, and nerve glide exercises are effective short-term treatments for carpal tunnel syndrome.

B

2527

Endoscopic and open carpal tunnel release are equally effective, long-lasting treatments for carpal tunnel syndrome.

A

30


A = consistent, good-quality patient-oriented evidence; B = inconsistent or limited-quality patient-oriented evidence; C = consensus, disease-oriented evidence, usual practice, expert opinion, or case series. For information about the SORT evidence rating system, go to http://www.aafp.org/afpsort.

The carpal tunnel is bordered superiorly by the transverse carpal ligament and inferiorly by the carpal bones, through which the median nerve and nine flexor tendons of the forearm pass. Increased pressure in the carpal tunnel leads to compression and damage of the median nerve.4

Symptoms

The hallmarks of CTS are pain and

The Authors

show all author info

JENNIFER WIPPERMAN, MD, MPH, is an assistant professor with the University of Kansas School of Medicine–Wichita, and is an associate director with the Via Christi Family Medicine Residency in Wichita....

KYLE GOERL, MD, is an assistant professor in the Department of Family and Community Medicine at the University of Kansas School of Medicine–Wichita, and an associate director with the Via Christi Sports Medicine Fellowship and Family Medicine Residency.

Address correspondence to Jennifer Wipperman, MD, MPH, University of Kansas School of Medicine–Wichita, 1010 N. Kansas, Wichita, KS 67214 (e-mail: Jennifer.wipperman@viachristi.org). Reprints are not available from the authors.

Author disclosure: No relevant financial affiliations.

REFERENCES

show all references

1. Atroshi I, Gummesson C, Johnsson R, Ornstein E, Ranstam J, Rosén I. Prevalence of carpal tunnel syndrome in a general population. JAMA. 1999;282(2):153–158....

2. Kozak A, Schedlbauer G, Wirth T, Euler U, Westermann C, Nienhaus A. Association between work-related biomechanical risk factors and the occurrence of carpal tunnel syndrome: an overview of systematic reviews and a meta-analysis of current research. BMC Musculoskelet Disord. 2015;16:231.

3. Harris-Adamson C, Eisen EA, Kapellusch J, et al. Biomechanical risk factors for carpal tunnel syndrome: a pooled study of 2474 workers. Occup Environ Med. 2015;72(1):33–41.

4. Keir PJ, Rempel DM. Pathomechanics of peripheral nerve loading. Evidence in carpal tunnel syndrome. J Hand Ther. 2005;18(2):259–269.

5. LeBlanc KE, Cestia W. Carpal tunnel syndrome. Am Fam Physician. 2011;83(8):952–958.

6. Pryse-Phillips WE. Validation of a diagnostic sign in carpal tunnel syndrome. J Neurol Neurosurg Psychiatry. 1984;47(8):870–872.

7. Shiri R. A square-shaped wrist as a predictor of carpal tunnel syndrome: a meta-analysis. Muscle Nerve. 2015;52(5):709–713.

8. D'Arcy CA, McGee S. The rational clinical examination. Does this patient have carpal tunnel syndrome? [published correction appears in JAMA. 2000;284(11): 1384]. JAMA. 2000;283(23):3110–3117.

9. MacDermid JC, Wessel J. Clinical diagnosis of carpal tunnel syndrome: a systematic review. J Hand Ther. 2004;17(2):309–319.

10. Ahn DS. Hand elevation: a new test for carpal tunnel syndrome. Ann Plast Surg. 2001;46(2):120–124.

11. Katz JN, Stirrat CR, Larson MG, Fossel AH, Eaton HM, Liang MH. A self-administered hand symptom diagram for the diagnosis and epidemiologic study of carpal tunnel syndrome. J Rheumatol. 1990;17(11):1495–1498.

12. Jablecki CK, Andary MT, Floeter MK, et al. Practice parameter: electrodiagnostic studies in carpal tunnel syndrome. Report of the American Association of Electrodiagnostic Medicine, American Academy of Neurology, and the American Academy of Physical Medicine and Rehabilitation. Neurology. 2002;58(11):1589–1592.

13. Witt JC, Hentz JG, Stevens JC. Carpal tunnel syndrome with normal nerve conduction studies. Muscle Nerve. 2004;29(4):515–522.

14. Tai TW, Wu CY, Su FC, Chern TC, Jou IM. Ultrasonography for diagnosing carpal tunnel syndrome: a meta-analysis of diagnostic test accuracy. Ultrasound Med Biol. 2012;38(7):1121–1128.

15. Fowler JR, Hirsch D, Kruse K. The reliability of ultrasound measurements of the median nerve at the carpal tunnel inlet. J Hand Surg Am. 2015;40(10):1992–1995.

16. Shi Q, MacDermid JC. Is surgical intervention more effective than non-surgical treatment for carpal tunnel syndrome? A systematic review. J Orthop Surg Res. 2011;6:17.

17. Page MJ, Massy-Westropp N, O'Connor D, Pitt V. Splinting for carpal tunnel syndrome. Cochrane Database Syst Rev. 2012(7):CD010003.

18. Burke DT, Burke MM, Stewart GW, Cambré A. Splinting for carpal tunnel syndrome: in search of the optimal angle. Arch Phys Med Rehabil. 1994;75(11):1241–1244.

19. Marshall S, Tardif G, Ashworth N. Local corticosteroid injection for carpal tunnel syndrome. Cochrane Database Syst Rev. 2007;(2):CD001554.

20. Atroshi I, Flondell M, Hofer M, Ranstam J. Methylprednisolone injections for the carpal tunnel syndrome: a randomized, placebo-controlled trial. Ann Intern Med. 2013;159(5):309–317.

21. Karadaş Ö, Tok F, Akarsu S, Tekin L, Balaban B. Triamcinolone acetonide vs procaine hydrochloride injection in the management of carpal tunnel syndrome: randomized placebo-controlled study. J Rehabil Med. 2012;44(7):601–604.

22. Ly-Pen D, Andréu JL, Millán I, de Blas G, Sánchez-Olaso A. Comparison of surgical decompression and local steroid injection in the treatment of carpal tunnel syndrome: 2-year clinical results from a randomized trial. Rheumatology (Oxford). 2012;51(8):1447–1454.

23. Peters-Veluthamaningal C, Winters JC, Groenier KH, Meyboom-de Jong B. Randomised controlled trial of local corticosteroid injections for carpal tunnel syndrome in general practice. BMC Fam Pract. 2010;11:54.

24. Lee JY, Park Y, Park KD, Lee JK, Lim OK. Effectiveness of ultrasound-guided carpal tunnel injection using in-plane ulnar approach: a prospective, randomized, single-blinded study. Medicine (Baltimore). 2014;93(29):e350.

25. Huisstede BM, Hoogvliet P, Randsdorp MS, Glerum S, van Middelkoop M, Koes BW. Carpal tunnel syndrome. Part I: effectiveness of nonsurgical treatments—a systematic review. Arch Phys Med Rehabil. 2010;91(7):981–1004.

26. Page MJ, O'Connor D, Pitt V, Massy-Westropp N. Exercise and mobilisation interventions for carpal tunnel syndrome. Cochrane Database Syst Rev. 2012;(6):CD009899.

27. Page MJ, O'Connor D, Pitt V, Massy-Westropp N. Therapeutic ultrasound for carpal tunnel syndrome. Cochrane Database Syst Rev. 2013;(3):CD009601.

28. Garfinkel MS, Singhal A, Katz WA, Allan DA, Reshetar R, Schumacher HR Jr. Yoga-based intervention for carpal tunnel syndrome: a randomized trial. JAMA. 1998;280(18):1601–1603.

29. Turner A, Kimble F, Gulyás K, Ball J. Can the outcome of open carpal tunnel release be predicted?: a review of the literature. ANZ J Surg. 2010;80(1–2):50–54.

30. Vasiliadis HS, Georgoulas P, Shrier I, Salanti G, Scholten RJ. Endoscopic release for carpal tunnel syndrome. Cochrane Database Syst Rev. 2014;(1):CD008265.

31. American Academy of Orthopaedic Surgeons. Management of carpal tunnel syndrome evidence-based clinical practice guideline. December 15, 2016. http://www.aaos.org/ctsguideline. Accessed December 15, 2016.

32. Viera AJ. Management of carpal tunnel syndrome. Am Fam Physician. 2003;68(2):265–272.

 

 

Copyright © 2016 by the American Academy of Family Physicians.
This content is owned by the AAFP. A person viewing it online may make one printout of the material and may use that printout only for his or her personal, non-commercial reference. This material may not otherwise be downloaded, copied, printed, stored, transmitted or reproduced in any medium, whether now known or later invented, except as authorized in writing by the AAFP. Contact afpserv@aafp.org for copyright questions and/or permission requests.

Want to use this article elsewhere? Get Permissions

CME Quiz

More in AFP


Editor's Collections


Related Content


More in Pubmed

MOST RECENT ISSUE


Sep 15, 2017

Access the latest issue of American Family Physician

Read the Issue


Email Alerts

Don't miss a single issue. Sign up for the free AFP email table of contents.

Sign Up Now

Navigate this Article