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Carpal Tunnel Syndrome

From WikiSM

Other Names

  • Median Neuropathy
  • CTS
  • Entrapment of the median nerve
  • Carpal Tunnel Syndrome
  • Median nerve compression syndrome
  • Median nerve entrapment at the wrist
  • Median neuropathy at the wrist
  • Carpal tunnel neuropathy
  • Anterior wrist neuropathy (less common)

Background

History

  • Needs to be updated

Epidemiology

  • Most common nerve entrapment syndrome, affecting 3-6% of adults[1][2]
  • Up to 15% incidence
Illustration of carpal tunnel syndrome[3]
Illustration of the carpal tunnel overlying an MRI of the wrist[4]
Illustration of the carpal tunnel[5]

Introduction

General

  • Compressive Neuropathy of the median nerve
  • Associated with significant morbidity, and disability
  • Dominant hand most commonly affected, however bilateral approximately 30% of the time
  • Occurs as either a result decrease in size of the carpal tunnel and/or diseases increasing the contents of the carpal tunnel

Decrease in carpal tunnel size

Increase in carpal tunnel contents

  • Masses
  • Deposition of pathologic material
  • Synovial hypertrophy or inflammation (most common)

Anatomy of the Carpal Tunnel

  • Carpal tunnel anatomic borders
  • Median Nerve
    • Contributions from C5 to T1
    • innervates multiple muscles of the hand and wrist primarily responsible for flexion activities
    • Sensory of the palmar aspects of digits 1-3, half of 4 as well as dorsal side of the fingertips

Risk Factors

Predisposing factors that might be implicated in carpal tunnel syndrome[6]

Mnemonic: MEDIAN TRAP

General

  • Ages 30s-60s
  • Women > Men
  • Obesity
  • Pregnancy
  • Hypothyroidism
  • Rheumatoid Arthritis
  • Chronic Renal Failure
  • Tobacco Use
  • Alcohol Use
  • Repetitive activities
  • Mucopolysaccharidosis
  • Mucolipidosis
  • Leukemia
  • Multiple Myeloma

Sports

Differential Diagnosis

Differential Diagnosis Wrist Pain

Differential Diagnosis Hand Pain

Other Considerations

Clinical Features

Typical distribution of symptoms
Thenar atrophy of the left hand[7]
Clinical demonstration of Durkan's test[8]

History

  • Symptoms in distribution of median nerve
  • Patients typically report nocturnal pain ascending from the wrist (brachialgia paraesthetica nocturna)
  • Sensory symptoms affect first 3 and 1/2 digits (radial side)
  • Symptoms may radiate into forearm
  • Flick Sign: Patient 'flicks' wrist and hand similar to shaking a thermometer

Physical Exam: Physical Examination Wrist

  • Typically reassuring
  • Motor weakness is a late symptom
  • Thenar atrophy

Special Tests

Longitudinal axis U/S image of the median nerve showing the notch sign and corresponding schematic drawing. Swelling portion (open arrows), proximal to the level of compression (arrowheads) and the nerve flattening (white arrows) deep to the transverse carpal ligament (curved arrow)[9]

Evaluation

Radiographs

Ultrasound

  • A normal cross sectional area is between 10-13mm
  • A cross sectional area >13mm is consistent with carpal tunnel syndrome
  • You can also visualize flattening of the median nerve at the hamate.
  • Palmer bowing of the flexor retinaculum [10]
  • Engorgement or enlargement of the nerve proximal to the retinaculum

MRI

  • Palmer bowing of flexor retinaculum
  • Elargement of median nerve
  • Flattening of median nerve

Diagnostic Criteria

  • Numbness, tingling in median nerve distribution
  • Weakness/atrophy of thenar musculature
  • Nocturnal symptoms
  • Positive tinel or phalen test
  • Loss of 2PV

EMG/NCS

  • Most objective diagnostic modality and thus gold standard
  • Not needed to diagnose, helpful in refractory cases or uncertainty in diagnosis
  • Useful to confirm if surgical management being considered
  • NCS: Prolonged latencies, slower conduction velocities
  • EMG: sharp waves, fibrillations, fasciulations, complex repetitive changes

Classification

Disease Classification in Carpal Tunnel Syndrome

Classification Duration Two-Point Discrimination Weakness Atrophy EMG NCS
Mild Less than 1 year Normal Absent Absent Non deneveration No-to-mild velocity decrease
Moderate Shorter or longer than 1 year Possible abnormality Minimal presence Minimal presence No-to-mild deneveration No-to-mild velocity decrease
Severe Longer than 1 year Marked abnormality Marked presence Marked presence Marked deneveration Marked velocity decrease

Management

Cock Up Wrist Splint

A carpal tunnel following standard surgical release[11]
Open carpal tunnel release (OCTR) – transverse carpal ligament released[12]

Nonoperative

  • Indications
    • First line treatment for all atraumatic cases
  • Splints
  • Activity modification[15]
    • Avoiding repetitive motions
    • Use ergonomic equipment (e.g., wrist rest, mouse pad)
    • Take breaks
    • Using keyboard alternatives (e.g., digital pen, voice recognition and dictation software)
    • Alternative job functions
  • Physical Therapy
    • Ultrasound Therapy: Superior to sham treatment[16]
  • Corticosteroid Injection
    • Transient improvement often for only 1-2 months, only 20% or so symptom free at 1 year[17]
    • Lack of response is poor prognostic indicator for surgery
  • Platelet Rich Plasma
    • In a single arm, prospective study, 70% of patients reported positive outcomes ≥2 years post-injection[18]
  • Medications

Operative

  • Carpal tunnel release
    • Failure of conservative management
    • Acute median neuropathy following trauma
  • Revision of carpal tunnel release
    • Most commonly due to incomplete primary release

Rehab and Return to Play

Exercises for Carpal Tunnel Syndrome
Carpal tunnel rehab exercises[22]

Rehabilitation

  • General care
    • Duration 4-6 weeks
    • Manual therapy with median nerve gliding and tendon gliding exercises
    • Carpal mobilization and soft tissue release
    • Cervical and shoulder mobilization of proximal entrapment considered
  • Therapeutic exercises
    • Median Nerve Glide
    • Tendon Glide
    • Strengthening
    • Stretching
  • Treatment Modalities
    • Ultrasound therapy
    • Iontophoresis with dexamethasone
    • Low level laser therapy (LLLT)
    • Contrast baths or paraffin wax

Home Exercise Program PDFs

Return to Play/Work

  • Depends on patient tolerance and ability to play
  • In surgical cases, at discretion of surgeon
  • General RTP guidelines
    • Asymptomatic during activity
    • Normal grip strength
    • Absence of nocturnal symptoms

Prognosis and Complications

Prognosis

  • General
    • Generally favorable with appropraite treatment
    • Varies depending on symptom severity, duration and management strategy
  • Conservative management
    • Mild to moderate symptom relief with conservative management
    • A substantial portion will eventually require surgery
    • 23–89% of conservatively managed patients have persistent or worsening symptoms at 3 years, and 57–66% ultimately undergo surgery[23]
    • Younger patients, milder cases associated with better outcomes
  • Surgical management
    • High likelihood of symptom resolution and functional improvement
    • 82% of patients report improved or vast improvement at 18 months compared to 61% with corticosteroids[24]
    • Median time to recovery is shorter at 9 months compared to injection at 18 months
    • Early surgical intervention is particularly beneficial
  • Favorable prognostic indicators[25]
    • Higher baseline health utility
    • Fewer comorbidities
    • Lower anxiety
    • Good response to corticosteroid injection

Complications

  • Progressive sensory and motor deficits
  • Functional impairments
  • Irreversible nerve damage
  • Chronic pain
  • Weakness
  • Inability to perform job
  • Thenar muscle atrophy
  • Reduced quality of life

See Also

External

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. ↑ Miller TT, Reinus WR. Nerve entrapment syndromes of the elbow, forearm, and wrist. AJR Am J Roentgenol. 2010;195 (3): 585-94. AJR Am J Roentgenol (full text) - doi:10.2214/AJR.10.4817
  3. ↑ Joshi, Aditya, et al. "Carpal tunnel syndrome: pathophysiology and comprehensive guidelines for clinical evaluation and treatment." Cureus 14.7 (2022).
  4. ↑ Image courtesy of orthobullets.com
  5. ↑ Li, Yiming, et al. "A Retrospective Clinical Study of Endoscopic Treatment of Carpal Tunnel Syndrome using the Modified Soft Tissue Release kit." Orthopaedic Surgery 15.1 (2023): 179-186.
  6. ↑ Malakootian, Mahshid, et al. "Pathophysiology, diagnosis, treatment, and genetics of carpal tunnel syndrome: a review." Cellular and molecular neurobiology 43.5 (2023): 1817-1831.
  7. ↑ Image courtesy of stanfordmedicine25.stanford.edu
  8. ↑ Zhang, Dafang, et al. "Accuracy of Provocative Tests for Carpal Tunnel Syndrome." Journal of Hand Surgery Global Online 2.3 (2020): 121-125.
  9. ↑ Kolovos, Stylianos, and Dimitrios Tsiotas. "Ultrasonographic diagnosis of carpal tunnel syndrome: introducing a new approach." European Journal of Orthopaedic Surgery & Traumatology 26 (2016): 167-175.
  10. ↑ https://radiopaedia.org/articles/carpal-tunnel-syndrome-1?lang=us
  11. ↑ Castillo, Rochelle, et al. "Recurrent carpal tunnel syndrome associated with extension of flexor digitorum muscle bellies into the carpal tunnel: a case series." Archives of Plastic Surgery 45.05 (2018): 474-478.
  12. ↑ Mizia, Ewa, et al. "Carpal tunnel syndrome—anatomical and clinical correlations." Folia Medica Cracoviensia (2013).
  13. ↑ Brininger TL, Rogers JC, Holm MB, Baker NA, Li ZM, Goitz RJ. Efficacy of a fabricated customized splint and tendon and nerve gliding exercises for the treatment of carpal tunnel syndrome: a randomized controlled trial. Arch Phys Med Rehabil. 2007;88(11):1429–1435.
  14. ↑ Walker WC, Metzler M, Cifu DX, Swartz Z. Neutral wrist splinting in carpal tunnel syndrome: a comparison of night-only versus full-time wear instructions. Arch Phys Med Rehabil. 2000;81(4):424–429.
  15. ↑ https://www.aafp.org/afp/2011/0415/p952.html#afp20110415p952-b6
  16. ↑ Ebenbichler GR, Resch KL, Nicolakis P, Wiesinger GF, Uhl F, Ghanem AH, et al. Ultrasound treatment for treating the carpal tunnel syndrome: randomised “sham” controlled trial. BMJ. 1998;316:731–5.
  17. ↑ Marshall S, Tardif G, Ashworth N. Local corticosteroid injection for carpal tunnel syndrome. Cochrane Database Syst Rev. 2007;(2):CD001554.
  18. ↑ Lai CY, Li TY, Lam KHS, Chou YC, Hueng DY, Chen LC, Wu YT. The long-term analgesic effectiveness of platelet-rich plasma injection for carpal tunnel syndrome: a cross-sectional cohort study. Pain Med. 2022 Jan 19:pnac011. doi: 10.1093/pm/pnac011. Epub ahead of print. PMID: 35043941.
  19. ↑ Spooner GR, Desai HB, Angel JF, Reeder BA, Donat JR. Using pyridoxine to treat carpal tunnel syndrome. Randomized control trial. Can Fam Physician. 1993;39:2122–7.
  20. ↑ Chang MH, Chiang HT, Lee SS, Ger LP, Lo YK. Oral drug of choice in carpal tunnel syndrome. Neurology. 1998;51:390–3.
  21. ↑ Pal B, Mangion P, Hossain MA, Wallace AS, Diffey BL. Should diuretics be prescribed for idiopathic carpal tunnel syndrome? Results of a controlled trial. Clin Rehabil. 1988;2:299–301.
  22. ↑ Image courtesy of https://ptandme.com/
  23. ↑ Burton, Claire L., et al. "Clinical course and prognostic factors in conservatively managed carpal tunnel syndrome: a systematic review." Archives of physical medicine and rehabilitation 97.5 (2016): 836-852.
  24. ↑ Palmbergen, Wijnand AC, et al. "Surgery versus corticosteroid injection for carpal tunnel syndrome (DISTRICTS): an open-label, multicentre, randomised controlled trial." The Lancet 405.10495 (2025): 2153-2163.
  25. ↑ Jerosch‐Herold, Christina, et al. "Prognostic factors for response to treatment by corticosteroid injection or surgery in carpal tunnel syndrome (palms study): a prospective multicenter cohort study." Muscle & Nerve 60.1 (2019): 32-40.
Created by:
John Kiel on 14 June 2019 08:38:10
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Last edited:
9 March 2026 19:13:21
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