Carpal tunnel syndrome

Last updated: September 15, 2023

Summarytoggle arrow icon

Carpal tunnel syndrome (CTS) is a peripheral neuropathy caused by chronic or acute compression of the median nerve under the transverse carpal ligament. CTS is the most common form of entrapment neuropathy, a group that includes cubital tunnel syndrome, radiculopathies, and tarsal tunnel syndrome. It is characterized by both sensory disturbances (pain, tingling, and numbness) and motor symptoms (weakened thenar muscles leading to weakened pinch and grip of the thumb) in the area innervated by the median nerve distal to the carpal tunnel. Several occupational and nonoccupational risk factors (e.g., manual labor, age, sex, diabetes) have been associated with CTS. Diagnosis is usually clinical, supported by symptoms and results of provocative tests for CTS (e.g., hand elevation test, carpal compression test, and Phalen test). Additional testing (e.g., electrodiagnostic studies) is indicated if there is diagnostic uncertainty. Patients with mild to moderate symptoms are generally managed conservatively (e.g., immobilization with a splint, local steroid injections). Surgical release of the transverse carpal ligament with decompression of the median nerve may be indicated for patients with severe disease (e.g., atrophy of the thenar eminence) or symptoms refractory to conservative treatment.

Epidemiologytoggle arrow icon

Epidemiological data refers to the US, unless otherwise specified.

Etiologytoggle arrow icon

CTS is caused by compression of the median nerve in the carpal tunnel, under the transverse carpal ligament. [2]

Risk factors [2][3][4]

Pathophysiologytoggle arrow icon

Clinical featurestoggle arrow icon

Symptoms [12]

  • Develop in the areas innervated by the median nerve: palmar surface of the thumb, index, and middle fingers, and radial half of the ring finger.
    • Paresthesia: burning sensation, tingling
    • Loss of sensation/numbness
    • Pain: may radiate to the forearm and/or upper arm
  • Typically worsen at night
  • Patients often report that symptoms improve by shaking the hand (flick sign). [12]
  • Severely affected patients may report:
    • Dropping objects; and difficulty with fine motor skills (e.g., buttoning up clothing) secondary to weakened finger pinch and grip strength
    • Disappearance of pain [12]

Motor deficits are typically only seen in severe disease. [12]

Examination findings [12]

Sensory innervation of the thenar eminence is not affected in CTS.

The "pope's blessing" (inability to flex the first three digits when making a fist) is not a symptom of CTS. It is only seen in proximal lesions of the median nerve

Examine the entire upper limb to rule out differential diagnoses of CTS. [12]

Diagnosticstoggle arrow icon

General principles [2][12]

Provocative tests for CTS [2][12]

  • Overview
  • Commonly used provocation tests
    • Phalen test: The patient's wrist is held in full flexion (90°) for one minute. [13]
    • Tinel sign: The examiner percusses or taps with the fingertips over the carpal tunnel.
    • Hand elevation test: The patient holds both hands above their head for one minute.
    • Carpal compression test: The examiner uses a finger to apply moderate pressure directly over the carpal tunnel for 30 seconds.

Do not use a single provocative test to diagnose CTS; using a combination of tests increases diagnostic accuracy. [2]

Electrophysiological tests [2][12]

Electrodiagnostic studies are not necessary to confirm a clinical diagnosis of CTS but should be ordered when the diagnosis is uncertain and for patients scheduled to have surgery. [2][12]

Additional evaluation [2][12][16]

Differential diagnosestoggle arrow icon

The differential diagnoses listed here are not exhaustive.

Treatmenttoggle arrow icon

Approach [2][12]

  • Mild to moderate disease [12]
    • Trial immobilization or glucocorticoid injection.
    • No response after 6 weeks [12]
      • Assess for adherence.
      • Trial alternate conservative methods.
  • Severe or refractory disease: Refer to a hand specialist for possible surgery. [12]

Conservative management [2][12]

Oral analgesia (e.g., NSAIDs, gabapentin) is not effective in managing CTS. [2][12]

Surgery [2][12]

Patients with severe disease may not fully recover function but nerve conduction studies should show an improvement. [12]

Complicationstoggle arrow icon

Recurrence of CTS is rare (0.5–3%). [18]

We list the most important complications. The selection is not exhaustive.

Special patient groupstoggle arrow icon

Carpal tunnel syndrome in pregnancy [7]

Referencestoggle arrow icon

  1. Ibrahim I, Khan WS, Goddard N, Smitham P. Carpal Tunnel Syndrome: A Review of the Recent Literature. Open Orthop J. 2012; 6: p.69-76.doi: 10.2174/1874325001206010069 . | Open in Read by QxMD
  2. Graham et al. Management of Carpal Tunnel Syndrome Evidence-Based Clinical Practice Guideline. J Bone Joint Surg Am. 2016; 98 (20): p.1750-1754.doi: 10.2106/JBJS.16.00719 . | Open in Read by QxMD
  3. Geoghegan JM, Clark DI, Bainbridge LC, Smith C, Hubbard R. Risk factors in carpal tunnel syndrome. J Hand Surg Br. 2004; 29 (4): p.315-320.doi: 10.1016/j.jhsb.2004.02.009 . | Open in Read by QxMD
  4. Al Shahrani E, Al Shahrani A, Al-Maflehi N. Personal factors associated with carpal tunnel syndrome (CTS): a case-control study. BMC Musculoskelet Disord. 2021; 22 (1).doi: 10.1186/s12891-021-04941-y . | Open in Read by QxMD
  5. Cansü E, Heydar AM, Alakbarov A, Ünal MB. Neglected lunate dislocation presenting as carpal tunnel syndrome. Case Reports Plast Surg Hand Surg. 2015; 2 (1): p.22-24.doi: 10.3109/23320885.2014.993397 . | Open in Read by QxMD
  6. Palmer KT. Carpal tunnel syndrome: The role of occupational factors. Best Pract Res Clin Rheumatol. 2011; 25 (1): p.15-29.doi: 10.1016/j.berh.2011.01.014 . | Open in Read by QxMD
  7. Gooding MS, Evangelista V, Pereira L. Carpal Tunnel Syndrome and Meralgia Paresthetica in Pregnancy. Obstet Gynecol Surv. 2020; 75 (2): p.121-126.doi: 10.1097/ogx.0000000000000745 . | Open in Read by QxMD
  8. Haddiya I, Yacoubi H, Bentata Y. Why does Carpal Tunnel Syndrome Still Occur in our Chronic Hemodialysis Patients?. Journal of Nephrology & Therapeutics. 2018; 08 (03).doi: 10.4172/2161-0959.1000310 . | Open in Read by QxMD
  9. Karne SS, Bhalerao NS. Carpal Tunnel Syndrome in Hypothyroidism. J Clin Diagn Res. 2016; 10 (2): p.OC36-OC38.doi: 10.7860/JCDR/2016/16464.7316 . | Open in Read by QxMD
  10. Wipperman J, Goerl K. Carpal Tunnel Syndrome: Diagnosis and Management. Am Fam Physician. 2016; 94 (12): p.993-999.
  11. Robert A. Werner, Cynthia Bir, Thomas J. Armstrong. Reverse Phalen's maneuver as an aid in diagnosing carpal tunnel syndrome. Arch Phys Med Rehabil. 1994; 75 (7): p.783-786.doi: 10.1016/0003-9993(94)90136-8 . | Open in Read by QxMD
  12. Wang L. Electrodiagnosis of Carpal Tunnel Syndrome. Phys Med Rehabil Clin N Am. 2013; 24 (1): p.67-77.doi: 10.1016/j.pmr.2012.09.001 . | Open in Read by QxMD
  13. Padua L, Coraci D, Erra C, et al. Carpal tunnel syndrome: clinical features, diagnosis, and management. Lancet Neurol. 2016; 15 (12): p.1273-1284.doi: 10.1016/s1474-4422(16)30231-9 . | Open in Read by QxMD
  14. Rubin DA, Roberts CC, Bencardino JT, Bell AM, Carter Cassidy R et al. ACR Appropriateness Criteria ® Chronic Wrist Pain. J Am Coll Radiol. 2018; 15 (5): p.S39-S55.doi: 10.1016/j.jacr.2018.03.021 . | Open in Read by QxMD
  15. Page MJ, Massy-Westropp N, O’Connor D, Pitt V. Splinting for carpal tunnel syndrome. Cochrane Database Syst Rev. 2012.doi: 10.1002/14651858.cd010003 . | Open in Read by QxMD
  16. Concannon MJ, Brownfield ML, Puckett CL. The incidence of recurrence after endoscopic carpal tunnel release. Plast Reconstr Surg. 2000; 105 (5): p.1662-1665.
  17. Wright C, Smith B, Wright S, Weiner M, Wright K, Rubin D. Who develops carpal tunnel syndrome during pregnancy: An analysis of obesity, gestational weight gain, and parity. Obstet Med.. 2014; 7 (2): p.90-94.doi: 10.1177/1753495x14523407 . | Open in Read by QxMD
  18. Padua L, Pasquale AD, Pazzaglia C, Liotta GA, Librante A, Mondelli M. Systematic review of pregnancy-related carpal tunnel syndrome. Muscle Nerve. 2010; 42 (5): p.697-702.doi: 10.1002/mus.21910 . | Open in Read by QxMD
  19. Martins RS, Siqueira MG. Conservative therapeutic management of carpal tunnel syndrome. Arq Neuropsiquiatr. 2017; 75 (11): p.819-824.doi: 10.1590/0004-282x20170152 . | Open in Read by QxMD
  20. KLEIN A. Peripheral Nerve Disease in Pregnancy. Clin Obstet Gynecol. 2013; 56 (2): p.382-388.doi: 10.1097/grf.0b013e31828f260e . | Open in Read by QxMD
  21. Ghasemi-rad M, Nosair E, Vegh A, Mohammadi A, Akkad A, Lesha E et al.. A handy review of carpal tunnel syndrome: From anatomy to diagnosis and treatment. World J Radiol. 2014; 6 (6): p.284-300.doi: 10.4329/wjr.v6.i6.284 . | Open in Read by QxMD
  22. Aboong MS. Pathophysiology of carpal tunnel syndrome. Neurosciences (Riyadh). 2015; 20 (1): p.4-9.

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