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Carpal Tunnel Syndrome Clinical Presentation

  • Author: Nigel L Ashworth, MBChB, MSc, FRCPC; Chief Editor: Robert H Meier, III, MD  more...
 
Updated: Jul 01, 2015
 

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 of the autonomic fibers to the 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.
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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.
    • 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.
    • L - First and second lumbricals
    • O - Opponens pollicis
    • A - Abductor pollicis brevis
    • F - Flexor pollicis brevis
  • Special tests - No good clinical test exists to support the diagnosis of CTS.
    • 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.
    • 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.
    • 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%.
    • 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.
    • 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.
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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
    • Increasing age
    • Female sex
    • Increased body mass index (BMI), especially a recent increase
    • Square-shaped wrist
    • Short stature
    • Dominant hand
    • Race (white)
  • Genetics
    • 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).
  • Medical conditions
    • 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

A study by Fernández-Munoz et al reported that in women with CTS, the following predict the severity of hand pain[10] :

  • Function
  • Thumb-middle finger pinch tip grip force
  • Thumb-little finger pinch tip grip force
  • Depression
  • Pressure pain threshold (radial nerve)
  • Pressure pain threshold (carpal tunnel)
  • Heat pain threshold (carpal tunnel)

The study, which involved 224 women with CTS, indicated that these factors are responsible for 36.5% of variance in pain intensity.

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Contributor Information and Disclosures
Author

Nigel L Ashworth, MBChB, MSc, FRCPC Professor, Divisions of Physical Medicine and Rehabilitation and Neurology, University of Alberta Faculty of Medicine and Dentistry, Canada

Nigel L Ashworth, MBChB, MSc, FRCPC is a member of the following medical societies: Canadian Society of Clinical Neurophysiologists, Australian & New Zealand Association of Neurologists, American Association of Neuromuscular and Electrodiagnostic Medicine, British Medical Association, Canadian Medical Association, Royal College of Physicians and Surgeons of Canada

Disclosure: Nothing to disclose.

Specialty Editor Board

Francisco Talavera, PharmD, PhD Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Received salary from Medscape for employment. for: Medscape.

Patrick M Foye, MD Director of Coccyx Pain Center, Professor and Interim Chair of Physical Medicine and Rehabilitation, Rutgers New Jersey Medical School; Co-Director of Musculoskeletal Fellowship, Co-Director of Back Pain Clinic, University Hospital

Patrick M Foye, MD is a member of the following medical societies: American Academy of Physical Medicine and Rehabilitation, International Spine Intervention Society, American Association of Neuromuscular and Electrodiagnostic Medicine, Association of Academic Physiatrists

Disclosure: Nothing to disclose.

Chief Editor

Robert H Meier, III, MD Director, Amputee Services of America; Active Medical Staff, Presbyterian/St Luke’s Hospital, Spalding Rehabilitation Hospital, Select Specialty Hospital; Consulting Staff, Kindred Hospital

Robert H Meier, III, MD is a member of the following medical societies: American Academy of Physical Medicine and Rehabilitation, Association of Academic Physiatrists

Disclosure: Nothing to disclose.

Additional Contributors

Benjamin M Sucher, DO, FAOCPMR, FAAPMR Medical Director, EMG Labs of AARA (Arizona Arthritis and Rheumatology Associates)

Benjamin M Sucher, DO, FAOCPMR, FAAPMR is a member of the following medical societies: American Academy of Physical Medicine and Rehabilitation, American Osteopathic College of Physical Medicine and Rehabilitation, Arizona Society of Physical Medicine and Rehabilitation, American Association of Neuromuscular and Electrodiagnostic Medicine, American Osteopathic Association

Disclosure: Nothing to disclose.

References
  1. de Krom MC, Kester AD, Knipschild PG, et al. Risk factors for carpal tunnel syndrome. Am J Epidemiol. 1990 Dec. 132(6):1102-10. [Medline].

  2. Atroshi I, Gummesson C, Johnsson R, et al. Prevalence of carpal tunnel syndrome in a general population. JAMA. 1999 Jul 14. 282(2):153-8. [Medline]. [Full Text].

  3. de Krom MC, Knipschild PG, Kester AD, et al. Carpal tunnel syndrome: prevalence in the general population. J Clin Epidemiol. 1992 Apr. 45(4):373-6. [Medline].

  4. Goga IE. Carpal tunnel syndrome in black South Africans. J Hand Surg [Br]. 1990 Feb. 15(1):96-9. [Medline].

  5. Garland FC, Garland CF, Doyle EJ Jr, et al. Carpal tunnel syndrome and occupation in U.S. Navy enlisted personnel. Arch Environ Health. 1996 Sep-Oct. 51(5):395-407. [Medline].

  6. Durkan JA. The carpal-compression test. An instrumented device for diagnosing carpal tunnel syndrome. Orthop Rev. 1994 Jun. 23(6):522-5. [Medline].

  7. Kao SY. Carpal tunnel syndrome as an occupational disease. J Am Board Fam Pract. 2003 Nov-Dec. 16(6):533-42. [Medline]. [Full Text].

  8. Palmer KT, Harris EC, Coggon D. Carpal tunnel syndrome and its relation to occupation: a systematic literature review. Occup Med (Lond). 2007 Jan. 57(1):57-66. [Medline].

  9. Bernard PB, ed. Musculoskeletal Disorders and Workplace Factors: A Critical Review of Epidemiologic Evidence for Work-Related Musculoskeletal Disorders of the Neck, Upper Extremity, and Low Back. National Institute for Occupational Safety and Health. Jul 1997. Available at http://www.cdc.gov/niosh/docs/97-141/.

  10. Fernandez-Munoz JJ, Palacios-Cena M, Cigaran-Mendez M, et al. Pain is Associated to Clinical, Psychological, Physical, and Neuro-physiological Variables in Women with Carpal Tunnel Syndrome. Clin J Pain. 2015 Apr 15. [Medline].

  11. Zagnoli F, Andre V, Le Dreff P, et al. Idiopathic carpal tunnel syndrome. Clinical, electrodiagnostic, and magnetic resonance imaging correlations. Rev Rhum Engl Ed. 1999 Apr. 66(4):192-200. [Medline].

  12. Lee D, van Holsbeeck MT, Janevski PK, et al. Diagnosis of carpal tunnel syndrome. Ultrasound versus electromyography. Radiol Clin North Am. 1999 Jul. 37(4):859-72, x. [Medline].

  13. 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 Jul. 38(7):1121-8. [Medline].

  14. Cartwright MS. Ultrasound of focal neuropathies. Walker FO, Cartwright MS, eds. Neuromuscular Ultrasound. Philadelphia, Pa: Elsevier Saunders; 2011. 74-76.

  15. Robinson LR. Electrodiagnosis of carpal tunnel syndrome. Phys Med Rehabil Clin N Am. 2007 Nov. 18(4):733-46, vi. [Medline].

  16. Practice parameter for electrodiagnostic studies in carpal tunnel syndrome: summary statement. American Association of Electrodiagnostic Medicine, American Academy of Neurology, American Academy of Physical Medicine and Rehabilitation. Muscle Nerve. 1993 Dec. 16(12):1390-1. [Medline].

  17. Stevens JC. AAEM minimonograph #26: the electrodiagnosis of carpal tunnel syndrome. American Association of Electrodiagnostic Medicine. Muscle Nerve. 1997 Dec. 20(12):1477-86. [Medline].

  18. Chang MH, Lee YC, Hsieh PF. The real role of forearm mixed nerve conduction velocity in the assessment of proximal forearm conduction slowing in carpal tunnel syndrome. J Clin Neurophysiol. 2008 Nov 6. [Medline].

  19. Banta CA. A prospective, nonrandomized study of iontophoresis, wrist splinting, and antiinflammatory medication in the treatment of early-mild carpal tunnel syndrome. J Occup Med. 1994 Feb. 36(2):166-8. [Medline].

  20. Page MJ, O'Connor D, Pitt V, Massy-Westropp N. Therapeutic ultrasound for carpal tunnel syndrome. Cochrane Database Syst Rev. 2012 Jan 18. 1:CD009601. [Medline].

  21. O'Connor D, Marshall S, Massy-Westropp N. Non-surgical treatment (other than steroid injection) for carpal tunnel syndrome. Cochrane Database Syst Rev. 2003. CD003219. [Medline].

  22. Incebiyik S, Boyaci A, Tutoglu A. Short-term effectiveness of short-wave diathermy treatment on pain, clinical symptoms, and hand function in patients with mild or moderate idiopathic carpal tunnel syndrome. J Back Musculoskelet Rehabil. 2014 Jul 24. [Medline].

  23. Page MJ, O'Connor D, Pitt V, Massy-Westropp N. Exercise and mobilisation interventions for carpal tunnel syndrome. Cochrane Database Syst Rev. 2012 Jun 13. 6:CD009899. [Medline].

  24. Page MJ, Massy-Westropp N, O'Connor D, Pitt V. Splinting for carpal tunnel syndrome. Cochrane Database Syst Rev. 2012 Jul 11. 7:CD010003. [Medline].

  25. O'Connor D, Page MJ, Marshall SC, Massy-Westropp N. Ergonomic positioning or equipment for treating carpal tunnel syndrome. Cochrane Database Syst Rev. 2012 Jan 18. 1:CD009600. [Medline].

  26. Ugurlu U, Ozkan M, Ozdogan H. The development of a new orthosis (neuro-orthosis) for patients with carpal tunnel syndrome: its effect on the function and strength of the hand. Prosthet Orthot Int. 2008 Dec. 32(4):403-21. [Medline].

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

  28. Goodyear-Smith F, Arroll B. What can family physicians offer patients with carpal tunnel syndrome other than surgery? A systematic review of nonsurgical management. Ann Fam Med. 2004 May-Jun. 2(3):267-73. [Medline]. [Full Text].

  29. Meys V, Thissen S, Rozeman S, Beekman R. Prognostic factors in carpal tunnel syndrome treated with a corticosteroid injection. Muscle Nerve. 2011 Nov. 44(5):763-8. [Medline].

  30. Scholten RJ, Mink van der Molen A, Uitdehaag BM, et al. Surgical treatment options for carpal tunnel syndrome. Cochrane Database Syst Rev. 2007. (4):CD003905. [Medline].

  31. Boya H, Ozcan O, Oztekin HH. Long-term complications of open carpal tunnel release. Muscle Nerve. 2008 Nov. 38(5):1443-6. [Medline].

  32. Verdugo RJ, Salinas RA, Castillo JL, Cea JG. Surgical versus non-surgical treatment for carpal tunnel syndrome. Cochrane Database Syst Rev. 2008 Oct 8. CD001552. [Medline].

  33. Rozanski M, Neuhaus V, Thornton E, Becker SJ, Rathmell JP, Ring D. Symptoms During or Shortly After Isolated Carpal Tunnel Release and Problems Within 24 hours After Surgery. J Hand Microsurg. 2015 Jun. 7 (1):30-5. [Medline].

  34. Verhagen AP, Karels C, Bierma-Zeinstra SM, et al. Ergonomic and physiotherapeutic interventions for treating work-related complaints of the arm, neck or shoulder in adults. A Cochrane systematic review. Eura Medicophys. 2007 Sep. 43(3):391-405. [Medline].

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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.
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.
 
 
 
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