Guidelines
Guidelines Summary
In February 2016, the American Academy of Orthopaedic Surgeons released an evidence-based clinical practice guideline on the management of CTS. Recommendations based on strong or moderate evidence included the following [41] :
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Thenar atrophy is strongly associated with ruling in CTS but is poorly associated with ruling it out
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Do not use the Phalen test, Tinel sign, flick sign, or upper limb neurodynamic/nerve tension test (ULNT) criterion A/B as independent physical examination maneuvers to diagnose CTS, because alone, each has a poor or weak association with ruling in or ruling out the condition
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Do not use the following as independent physical examination maneuvers to diagnose CTS, because alone, each has a poor or weak association with ruling in or ruling out the condition: carpal compression test, reverse Phalen test, thenar weakness or thumb abduction weakness or abductor pollicis brevis manual muscle testing, two-point discrimination, Semmes-Weinstein monofilament test, CTS-relief maneuver, pin prick sensory deficit (thumb or index or middle finger), ULNT criterion C, tethered median nerve stress test, vibration perception (tuning fork), scratch collapse test, Luthy sign, and pinwheel
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Do not use the following as independent history interview topics to diagnose CTS, because alone, each has a poor or weak association with ruling in or ruling out the condition: sex/gender, ethnicity, bilateral symptoms, diabetes mellitus, worsening symptoms at night, duration of symptoms, patient localization of symptoms, hand dominance, symptomatic limb, age, and body mass index
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Do not routinely use magnetic resonance imaging (MRI) for the diagnosis of CTS
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Diagnostic questionnaires and/or electrodiagnostic studies can be used to aid the diagnosis of CTS
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The following factors are associated with an increased risk of developing CTS: peri-menopausal, wrist ratio/index, rheumatoid arthritis, psychosocial factors, distal upper extremity tendinopathies, gardening, American Conference of Governmental Industrial Hygienists (ACGIH) hand activity level at or above threshold, assembly line work, computer work, vibration, tendonitis, workplace forceful grip/exertion
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Physical activity/exercise is associated with a decreased risk of developing CTS
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The use of oral contraception and female hormone replacement therapy are not associated with increased or decreased risk of developing CTS
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The use of immobilization (brace/splint/orthosis) should improve patient reported outcomes
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The use of steroid (methylprednisolone) injection should improve patient reported outcomes
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Magnet therapy should not be used for the treatment of CTS
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There is no benefit to oral CTS treatments (diuretic, gabapentin, astaxanthin capsules, nonsteroidal anti-inflammatory drugs [NSAIDs], or pyridoxine) over placebo
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Oral steroids could improve patient reported outcomes in comparison with placebo
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Ketoprofen phonophoresis could provide reduction in pain in comparison with placebo
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The surgical release of the transverse carpal ligament should relieve CTS symptoms and improve function
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Surgical treatment of CTS should have a greater therapeutic benefit at 6 and 12 months in comparison with splinting, NSAIDs/therapy, and a single steroid injection
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There is no benefit to routine postoperative immobilization after carpal tunnel release
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There is no benefit to routine inclusion of the following adjunctive techniques: epineurotomy, neurolysis, flexor tenosynovectomy, and lengthening/reconstruction of the flexor retinaculum (transverse carpal ligament)
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Buffered lidocaine rather than plain lidocaine should be used for local anesthesia because buffered lidocaine could result in less injection pain
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There is no additional benefit to routine supervised therapy over home programs in the immediate postoperative period; no evidence meeting the inclusion criteria was found comparing the potential benefit of exercise versus no exercise after surgery
Media Gallery
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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.
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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.
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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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