Guidelines
Guidelines Summary
American Academy of Orthopaedic Surgeons Guidelines
The AAOS has published guidelines on diagnosis and treatment of carpal tunnel syndrome, including the following [16] :
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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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Carpal tunnel syndrome. Carpal and Guyon tunnels. Drawing showing the proximal level of the carpal tunnel delimited by the pisiform (P) and the scaphoid (S). The flexor retinaculum (medium gray region) forms the roof of the carpal tunnel and the floor of the Guyon tunnel. The palmar carpal ligament (dark gray region) forms the volar boundary of the Guyon tunnel. * = flexor pollicis longus tendon, * = flexor carpi radialis tendon. From Martinoli C, Bianchi S, et al. US of nerve entrapments in osteofibrous tunnels of the upper and lower limbs. Radiographics 2000; 20:S199-S217. Used by permission of the authors and RSNA.
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Carpal tunnel syndrome. Carpal and Guyon tunnels. Transverse 5-12-MHz ultrasound scan corresponding to the image above shows the proximal level of the carpal tunnel delimited by the pisiform (P) and the scaphoid (S). The flexor tendons and median nerve (MN) extend through the carpal tunnel, with the nerve lying palmar and radial. The flexor retinaculum (open arrowheads) forms the roof of the carpal tunnel and the floor of the Guyon tunnel. At the level of the pisiform, the ulnar nerve (U) courses medial to the ulnar artery (solid arrowhead) within the Guyon tunnel. * = flexor pollicis longus tendon. From Martinoli C, Bianchi S, et al. US of nerve entrapments in osteofibrous tunnels of the upper and lower limbs. Radiographics 2000; 20:S199-S217. Used by permission of the authors and RSNA.
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Carpal tunnel syndrome. Carpal and Guyon tunnels. Drawing showing the distal level of the carpal tunnel delimited by the hook of the hamate (H) and the tubercle of the trapezium (T). The flexor retinaculum (medium gray region) forms the roof of the carpal tunnel. From Martinoli C, Bianchi S, et al. US of nerve entrapments in osteofibrous tunnels of the upper and lower limbs. Radiographics 2000; 20:S199-S217. Used by permission of the authors and RSNA.
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Carpal tunnel syndrome. Carpal and Guyon tunnels. Transverse 5-12-MHz ultrasound scan corresponding to the image above shows the distal level of the carpal tunnel delimited by the hook of the hamate (H) and the tubercle of the trapezium (T). The flexor retinaculum (open arrowheads) forms the roof of the carpal tunnel. The flexor tendons and median nerve (MN) extend through the carpal tunnel, with the nerve lying palmar and radial. At the level of the pisiform, the ulnar nerve courses medial to the ulnar artery (solid arrowhead) within the Guyon tunnel. At the level of the hamate, the ulnar nerve divides into two terminal branches, a deep motor branch (curved arrow) and a superficial sensory branch (straight arrow). From Martinoli C, Bianchi S, et al. US of nerve entrapments in osteofibrous tunnels of the upper and lower limbs. * = flexor pollicis longus tendon. Radiographics 2000; 20:S199-S217. Used by permission of the authors and RSNA.
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Carpal tunnel syndrome. Normal findings on an axial spin-echo T1 MRI of the carpal tunnel showing the intermediate signal intensity of the median nerve (arrow).
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Carpal tunnel syndrome. Normal findings of isointense-to-hypointense appearance of the median nerve on fast spin-echo T2-weighted MRI (arrow). Note the fairly well-defined nerve fascicles within the median nerve sheath.
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Carpal tunnel syndrome. Axial fast spin-echo T2-weighted MRI with fat saturation. Note the increased T2-weighted signal within the median nerve (arrow). A slightly increased cross sectional area of the nerve is noted but the nerve architecture is preserved, consistent with early or mild inflammation.
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Carpal tunnel syndrome. Fast spin-echo T2-weighted MRI illustrates more pronounced increased signal within the median nerve (arrow). Note the small amount of fluid within the carpal tunnel, a secondary sign of inflammation. Slightly less optimal fat saturation is noted than on other images, which is a common occurrence.
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Carpal tunnel syndrome. Axial fast spin-echo T2-weighted MRI with greater increase in signal and loss of definition within the nerve (arrow). Inflammatory change is noted within the carpal tunnel, adjacent to the flexor digitorum superficialis tendons. The appearance is consistent with pronounced inflammatory change within the carpal tunnel.
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