Background

Carpal tunnel syndrome (CTS) is a collection of characteristic symptoms and signs that
occurs following compression of the median nerve within the carpal tunnel. Usual symptoms
include numbness, paresthesias, and pain in the median nerve distribution. These symptoms
may or may not be accompanied by objective changes in sensation and strength of median-
innervated structures in the hand.[1, 2] See image below.

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.

Pathophysiology
Until the advent of electrophysiologic testing in the 1940s, carpal tunnel syndrome (CTS)
commonly was thought to be the result of compression of the brachial plexus by cervical ribs
and other structures in the anterior neck region. It is now known that the median nerve is
damaged within the rigid confines of the carpal tunnel, initially undergoing demyelination
followed by axonal degeneration. Sensory fibers often are affected first, followed by motor
fibers. Autonomic nerve fibers carried in the median nerve also may be affected.

The cause of the damage is subject to some debate; however, it seems likely that abnormally
high carpal tunnel pressures exist in patients with CTS. This pressure causes obstruction to
venous outflow, back pressure, edema formation, and ultimately, ischemia in the nerve.

The risk of development of CTS appears to be associated, at least in part, with a number of
different epidemiologic factors, including genetic, medical, social, vocational, avocational,
and demographic.[3] A complex interaction probably exists between some or all these factors,
eventually leading to the development of CTS. Definite causative factors, however, are far
from clear.
Rehabilitation Program
Physical Therapy

Given that carpal tunnel syndrome (CTS) is associated with low aerobic fitness and increased
BMI, it makes some inherent sense to provide the patient with an aerobic fitness and weight-
loss program. Stationary biking, cycling, or any other exercise that puts strain on the wrists
probably should be avoided.

The use of modalities (in particular therapeutic ultrasound) may provide short-term relief in
some patients.[21, 22, 23] A study by Incebiyik et al indicated that in patients with mild to
moderate CTS, treatment with short-wave diathermy (SWD) can produce significant short-
term benefits, including alleviation of clinical symptoms and pain and improvement of hand
function. In the prospective, randomized, controlled, double-blind trial, 31 patients (58
wrists) with mild to moderate CTS were treated with a combination of a hot pack, nerve and
tendon gliding exercises, and either SWD or placebo SWD, undergoing this therapy five
times per week for three weeks. A variety of evaluation measures, including the Tinel sign
test, Phalen sign test, carpel tunnel compression test, and Boston Carpal Tunnel
Questionnaire (BCTQ) Symptom Severity and Functional Status scales, were used to assess
patient outcomes. Significant improvements were found in the patients who underwent SWD
but not in those who receivedthe placebo treatment.[24]

Additionally, yoga and carpal bone mobilization techniques have some weak evidence for
reducing symptoms in the short term.[23, 25]

Occupational Therapy

Wrist splints with the wrist joint in neutral or slight extension (to be worn at nighttime for a
minimum of 3-4 wk) have some evidence for efficacy. Certainly, they are low cost and have
very low risk of adverse effects and therefore can be considered as an initial therapy.[26] No
evidence suggests that a specific stretching/strengthening program for the hand and wrist is
useful for treating carpal tunnel syndrome.[25] Massage and/or nerve-glide techniques offer no
proven benefit.[23, 25] Work-site ergonomic assessment, equipment, and/or ergonomic
positioning seem to not provide any benefit.[22, 27]

Medical Treatment
Most individuals with mild-to-moderate carpal tunnel syndrome (CTS; according to
electrophysiologic data) respond to conservative management, usually consisting of splinting
the wrist at nighttime for a minimum of 3 weeks. Many off-the-shelf wrist splints seem to
work well, although theoretically, a custom-made splint in neutral is probably the best
choice.[21, 28, 26]

Steroid injection into the carpal tunnel has been shown to be of long-term benefit and can be
tried if more conservative treatments have failed[29] . Injections may also be worthwhile prior
to surgical management or in cases in which surgery is relatively contraindicated (eg, because
of pregnancy).[29, 30] Ultrasound measurements of the median nerve can help predict response
to steroid injection.[31] .

The anticonvulsants gabapentin and pregabalin, which have come to be administered for
various types of neuropathic pain, can be used, off-label, for CTS.[32, 33]

Nonsteroidal anti-inflammatory drugs (NSAIDs) and/or diuretics may be of benefit against

CTS in certain populations (eg patients with fluid retention or with wrist flexor tendinitis).
The efficacy of gabapentin, diuretics, and NSAIDs is controversial, however, with guidelines
from the American Academy of Orthopaedic Surgeons stating that oral agents are no better
than placebo in the treatment of CTS.[34] Additionally, vitamin B-6 and B-12 supplements are
of no proven benefit against the disorder.[23]

Surgical Intervention
Patients whose condition does not improve following conservative treatment and patients
who initially are in the severe carpal tunnel syndrome (CTS) category (as defined by
electrophysiologic testing) should be considered for surgery. Surgical release of the
transverse ligament provides high initial success rates (greater than 90%), with low rates of
complication; however, it has been suggested that the long-term success rate may be much
lower than previously thought (approximately 60% at 5 y). Success rates also are
considerably lower for individuals with normal electrophysiologic studies.[35, 36, 37]

A study by Rozanski et al indicated that in patients who have undergone isolated carpal
tunnel release, the greatest risk factors for symptoms in the ambulatory surgery center or
problems within 24 hours after discharge are as follows: male sex, age 45 years or above, and
participation of an anesthesiologist in the procedure. However, all such symptoms or
problems in the study, which were found in 10% of patients, were minor and transient,
according to the investigators. The study involved the records of 400,000 adult patients with
CTS, as contained in the National Survey of Ambulatory Surgery database, who underwent
isolated carpal tunnel release.[38]

Consultations
Refer patients with suggested carpal tunnel syndrome to a specialist trained in clinical
neurophysiology (usually a neurologist, physiatrist, or physical medicine and rehabilitation
specialist) for possible electrophysiologic studies. These test results are important for
diagnosis, instigation of appropriate treatment, determination of prognosis, and long-term
follow-up.

Other Treatment
Techniques and devices to stretch or manipulate the carpal tunnel have shown some promise
but still are not accepted widely.[25]

Background
Carpal tunnel syndrome (CTS) is a compressive neuropathy of the median nerve at the
wrist.[1] The carpal tunnel is located at the base of the palm and is bounded on 3 sides by
carpal bones and anteriorly by the transverse carpal ligament. Inside run the median nerve,
flexor tendons, and their synovial sheaths. It is the most common entrapment neuropathy,
with repetitive, forceful angular hand movements or vibration placing persons at risk for the
condition. Diagnosis is based on clinical history and findings, along with corroborating
electrodiagnostic studies.[2, 3, 4, 5, 6, 7]

Pathophysiology
Carpal tunnel syndrome (CTS) is caused predominantly by compression of the median nerve
at the wrist because of hypertrophy or edema of the flexor synovium. Pain is thought to be
secondary to nerve ischemia rather than direct physical damage of the nerve.[8]

See the images below.

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.

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.

Epidemiology
Carpal tunnel syndrome (CTS) is the most frequently encountered peripheral compressive
neuropathy. The prevalence of carpal tunnel syndrome in the United States is estimated at
3.7%, and the annual incidence is estimated at 0.4%.[9, 10] Early in the course of CTS, the
neurologic findings are reversible. If untreated, CTS can result in thenar atrophy, chronic
hand weakness, and numbness in the median nerve distribution of the hand. CTS is more
prevalent in females than in males[11, 2] and most common in middle age.

Tosti R, Ilyas AM. Acute carpal tunnel syndrome. Orthop Clin North Am. 2012 Oct. 43(4):459-65.
[Medline].

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

o 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.
o 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.
o 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
o 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.
o 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
o 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).
o 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.

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
o 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.
o 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.
o L - First and second lumbricals
o O - Opponens pollicis
o A - Abductor pollicis brevis
o F - Flexor pollicis brevis
Special tests - No good clinical test exists to support the diagnosis of CTS.
o 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.
o 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.
o The carpal compression test[8]
 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%.
o 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.
o 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.

Causes
Note that carpal tunnel syndrome (CTS) is associated with many different factors.[9] 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
o Increasing age
o Female sex
o Increased body mass index (BMI), especially a recent increase
o Square-shaped wrist
o Short stature
o Dominant hand
o Race (white)
Genetics
o A strong family susceptibility exists and is probably related to multiple
inherited characteristics (eg, square wrist, thickened transverse ligament,
stature).
o A number of inherited medical conditions also are associated with CTS (eg,
diabetes, thyroid disease, hereditary neuropathy with liability to pressure
palsies).
Medical conditions
o Wrist fracture (Colles)
o Acute, severe flexion/extension injury of wrist
o Space-occupying lesions within the carpal tunnel (eg, flexor tenosynovitis,
ganglions, hemorrhage, aneurysms, anomalous muscles, various tumors,
edema)
o Diabetes
o Thyroid disorders (usually myxedema)
o Rheumatoid arthritis and other inflammatory arthritides of the wrist
o Recent menopause (including post-oophorectomy)[3]
o Renal dialysis
o Acromegaly
 o Amyloidosis
Vocational/avocational[9, 10, 11] - Activities that may be associated with CTS
(particularly in combination) involve the following:
o Prolonged, severe force through the wrist
o Prolonged, extreme posture of the wrist
o High amounts of repetitive movements
o Exposure to vibration and/or cold
Other factors
o Lack of aerobic exercise
o Pregnancy and breastfeeding
o Use of wheelchairs and/or walking aids

A study by Fernndez-Munoz et al reported that in women with CTS, the following predict
the severity of hand pain[12] :

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.

Chammas M, Boretto J, Burmann LM, Ramos RM, Dos Santos Neto FC, Silva JB. Carpal
tunnel syndrome - Part I (anatomy, physiology, etiology and diagnosis). Rev Bras Ortop.
2014 Sep-Oct. 49 (5):429-36. [Medline]. [Full Text].

Chammas M, Boretto J, Burmann LM, Ramos RM, Neto FS, Silva JB. Carpal tunnel
syndrome - Part II (treatment). Rev Bras Ortop. 2014 Sep-Oct. 49 (5):437-45. [Medline].
[Full Text].