Carpal Tunnel Syndrome

Disease/ Disorder

Definition

Carpal tunnel syndrome (CTS) is a condition brought on by increased pressure on the median nerve through the carpal tunnel region located at the wrist, leading to symptoms of pain, paresthesia, and sometimes weakness.

Etiology

Median nerve compression results from either a decrease in the size of the carpal tunnel, an increase in the size of its contents, or increased susceptibility of the nerve to pressure.

Epidemiology including risk factors and primary prevention

• Estimated prevalence of 3 to 6% of adults in the United States, with studies showing American workers at higher rates of 8%.¹
• Most frequent compressive focal mononeuropathy seen in clinical practice, accounting for 90% of all nerve entrapment neuropathies¹
• In patients with nerve conduction study (NCS) evidence of CTS in one hand, the contralateral asymptomatic hand will show NCS abnormalities about 50% of the time.²
• Known risk factors include
  • Obesity
    • One-unit increase in BMI over 30 increased the risk of CTS by 7%.⁵
  • Female sex, (3:1) compared to males
    • Decreased cross-sectional area of carpal tunnel
    • Hormonal factors may play a role
      • Pregnancy, oral contraceptives, and estrogen therapy increase the risk

• Arthritis and Inflammatory diseases
  • Osteoarthritis
  • Rheumatoid arthritis
  • Amyloidosis

• Metabolic
  • Diabetes mellitus type 1 and 2³
  • Hypothyroidism⁴

• Familial and congenital CTS
  • Bilateral CTS patients are more likely to have a family history than patients with unilateral CTS.

• Anatomical
  • Anatomic “square wrist”
  • Ratio of AP to the mediolateral diameter at wrist crease >0.7
  • Wrist/hand fractures
  • Mass lesions (lipoma, synovial cyst, or neural tumor)

• Medications
  • Aromatase Inhibitors
  • Occupational
    • Production and manufacturing
    • Construction
    • Food processing and preparation

• Environmental
  • Wheelchair useProlonged or repeated wrist flexion/extensionHigh levels of hand forceWorking with vibratory tools
  • No clear association has been established between computer work and CTS

Patho-anatomy/physiology

• The carpal tunnel is formed by the flexor retinaculum on the volar surface and carpal bones dorsally.
• Traversing through this tunnel are the median nerve and nine flexor tendons of the forearm (flexor pollicis longus and the four flexor digitorum superficialis and four flexor digitorum profundus tendons).
• Increased pressure or susceptibility of the median nerve within the carpal tunnel leads to myelin injury from intraneural microvascular ischemia and mechanical disruption.
  • Lowest carpal tunnel pressure is in a neutral position, with greater pressure in wrist extension than flexion.⁶
• Sensory fibers are more sensitive to compression and are routinely affected before motor fibers.

Disease progression including natural history, disease phases or stages, disease trajectory (clinical features and presentation over time)

• Acute
  • Intermittent numbness, tingling, pain and/or burning sensation involving the thumb, second and third digits, and radial half of the fourth digit.
  • Nocturnal paresthesias with relief by shaking hand/wrist
• Subacute
  • Persistence or worsening of acute symptoms
• Chronic
  • Sensory symptoms may progress from intermittent to persistent as CTS worsens.
  • Progression leads to weakness of the hand and coordination deficits.
  • Often impairing one or more activities of daily living
  • Fixed sensory loss is often a late finding.
  • CTS may progress without worsening symptoms.
  • Late-stage CTS can become difficult to treat and may not respond to surgical decompression.

Essentials of Assessment

History

• Most often presents as paresthesias affecting the sensory distribution of the median nerve in the first 3.5 digits of the hand, with symptoms worse at night.⁷
• Although sensory symptoms are usually limited to median-innervated fingers, there is a wide range of variability in the presentation, including the entire hand and proximal extremity.⁶
• May complain of deep, aching pain in the hand and wrist.
• Symptoms may be worsened by activities such as driving or reading.
• Report relief by shaking their hands (flick sign) or by placing them under warm water
  • (+) flick sign predicted electrodiagnostic abnormality in 93% of cases.⁸

Physical examination

• Evaluation should include the cervical spine, shoulder, and elbow.
• Findings may be normal in mild cases.
• Sensory findings
  • Objective sensory deficits may be detected involving the median-innervated fingers but sparing the thenar eminence as the palmar cutaneous sensory branch of the median nerve arises proximal to the carpal tunnel.
  • 2-point discrimination is generally affected before pain and temperature.
• Motor findings
  • Objective weakness can occur in advanced CTS, manifesting as weakness of thumb abduction and opposition.
  • Atrophy of the thenar eminence may be observed.
• Provocative tests targeting the hand muscles in those with CTS may reproduce the patient’s paresthesia and include:
  • Tinel’s sign, 67% sensitive and 68% specific.⁹
  • Phalen’s test, 85% sensitive and 89% specific.⁹
  • Carpal compression test (Durkan’s test), 87-89% sensitive.¹⁰
    • A reasonable approach is to screen with Tinel’s sign, and if negative, check the more sensitive carpal compression test.

Functional assessment

• A detailed occupational history includes the type of work performed, tools used, tool technique, and workstation design.
• The history should also include an assessment of all activities outside of work that may predispose to CTS.

Laboratory studies

While laboratory studies are not used to diagnose CTS, they may be utilized to screen for conditions that may predispose to the development of CTS (see epidemiology section for an overview of conditions). Therefore, a holistic approach that considers the patient’s past medical history along with their functional assessment is essential.

Imaging

Ultrasound (US) is becoming increasingly used for the evaluation of CTS, with mounting data on its utility for both the diagnosis of CTS and identification of its underlying cause ^11,12,32

Advantages include:

• Noninvasive
• More cost-effective and accessible in most regions of the United States
• Ability to perform a dynamic assessment, most notably the morphological changes and displacements of the median nerve during flexor tendon sliding.
• Ability to detect an underlying structural abnormality (i.e., a mass).
• Capacity to identify a systemic disease process such as rheumatoid arthritis or dialysis-related amyloidosis.
• US can confirm median nerve compression in individuals with signs/symptoms of CTS but normal NCS.¹¹
• US demonstrates a reduction in the median nerve at the site of entrapment and increased size proximal to the entrapment.  Diagnosis may be based on the absolute measurement of median nerve cross-sectional area (e.g., ≥ 10 mm²) or relative enlargement compared to a forearm measurement (e.g., wrist-to-forearm ratio ≥ 1.5).^11,12
• New US imaging modalities include elastography which can measure the elasticity of the median nerve (which would be decreased in CTS patients), shear stress of the subsynovial connective tissue relative to adjacent tendons (which would be increased in CTS patients,) and strain (which would be increased in CTS patients). However, the quantitative criteria are still being developed.
• Recent studies have demonstrated similar specificity and sensitivity to NCS for diagnosing CTS.¹²

MRI is reserved for unusual cases (i.e., to evaluate for a mass).

Supplemental assessment tools

Electromyography (EMG)

• NCS is the current reference standard for the diagnosis of CTS.
• EMG/NCS also screens for cervical radiculopathy, ulnar neuropathy, brachial plexopathy, and proximal median neuropathy, which helps differentiate CTS from these pathologies.
• The combined sensory index (CSI) has been shown to have the greatest sensitivity and specificity among NCS techniques.¹³
• Prolonged median sensory distal latency is usually the first abnormal finding on electrodiagnostic testing, secondary to damage to the myelin sheath.
• As CTS progresses, prolongation of the median distal motor latency will be noted on NCS
• In more severe cases, axon loss may occur, resulting in a reduction of the median sensory nerve action potential amplitude or compound muscle action potential amplitude in association with abnormal findings on EMG of the abductor pollicis brevis (APB)
• In mild cases, abnormalities with an estimated 15% false negative rate may be absent.¹⁴

Early predictions of outcomes

• Symptoms of untreated patients with minimal or mild compression tended to worsen over the first year, while those with initially moderate or severe involvement tended to improve
• Factors that have been associated with a failure of conservative therapy include long duration of symptoms (>10 months), age >50, constant paresthesia, and impaired 2-point discrimination
• In approximately 50% of cases where CTS occurs in one wrist, the other will eventually become involved.

Environmental

Controversy remains regarding the role of workplace factors in the development of CTS.

• There is reasonable evidence that regular, prolonged use of hand-held vibratory tools increases the risk of CTS >2-fold as well as activities such as prolonged and repetitious flexion and extension of the wrist, especially when coupled with a forceful grip.¹⁵
• Food processing, construction, beauty industry, and manufacturing are occupations that have a higher incidence of CTS
• Multiple studies have shown that keyboard use has no association with CTS; however, there is association between median mononeuropathy symptoms at the wrist and use of a right-handed mouse.¹⁵

Rehabilitation Management and Treatments

Available or current treatment guidelines

The American Academy of Orthopedic Surgeons (AAOS) provides guidelines for treating CTS.

At different disease stages

New onset/acute

• Conservative therapy for mild-moderate symptoms
  • Activity modification
  • Nocturnal orthosis use, with the wrist maintained in a neutral position, has proven effective in relieving symptoms of CTS. All-day wearing has not proven superior to nighttime-only use, and while up to 30 degrees of wrist extension has been considered reasonable, there is weak evidence suggesting that a neutral position is preferred to gentle extension.¹⁶
  • Tendon and nerve gliding exercises of the wrist and upper extremities are employed to maintain function and ROM. However, only limited and low-quality evidence has shown the efficacy of these interventions for CTS.
  • NSAIDs and vitamin B6 have been shown to offer no symptomatic benefit.¹⁷
  • Oral steroids of short duration have been shown to be of some benefit at 2- and 4-week follow-ups but have limited long-term effects.¹⁶
  • Corticosteroid injection INSTINCTS trial demonstrated superior clinical efficacy at 6 weeks compared to night splinting as a first-line treatment for mild-moderate CTS. Outcomes were similar to night splinting at 6 months.¹⁸
  • Local corticosteroid injection has also been shown to be more effective than oral corticosteroids in the short term.¹⁶
• Consider carpal tunnel release earlier in severe CTS or per patient preference
  • Constant symptoms
  • Sensory loss
  • APB weakness/thenar atrophy

Subacute

• Corticosteroid injection
  • Agarwal et al. (2005) reported marked symptom improvement in 93.7% of patients at 3 months and statistically significant benefit of symptoms at 6 months, as well as improvement in nerve conduction studies and decrease in cross-sectional area (i.e., swelling) of the nerve in the carpal tunnel.¹⁹
  • Regarding long-term outcomes, Evers et al. (2017) reported that 32% of patients did not require re-intervention. 63% ultimately went on to surgery.²⁰
  • Although there have been studies demonstrating similar outcomes²¹, the cumulative body of literature based on a meta-analysis of randomized controlled trials on ultrasound-guided local corticosteroid injection for carpal tunnel syndrome found that ultrasound guided injections are generally superior to landmark-guided approaches in improving symptom severity, functional status, and adverse events.²²
• Carpal tunnel release for severe CTS

Chronic/stable

• Carpal tunnel release may be indicated when conservative treatment modalities have failed and in those with severe symptoms.
• The goal of carpal tunnel release is to expand the carpal tunnel via division of the transverse carpal ligament to relieve pressure on the median nerve.
• Surgical
  • Open
  • Endoscopic
  • Mini-open
  • There is no definitive evidence supporting an open or endoscopic approach being more effective than the other, and the technique is typically guided by surgeon preference. There is some evidence to suggest that the endoscopic approach yields a shorter recovery than the open approach and limited evidence that the mini-open technique assisted by the Knifelight instrument is more effective than a standard open release at a follow-up of 19 months but not at 30.^23-25
• Ultrasound-guided
  • Advantages: shorter recovery period, can be performed in-office setting
  • Rojo-Manaute et al. reported superior functional outcomes from the first week to the sixth month using an ultrasound-guided hook knife technique compared to a mini-open surgical technique, with functional scores (QuickDASH) approaching each other at 12 months.²⁶
  • The SX-One MicroKnife is a single-use device that employs a balloon catheter to establish a safe zone for the transection of the transverse carpal ligament. Results comparable to mini-open and endoscopic release have been documented at 3 months.²⁸
• Recurrence of CTS after successful treatment is rare, although some patients experience residual numbness, pain, or weakness.
  • If pain and symptoms return, then surgery may be repeated.
  • Consider ultrasound evaluation of the median nerve at 3 months postop in patients with persistent symptoms.²⁸
• No consensus exists regarding the optimal presurgical or postsurgical rehabilitation and treatment programs. A study looking into different rehabilitation treatments post CTS surgery, including immobilization using a wrist orthosis, dressings, exercise, controlled cold therapy, ice therapy, multi‐modal hand rehabilitation, laser therapy, electrical modalities, scar desensitization, and arnica have shown that these postoperative rehabilitation interventions have limited evidence of efficacy.²⁹

Pre-terminal or end-of-life care

Not applicable.

Patient & family education

• Activity modification
• Proper orthotic use
• Risks and benefits of medical vs. surgical intervention

Emerging/unique interventions

• Yoga – limited evidence
  • A study looking into eight weeks of treatment with yoga versus using wrist splinting for CTS showed that patients in the yoga group had greater pain reduction and improvement in grip strength compared with patients in the wrist splint group at 8 weeks.³⁰
• Ultrasound therapy – limited evidence
  • Ultrasound therapy is sometimes used to promote healing after nerve and tendon injuries
  • According to a systematic review in 2013, ultrasound therapy, especially deep pulsed ultrasound, may provide some symptom improvement in CTS.³¹

Impairment-based measurement

The AMA Guides to the Evaluation of Permanent Impairment

Measurement of patient outcomes

• QuickDASH Outcome Measure
• The Carpal Tunnel Questionnaire (CTQ) has demonstrated greater responsiveness to clinical change following the release of the carpal tunnel than the Michigan Hand Outcomes Questionnaire (MHQ).
• The combined sensory index electrodiagnostic tool has been shown to effectively establish a correlation with clinical outcomes following surgical intervention for carpal tunnel syndrome.¹³

Translation into practice: practice “pearls”/performance improvement in practice (PIPs)/changes in clinical practice behaviors and skills

• Presentations of CTS will often include symptoms that do not fit a classical median nerve distribution.
• Anatomical variants may also contribute to symptoms outside the typical median portion of the hand.
• A normal physical exam does not rule out CTS.
• Electrodiagnosis is the current reference standard. However, recent studies have demonstrated comparable diagnostic sensitivity and specificity with ultrasound.
• Diagnostic ultrasound should be considered in patients with signs/symptoms of CTS and normal NCS.
• Many non-surgical methods have proven beneficial and warrant trials before carpal tunnel release in patients with mild-moderate CTS.
• Ultrasound-guided carpal tunnel injections can decrease the risk of surgery for up to one year but may not reduce the risk in subsequent years.^31,32
• Minimally invasive ultrasound-guided techniques for carpal tunnel release can be performed in the office setting, have less morbidity compared to open or mini-open carpal tunnel release, and have been shown to have comparable short- to medium-term results.

Cutting Edge/ Emerging and Unique Concepts and Practice

• Diagnostic ultrasound is demonstrated to have utility similar to NCS in diagnosing CTS.
• Ultrasound-guided carpal tunnel injections have superior outcomes over landmark-guided injections³³.
• Ultrasound-guided carpal tunnel release has emerged as an alternative to open or endoscopic surgery for CTS as it provides shorter recovery times for patients

Gaps in the Evidence-Based Knowledge

• Long-term follow-up data are lacking for outcomes of ultrasound-guided carpal tunnel release.
• Randomized prospective trials are needed to evaluate the effectiveness of ultrasound-guided versus standard surgical techniques.
• The optimal timing of surgery in the natural history of CTS has yet to be established.
• The outcomes of long-term serial carpal tunnel injections have not been studied.

References

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18. Chesterton LS et al. The clinical and cost-effectiveness of corticosteroid injection versus night splints for carpal tunnel syndrome (INSTINCTS trial): an open-label, parallel group, randomized controlled trial. Lancet. 2018; 392:1423-33.
19. Agarwal V et al. A prospective study of the long-term efficacy of local methyl prednisolone acetate injection in the management of mild carpal tunnel syndrome.  Rheumatology (Oxford). 2005 May;44(5):647-50.
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21. Agarwal V et al. A prospective study of the long-term efficacy of local methyl prednisolone acetate injection in the management of mild carpal tunnel syndrome.  Rheumatology (Oxford). 2005 May;44(5):647-50.
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Bibliography

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Original Version of the Topic:

Michael Mehnert, MD. Carpal Tunnel Syndrome. 11/10/2011

Previous Revision(s) of the Topic

Stephen Kishner, MD, John Faciane, MD, Casey Murphy, MD. Carpal Tunnel Syndrome. 5/05/2016.

William A. Anderson, MD. Carpal Tunnel Syndrome. 7/27/2020.

Author Disclosures

Thomas Chai, MD
Nothing to Disclose

Royce Copeland, DO
Nothing to Disclose

Christian Vangeison, DO
Nothing to Disclose

Loc Lam, DO
Nothing to Disclose

Colton Reeh, MD
Nothing to Disclose

Daniel Briggi, MD
Nothing to Disclose