Diagnosis
History
Individuals may describe pain, tingling, numbness, or a feeling of weakness in the wrist, hand, or fingers. In mild cases, the symptoms are intermittent and often worsen at night or when the individual first arises in the morning. The individual may complain of decreased grip strength, dropping items more frequently than usual, and having problems pinching or grasping items or making a fist. The fingers may at times feel "locked," and the individual may feel a need to shake the hand and fingers to unlock them. On occasion, pain may radiate into the forearm, shoulder, neck, or chest. The hands or lower arms may feel weak in the morning after sleeping with wrists flexed. Performance of detailed tasks such as writing or tying shoes may be difficult. Symptoms may occur during specific activities or at particular times, such as while holding a phone or a newspaper, gripping a steering wheel, or sleeping. The individual may not be sensitive to hot and cold by touch.
Physical Exam
The physical exam may reveal no abnormalities. Subjectively altered sensation may be noted in the distribution of the median nerve in the thumb and the first three fingers, with no changes in sensation in the palm. Even though patients frequently complain of "swelling," soft tissue swelling is not usually observed in carpal tunnel syndrome (CTS). In chronic or severe cases, the palm may appear to be wasting away near the thumb (thenar eminence atrophy). In severe cases, weakness of thumb opposition and decreased sensation in the distal phalanges of the thumb and first three fingers (2 point discrimination and/or monofilament testing) may be noted. The individual may be shown a diagram of the hand and wrist to indicate where pain or other sensations are present. An unaffected little finger may indicate CTS.
Tapping on the volar aspect of the wrist over the course of the median nerve near the front of the wrist typically reproduces the tingling feeling in the hand or forearm (Tinel's sign). Positioning the wrist in a fully flexed posture for 60 seconds may reproduce the pain and tingling (Phalen's sign). These methods have a high rate of both false positive and false negative findings. Hand grip strength test may show weakness.
Tests
Electrodiagnostic nerve tests are performed to evaluate nerve function (e.g., nerve conduction velocity, electromyography). Nerve conduction tests apply small electric shocks and measure the speed with which nerves are able to transmit impulses. Mild cases may show prolonged motor and/or sensory distal latency of the median nerve and slowing of the conduction speed in the carpal tunnel. Moderate cases show conduction block, in which some of the axons or nerve fibers fail to transmit impulses, resulting in decreased amplitude (voltage) on nerve conduction. Severe cases, which are uncommon, show significant prolongation of motor latency and reduced conduction speed, evidence of axon loss or death of some of the axons in the nerve. There is no agreement about the definitions of mild, moderate, or severe CTS with regard to electrodiagnostic testing, but abnormal results on nerve conduction tests confirm CTS.
Electromyography involves insertion of a fine needle into a muscle and recording of the electric impulses so that electrical activity seen on a monitor can reveal damage to the nerve supplying the muscle tested. The most severe cases will show voltage or at least conduction block), suggesting more severe nerve injury.
Blood tests (serology) to detect possible underlying rheumatoid arthritis (sedimentation rate), diabetes, and thyroid disease are frequently performed. Plain film x-rays of the wrist are used to rule out bony abnormalities, but are almost always normal. Magnetic resonance imaging (MRI) and ultrasound are currently considered to be experimental methods of evaluating for the presence of CTS. If a tumor in the carpal tunnel is a rare but possible explanation for an individual's carpal tunnel syndrome, MRI may be used.
Treatment
Conservative treatment may include eliminating or greatly reducing movements or tasks that seem to cause or exacerbate the symptoms, such as repetitive motion of the wrist and fingers or wrist-bending extremes (flexion and extension). Other treatment may include use of nonsteroidal anti-inflammatory drugs (NSAIDs) such as aspirin and ibuprofen, wearing protective splints while working and/or sleeping, stretching and strengthening exercises, diuretics to reduce excess fluids, and possible corticosteroid injections into the carpal tunnel. An electrical current may be used to deliver medication (usually corticosteroids) through the skin into the area requiring treatment (iontophoresis). Studies have shown that vitamin B6 (pyridoxine) supplements help reduce symptoms of CTS only in those who are deficient in this vitamin; yoga has been shown to reduce pain and increase grip strength.
In chronic or severe cases unrelated to fluid buildup in pregnancy or menopause, surgery may be required. The procedure (open carpal tunnel release) involves cutting the transverse carpal ligament (roof of the carpal tunnel) to relieve pressure on the median nerve. This is generally done on an outpatient basis with local or regional anesthesia. In some cases, surgery can be performed endoscopically by inserting a fiberoptic endoscope through a small incision to observe the inside of the carpal tunnel while incising the transverse carpal ligament (endoscopic carpal tunnel release).
See the original guideline document for information on prognosis and differential diagnoses.
Rehabilitation
Conservative management remains effective in most cases of carpal tunnel syndrome. Generally, therapy should occur up to 3 times a week for up to 8 weeks in order to educate the individual in symptom control and management. After a diagnosis of CTS, reduction of the symptoms and the identification of activities that increase the symptoms, both at home and at work, are the first goals. Individuals should receive therapy from an occupational therapist, a physical therapist, or a hand therapist.
The first objective of therapy is to reduce pain and swelling, using modalities such as heat and cold. The hand and wrist are elevated to reduce swelling and may be positioned in a static resting hand splint to decrease movement in the painful region and to provide proper alignment. After pain is consistently reduced, activities to increase muscle flexibility, range of motion, strength, and body posture are a second objective. During this stage, the therapist also monitors sensory status and, if deficits are noted, provides sensory reeducation. Patient education also addresses awareness of body posture during task performance. An ergonomic evaluation may also be beneficial.
In order to increase the individual's overall comfort and function, clinicians and therapists must devise specific plans that will help the individual reduce activities that increase the symptoms in the course of daily activities. In the workplace, modified work is important until symptoms resolve. This needs to be specifically addressed with company representatives if possible. Some have programs with alternative work options.
Additional information may provide insight into the rehabilitation needs of these individuals.
Frequency of Rehabilitation Visits
| Nonsurgical |
Occupational / Hand / Physical Therapist |
Up to 5 visits within 8 weeks |
| Surgical |
Occupational / Hand / Physical Therapist |
Up to 5 visits within 6 weeks |
Rehabilitation Disclaimer: The table above represents a range of the usual acceptable number of visits for uncomplicated cases. It provides a framework based on the duration of tissue healing time and standard clinical practice. The number of visits have been adjusted (2009), bringing them into harmony with "Carpal Tunnel Release" and with current best practices.
See the original guideline document for information about comorbid conditions, complications, and factors influencing duration.
Length of Disability
In a small percentage of cases, individuals may experience chronic problems because of nerve damage that may result from carpal tunnel syndrome.
Medical Treatment, Carpal Tunnel Syndrome
| Duration in Days |
| Job Class |
Minimum |
Optimum |
Maximum |
| Sedentary Work |
0 |
7 |
21 |
| Light Work |
0 |
7 |
21 |
| Medium Work |
0 |
14 |
28 |
| Heavy Work |
0 |
21 |
42 |
| Very Heavy Work |
0 |
28 |
63 |
Surgical Treatment, Open or Endoscopic Carpal Tunnel Release
| Duration in Days |
| Job Class |
Minimum |
Optimum |
Maximum |
| Sedentary Work |
1 |
14 |
42 |
| Light Work |
3 |
21 |
42 |
| Medium Work |
14 |
28 |
56 |
| Heavy Work |
21 |
42 |
84 |
| Very Heavy Work |
28 |
56 |
91 |
Return to Work (Restrictions/Accommodations)
The individual may need to decrease tasks requiring repetitive wrist motion and extremes of wrist bending (flexion, extension) until the condition is resolved. Additionally, protective wrist splints may be used during work and sleep to maintain neutral wrist positions. Accommodation may be required at workstations, such as ergonomically designed computer keyboards to provide support for the individual's hand and wrist. If the individual has had surgery and the operated hand must be used for heavy activity, time off from work may be needed for several weeks for recovery. The individual may be required to avoid heavy lifting and repetitive motion for up to 2 months after surgery. Grip strength may continue to improve for 1-2 years after surgery.
Failure to Recover
If an individual fails to recover within the maximum duration expectancy period, the reader may wish to reference the following questions to assist in better understanding the specifics of an individual's medical case.
Regarding Diagnosis
- Does individual have pain, tingling, numbness, or feeling of weakness in the wrist, hand, or fingers? Is pain intermittent, often worsening at night or when individual first gets up in the morning?
- Does individual complain of dropping items more frequently than usual?
- Do fingers feel "locked" at times? Is associated but untreated trigger digit present?
- Does individual have problems pinching or grasping objects?
- Does physical exam reveal changes in sensation along the median nerve in the thumb and first three fingers?
- Does palm appear to be wasting away near the thumb (thenar eminence atrophy) indicating potentially severe neuropathy, or comorbid osteoarthritis of the thumb carpal-metacarpal joint?
- Does individual have Tinel's or Phalen's sign?
- Does the individual have comorbid lateral elbow tendinopathy or ulnar neuropathy at the elbow?
- Does the individual have comorbid shoulder or neck pathology?
- Were nerve conduction studies performed to evaluate the nerve function (distal latency, nerve conduction velocity, electromyography needle testing), and if so, were the results normal or abnormal?
- Was testing for inflammatory disease (sedimentation rate) and thyroid disease (TSH) that might cause or masquerade as CTS performed?
Regarding Treatment
- If conservative methods have failed to relieve symptoms, is individual a candidate for carpal tunnel release?
- If the case is atypical, did an injection of steroids reduce numbness and pain prior to an attempt at surgery?
- Did individual undergo open or endoscopic carpal tunnel release?
- Did individual experience any complications from the surgical procedure itself?
- Did the operation report describe inflammatory synovium suggesting inflammatory disease and not idiopathic CTS was present? If "yes", was a synovial biopsy done? If the biopsy showed inflammatory cells in the synovium, has the patient been referred to a rheumatologist?
- Does individual continue to experience symptoms even after surgical intervention? If yes, were repeat nerve conduction tests done by the same physician to see if the nerve function improved?
- What further treatment options are being considered?
Regarding Prognosis
- Does pain persist even after 2 months have passed since treatment?
- Does individual perform repetitive tasks such as gripping a tool for prolonged periods of time?
- Can individual refrain from activities that may increase the symptoms for as long as pain or other symptoms persist?
- Until symptoms resolve, should individual be transferred temporarily to a position that does not require repetitive motion?
- Is individual's work station or computer keyboard ergonomically designed to provide support for the hand and wrist?
- Was individual given a splint to provide support for the wrist and hand? If so, is it being used as instructed?
- Does individual have a coexisting condition such as diabetes or pregnancy that may affect recovery?
