Carpal Tunnel Syndrome: Difference between revisions

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== Definition ==
== Introduction ==


<br>Carpal tunnel syndrome (CTS) is the most common peripheral nerve entrapment word wide. The general trend for this condition is progressive worsening, although spontaneous regression of symptoms is possible. Patients can be diagnosed quickly and respond well to treatment but the best means of integrating clinical, functional, and anatomical information for selecting treatment choices has not yet been identified.<ref>Padua L, Coraci D, Erra C, Pazzaglia C, Paolasso I, Loreti C, Caliandro P, Hobson-Webb LD. Carpal tunnel syndrome: clinical features, diagnosis, and management. The Lancet Neurology. 2016 Nov 1;15(12):1273-84.</ref><ref name="Chammas">Chammas M, Boretto J, Burmann LM, Ramos RM, Neto FCS, Silva JB. Carpal tunnel syndrome – part 1 (anatomy, physiology, etiology and diagnosis). Revista brasileira de Ortopedia (English edition) 2014 September-October; 49 (5):429-436. </ref>
Carpal tunnel syndrome (CTS) is an '''entrapment neuropathy''' caused by compression of the [[Median Nerve|median nerve]] as it travels through the wrist's carpal tunnel. Normal tissue pressure within the tunnel is approximately 3-7mm Hg. CTS can result in pressure with greater than 30mm Hg.  [[File:Carpal Tunnel Syndrome.png|300x300px|Fig.1  Median nerve compression.|right|frameless]]
* It is the most common nerve entrapment [[Neuropathies|neuropathy]], accounting for 90% of all neuropathies.
* Early symptoms of carpal tunnel syndrome include pain, numbness, and paresthesias. Sensory changes and paresthesia along with median nerve distribution in Hand.  
* Symptoms typically present, with some variability, in the thumb, index finger, middle finger, and the radial half (thumb side) of the ring finger.
* Pain also can radiate up the affected arm. Radiate into upper extremity, shoulder and neck. With further progression, night pain, hand weakness, decreased fine motor coordination,decreased grip strength, clumsiness, reduced wrist mobility and thenar atrophy can occur. <ref name=":5">[https://www.ncbi.nlm.nih.gov/books/NBK448179/ Carpal Tunnel Syndrome] Justin O. Sevy; Matthew Varacallo.
Last Update: December 21, 2019. Available from:https://www.ncbi.nlm.nih.gov/books/NBK448179/ (last accessed 22.3.2020)
</ref>
Patients can be diagnosed quickly and respond well to treatment but the best means of integrating clinical, functional, and anatomical information for selecting treatment choices have not yet been identified.<ref>Padua L, Coraci D, Erra C, Pazzaglia C, Paolasso I, Loreti C, Caliandro P, Hobson-Webb LD. Carpal tunnel syndrome: clinical features, diagnosis, and management. The Lancet Neurology. 2016 Nov 1;15(12):1273-84.</ref><ref name="Chammas">Chammas M, Boretto J, Burmann LM, Ramos RM, Neto FCS, Silva JB. Carpal tunnel syndrome – part 1 (anatomy, physiology, etiology and diagnosis). Revista brasileira de Ortopedia (English edition) 2014 September-October; 49 (5):429-436. </ref>


== Clinically Relevant Anatomy  ==
== Clinically Relevant Anatomy  ==


[[File:Carpal Tunnel Syndrome.png|300x300px|thumb|Fig.1  Median nerve compression.]]
[[File:Carpal tunnel.png|442x442px|Fig.2 Transverse plane view of carpal tunnel.|right|frameless]]The carpal tunnel (CT) is formed by a '''non-extendable osteofibrous wall''' that forms a tunnel protecting the median nerve and flexor tendons.


'''Walls'''
The transverse carpal ligament (flexor retinaculum) makes up the superior boundary, and the [[Carpal Instability|carpal]] bones form the inferior border.


The carpal tunnel (CT) is formed by non extendable osteofibrous wall surrounding its content. The wall of the tunnel tunnel consists of carpal bones, joint capsule, carpal ligamets, flexor carpi radialis tendon and the flexor retinaculum. Carpal bones form an arch like base for the tunnel. Flexor  retinaculum spanning from the pisiform bone and the hamulus of the hamate bone to the scaphoid and the trapezium complete and close the tunnel. <ref name="Shiel">Shiel WC. Carpal tunnel syndrome [internet]. 2008 [2013 November 13 ; 2015 April 4]. Available from : http://www.emedicinehealth.com/carpal_tunnel_syndrome/article_em.htm.</ref>&nbsp;<ref name="Moses">Moses KP, Banks JC, Nava PB, Petersen D. Altals of clinical gross anatomy. Elsevier Mosby; 2008. Chapter 23, Wrist and hand joints; p.260-265.</ref><br>The eight carpal bones are oriented in two rows between the ulna and radius and the metacarpal bones. These form an articulated connection between the forearm and the hand.
The carpal tunnel includes the median nerve and nine flexor tendons.  


'''Content'''
The flexor tendons include
* Four tendons from the flexor digitorum profundus
* Four tendons from the flexor digitorum superficialis
* One tendon from the flexor pollicis longus. <ref name=":5" />
== Etiology  ==
Carpal tunnel syndrome results from increased pressure in the carpal tunnel and subsequent compression of the median nerve. The most common causes of carpal tunnel syndrome include genetic predisposition, history of repetitive wrist movements such as repetitive use, typing, or machine work as well as [[obesity]], diabetes, cumulative trauma disorders, tumor, hypothyroidism, wrist spine and fracture, [[Autoimmune Disorders|autoimmune]] disorders such as [[Rheumatoid Arthritis|rheumatoid arthritis,]] and pregnancy.<ref name=":5" />


CT allows passage of multiple structures between hand and proximal segments of body (''Picture 2). T''endons of flexor digitorum profundus, flexor digitorum superficialis and flexor pollicis longus muscles and the median nerve form the content of carpal tunnel. The median nerve  passes from the forearm to the palmar aspect of the hand, Its sensory axons convey sensory stimulation for median nerve distribution consisting of palmar aspect of  thumb and fingers, except for the fifth digit and ulnar half of fourth digit. Motor axons of median nerve supply the muscles of thenar eminence. <ref name="CTS fact sheet">Carpal tunnel syndrome fact sheet [internet]. Bethesda; 2012 July [2015 April 17; 2015 april 20]. Available from: http://www.ninds.nih.gov/disorders/carpal_tunnel/detail_carpal_tunnel.htm#280913049.</ref>
=== Epidemiology ===
* The prevalence of carpal tunnel syndrome is estimated to be 2.7-5.8% of the general adult population, with a lifetime incidence of 10-15%, depending on occupational risk 4.
* Carpal tunnel syndrome usually occurs between ages '''36 and 60''' and is more common in '''women''', with a female-to-male ratio of 2-5:1.<ref name=":0" />


Go [https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4487499/#bib0115 here] form more nuanced discussion of CT anatomy including its normal variations found in general and clinical populations.<br>.
=== Clinical Biomechanics of Carpal Tunnel Syndrome ===
Click [https://www.physio-pedia.com/Clinical_Biomechanics_of_Carpal_Tunnel_Syndrome here] for information


[[File:Carpal tunnel.png|center|frame|661x661px|Fig.2 Transverse plane view of carpal tunnel.]]<div></div>
=== Pathophysiology ===
There is a wide spectrum of causative pathologies, converging on two mechanisms of disease, both of which lead to entrapment:
* A decrease in the size of the carpal tunnel caused by such conditions as:
** Mechanical overuse (considered the most common association)
** [[osteoarthritis]]
** Trauma
** [[acromegaly]]
* Disease states leading to augmentation of carpal tunnel contents:
** Masses, For example, ganglion cysts, primary nerve sheath tumours
** Deposition of foreign material, e.g. amyloid
** Synovial hypertrophy in rheumatoid arthritis<ref name=":0">Radiopedia [https://radiopaedia.org/articles/carpal-tunnel-syndrome-1 CTS] Available from:https://radiopaedia.org/articles/carpal-tunnel-syndrome-1 (last accessed 23.3.2020)</ref>
In general, the pathophysiology of CTS results from a combination of compression and traction mechanisms. 
# The compressive element of the pathophysiology includes a detrimental cycle of increased pressure, obstruction of overall venous outflow, increasing local edema, and compromise to the median nerve's intraneural microcirculation.  Nerve dysfunction becomes compromised, and the structural integrity of the nerve itself further propagates the dysfunctional environment-- the myelin sheath and axon develop lesions, and the surrounding connective tissues become inflamed and lose normal physiologic protective and supportive function. 
# Repetitive traction and wrist motion exacerbates the negative environment, further injuring the nerve.  In addition,  any of the nine flexor tendons traveling through the carpal tunnel can become inflamed and compress the median nerve<ref name=":5" />


== Etiology and epidemiology<ref name="Chammas" />  ==
=== Idiopathic Carpal Tunnel Syndrome ===
<br>The estimated prevalence of CTS is 4-5% of the population.There are two peak age frequencies: the first and biggest peak is between 45 and 59 years of which 75% is female. The second age peak is between 75 and 84 years, of which 64% is femal.Most cases of CTS are idiopathic, A portion of incidences of CTS are caused by pathological changes in structures passing through the carpal tunnel or the tissues forming it's walls. Finally, considerable proportion of CTS cases are linked to pathological demands on wrist motion.
* Idiopathic CTS occurs more frequently in females (65–80%), between the ages of 40 and 60 years; 50–60% of the cases are bilateral.<ref>Michelsen H, Posner MA. Medical history of carpal tunnel syndrome. Hand clinics. 2002 May 1;18(2):257-68.</ref>  
 
'''<u>Idiopatic carpal tunnel syndrome</u>'''
* Idiopathic CTS occurs more frequently in females (65–80%) and between the ages of 40 and 60 years; 50–60% of the cases are bilateral.<ref>Michelsen H, Posner MA. Medical history of carpal tunnel syndrome. Hand clinics. 2002 May 1;18(2):257-68.</ref>  
* The bilateral characteristic increases in frequency with the duration of symptoms.<ref>Bagatur A.E., Zorer G. The carpal tunnel syndrome is a bilateral disorder. J Bone Joint Surg Br. 2001;83(5):655–658.</ref> 
* The bilateral characteristic increases in frequency with the duration of symptoms.<ref>Bagatur A.E., Zorer G. The carpal tunnel syndrome is a bilateral disorder. J Bone Joint Surg Br. 2001;83(5):655–658.</ref> 
* Idiopathic CTS is correlated with hypertrophy of the synovial membrane of the flexor tendons caused by degeneration of the connective tissue, with vascular sclerosis, edema and collagen fragmentation.<ref>Schuind F., Ventura M., Pasteels J.L. Idiopathic carpal tunnel syndrome: histologic study of flexor tendon synovium. J Hand Surg Am. 1990;15(3):497–503. </ref> The histological changes were thought to be suggestive of dynamic factors as repetitive strain.
* Idiopathic CTS is correlated with hypertrophy of the synovial membrane of the flexor tendons caused by degeneration of the connective tissue, with vascular sclerosis, edema and collagen fragmentation.<ref>Schuind F., Ventura M., Pasteels J.L. Idiopathic carpal tunnel syndrome: histologic study of flexor tendon synovium. J Hand Surg Am. 1990;15(3):497–503. </ref>  
* '''Predisposing factors'''  based on meta-analyses conducted in 2002<ref>Falkiner S., Myers S. When exactly can carpal tunnel syndrome be considered work-related? ANZ J Surg. 2002;72(3):204–209. </ref> and 2008,<ref name=":2">Lozano-Calderon S., Anthony S., Ring D. The quality and strength of evidence for etiology: example of carpal tunnel syndrome. J Hand Surg Am. 2008;33(4):525–538. </ref> include:
* The histological changes were thought to be suggestive of dynamic factors as repetitive strain.
** sex
** age
** genetic and anthropometric factors (size of the carpal tunnel) were of most importance followed by other correctable predisposing factors of clinical importance as:
*** besity
*** smoking
*** excessive alcohol consumption
** repetitive manual activities and exposure to vibrations and cold temperatures were the least important and of little clinical  relevance
 
<br>'''<u>Secondary  carpal tunnel syndrome</u>'''
 
'''Abnormalities of the walls of CT'''
* Any condition that modifies the walls of the carpal tunnel may cause compression of the median nerve.<ref name=":0">Knoll V.D., Allan C., Trumble T.E. Trans-scaphoid perilunate fracture dislocations: results of screw fixation of the scaphoid and lunotriquetral repair with a dorsal approach. J Hand Surg Am. 2005;30(6):1145–1152.</ref>
* Abnormalities of the shape or position of the carpal bones: dislocation or subluxation of the carpus<ref name=":0" /><ref>Monsivais J.J., Scully S. Rotary subluxation of the scaphoid resulting in persistent carpal tunnel syndrome. J Hand Surg Am. 1992;17(4):642–644.</ref>
* Abnormalities of the shape of the distal extremity of the radius: fractures (translation of more than 35%)<ref>Dyer G., Lozano-Calderon S., Gannon C., Baratz M., Ring D. Predictors of acute carpal tunnel syndrome associated with fracture of the distal radius. J Hand Surg Am. 2008;33(8):1309–1313.</ref> or skewed consolidation of the distal radius; osteosynthesis material on the anterior face of the radius;<ref>Henry M., Stutz C. A prospective plan to minimise median nerve related complications associated with operatively treated distal radius fractures. Hand Surg. 2007;12(3):199–204.</ref>
* Joint abnormalities: wrist arthrosis,<ref>Fassler P.R., Stern P.J., Kiefhaber T.R. Asymptomatic SLAC wrist: does it exist? J Hand Surg Am. 1993;18(4):682–686.</ref> inflammatory arthritis<ref name=":4" /> (due to synovial hypertrophy, bone deformation an/or carpal shortening), infectious arthritis,<ref>Hassanpour S.E., Gousheh J. Mycobacterium tuberculosis-induced carpal tunnel syndrome: management and follow-up evaluation. J Hand Surg Am. 2006;31(4):575–579.</ref> rhizarthrosis<ref>Brutus J.P., Baeten Y., Chahidi N., Kinnen L., Ledoux P., Moermans J.P. Atypical mycobacterial infections of the hand: report of eight cases and literature review. Chir Main. 2001;20(4):280–286.</ref> or villonodular synovitis<ref>Chidgey L.K., Szabo R.M., Wiese D.A. Acute carpal tunnel syndrome caused by pigmented villonodular synovitis of the wrist. Clin Orthop Relat Res. 1988;(228):254–257. </ref>
* Acromegaly.<ref>Jenkins P.J., Sohaib S.A., Akker S., Phillips R.R., Spillane K., Wass J.A. The pathology of median neuropathy in acromegaly. Ann Intern Med. 2000;133(3):197–201.</ref>
 
'''Abnormalities of the content of CT'''
* Tenosynovial hypertrophy;
* Inflammatory tenosynovitis: inflammatory rheumatism<ref name=":4">Chammas M. Le poignet rhumatoide. Chir Main. 2005;24(6):275–298.</ref> lupus and infection
* Metabolic tenosynovitis: diabetes mellitus<ref>Chammas M., Bousquet P., Renard E., Poirier J.L., Jaffiol C., Allieu Y. Dupuytren's disease, carpal tunnel syndrome, trigger finger, and diabetes mellitus. J Hand Surg Am. 1995;20(1):109–114.</ref> (abnormality of collagen turnover), primary or secondary amyloidosis (chronic hemodialysis with deposition of beta-2-microglobulin),<ref name=":1">Allieu Y., Chammas M., Idoux O., Hixson M., Mion C. Carpal tunnel syndrome and amyloid tenosynovitis in patients undergoing chronic hemodialysis. Evaluation and treatment apropos of 130 cases. Ann Chir Main Memb Super. 1994;13(2):113–121. </ref> gout<ref>Schuind F.A., Clermont D., Stallenberg B., Remmelink M., Pasteels J.L. Gouty involvement of flexor tendons. Chir Main. 2003;22(1):46–50</ref> and chondrocalcinosis;<ref>Gerster J.C., Lagier R., Boivin G., Schneider C. Carpal tunnel syndrome in chondrocalcinosis of the wrist. Clinical and histologic study. Arthritis Rheum. 1980;23(8):926–931.</ref>
* Abnormalities of fluid distribution: pregnancy<ref>Stolp-Smith K.A., Pascoe M.K., Ogburn P.L., Jr. Carpal tunnel syndrome in pregnancy: frequency, severity, and prognosis. Arch Phys Med Rehabil. 1998;79(10):1285–1287.</ref><ref>M’Bappé P. Complications neurologiques de la grossesse (sciatique exclue) Rev Rhum Ed Fr. 2005;72:719–724.</ref> in 0.34% to 25% of the cases, especially in the third trimester, with frequent signs of deficit in 37–85% of the cases; hypothyroidism<ref name=":3">Bradley W.G., Walton J.N. Neurologic manifestations of thyroid disease. Postgrad Med. 1971;50(3):118–121.</ref> and chronic kidney failure (arteriovenous fistula).<ref name=":1" />
* Abnormal or supernumerary muscle: deep palmar muscle<ref>Floyd T., Burger R.S., Sciaroni C.A. Bilateral palmaris profundus causing bilateral carpal tunnel syndrome. J Hand Surg Am. 1990;15(2):364–366.</ref> intratunnel position of the muscle body of the superficial flexor<ref>Schon R., Kraus E., Boller O., Kampe A. Anomalous muscle belly of the flexor digitorum superficialis associated with carpal tunnel syndrome: case report. Neurosurgery. 1992;31(5):969–970. </ref> or proximal extension of the muscle body of the lumbrical muscles<ref>Pierre-Jerome C., Bekkelund S.I., Husby G., Mellgren S.I., Osteaux M., Nordstrom R. MRI of anatomical variants of the wrist in women. Surg Radiol Anat. 1996;18(1):37–41.</ref>
* Persistent arterial hypertrophy of the median nerve
* Intratunnel tumor: lipoma, synovial cyst, synovial sarcoma or neural tumor (schwannoma, neurofibroma or lipofibroma);
* Hematoma: hemophilia<ref>Moneim M.S., Gribble T.J. Carpal tunnel syndrome in hemophilia. J Hand Surg Am. 1984;9(4):580–583. </ref> anticoagulant accident<ref>Bindiger A., Zelnik J., Kuschner S., Gellman H. Spontaneous acute carpal tunnel syndrome in an anticoagulated patient. Bull Hosp Jt Dis. 1995;54(1):52–53.</ref> or trauma<ref>Paley D., McMurtry R.Y. Median nerve compression by volarly displaced fragments of the distal radius. Clin Orthop Relat Res. 1987;(215):139–147.</ref>
* Obesity<ref>Bland J.D. The relationship of obesity, age, and carpal tunnel syndrome: more complex than was thought? Muscle Nerve. 2005;32(4):527–532.</ref>
 
'''<u>Dynamic carpal tunnel syndrome</u>'''
 
The pressure inside the carpal tunnel increases during wrist extension and flexion<ref>Gelberman R.H., Hergenroeder P.T., Hargens A.R., Lundborg G.N., Akeson W.H. The carpal tunnel syndrome. A study of carpal canal pressures. J Bone Joint Surg Am. 1981;63(3):380–383.</ref> Repetitive extension and flexion movements of the wrist, along with flexion of the fingers and supination of the forearm, have been implicated in this increase<ref>Mackinnon S.E. Pathophysiology of nerve compression. Hand Clin. 2002;18(2):231–241.</ref>  Incursions of muscle bodies from the superficial and deep flexors of the fingers, when the wrist and fingers are extended, have been found in 50% of the cases This particular movement can be seen in occupational pathological conditions<ref>Kerwin G., Williams C.S., Seiler J.G., 3rd. The pathophysiology of carpal tunnel syndrome. Hand Clin. 1996;12(2):243–251.</ref>
 
'''Computer work and CTS'''
 
No increase in the prevalence of CTS in cases of working on computers for more than 15 h per week has been observed. A tendency toward increased prevalence has been demonstrated in cases of working on computers for more than 20 h per week<ref>Andersen J.H., Fallentin N., Thomsen J.F., Mikkelsen S. Risk factors for neck and upper extremity disorders among computers users and the effect of interventions: an overview of systematic reviews. PLoS ONE. 2011;6(5):e19691. </ref>
 
'''Exposure to vibration'''
 
Exposure to vibration is one of the lesser predisposing factors.<ref name=":3" /><ref name=":2" /> The ultrastructural consequences comprise microcirculatory compression problems and intraneural edema following injury of the myelin and axons.
 
'''Occupational factors'''
 
Occupational biomechanical factors play a substantial role in the causation of CTS. Data from current primary studies on dose-response suggest that the risk of CTS increases with the [http://personal.health.usf.edu/tbernard/HollowHills/HALTLVM15.pdf American Conference of Governmental Industrial Higenists]
 
[http://personal.health.usf.edu/tbernard/HollowHills/HALTLVM15.pdf threshold limit values  ACGIH® TLV® for Hand Activity Levels.]<ref>Kozak A, Schedlbauer G, Wirth T, Euler U, Westermann C, Nienhaus A. Association between work-related biomechanical risk factors and the occurrence of carpal tunnel syndrome: an overview of systematic reviews and a meta-analysis of current research. BMC musculoskeletal disorders. 2015 Dec;16(1):231.</ref>
 
'''Acute CTS'''
 
Etiologies:
* Trauma: displacement due to fracturing of the distal radius or dislocation of the wrist;
* Infection;
* Hemorrhage due to overdose of anticoagulant or in cases of hemophilia;
* High-pressure injection;
* Acute thrombosis of the artery of the median nerve;
* Burns.
 
== Clinical presentation  ==
[[File:Median nerve domain.gif|alt=|thumb|549x549px|Fig. 3  Right hand sensory distribution.<ref>Gray, Henry. ''Anatomy of the Human Body.'' Philadelphia: Lea & Febiger, 1918; Bartleby.com, 2000. www.bartleby.com/107/. [Date of Printout].</ref>]]
 
CTS onset is generally gradual  with tingling or numbness in median nerve distribution of affected hand. Fig.3. <ref name="Jesus">Jesus Filho AG, do Nascimento BF. Comparative study between physical examination, electroneuromyography and ultrasonography in diagnosing carpal tunnel syndrome. Revista Brasileira de Ortopedia (English Edition). 2014 September–October; 49(5): 446–451.</ref>&nbsp;<ref name="Ashworth">Ashworth NL, MBChB. Carpal Tunnel Syndrome Clinical Presentation [Internet]. 1994 [Updated 2014 Aug 25; cited 2015 March 20].fckLRAvailable from:fckLRhttp://emedicine.medscape.com/article/327330-clinical.</ref>&nbsp;<ref name="Krom">Krom de M.C.T.F.M., MD, KnipschildP.G. Prof. Efficacy of provocative tests for diagnosis of carpal tunnel syndrome. The Lancet. 1990 Feb 17; Vol.335 Issue 8686: 393-395. </ref><br>Patients may notice aggravation of symptoms with static gripping  of objects as  phone or steering wheel but also at night or early in the morning. <ref name="Ashworth" />&nbsp;<ref name="Krom" /> Many patients will report improvement of symptoms following shaking or flicking of their hand.
 
As the disorder progresses, the feeling of tingling or numbness may become constant and patients may complain of burning pain. <ref name="Ashworth" /><br>The final symptoms are weakness and atrophy of muscles  thenar eminence.<br>These  combined effects of sensory deprivation and weakness may result in complaint of clumsiness and loss of grip and pinch strength or dropping things, <ref name="Ashworth" />
 
== Differential diagnosis  ==
[[File:Dermatomes_Grant.png|thumb|525x525px|Fig. 4. Location  of C7 dermatome. Note overlap with median nerve sensory distribution of hand.]]
Process of differential diagnosis should give consideration to all conditions which could potentially cause a dysfunction of  median nerve, or its contributories in brachial plexus, C 5 to 8 nerve roots and central nervous system. For example: an '''injury of  nn. digitales''' in the palm,  [https://en.wikipedia.org/wiki/Pronator_teres_syndrome '''pronator teres syndrome'''] or cervicobrachial syndrome, particularly when C7 nerveroot is involved.  Even though the neurological symptoms of this pathology have a distinct dermatomal character, the '''C7-C8 dysfunction with [[radiculopathy]]''' will overlap with CTS in location of paraesthesia of hand as demonstrated in Fig. 3 and 4. 
 
Other conditions to be aware of when diagnosing CTS include:
* '''[https://www.orpha.net/consor/cgi-bin/OC_Exp.php?Expert=2901 neuralgic amyotrophy]'''  .<ref name="Amadio">Amadio P. Differential Diagnosis of Carpal Tunnel Syndrome. Carpal Tunnel Syndrome. 2007. Chapter 41, Differential diagnosis of carpal Tunnel; p.89-94</ref>
* '''ntracranial neoplasms'''
* '''[[MS Multiple Sclerosis|multiple sclerosis]]'''  <ref name="Amadio" />&nbsp;<ref name="AshworthNL">Ashworth NL, MBChB. Carpal Tunnel Syndrome Differential Diagnoses [Internet]. 1994 [Updated 2014 Aug 25; cited 2015March 20] Available from: http://emedicine.medscape.com/article/327330-differntial .</ref>
* Cervical '''[[syringomyelia]]'''
* [[Brachial plexus injury|'''brachial plexus injury''']]
* '''[https://www.physio-pedia.com/Pancoast_Tumor pancoast tumor]'''  <ref name="Amadio" /><br>
 
== Diagnostic procedures  ==
 
'''Electroneuromyography (ENMG)''' examination<ref name="Jesus" /> is used  to examine the sensory and motor nerve conductance of the median nerve. It also highlights the elective weakening in passing through the carpal tunnel. It is considered abnormal when there is a diminished sensory conduction velocity between the wrist, the palm of the hand and the fingers. This test may be used to diagnose the condition and rule out other pathologies. <ref name="Chammas" />
 
'''Electromyogram (EMG''') of the muscles innervated by the median nerve measures electrical dischargers produced in the muscles. This test can determine if there is any muscle damage and can rule out other conditions. <ref name="Visser">Visser LH, Smidt MH, Lee ML. High-resolution sonography versus EMG in the diagnosis of carpal tunnel syndrome. J Neurol Neurosurg Psychiatry. 2008;79:63-67. </ref>&nbsp;<ref name="Simpson">Simpson JA. Electrical signs in the diagnosis of carpal tunnel and related syndromes. J Neurol Neurosurg Psychiatry. 1956 Nov; 19(4):275-280. </ref>
 
'''Ultrasonography'''  can identify space-occupying lesion in and around the median nerve. The test can confirm abnormalities that can diagnose CTS and help guide steroid injections into the carpal tunnel. <ref name="Jesus" />&nbsp;<ref name="AshworthNLM">Ashworth NL, MBChB. Carpal Tunnel Syndrome Workup [Internet]. 1994 [Updated 2014 Aug 25; cited 2015 March 20].fckLRAvailable from: http://emedicine.medscape.com/article/327330-workup. </ref>
 
'''X-ray''' is recommended to exclude other causes of wrist pain like arthritis or bony pathology. <ref name="Chammas" />
 
== Outcome measures  ==
 
There are several questionnaires available to determine the outcome measures for CTS. The four questionnaires below are all supported by studies with level of evidence 2A or 2B. Only the study of Levine et al. <ref name="Levine">Levine DW, Simmons BP, Koris MJ, Daltroy LH, Hohl GG, Fossel AH, Katz JN. A self-administered questionnaire for the assessment of severity of symptoms and functional status in carpal tunnel syndrome. J Bone Surg Am. 1993 Nov; 75(11):1585-92. </ref>, describing the BCTQ, has level of evidence 4. This questionnaire is, however supported by other, higher level  studies as well.
 
1. '''Boston Carpal Tunnel Questionnaire''' ([http://journals.plos.org/plosone/article/file?id=info:doi/10.1371/journal.pone.0129918.s002&type=supplementary BCTQ])<br>The BCTQ or the Levine Scale, originally developed by Levine et al. (1993) <ref name="Levine" />, is the most commonly used outcome measure in the assessment of CTS patients. It can be self-, interview- or telephone-administered. The questionnaire comprises of two scales: the Symptom Severity Scale (SSS) and the Functional Status Scale (FSS). <ref name="Hadi">Hadi M, Gibbons E, Fitzpatrick R. A structured review of patient-reported outcome measures for procedures for carpal tunnel syndrome. Oxford: Departmet of Public Health (University of Oxford); 2011. 33p. </ref>&nbsp;<ref name="Sambandam">Sambandam SN, Priyanka P, Gul A, Ilango B. Critical analysis of outcome measures used in the assessment of carpal tunnel sundrome. Int Orthop. 2008 Aug; 32(4):497-504.</ref>
 
The SSS consist of 11 questions, scored on a five-point rating scale, for the evaluation of pain, test-retest reliability of paraesthesia, numbness, weakness, nocturnal symptoms and overall function status. <ref name="Hadi" />&nbsp;<ref name="Sambandam" />
 
The FSS rates 8 functional activities on difficulty level, also scored on a five-point rating scale. The overall score for both scales is calculated as the mean of the items. <ref name="Sambandam" /><br>The reliability, validity and responsiveness of the BCTQ has been found to be very good by several studies, such as the report of the University of Oxford16 and the studies of Sambandam et al. <ref name="Sambandam" />, Bakhsh et al. <ref name="Bakhsh">Bakhsh H, Ibrahim I, Khan W, Smitham P, Goddard N. Assessment of validity, reliability, responsiveness and bias of three commonly used patient-reported outcome measures in carpal tunnel syndrome. Ortop traumatol Rehabil. 2012 Jul/Aug; 14(4):335-340. </ref>&nbsp; and Greenslade et al. <ref name="Greenslade">Greenslade JR, Mehta RL, Belward P, Warwick DJ. Dash and Boston questionnaire assessment of carpal tunnel syndrome outcome: what is the responsiveness of an outcome questionnaire? JHS. 2004 Apr; 29(2):159-164.</ref>.
 
<br>2. '''Disability of Hand and Shoulder ([[DASH Outcome Measure|DASH]]) Questionnaire '''<br>The DASH-questionnaire is a self-, interview- or telephone-administered region-specific outcome instrument developed as a measure of self-rated upper-extremity disability and symptoms. The DASH is a 30-item scale, each scored on a 5-point Likert scale and overall scored on a scale from 0 (no disability) to 100 (maximum disability). It consists of two dimensions: Physical Functioning and Symptoms. The DASH is not specific for CTS, but can detect and differentiate small and large changes in disability over time after surgery in patients with several upper extremity musculoskeletal disorders. <ref name="Hadi" /><br>The DASH questionnaire is also found to be a valid and reliable test with good responsiveness. <ref name="Hadi" />&nbsp;<ref name="Sambandam" />&nbsp;<ref name="Greenslade" />&nbsp;<ref name="Hobby">Hobby JL, Watts C, Elliot D. Validity and responsiveness of the patient evaluation measure as an outcome measure for carpal tunnel syndrome. J Hand Surg Br. 2005 Aug; 30(4):350-354.</ref>&nbsp;Bakhsh et al. <ref name="Bakhsh" />&nbsp;however found the DASH questionnaire to be less responsive than the BCTQ.<br>&nbsp;<br>3. Michigan Hand Outcomes Questionnaire (MHQ)<br>The MHQ is a self-, interview- or telephone-administered questionnaire used to assess the outcome for various hand disorders. <ref name="Hadi" />&nbsp;It consists of 37 items, grouped into 6 domains: overall hand function, activity of daily living, pain, work performance, aesthetics and patient satisfaction with hand function. All questions are scored from 1 to 5, with high scores denoting better performance, except for the pain scale, in which a higher score means more pain. The score of each scale is converted to a score from 0 to 100. <ref name="Hadi" />&nbsp;<ref name="Sambandam" /><br>The MHQ is found to be a valid and reliable measurement with good responsiveness. <ref name="Hadi" />&nbsp;<ref name="Sambandam" />
 
A short 12 item version was also validated for CTS and several other common hand conditions to reduce the burden and promote its use in clinical setting.<ref>Shauver MJ, Chung KC. The Michigan Hand Outcomes Questionnaire (MHQ) after 15 years of field trial. Plastic and reconstructive surgery. 2013 May;131(5):779e.</ref> <br>
 
4. Patient Evaluation Measures (PEM)<br>The PEM is a self-, interview- or telephone-administered questionnaire to measure physical health. It consists of 3 components (patient’s opinion on delivery of care, hand health profile, overall assessment) and a total of 18 items scored on a 7-point scale. Low scores indicate positive outcomes.16 17 Hobby et al.20 found this instrument to be valid and reliable and to have good responsiveness. <ref name="Hadi" />&nbsp;<ref name="Sambandam" />
 
== Examination  ==
 
'''Clinical prediction rules''' (CPR), specifically for the Carpal Tunnel Syndrome, are a reliable examination method. It consists of five tests. Wainner et al. <ref name="Wainner">Wainner RS, Fritz JM, Irrgang JJ, Delitto A, Allison S, Boninger ML. Development of a clinical prediction rule for the diagnosis of carpal tunnel syndrome. Archives of Physical Medicine and Rehabilitation. 2005 Apr; 86(4): 609-618. </ref>&nbsp;found that the CPR is more useful for diagnosis of CTS than any single test item. Using CPR results is posttest probability changes up to 56%.<br>
{{#ev:youtube|h136sLsCZcc}}<ref>Physiotutors. Wainner Clinical Prediction Rule (CPR) | Carpal Tunnel Syndrome (CTS). Available from: https://www.youtube.com/watch?v=h136sLsCZcc</ref>
<br>Other than the CPR, there are several provocative tests and the thenar atrophy observation that can be used in the clinical examination of a CTS patient. In Table 2 <ref name="Makanji">Makanji HS, Becker SJE, Mudgal CS, Jupiter JB, Ring D. Evaluation of the scratch collapse test for the diagnosis of carpal tunnel syndrome. JHS. 2014 Feb; 39(2):181-186. </ref>&nbsp;you find the sensitivity and specificity rates of all the tests explained below.
 
{| cellspacing="1" cellpadding="1" border="1" width="700"
|+ Table 2: Diagnostic Parameters of Clinical Tests for Carpal Tunnel Syndrome
|-
|
| Sensitivity (%)
| Specificity (%)
| Positive Prediction Value (%)
| Negative Prediction Value (%)
| Accuracy (%)
|-
| Scratch Collapse Test
| 34
| 61
| 71
| 25
| 41
|-
| [http://www.physio-pedia.com/Phalen's_Test Phalen’s Test]
| 67
| 33
| 75
| 25
| 59
|-
| Durkan’s Test
| 77
| 18
| 73
| 21
| 62
|-
| [http://www.physio-pedia.com/Tinel%E2%80%99s_Test Tinel’s Test]
| 43
| 56
| 74
| 25
| 46
|-
| Thenar Atrophy
| 18
| 96
| 92
| 29
| 39
|-
| Thumb Abduction Weakness
| 37
| 73
| 80
| 28
| 46
|-
| CTS-6 Lax
| 88
| 13
| 74
| 27
| 68
|-
| CTS-6 Stringent
| 54
| 48
| 74
| 27
| 52
|}


<br>
== Clinical Presentation  ==
 
[[File:Median nerve domain.gif|alt=|549x549px|Fig. 3  Right hand sensory distribution.<ref>Gray, Henry. ''Anatomy of the Human Body.'' Philadelphia: Lea & Febiger, 1918; Bartleby.com, 2000. www.bartleby.com/107/. [Date of Printout].</ref>|right|frameless]]
Atrophy of the thenar can often be observed and the thumb muscle innervated by the median nerve are often weakened, dependent on the stage of the syndrome. <ref name="Makanji" />&nbsp;<ref name="Phalen">Phalen GS. The Carpal-tunnel Syndrome: Clinical Evaluation of 598 Hands. Clinical Orthopaedics. 1972 Mar/Apr; 83:29-40.</ref>&nbsp;<ref name="PhalenGS">Phalen GS. The Carpal-Tunnel Syndrome – seventeen years’ of experience in diagnosis and treatment of six hundredfifty-four hands. J Bone Joint Surg Am. 1966 Mar; 48(2):211-228.</ref>  
 
<br>


Provocative tests:  
CTS onset is generally gradual with tingling or numbness in the median nerve distribution of the affected hand. Fig.3. <ref name="Jesus">Jesus Filho AG, do Nascimento BF. Comparative study between physical examination, electroneuromyography and ultrasonography in diagnosing carpal tunnel syndrome. Revista Brasileira de Ortopedia (English Edition). 2014 September–October; 49(5): 446–451.</ref>&nbsp;<ref name="Ashworth">Ashworth NL, MBChB. Carpal Tunnel Syndrome Clinical Presentation [Internet]. 1994 [Updated 2014 Aug 25; cited 2015 March 20].fckLRAvailable from:fckLRhttp://emedicine.medscape.com/article/327330-clinical.</ref>&nbsp;<ref name="Krom">Krom de M.C.T.F.M., MD, KnipschildP.G. Prof. Efficacy of provocative tests for diagnosis of carpal tunnel syndrome. The Lancet. 1990 Feb 17; Vol.335 Issue 8686: 393-395. </ref><br>Patients may notice aggravation of symptoms with static gripping of objects such as a phone or steering wheel but also at night or early in the morning. <ref name="Ashworth" />&nbsp;<ref name="Krom" /> Many patients will report an improvement of symptoms following shaking or flicking of their hand.


1. [http://www.physio-pedia.com/Phalen's_Test Phalen’s test] <br>The patient flexes his wrist for one minute and reports any symptoms that may occur. The test is described in many different positions. As described by G. A. Phalen (1966) <ref name="PhalenGS" />, the patient holds his forearm vertically and lets his wrist drop down in 90° flexion <ref name="Diagnosing">Diagnosing CTS; Provocative tests [internet]. NHS; 2010 [Updated 2011 June 11].             Available from: http://www.carpal-tunnel.net/diagnosing/provocative. </ref>. The arm can also be held horizontally in front of the patient with the wrist hanging down. <ref name="Romito">Romito K. Physical Exam for Carpal Tunnel Syndrome [internet]. Healthwise; 2005 [Updated 2012 Oct 2]. Available from: fckLRhttp://www.webmd.com/pain-management/carpal-tunnel/physical-exam-for-carpal-tunnel-syndrome. </ref>&nbsp;Another common way of executing the test is to hold both wrists against each other in 90° flexion with elbows also flexed and fingers pointing in the patient’s direction. <ref name="Urbano">Urbano FL. Tinel’s sign and Phalen’s Maneuver: Physical Signs of Carpal Tunnel Syndrome. Hospital Physician. 2000 Jul: 39-44.</ref>&nbsp;<ref name="Wolgin">Wolgin MA. Carpal Tunnel Syndrome http://www.drwolgin.com/carpal-tunnel-syndrome/</ref><br>The Reverse Phalen’s test, where the patient holds his wrist and fingers in full extension, provokes the same symptoms as the original test, which are the symptoms that are usually experienced by patients with CTS, such as tingling, paresthesia or pain in the fingers. <ref name="Diagnosing" /><ref name="Romito" />  
As the disorder progresses, the feeling of '''tingling or numbness''' may become constant and patients may complain of burning pain. <ref name="Ashworth" /><br>The final symptoms are weakness and atrophy of muscles of the thenar eminence. These  combined effects of sensory deprivation and weakness may result in a complaint of clumsiness and loss of grip and pinch strength or dropping things, <ref name="Ashworth" />  


<br>2. [http://www.physio-pedia.com/Tinel%E2%80%99s_Test Tinel’s sign]<br>The examiner taps with his fingers of with a tendon hammer on the inside of the wrist onto the medial nerve at carpal tunnel level. Patients with CTS will not feel pain, but experience a tingling sensation in their hand. <ref name="Diagnosing" /><ref name="Romito" /><ref name="Urbano" />
== Differential Diagnosis  ==
The process of differential diagnosis should give consideration to all conditions which could potentially cause a dysfunction of the median nerve, or its contributories in brachial plexus, C 5 to 8 nerve roots and central nervous system.  


<br>3. Hand elevation test ([http://www.physio-pedia.com/Roos_Stress_Test '''Roos Stress Test'''])<br>Isn’t this a test for thoracic outlet syndrome? The Roos Stress Test is indeed an indicative test for TOS and not for CTS. The hand elevation test is however a CTs test. The link to Roos Stress Test should be removed.The patient hold his arm above his head as straight as possible and holds this position for a minimum of two minutes. <ref name="Diagnosing" />&nbsp;The test is positive when the patient experiences typical CTS symptoms, such as a numb or tingling feeling in the fingers or pain or stiffness in the fingers, palm or wrist. Some patients also experience soreness in the shoulder. <ref name="How">How to Use a Hand Elevation Test to Detect Carpal Tunnel Syndrome [internet]. Demand Media;  1999-2015. Available from: http://www.ehow.com/how_2088359_use-hand-elevation-test-detect.html.</ref>  
Possible differential diagnoses of carpal tunnel syndrome include: 
* other median nerve entrapment syndromes
* [[Pronator Teres Syndrome Test|pronator teres syndrome]]
* anterior interosseous nerve syndrome
* an injury of nerve digitales in the palm.
* [[Cervicobrachial Syndrome|cervicobrachial]] syndrome.<ref name=":0" />


This test is only considered meaningful if the results can be duplicated by other, more specific CTS tests. <ref name="How" />  
== Diagnostic Procedures  ==
[[Ultrasound Scans|Ultrasound]] and [[MRI Scans|MRI]] are the two imaging modalities which best lend themselves to investigating entrapment syndromes. Next to directly visualizing direct causes and anatomical variants recognizing pathological muscle signal patterns on MRI can point to the affected nerve.<ref name=":0" />


<br>4. Scratch Collapse Test (CTS-6 Lax/Sringent)<br>Cheng et al. <ref name="Cheng">Cheng CJ, Mackinnon-Patterson B, Beck JL, Mackinnon SE. Scratch Collapse Test for Evaluation of Carpal and Cubital Tunnel Syndrome. JHS. 2008 Nov; 33(9):1518-1524.</ref>&nbsp;introduced this test in 2008 as an improved method to diagnose CTS among other syndromes. The test is executed with the patient facing the examiner with his arms adducted, elbows flexed and hands outstretched with the wrists in neutral position. The patient has to resist the external rotation movement the examiner is trying to make by pushing both the patient’s forearms out. The examiner then scratches the median nerve at carpal tunnel level and the previous exercise is repeated. A brief loss of resistance against the external rotation force of the affected side after scratching the median nerve is considered a positive scratch collapse test. <ref name="Cheng" />  
Electromyography and nerve conduction studies are the basis for carpal tunnel syndrome diagnosis. Other clinical or special exams do not confirm carpal tunnel syndrome but do assist in ruling out other diagnoses. These findings can prompt electromyography and nerve conduction studies.<ref name=":5" />


Video of the Scratch Collapse Test: https://www.youtube.com/watch?v=Uh6bM2Z1ESk<br>  
[https://www.physio-pedia.com/X-Rays X-ray] is recommended to exclude other causes of wrist pain like arthritis or bony pathology. <ref name="Chammas" />  


5. Durkan’s Carpal Compression Test<br>The examiner externally applies pressure directly over the carpal tunnel. This test is also positive when the typical CTS symptoms occur while the pressure is applied. <ref name="Diagnosing" /><br>
== Outcome Measures ==
== Medical Management ==


'''Non-surgical treatment''' comprises oral steroids <ref name="Oconnor">O’Connor D, Marshall SC, Massy-Westropp N, Pitt V. Non-surgical treatment (other than steroid injection) for carpal tunnel syndrome (Review). The Cochrane database of systematic reviews. 2012; volume (7):1-106. </ref>&nbsp;<ref name="Huisstede">Huisstede BM, Hoogvliet P, Randsdorp MS, Glerum S, van Middelknoop M, Koes BW. Carpal Tunnel Syndrome. Part I: Effectiveness of Nonsurgical Treatments–A Systematic Review. Archives of physical medicine and rehabilitation. 2010 Jul; 91(7):981-1004. </ref>, corticosteroid injections <ref name="Huisstede" />, NSAID <ref name="Oconnor" /><ref name="Huisstede" />,&nbsp;diuretics <ref name="Oconnor" /><ref name="Piazzini">Piazzini DB, Aprile I, Ferrara PE, Bertolini C, Tonali P, Maggi L, Rabini A, Piantelli S, Padua L. A systematic review of conservative treatment of carpal tunnel syndrome. Clinical rehabilitation. 2007 Apr; 21(4):299-314. </ref>, vitamin B6 <ref name="Oconnor" />&nbsp;and splinting/hand brace <ref name="Oconnor" /><ref name="Huisstede" /><ref name="Piazzini" />. <br>Reviews show that there is moderate and strong evidence for the effectiveness for curing CTS using oral and local steroids. <ref name="Oconnor" /> <ref name="Huisstede" /> <ref name="Piazzini" /> Huisstede et al <ref name="Huisstede" />&nbsp;says that for both treatments no evidence was found for long term effectiveness. Diuretics, NSAID and vitamin B6 turn out to be ineffective <ref name="Oconnor" /><ref name="Huisstede" /><ref name="Piazzini" />. There is limited <ref name="Oconnor" />&nbsp;to moderate<ref name="Piazzini" />&nbsp;evidence of the effectiveness of splinting in short term. Huisstede et al <ref name="Huisstede" />&nbsp;claim that number of nonsurgical interventions benefit CTS in the short term, but there is sparse evidence on the midterm and long-term effectiveness of these interventions<ref name="Ashworth" /><ref name="Huisstede" />&nbsp;<br>  
There are several questionnaires available to determine the outcome measures for CTS. 
* '''[[Brigham and Women's Carpal Tunnel Questionnaire|Boston Carpal Tunnel Questionnaire]] ([http://journals.plos.org/plosone/article/file?id=info:doi/10.1371/journal.pone.0129918.s002&type=supplementary BCTQ])'''
* '''Disability of Hand and Shoulder ([[DASH Outcome Measure|DASH]]) Questionnaire'''
* [https://physio-pedia.com/Brigham_and_Women's_Carpal_Tunnel_Questionnaire Brigham_and_Women's_Carpal_Tunnel_Questionnaire].
* '''Patient Evaluation Measures (PEM)''' The PEM is a self-, interview- or telephone-administered questionnaire to measure physical health. It consists of 3 components (patient’s opinion on delivery of care, hand health profile, overall assessment) and a total of 18 items scored on a 7-point scale. Low scores indicate positive outcomes.16 17 Hobby et al.20 found this instrument to be valid and reliable and to have good responsiveness. <ref name="Hadi">Hadi M, Gibbons E, Fitzpatrick R. A structured review of patient-reported outcome measures for procedures for carpal tunnel syndrome. Oxford: Departmet of Public Health (University of Oxford); 2011. 33p. </ref>&nbsp;<ref name="Sambandam">Sambandam SN, Priyanka P, Gul A, Ilango B. Critical analysis of outcome measures used in the assessment of carpal tunnel sundrome. Int Orthop. 2008 Aug; 32(4):497-504.</ref>


Huistede et al <ref name="HuisstedeBM">Huisstede BM, Randsdorp MS, Coert JH, Glerum S, van Middelknoop M, Koes BW. Carpal Tunnel Syndrome. Part II: Effectiveness of Surgical Treatments—A Systematic Review. Archives of physical medicine and rehabilitation. 2010 Jul; 91(7):1005-24.</ref> concluded that '''surgical treatment''' seems to be more effective than splinting and anti-inflammatory drugs plus hand therapy in the midterm and long term to treat CTS <ref name="Ashworth" /><ref name="Huisstede" />. However, there is no unequivocal evidence that suggestsone surgical treatment is more effective than the other<ref name="Ashworth" />.  
== Physical Examination  ==
'''May include testing for sensory and motor deficits and evidence of thenar wasting. There are several special tests with varying degrees of sensitivities and specificities.'''
* The best of these include the [[Carpal Compression Test|carpal compression test]]. This is done by applying firm pressure directly over the carpal tunnel for 30 seconds. The test is positive when paresthesias, pain, or other symptoms are reproduced.
* The square sign test is an evaluation to determine the risk of developing carpal tunnel syndrome. The test is positive if the ratio of the thickness of the wrist divided by the width of the wrist is great than 0.7.
* Another test is a palpatory diagnosis. In this test, the health care provider examines soft tissue over the median nerve for mechanical restriction.
* The [[Phalen’s Test|Phalen's]] test or ‘reverse prayer’ is performed by having the patient fully flex their wrists by placing dorsal surfaces of both hands for one minute. A positive test is when symptoms (numbness, tingling, pain) are reproduced.
* The reverse Phalen's, or ‘prayer test,’ is done by having the patient extend both of their wrists by placing palmar surfaces of both hands together for 1 minute (as if praying). Again a positive test is with reproduction of symptoms.
* Although a low sensitivity and specificity, the Hoffmann-Tinel sign is another test commonly performed. In this test the healthcare professional taps immediately over the carpal tunnel to stimulate the median nerve. Like the above tests, a positive test is when symptoms are reproduced.<ref name=":5" />
* The [[Scratch Collapse Test|'Scratch Collapse Test' (SCT)]] has emerged as a new provocative test to assist in the localisation of peripheral nerve compression.
'''[[CPR for Carpal Tunnel Syndrome|Clinical prediction rules]]''' [[CPR for Carpal Tunnel Syndrome|(CPR),]] specifically for the Carpal Tunnel Syndrome, are a reliable examination method.


The two main manners to decompress the median nerve by surgery are the [https://www.youtube.com/watch?v=xSnGWeN1sDE open carpal tunnel release] (OCTR) and the [https://www.youtube.com/watch?v=xSnGWeN1sDE endoscopic carpal tunnel release] (ECTR). During the OCTR  the 2 cm incision is performed through skin, palmar fascia to access and release  transverse carpal ligament. The less invasive ECTR allows to minimize the size of skin incision while releasing the  transverse ligament. During this operation the surgeon can use the single-portal technique and the two-portal technique. The first technique uses one incision, the second one two. Using a camera, surgeons can see what happens inside.  
== Medical Management ==
If carpal tunnel syndrome is identified early conservative treatment is recommended.
* Initially, the patient should be instructed in modifying symptom provoking wrist movement, For example, proper hand [https://www.physio-pedia.com/Ergonomics ergonomics] such as placing the keyboard at a proper height and minimizing flexion, extension, abduction, and adduction of the hand when typing. It should be recommended to '''decrease repetitive activities''' if possible.<ref name=":5" />
* '''Non-surgical treatment''' comprises oral steroids <ref name="Oconnor">O’Connor D, Marshall SC, Massy-Westropp N, Pitt V. Non-surgical treatment (other than steroid injection) for carpal tunnel syndrome (Review). The Cochrane database of systematic reviews. 2012; volume (7):1-106. </ref>&nbsp;<ref name="Huisstede">Huisstede BM, Hoogvliet P, Randsdorp MS, Glerum S, van Middelknoop M, Koes BW. Carpal Tunnel Syndrome. Part I: Effectiveness of Nonsurgical Treatments–A Systematic Review. Archives of physical medicine and rehabilitation. 2010 Jul; 91(7):981-1004. </ref>, corticosteroid injections <ref name="Huisstede" />, NSAID <ref name="Oconnor" /><ref name="Huisstede" />,&nbsp;diuretics <ref name="Oconnor" /><ref name="Piazzini">Piazzini DB, Aprile I, Ferrara PE, Bertolini C, Tonali P, Maggi L, Rabini A, Piantelli S, Padua L. A systematic review of conservative treatment of carpal tunnel syndrome. Clinical rehabilitation. 2007 Apr; 21(4):299-314. </ref>, vitamin B6 <ref name="Oconnor" />&nbsp;and splinting/hand brace <ref name="Oconnor" /><ref name="Huisstede" /><ref name="Piazzini" />. If conservative treatments are not successful, an '''oral or local glucocorticoid''' could be offered. 


* The definitive treatment for persistent carpal tunnel syndrome is '''surgical intervention''' with carpal tunnel release after nerve conduction studies showing significant axonal degeneration. Carpal tunnel release typically is performed by an orthopedic surgeon or hand surgeon. This procedure can be performed either open or endoscopically. Carpal tunnel release is considered a minor surgery in which the transverse carpal ligament or flexor retinaculum is cut, opening more space in the carpal tunnel and decreasing pressure on the median nerve. It does not typically require overnight hospitalization.<ref name=":5" />


== Physical Therapy Management  ==


Benson et al <ref name="Benson">Benson LS, Bare AA, Nagle DJ, Harder VS, Williams CS, Visotskv JL. Complications of Endoscopic and Open Carpal Tunnel Release. Arthroscopy. 2006 Sep; 22(9):919-24. </ref> says that with both techniques (OCTR and ECTR) the structural complications for nerves, blood vessels or tendons are low. According to Chen et al <ref name="Chen">Chen L, Duan X, Huang X, Lv J, Peng K, Xiang Z. Effectiveness and safety of endoscopic versus open carpal tunnel decompression. Archives of orthopaedic and trauma surgery. 2014 Apr; 134(4):585-93. </ref>&nbsp; there are no obvious statistical differences in relief of symptoms (pain en paraesthesia), recovery of grip strength a reoperation rate. Though, two articles with moderate to strong level of evidence declares the ECTR causes a faster return to work <ref name="Chen" /><ref name="Saw">Saw NL, Jones S, Shepstone L, Meyer M, Chapman PG, Logan AM. Early outcome and cost-effectiveness of endoscopic versus open carpal tunnel release: a randomized prospective trial. Journal of hand surgery. 2003 Oct; 28(5):444-9. </ref>&nbsp;and a better recovery of pinch strength.<br>
Patients with mild to moderate symptoms can be effectively treated in a primary care environment <ref name="Oskouei">Oskouei AE, Talebi GA, Shakouri SK, Ghabili K. Effects of Neuromobilization Maneuver on Clinical and Electrophysiological Measures of Patients with Carpal Tunnel Syndrome. Journal of physical therapy science. 2014 Jul; 26(7):1017-22. </ref> <ref name="Burke">Burke FD, Ellis J, McKenna H, Bradley MJ. Primary care management of carpal tunnel syndrome. Postgraduate medical journal. 2003 Aug; 79 (934):433-7.</ref>&nbsp;
== Physical Therapy management  ==


Patients with mild to moderate symptoms do not need to be immediately operated but can be effectively treated in a primary care environment <ref name="Oskouei">Oskouei AE, Talebi GA, Shakouri SK, Ghabili K. Effects of Neuromobilization Maneuver on Clinical and Electrophysiological Measures of Patients with Carpal Tunnel Syndrome. Journal of physical therapy science. 2014 Jul; 26(7):1017-22. </ref> <ref name="Burke">Burke FD, Ellis J, McKenna H, Bradley MJ. Primary care management of carpal tunnel syndrome. Postgraduate medical journal. 2003 Aug; 79 (934):433-7.</ref>&nbsp;Physical therapy typically consists of modifications of activities and the work place (ergonomic modifications) <ref name="Oskouei" /><ref name="Burke" />, patient education, carpal bone and [https://www.youtube.com/watch?v=AlvlOC-bk8M nerve mobilisation] <ref name="Page">Page MJ, O’Connor D, Pitt V, Massy-Westropp N. Exercise and mobilisation interventions for carpal tunnel syndrome. Cochrane Database Syst Rev. 2012;6:CD009899. </ref>,,&nbsp;ultrasound <ref name="Oconnor" /><ref name="Huisstede" /><ref name="Page" />&nbsp;and electromagnetic field therapy <ref name="Oconnor" /><ref name="Huisstede" />  and splinting.<ref>Page MJ, Massy-Westropp N, O'Connor D, Pitt V. Splinting for carpal tunnel syndrome.</ref>
Physical therapists should give advice on '''modifications of activities''' and the workplace (ergonomic modifications) <ref name="Oskouei" /><ref name="Burke" />, task modification, For example, taking sufficient rest and variation of movements.


It’s important to mention that, in general, the evidence of the effectiveness of the exercise and mobilization interventions is limited and very low in quality. The physical therapist should always inform the patient about the limited evidence of effectiveness and safety as well as availability of surgical option without the pre-requite conservative therapy where appropriate. <ref name="Page" />.
Often simple obvious alterations to the working practice can be beneficial in controlling milder symptoms of CTS.<ref name="Burke" />  


The effectiveness of ultrasound varies between the studies and most of the time the evidence is low. According to Page et al  <ref name="PageMJ">Page MJ, O’Connor D, Pitt V, Massey-Westropp N. Therapeutic ultrasound for carpal tunnel syndrome (Review). The Cochrane database of systematic reviews. 2013 Mar; 28(3):1-156. </ref> there’s poor and limited evidence about the effect of therapeutic ultrasound. There is insufficient evidence that therapeutic ultrasound has a greater benefit than other non-surgical treatments, such as splinting, exercises or oral drugs.  
[https://www.physio-pedia.com/Manual_Therapy Manual therapy] techniques include [https://www.physio-pedia.com/Maitland%27s_Mobilisations mobilisation] of  
* Soft tissue
* Carpal bone
* Median nerve<ref name="Page">Page MJ, O’Connor D, Pitt V, Massy-Westropp N. Exercise and mobilisation interventions for carpal tunnel syndrome. Cochrane Database Syst Rev. 2012;6:CD009899. </ref>  
Other modalities include: ultrasound <ref name="Oconnor" /><ref name="Huisstede" /><ref name="Page" />&nbsp;and electromagnetic field therapy <ref name="Oconnor" /><ref name="Huisstede" />  and [https://www.physio-pedia.com/Splint splinting].<ref>Page MJ, Massy-Westropp N, O'Connor D, Pitt V. Splinting for carpal tunnel syndrome.</ref>


It is important to pay attention to the cause of the CTS. Physical therapists should give advice in task modification, like taking fufficient rest and variation of movements. Burke et al <ref name="Burke" />&nbsp; declare that often simple obvious alterations to the working practice can be beneficial in controlling milder symptoms of CTS.  
Research findings (varies)
* Physiotherapy modalities ([[Transcutaneous Electrical Nerve Stimulation (TENS)|TENS]] and [[Therapeutic Ultrasound|ultrasound]]) have little useful effects on hand sensory discomfort.<ref>Talebi GA, Saadat P, Javadian Y, Taghipour M. [https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6121348/ Manual therapy in the treatment of carpal tunnel syndrome in diabetic patients: A randomized clinical trial.] Caspian journal of internal medicine. 2018;9(3):283.Available from:https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6121348/ (last accessed 23.3.2020)</ref>
* The evidence of the effectiveness of the exercise and mobilization interventions is limited and very low in quality.<ref name="Page" />.
* Evidence about post-operative rehabilitation is also limited. None of them seems to have a prevailing benefit<ref name="Peters">Peters S, Page MJ, Coppieters MW, Ross M, Johnston V. Rehabilitation following carpal tunnel release (Review). The Cochrane database of systematic reviews. 2013 Jun; 5(6): 1-147. </ref>.


Peter et al <ref name="Peters">Peters S, Page MJ, Coppieters MW, Ross M, Johnston V. Rehabilitation following carpal tunnel release (Review). The Cochrane database of systematic reviews. 2013 Jun; 5(6): 1-147. </ref>&nbsp;declare that evidence about post-operative rehabilitation is also limited. Their reviewed interventions handle physical applications, differences between kinds of immobilisation and multimodal hand therapy. None of them seems to have a prevailing benefit. <br>
== Clinical Bottom Line  ==
== Clinical Bottom Line  ==


Patients may benefit form physiotherapy based treatment with goals of CTS symptom reduction and functional gains, provided that:
Patients may benefit from physiotherapy based treatment with goals of CTS symptom reduction and functional gains, provided that:
* their symptoms are intermittent and not rapidly worsening or if their CTS etiology is highly suggestive of possibility of remission as in example of pregnancy related CTS  
* Their symptoms are intermittent and not rapidly worsening or if their CTS etiology is highly suggestive of the possibility of remission as an example of pregnancy-related CTS  
* patients are informed about the lack of high quality evidence for effectiveness and safety of therapeutic modalities used by physiotherapists,  
* Patients are informed about the lack of high-quality evidence for the effectiveness and safety of therapeutic modalities used by physiotherapists,  
Treatment should be discontinued when shown to be ineffective and appropriate, evidence based discharge recommendations should be made.
Treatment should be discontinued when shown to be ineffective and appropriate, evidence-based discharge recommendations should be made.


CTS  symptoms typically escalate over a longer term despite conservative treatment.  Surgical interventions for appropriate patients have been shown to be safe and more effective than any conservative intervention,  Clinicians should be aware that constant tingling or numbness is associated with significant compression of median nerve. Prolonged duration of such symptoms may lead to irreversible changes in its internal structure, affecting effectiveness of surgery and leaving individuals with chronic symptoms and muscle atrophy of thenar eminence. Patients should be followed by their general practitioners to discuss surgical treatment options when necessary and desired.
CTS  symptoms typically escalate over a longer-term despite conservative treatment.  Surgical interventions for appropriate patients have been shown to be safe and more effective than any conservative intervention,  Clinicians should be aware that constant tingling or numbness is associated with significant compression of the median nerve. Prolonged duration of such symptoms may lead to irreversible changes in its internal structure, affecting the effectiveness of surgery and leaving individuals with chronic symptoms and muscle atrophy of thenar eminence. Patients should be followed by their general practitioners to discuss surgical treatment options when necessary and desired.


== References  ==
== References  ==
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[[Category:Conditions]]
[[Category:Wrist - Conditions]]
[[Category:Hand - Conditions]]

Latest revision as of 14:25, 31 August 2023

Original Editor - Kristin Sartore

Top Contributors - Jaroslaw Pospiech, Kristin Sartore, Admin, Laura Ritchie, Sien Bossant, Lucinda hampton, Kim Jackson, Rachael Lowe, Anas Mohamed, Mathieu Vanderroost, Kai A. Sigel, Sai Kripa, Camille Dewaele, Wanda van Niekerk, Erica Alexander, Chelsea Mclene, Blessed Denzel Vhudzijena and Stuart Wildman  


Introduction[edit | edit source]

Carpal tunnel syndrome (CTS) is an entrapment neuropathy caused by compression of the median nerve as it travels through the wrist's carpal tunnel. Normal tissue pressure within the tunnel is approximately 3-7mm Hg. CTS can result in pressure with greater than 30mm Hg.

Fig.1 Median nerve compression.
  • It is the most common nerve entrapment neuropathy, accounting for 90% of all neuropathies.
  • Early symptoms of carpal tunnel syndrome include pain, numbness, and paresthesias. Sensory changes and paresthesia along with median nerve distribution in Hand.
  • Symptoms typically present, with some variability, in the thumb, index finger, middle finger, and the radial half (thumb side) of the ring finger.
  • Pain also can radiate up the affected arm. Radiate into upper extremity, shoulder and neck. With further progression, night pain, hand weakness, decreased fine motor coordination,decreased grip strength, clumsiness, reduced wrist mobility and thenar atrophy can occur. [1]

Patients can be diagnosed quickly and respond well to treatment but the best means of integrating clinical, functional, and anatomical information for selecting treatment choices have not yet been identified.[2][3]

Clinically Relevant Anatomy[edit | edit source]

Fig.2 Transverse plane view of carpal tunnel.

The carpal tunnel (CT) is formed by a non-extendable osteofibrous wall that forms a tunnel protecting the median nerve and flexor tendons.

The transverse carpal ligament (flexor retinaculum) makes up the superior boundary, and the carpal bones form the inferior border.

The carpal tunnel includes the median nerve and nine flexor tendons.

The flexor tendons include

  • Four tendons from the flexor digitorum profundus
  • Four tendons from the flexor digitorum superficialis
  • One tendon from the flexor pollicis longus. [1]

Etiology[edit | edit source]

Carpal tunnel syndrome results from increased pressure in the carpal tunnel and subsequent compression of the median nerve. The most common causes of carpal tunnel syndrome include genetic predisposition, history of repetitive wrist movements such as repetitive use, typing, or machine work as well as obesity, diabetes, cumulative trauma disorders, tumor, hypothyroidism, wrist spine and fracture, autoimmune disorders such as rheumatoid arthritis, and pregnancy.[1]

Epidemiology[edit | edit source]

  • The prevalence of carpal tunnel syndrome is estimated to be 2.7-5.8% of the general adult population, with a lifetime incidence of 10-15%, depending on occupational risk 4.
  • Carpal tunnel syndrome usually occurs between ages 36 and 60 and is more common in women, with a female-to-male ratio of 2-5:1.[4]

Clinical Biomechanics of Carpal Tunnel Syndrome[edit | edit source]

Click here for information

Pathophysiology[edit | edit source]

There is a wide spectrum of causative pathologies, converging on two mechanisms of disease, both of which lead to entrapment:

  • A decrease in the size of the carpal tunnel caused by such conditions as:
  • Disease states leading to augmentation of carpal tunnel contents:
    • Masses, For example, ganglion cysts, primary nerve sheath tumours
    • Deposition of foreign material, e.g. amyloid
    • Synovial hypertrophy in rheumatoid arthritis[4]

In general, the pathophysiology of CTS results from a combination of compression and traction mechanisms. 

  1. The compressive element of the pathophysiology includes a detrimental cycle of increased pressure, obstruction of overall venous outflow, increasing local edema, and compromise to the median nerve's intraneural microcirculation.  Nerve dysfunction becomes compromised, and the structural integrity of the nerve itself further propagates the dysfunctional environment-- the myelin sheath and axon develop lesions, and the surrounding connective tissues become inflamed and lose normal physiologic protective and supportive function. 
  2. Repetitive traction and wrist motion exacerbates the negative environment, further injuring the nerve.  In addition,  any of the nine flexor tendons traveling through the carpal tunnel can become inflamed and compress the median nerve[1]

Idiopathic Carpal Tunnel Syndrome[edit | edit source]

  • Idiopathic CTS occurs more frequently in females (65–80%), between the ages of 40 and 60 years; 50–60% of the cases are bilateral.[5]
  • The bilateral characteristic increases in frequency with the duration of symptoms.[6] 
  • Idiopathic CTS is correlated with hypertrophy of the synovial membrane of the flexor tendons caused by degeneration of the connective tissue, with vascular sclerosis, edema and collagen fragmentation.[7]
  • The histological changes were thought to be suggestive of dynamic factors as repetitive strain.

Clinical Presentation[edit | edit source]

CTS onset is generally gradual with tingling or numbness in the median nerve distribution of the affected hand. Fig.3. [9] [10] [11]
Patients may notice aggravation of symptoms with static gripping of objects such as a phone or steering wheel but also at night or early in the morning. [10] [11] Many patients will report an improvement of symptoms following shaking or flicking of their hand.

As the disorder progresses, the feeling of tingling or numbness may become constant and patients may complain of burning pain. [10]
The final symptoms are weakness and atrophy of muscles of the thenar eminence. These combined effects of sensory deprivation and weakness may result in a complaint of clumsiness and loss of grip and pinch strength or dropping things, [10]

Differential Diagnosis[edit | edit source]

The process of differential diagnosis should give consideration to all conditions which could potentially cause a dysfunction of the median nerve, or its contributories in brachial plexus, C 5 to 8 nerve roots and central nervous system.

Possible differential diagnoses of carpal tunnel syndrome include:

Diagnostic Procedures[edit | edit source]

Ultrasound and MRI are the two imaging modalities which best lend themselves to investigating entrapment syndromes. Next to directly visualizing direct causes and anatomical variants recognizing pathological muscle signal patterns on MRI can point to the affected nerve.[4]

Electromyography and nerve conduction studies are the basis for carpal tunnel syndrome diagnosis. Other clinical or special exams do not confirm carpal tunnel syndrome but do assist in ruling out other diagnoses. These findings can prompt electromyography and nerve conduction studies.[1]

X-ray is recommended to exclude other causes of wrist pain like arthritis or bony pathology. [3]

Outcome Measures[edit | edit source]

There are several questionnaires available to determine the outcome measures for CTS.

  • Boston Carpal Tunnel Questionnaire (BCTQ)
  • Disability of Hand and Shoulder (DASH) Questionnaire
  • Brigham_and_Women's_Carpal_Tunnel_Questionnaire.
  • Patient Evaluation Measures (PEM) The PEM is a self-, interview- or telephone-administered questionnaire to measure physical health. It consists of 3 components (patient’s opinion on delivery of care, hand health profile, overall assessment) and a total of 18 items scored on a 7-point scale. Low scores indicate positive outcomes.16 17 Hobby et al.20 found this instrument to be valid and reliable and to have good responsiveness. [12] [13]

Physical Examination[edit | edit source]

May include testing for sensory and motor deficits and evidence of thenar wasting. There are several special tests with varying degrees of sensitivities and specificities.

  • The best of these include the carpal compression test. This is done by applying firm pressure directly over the carpal tunnel for 30 seconds. The test is positive when paresthesias, pain, or other symptoms are reproduced.
  • The square sign test is an evaluation to determine the risk of developing carpal tunnel syndrome. The test is positive if the ratio of the thickness of the wrist divided by the width of the wrist is great than 0.7.
  • Another test is a palpatory diagnosis. In this test, the health care provider examines soft tissue over the median nerve for mechanical restriction.
  • The Phalen's test or ‘reverse prayer’ is performed by having the patient fully flex their wrists by placing dorsal surfaces of both hands for one minute. A positive test is when symptoms (numbness, tingling, pain) are reproduced.
  • The reverse Phalen's, or ‘prayer test,’ is done by having the patient extend both of their wrists by placing palmar surfaces of both hands together for 1 minute (as if praying). Again a positive test is with reproduction of symptoms.
  • Although a low sensitivity and specificity, the Hoffmann-Tinel sign is another test commonly performed. In this test the healthcare professional taps immediately over the carpal tunnel to stimulate the median nerve. Like the above tests, a positive test is when symptoms are reproduced.[1]
  • The 'Scratch Collapse Test' (SCT) has emerged as a new provocative test to assist in the localisation of peripheral nerve compression.

Clinical prediction rules (CPR), specifically for the Carpal Tunnel Syndrome, are a reliable examination method.

Medical Management[edit | edit source]

If carpal tunnel syndrome is identified early conservative treatment is recommended.

  • Initially, the patient should be instructed in modifying symptom provoking wrist movement, For example, proper hand ergonomics such as placing the keyboard at a proper height and minimizing flexion, extension, abduction, and adduction of the hand when typing. It should be recommended to decrease repetitive activities if possible.[1]
  • Non-surgical treatment comprises oral steroids [14] [15], corticosteroid injections [15], NSAID [14][15], diuretics [14][16], vitamin B6 [14] and splinting/hand brace [14][15][16]. If conservative treatments are not successful, an oral or local glucocorticoid could be offered. 
  • The definitive treatment for persistent carpal tunnel syndrome is surgical intervention with carpal tunnel release after nerve conduction studies showing significant axonal degeneration. Carpal tunnel release typically is performed by an orthopedic surgeon or hand surgeon. This procedure can be performed either open or endoscopically. Carpal tunnel release is considered a minor surgery in which the transverse carpal ligament or flexor retinaculum is cut, opening more space in the carpal tunnel and decreasing pressure on the median nerve. It does not typically require overnight hospitalization.[1]

Physical Therapy Management[edit | edit source]

Patients with mild to moderate symptoms can be effectively treated in a primary care environment [17] [18] 

Physical therapists should give advice on modifications of activities and the workplace (ergonomic modifications) [17][18], task modification, For example, taking sufficient rest and variation of movements.

Often simple obvious alterations to the working practice can be beneficial in controlling milder symptoms of CTS.[18]

Manual therapy techniques include mobilisation of

  • Soft tissue
  • Carpal bone
  • Median nerve[19]

Other modalities include: ultrasound [14][15][19] and electromagnetic field therapy [14][15] and splinting.[20]

Research findings (varies)

  • Physiotherapy modalities (TENS and ultrasound) have little useful effects on hand sensory discomfort.[21]
  • The evidence of the effectiveness of the exercise and mobilization interventions is limited and very low in quality.[19].
  • Evidence about post-operative rehabilitation is also limited. None of them seems to have a prevailing benefit[22].

Clinical Bottom Line[edit | edit source]

Patients may benefit from physiotherapy based treatment with goals of CTS symptom reduction and functional gains, provided that:

  • Their symptoms are intermittent and not rapidly worsening or if their CTS etiology is highly suggestive of the possibility of remission as an example of pregnancy-related CTS
  • Patients are informed about the lack of high-quality evidence for the effectiveness and safety of therapeutic modalities used by physiotherapists,

Treatment should be discontinued when shown to be ineffective and appropriate, evidence-based discharge recommendations should be made.

CTS symptoms typically escalate over a longer-term despite conservative treatment. Surgical interventions for appropriate patients have been shown to be safe and more effective than any conservative intervention, Clinicians should be aware that constant tingling or numbness is associated with significant compression of the median nerve. Prolonged duration of such symptoms may lead to irreversible changes in its internal structure, affecting the effectiveness of surgery and leaving individuals with chronic symptoms and muscle atrophy of thenar eminence. Patients should be followed by their general practitioners to discuss surgical treatment options when necessary and desired.

References[edit | edit source]

  1. ↑ 1.0 1.1 1.2 1.3 1.4 1.5 1.6 1.7 Carpal Tunnel Syndrome Justin O. Sevy; Matthew Varacallo. Last Update: December 21, 2019. Available from:https://www.ncbi.nlm.nih.gov/books/NBK448179/ (last accessed 22.3.2020)
  2. ↑ Padua L, Coraci D, Erra C, Pazzaglia C, Paolasso I, Loreti C, Caliandro P, Hobson-Webb LD. Carpal tunnel syndrome: clinical features, diagnosis, and management. The Lancet Neurology. 2016 Nov 1;15(12):1273-84.
  3. ↑ 3.0 3.1 Chammas M, Boretto J, Burmann LM, Ramos RM, Neto FCS, Silva JB. Carpal tunnel syndrome – part 1 (anatomy, physiology, etiology and diagnosis). Revista brasileira de Ortopedia (English edition) 2014 September-October; 49 (5):429-436.
  4. ↑ 4.0 4.1 4.2 4.3 Radiopedia CTS Available from:https://radiopaedia.org/articles/carpal-tunnel-syndrome-1 (last accessed 23.3.2020)
  5. ↑ Michelsen H, Posner MA. Medical history of carpal tunnel syndrome. Hand clinics. 2002 May 1;18(2):257-68.
  6. ↑ Bagatur A.E., Zorer G. The carpal tunnel syndrome is a bilateral disorder. J Bone Joint Surg Br. 2001;83(5):655–658.
  7. ↑ Schuind F., Ventura M., Pasteels J.L. Idiopathic carpal tunnel syndrome: histologic study of flexor tendon synovium. J Hand Surg Am. 1990;15(3):497–503. 
  8. ↑ Gray, Henry. Anatomy of the Human Body. Philadelphia: Lea & Febiger, 1918; Bartleby.com, 2000. www.bartleby.com/107/. [Date of Printout].
  9. ↑ Jesus Filho AG, do Nascimento BF. Comparative study between physical examination, electroneuromyography and ultrasonography in diagnosing carpal tunnel syndrome. Revista Brasileira de Ortopedia (English Edition). 2014 September–October; 49(5): 446–451.
  10. ↑ 10.0 10.1 10.2 10.3 Ashworth NL, MBChB. Carpal Tunnel Syndrome Clinical Presentation [Internet]. 1994 [Updated 2014 Aug 25; cited 2015 March 20].fckLRAvailable from:fckLRhttp://emedicine.medscape.com/article/327330-clinical.
  11. ↑ 11.0 11.1 Krom de M.C.T.F.M., MD, KnipschildP.G. Prof. Efficacy of provocative tests for diagnosis of carpal tunnel syndrome. The Lancet. 1990 Feb 17; Vol.335 Issue 8686: 393-395.
  12. ↑ Hadi M, Gibbons E, Fitzpatrick R. A structured review of patient-reported outcome measures for procedures for carpal tunnel syndrome. Oxford: Departmet of Public Health (University of Oxford); 2011. 33p.
  13. ↑ Sambandam SN, Priyanka P, Gul A, Ilango B. Critical analysis of outcome measures used in the assessment of carpal tunnel sundrome. Int Orthop. 2008 Aug; 32(4):497-504.
  14. ↑ 14.0 14.1 14.2 14.3 14.4 14.5 14.6 O’Connor D, Marshall SC, Massy-Westropp N, Pitt V. Non-surgical treatment (other than steroid injection) for carpal tunnel syndrome (Review). The Cochrane database of systematic reviews. 2012; volume (7):1-106.
  15. ↑ 15.0 15.1 15.2 15.3 15.4 15.5 Huisstede BM, Hoogvliet P, Randsdorp MS, Glerum S, van Middelknoop M, Koes BW. Carpal Tunnel Syndrome. Part I: Effectiveness of Nonsurgical Treatments–A Systematic Review. Archives of physical medicine and rehabilitation. 2010 Jul; 91(7):981-1004.
  16. ↑ 16.0 16.1 Piazzini DB, Aprile I, Ferrara PE, Bertolini C, Tonali P, Maggi L, Rabini A, Piantelli S, Padua L. A systematic review of conservative treatment of carpal tunnel syndrome. Clinical rehabilitation. 2007 Apr; 21(4):299-314.
  17. ↑ 17.0 17.1 Oskouei AE, Talebi GA, Shakouri SK, Ghabili K. Effects of Neuromobilization Maneuver on Clinical and Electrophysiological Measures of Patients with Carpal Tunnel Syndrome. Journal of physical therapy science. 2014 Jul; 26(7):1017-22.
  18. ↑ 18.0 18.1 18.2 Burke FD, Ellis J, McKenna H, Bradley MJ. Primary care management of carpal tunnel syndrome. Postgraduate medical journal. 2003 Aug; 79 (934):433-7.
  19. ↑ 19.0 19.1 19.2 Page MJ, O’Connor D, Pitt V, Massy-Westropp N. Exercise and mobilisation interventions for carpal tunnel syndrome. Cochrane Database Syst Rev. 2012;6:CD009899. 
  20. ↑ Page MJ, Massy-Westropp N, O'Connor D, Pitt V. Splinting for carpal tunnel syndrome.
  21. ↑ Talebi GA, Saadat P, Javadian Y, Taghipour M. Manual therapy in the treatment of carpal tunnel syndrome in diabetic patients: A randomized clinical trial. Caspian journal of internal medicine. 2018;9(3):283.Available from:https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6121348/ (last accessed 23.3.2020)
  22. ↑ Peters S, Page MJ, Coppieters MW, Ross M, Johnston V. Rehabilitation following carpal tunnel release (Review). The Cochrane database of systematic reviews. 2013 Jun; 5(6): 1-147.



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