Guideline sources The following summarized guidelines for the evaluation and management of carpal tunnel syndrome (CTS) are prepared by our editorial team based on guidelines from the Academy of Orthopaedic Physical Therapy (AOPT/AHUEPT 2019), the American Academy of Orthopaedic Surgeons (AAOS 2016), and the American Association of Neuromuscular and Electrodiagnostic Medicine (AANEM 2012). 1 2 3 4 4 4 5 6 7 Definition CTS is condition characterized by symptomatic compressive neuropathy of the median nerve at the wrist. 4 Epidemiology https://web.pathway.md/diseases/recxCo9khYM5ugDtE 1/7 6/29/23, 3:44 AM Carpal tunnel syndrome Pathway CTS is caused by compression and traction of the median nerve in the carpal tunnel, either due to idiopathic causes or secondary to fibrous hypertrophy of synovial flexor sheath or due to repetitive movements of the wrist. 6 Pathophysiology The prevalence and incidence of CTS in the United State are 7.8% and 2.3 per 100 person-years, respectively. 5 Disease course The combination of increased pressure in the tunnel, median nerve microcirculation injury, median nerve connective tissue compression, and synovial tissue hypertrophy results in altered function of the nerve, demyelination, and degeneration of the nerve at the site of compression and beyond. These events cause paresthesias, weakness, and loss of function in the distal distribution of median nerve (thumb, index, middle finger, and the radial side of the ring finger) and even outside the distribution of the median nerve. 4 Prognosis and risk of recurrence Carpal tunnel release is effective in 70-90% of the patients. The recurrence rate after carpal tunnel release varies from 3-25%. 4 7 Guidelines 1. Screening and diagnosis Diagnosis: As per AOPT 2019 guidelines: Diagnose CTS in patients with 4 of the following: age > 45 years shaking hands relieves symptoms sensory loss in the thumb wrist ratio index (wrist depth divided by wrist width) > 0.67 CTQ-SSS score > 1.9. B Insufficient evidence to support the use of the following tests for the diagnosis of CTS: upper limb neurodynamic tests scratch-collapse test tests of vibration sense. I As per AAOS 2016 guidelines, use thenar atrophy for ruling in CTS but not ruling out CTS. A Show 4 more https://web.pathway.md/diseases/recxCo9khYM5ugDtE 2/7 6/29/23, 3:44 AM Carpal tunnel syndrome Pathway 2. Classification and risk stratification Risk factors: recognize that BMI and high hand/wrist repetition rate are associated with an increased risk of developing CTS. A Show 5 more 3. Diagnostic investigations Clinical assessment (sensory function tests): obtain Semmes-Weinstein monofilament testing using the 2.83 or 3.22 monofilament as the threshold for normal light touch sensation and static two-point discrimination on the middle finger to help in determining the extent of nerve damage in the evaluation of patients with suspected CTS. Assess any radial finger using the 3.22 filament as the threshold for normal in patients with suspected moderate-to-severe CTS. Repeat Semmes- Weinstein monofilament testing by the same provider. B Clinical assessment (motor function tests): Consider assessing grip strength and three-point or tip pinch strength in patients presenting with signs and symptoms of CTS and compare scores with established norms. C Consider obtaining the Purdue Pegboard or the Dellon-modified Moberg pick-up test to quantify dexterity at the onset of treatment and compare scores with established norms. C Clinical assessment (provocative tests): use the Katz hand diagram and obtain provocative tests such as the Phalen test, the Tinel sign, and carpal compression test to determine the likelihood of CTS, and interpret examination results in the context of all clinical exam findings. B Clinical assessment, patient-reported measures: As per AOPT/AHUEPT 2019 guidelines, obtain the CTQ-SSS for the assessment of symptoms and the CTQ-FS or the DASH questionnaire for the assessment of function in patients with CTS. B As per AAOS 2016 guidelines, consider using diagnostic questionnaires to aid the diagnosis of CTS. C Wrist ultrasound: As per AAOS 2016 guidelines, avoid obtaining routine ultrasound for the diagnosis of CTS. D As per AOPT 2012 guidelines: Consider obtaining neuromuscular ultrasound measurement of median nerve cross-sectional area at the wrist, if available, for the accurate diagnosis of CTS. B Consider obtaining neuromuscular ultrasound, if available, for the screening of structural abnormalities at the wrist in patients with CTS. C Wrist magnetic resonance imaging: avoid obtaining routine MRI for the diagnosis of CTS. D Nerve conduction studies: Consider obtaining electrodiagnostic studies to aid the diagnosis of CTS. C Consider obtaining hand-held nerve conduction study for the diagnosis of CTS. C https://web.pathway.md/diseases/recxCo9khYM5ugDtE 3/7 6/29/23, 3:44 AM Carpal tunnel syndrome Pathway 4. Medical management Oral corticosteroids: consider initiating oral corticosteroids to improve patient-reported outcomes in patients with CTS. C Other medications: Avoid using the following oral medications in patients with CTS: diuretics gabapentin NSAIDs pyridoxine astaxanthin capsules. D 5. Nonpharmacologic interventions Wrist immobilization: As per AOPT 2019 guidelines, offer neutral position wrist orthosis worn at night for short-term symptom relief and functional improvement in patients with CTS seeking non-surgical management. B Show 2 more As per AAOS 2016 guidelines, offer wrist immobilization (brace/splint/orthosis) to improve patient-reported outcomes in patients with CTS. A Exercise programs: as per AOPT 2019 guidelines, consider offering a combined orthotic/stretching program in patients with mild-to-moderate CTS without thenar atrophy and with normal two-point discrimination. Monitor those patients undergoing treatment for clinically significant improvement. C Manual therapy: Consider offering short-term manual therapy directed at the cervical spine and upper extremity in patients with mild-to-moderate CTS. C Insufficient evidence to support the use of neurodynamic mobilization for the management of patients with mild-to-moderate CTS. I 6. Therapeutic procedures Biophysical therapies: As per AOPT 2019 guidelines, consider offering a trial of superficial heat for short-term symptom relief in patients with CTS. C Show 6 more As per AAOS 2016 guidelines: Consider offering the following techniques in patients with CTS: ketoprofen phonophoresis - to improve pain reduction C https://web.pathway.md/diseases/recxCo9khYM5ugDtE 4/7 6/29/23, 3:44 AM Carpal tunnel syndrome Pathway therapeutic ultrasound C laser therapy. C Do not use magnet therapy for the treatment of patients with CTS. D Local corticosteroid injections: administer local corticosteroid (methylprednisolone) injections to improve patient-reported outcomes in patients with CTS. A 7. Perioperative care Preoperative management (antibiotic prophylaxis): avoid administering routine prophylactic antibiotics before carpal tunnel release because there is no demonstrated reduction in the rate of postoperative surgical site infections. D Preoperative management (aspirin): consider advising patients to continue the use of aspirin perioperatively. C Postoperative management (setting of care): avoid offering routine supervised therapy over home programs in the immediate postoperative period. D Postoperative management (immobilization): do not offer routine postoperative wrist immobilization after carpal tunnel release. D 8. Surgical interventions Carpal tunnel release surgery (indications): Perform surgical release of the transverse carpal ligament to relieve symptoms and improve function in patients with CTS. A Prefer surgical treatment over wrist splinting, NSAIDs, and a single corticosteroid injection for a greater treatment benefit at 6 and 12 months in patients with CTS. A Carpal tunnel release surgery (technical considerations): consider performing endoscopic carpal tunnel release, based on possible short-term benefits, if surgical treatment is chosen. C Show 2 more Carpal tunnel release surgery (local anesthesia): Consider preferring local anesthesia over IV regional anesthesia (Bier block) because it may offer longer pain relief after carpal tunnel release. C Consider preferring buffered over plain lidocaine for local anesthesia because it may result in less injection pain. C 9. Specific circumstances Pregnant patients: offer orthosis in pregnant patients experiencing CTS during pregnancy and obtain a postpartum follow-up evaluation to examine the resolution of symptoms. B https://web.pathway.md/diseases/recxCo9khYM5ugDtE 5/7 6/29/23, 3:44 AM Carpal tunnel syndrome Pathway 10. Patient education Patient education: Consider educating patients on CTS pathology, risk identification, symptom self-management, and postures/activities aggravating symptoms. C Consider educating patients regarding the effects of mouse use on carpal tunnel pressure and assisting patients to develop alternative strategies, including the use of arrow keys, touch screens, or alternating the mouse hand. Consider advising the use of keyboards with reduced strike force in patients reporting pain with keyboard use. C 11. Follow-up and surveillance Post-treatment assessment: obtain the CTQ-SSS for the assessment of change in patients with CTS undergoing non-surgical management. B Show 7 more Clinical findings Symptoms Neurological exam Clumsiness Flick sign Hand pain Tinel's sign Hand swelling pinprick sensation Numbness in hand threshold in terminal digit pad 3 with normal terminal digit pad 5 Numbness in the fingers Thumb pain threshold or absent sensation in any of first 3 terminal fingers pads Tingling in hand Tingling in the fingers Wrist pain Phalen's test Wrist stiffness Musculoskeletal exam Thenar atrophy Thenar hypotrophy Likelihood Ratios Pertinent positives The following findings increase the probability of carpal tunnel syndrome in adults. 7 Finding LR+ Value 1.2 (1.0-1.3) https://web.pathway.md/diseases/recxCo9khYM5ugDtE 6/7 6/29/23, 3:44 AM Carpal tunnel syndrome Pathway Decreased threshold or absent sensation in any of first 3 terminal fingers pads Pertinent negatives The following findings decrease the probability of carpal tunnel syndrome in adults. 7 Finding LR- Value threshold or absent sensation in any of first 3 terminal fingers pads not decreased 0.11 (0.02-0.64) References 1. Mia Erickson, Marsha Lawrence, Caroline W Stegink Jansen et al. Hand Pain and Sensory Deficits: Carpal Tunnel Syndrome. J Orthop Sports Phys Ther. 2019 May;49 5 CPG1 CPG85. Open 2. Brent Graham, Allan E Peljovich, Robert Afra et al. The American Academy of Orthopaedic Surgeons Evidence-Based Clinical Practice Guideline on: Management of Carpal Tunnel Syndrome. J Bone Joint Surg Am. 2016 Oct 19;98 20 1750 1754. Open 3. Cartwright MS, Hobson-Webb LD, Boon AJ et al. Evidence-based guideline: neuromuscular ultrasound for the diagnosis of carpal tunnel syndrome. Muscle Nerve. 2012 Aug;46 2 287 93. Open 4. Ibrahim I, Khan WS, Goddard N et al. Carpal tunnel syndrome: a review of the recent literature. Open Orthop J. 2012;6 69 76. Open 5. Dale AM, Harris-Adamson C, Rempel D et al. Prevalence and incidence of carpal tunnel syndrome in US working populations: pooled analysis of six prospective studies. Scand J Work Environ Health. 2013 Sep 1;39 5 495 505. Open 6. Aboonq MS. Pathophysiology of carpal tunnel syndrome. Neurosciences Riyadh). 2015 Jan;20 1 4 9. Open 7. Karthik K, Nanda R, Stothard J. Recurrent carpal tunnel syndrome analysis of the impact of patient personality in altering functional outcome following a vascularised hypothenar fat pad flap surgery. J Hand Microsurg. 2012 Jun;4 1 1 6. Open 8. Simel D, Rennie D. The Rational Clinical Examination: Evidence-Based Clinical Diagnosis. Mayo Clin Proc. 2009 Nov; 84 11 1045. Open 9. El Miedany Y, Ashour S, Youssef S et al. Clinical diagnosis of carpal tunnel syndrome: old tests-new concepts. Joint Bone Spine. 2008 Jul;75 4 451 7. Open 10. American Academy of Orthopaedic Surgeons. Choosing Wisely AAOS recommendations. Choosing Wisely. 2016. Open https://web.pathway.md/diseases/recxCo9khYM5ugDtE 7/7