Carpal Tunnel Syndrome

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Aetiology

  • Pregnancy
  • Obesity
  • Diabetes Mellitus
  • Hypothyroidism
  • Acute fluid retention
  • Connective tissue diseases
  • Rheumatoid arthritis
  • Local abnormalities/lesions involving the wrist, including previous fractures

Differential Diagnosis

  • Cervical radiculopathy
  • Thoracic outlet syndrome
  • Pronator teres syndrome
  • Radial neuropathy
  • Ulnar neuropathy
  • Tenosynovitis
  • Raynaud syndrome
  • Inflammatory arthropathy
  • Peripheral nerve tumour
  • Multiple sclerosis
  • Amyotrophic lateral sclerosis
  • Polyneuropathy (eg, diabetic or chronic inflammatory demyelinating polyneuropathy)
  • Polyneuropathy (eg, diabetic or chronic inflammatory demyelinating polyneuropathy)
  • Acute compression syndromes (eg, Saturday night palsy)

Assessment

  • Symptoms are often variable but classically include pain or paraesthesia in the median nerve distribution.
  • Neurological examination
  • Provocative tests
The value of history and physical examination features with EMG as the reference standard.[1]
Test Name LR+ LR- Sens Spec Kappa
Flick sign 21 0.1 93% 96%
Closed fist sign 7.3 0.4 61% 92%
Hypalgesia 3.1 0.7 39% 88%
Square wrist sign 2.7 0.6 53% 80%
Classic or probable Katz hand diagram 2.4 0.5 64% 73%
Weak thumb adduction 1.8 0.5 65% 65%
Thenar atrophy 1.6 0.9 16% 90%
Abnormal vibration 1.6 0.8 36% 77%
Abnormal monofilament findings 1.5 0.7 59% 59%
Bilateral symptoms 1.4 0.7 61% 58%
Tinel sign 1.4 0.8 36% 75%
Phalen sign 1.3 0.7 57% 58%
Age > 40 years 1.3 0.5 80% 41%
Nocturnal paresthesias 1.2 0.7 70% 43%
2-point discrimination 1.2 1.0 20% 83%

Investigations

Not normally required, but can include nerve conduction studies or diagnostic ultrasound. These modalities cannot exclude the condition.

Treatment

Conservative treatment for mild and intermittent symptoms, or symptoms that are likely to resolve soon such as during pregnancy.

Activity Modification
Corticosteroid injection

See Carpal Tunnel Injection article.

Splinting

A hand therapist can provide a custom thermoplastic or the patient can buy an off the shelf splints.

Manual Therapy

In one study 120 women with carpal tunnel syndrome were randomised to hand therapy versus surgery with no significant differences in pain or function at 1 year and 4 years. The hand therapy group had three 30 minute weekly sessions of physical therapy (figure). The sessions included desensitisation techniques targeted at potential sites of median nerve entrapment, lateral glide mobilisation of the cervical spine, a tendon/nerve gliding exercise, and instructions for a home tendon/nerve gliding exercise. The potential anatomical sites were scalene, pectoralis minor, bicipital aponeurosis, pronator teres, transverse carpal ligament, palmar aponeurosis. At each of these sites the therapist evaluated for pain on palpation and reproduction of sensory or motor symptoms. The surgery group also received the same educational session for performing the tendon/nerve gliding exercises at home.[2][3]

Surgery (Carpal tunnel release or decompression)

Consider conservative therapy first until severe pain or marked neurological signs. Access to surgery is variable across New Zealand. Surgery may not result in complete recovery of any neurological deficit but may prevent progression.

References

  1. D'Arcy & McGee The rational clinical examination. Does this patient have carpal tunnel syndrome?. JAMA 2000. 283:3110-7. PMID: 10865306. DOI.
  2. Fernández-de-Las-Peñas et al. Manual Therapy Versus Surgery for Carpal Tunnel Syndrome: 4-Year Follow-Up From a Randomized Controlled Trial. Physical therapy 2020. 100:1987-1996. PMID: 32766779. DOI.
  3. Fernández-de-Las Peñas et al. Manual Physical Therapy Versus Surgery for Carpal Tunnel Syndrome: A Randomized Parallel-Group Trial. The journal of pain : official journal of the American Pain Society 2015. 16:1087-94. PMID: 26281946. DOI.

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