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Carpal tunnel syndrome

Definition
CTS is condition characterized by symptomatic compressive neuropathy of the median nerve at the wrist.
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Pathophysiology
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.
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Epidemiology
The prevalence and incidence of CTS in the United State are 7.8% and 2.3 per 100 person-years, respectively.
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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.
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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%.
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Key sources
The following summarized guidelines for the evaluation and management of carpal tunnel syndrome 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).
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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
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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
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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

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  • Clinical assessment (motor function tests)

  • Clinical assessment (provocative tests)

  • Clinical assessment (patient-reported measures)

  • Wrist ultrasound

  • Wrist MRI

  • Nerve conduction studies

4.Medical management

Oral corticosteroids: consider initiating oral corticosteroids to improve patient-reported outcomes in patients with CTS.
C

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  • Other medications

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
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  • Exercise programs

  • Manual therapy

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
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  • Local corticosteroid injections

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

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  • Preoperative management (aspirin)

  • Postoperative management (setting of care)

  • Postoperative management (immobilization)

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

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  • Carpal tunnel release surgery (technical considerations)

  • Carpal tunnel release surgery (local anesthesia)

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

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
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