Most common entrapment neuropathy (prevalence about 1 in 25).
Females aged between 40 and 60 years are at highest risk.
Symptoms include numbness and/or tingling of the thumb and radial fingers, aching wrist, and clumsiness.
Physical examination mainly useful for ruling out other diagnoses.
Electrodiagnostic studies are useful in diagnosis and management.
Treatment options range from wrist splints through to surgical release.
Carpal tunnel syndrome (CTS) is a collection of symptoms and signs caused by compression of the median nerve in the carpal tunnel. Typical symptoms include numbness and tingling mainly in the thumb and radial fingers, aching and pain in the anterior wrist and forearm, and clumsiness in the hand.
History and exam
Key diagnostic factors
- presence of risk factors
- numbness of hand(s)
- night-time worsening
- numbness in median nerve distribution
- numbness confined to palmar aspect of the first 4 fingers
Other diagnostic factors
- symptoms are intermittent
- onset is gradual
- weakness of hand
- aching and pain in arm
- weakness of thenar muscles (abductor pollicis brevis, or APB, in particular)
- normal reflexes
- finger stiffness
- cold sensitivity
- atrophy of thenar eminence
- age over 30 years
- high BMI
- female sex
- smoking cigarettes
- white ethnicity
- alterations in carpal tunnel space
- fractured wrist/carpal bones
- square wrist
- rheumatoid arthritis
- thyroid disorders
- hormone replacement therapy and/or oophorectomy
- congenital carpal tunnel stenosis
- occupation involving exposure to repetitive bending, twisting, or vibration of the hands or wrists
- occupational keyboard/computer use
- physical inactivity
- sports and activities
- mobility aids
1st investigations to order
- electromyogram (EMG)
Investigations to consider
- ultrasound of the wrist
- MRI of the wrist
clinical diagnosis of CTS without electromyogram (EMG) confirmation, or pregnant women
mild or moderate based on EMG findings (non-pregnant)
severe based on EMG findings (non-pregnant)
moderate based on EMG findings + failed splint and corticosteroid injections
refractory to surgery
Nigel Ashworth, MBChB, MSc, FRCP(Can)
Division of Physical Medicine & Rehabilitation
Faculty of Medicine & Dentistry
University of Alberta
NA is an author of a number of references cited in this topic.
Shawn Marshall, MD, MSc
University of Ottawa
SM declares that he has been primary author and co-author of Cochrane systematic reviews of nonsurgical interventions for treatment of carpal tunnel syndrome.
Tim J. Doherty, MD, PhD
The University of Western Ontario
TJD declares that he has no competing interests.
Michael Plant, MD, FRCP
The James Cook University Hospital
South Tees Hospitals NHS Foundation Trust
MP declares that he has no competing interests.
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