Carpal tunnel syndrome

Last reviewed: 6 Jun 2022
Last updated: 23 Oct 2019

Summary

Definition

History and exam

Key diagnostic factors

  • numbness of hand(s)
  • nighttime worsening
  • numbness in median nerve distribution
  • numbness confined to palmar aspect of the first 4 fingers
More key diagnostic factors

Other diagnostic factors

  • symptoms are intermittent
  • onset is gradual
  • weakness of hand
  • clumsiness
  • 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
Other diagnostic factors

Risk factors

  • 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
  • diabetes
  • thyroid disorders
  • dialysis
  • pregnancy
  • 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
More risk factors

Diagnostic investigations

1st investigations to order

  • electromyogram (EMG)
More 1st investigations to order

Investigations to consider

  • ultrasound of the wrist
  • MRI of the wrist
More investigations to consider

Treatment algorithm

ACUTE

clinical diagnosis of CTS without electromyogram (EMG) confirmation, or pregnant women

mild or moderate based on EMG findings (nonpregnant)

severe based on EMG findings (nonpregnant)

ONGOING

moderate based on EMG findings + failed splint and corticosteroid injections

refractory to surgery

Contributors

Authors

Nigel Ashworth, MBChB, MSc, FRCP(Can)
Nigel Ashworth

Professor

Division of Physical Medicine & Rehabilitation

Faculty of Medicine & Dentistry

University of Alberta

Edmonton

Canada

Disclosures

NA is an author of a number of references cited in this topic.

Peer reviewers

Shawn Marshall, MD, MSc

Associate Professor

University of Ottawa

Ottawa

Ontario

Canada

Disclosures

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

Associate Professor

The University of Western Ontario

London

Ontario

Canada

Disclosures

TJD declares that he has no competing interests.

Michael Plant, MD, FRCP

Consultant Rheumatologist

The James Cook University Hospital

South Tees Hospitals NHS Foundation Trust

Middlesbrough

UK

Disclosures

MP declares that he has no competing interests.

  • Carpal tunnel syndrome images
  • Differentials

    • Osteoarthritis (OA)
    • Stroke, acute
    • C6 radiculopathy
    More Differentials
  • Guidelines

    • ACR appropriateness criteria: chronic wrist pain
    • Hand, wrist and forearm disorders guideline
    More Guidelines
  • Patient leaflets

    Carpal tunnel syndrome

    More Patient leaflets
  • padlock-lockedLog in or subscribe to access all of BMJ Best Practice

Use of this content is subject to our disclaimer