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Carpal tunnel syndrome (CTS) is caused by compression of the median nerve as it travels through the carpal tunnel. Patients commonly experience pain, paresthesia, and, less often, weakness in the distribution of the median nerve. Provocative maneuvers, such as the Phalen test and Tinel sign, have varying sensitivity and specificity for the diagnosis of CTS. Thenar atrophy is a late finding and highly specific for CTS. Although patients with a classic presentation of CTS do not need additional testing for diagnosis, electrodiagnostic studies can confirm the diagnosis in atypical cases, exclude other causes, and gauge severity for surgical prognosis. An abnormal nerve conduction study is useful for ruling in CTS, but a normal test does not necessarily exclude it. Over-the-counter analgesics, such as nonsteroidal anti-inflammatory drugs and acetaminophen, have not shown benefit for CTS. Patients with mild to moderate CTS initially may be offered nonsurgical treatments, such as splinting or local corticosteroid injections. Night-only splinting is as effective as continuous wear. A neutral wrist splint may be more effective than an extension splint. In patients with recent onset of CTS, corticosteroid injections provide slightly greater improvement of symptoms compared with splinting at 6 weeks, with similar outcomes at 6 months. Patients with severe CTS, including objective weakness or sensory deficits, should be offered surgical decompression. Endoscopic and open carpal tunnel release techniques are equally effective.

Carpal tunnel syndrome, the most common entrapment neuropathy of the upper extremity, is caused by compression of the median nerve as it travels through the carpal tunnel. Classically, patients with the condition experience pain and paresthesias in the distribution of the median nerve, which includes the palmar aspect of the thumb, index and middle fingers, and radial half of the ring finger. Additional clues include positive physical examination findings, such as the flick sign, Phalen maneuver, and median nerve compression test. Although patients with typical symptoms and signs of carpal tunnel syndrome do not need additional testing, ultrasonography and electrodiagnostic studies are useful to confirm the diagnosis in atypical cases and rule out other causes. If surgical decompression is planned, electrodiagnostic studies should be obtained to determine severity and surgical prognosis. Conservative treatment may be offered initially to patients with mild to moderate carpal tunnel syndrome. Options include splinting, corticosteroids, physical therapy, therapeutic ultrasound, and yoga. Nonsteroidal anti-inflammatory drugs, diuretics, and vitamin B6 are not effective therapies. Local corticosteroid injection can provide relief for more than one month and delay the need for surgery at one year. Patients with severe carpal tunnel syndrome or whose symptoms have not improved after four to six months of conservative therapy should be offered surgical decompression. Endoscopic and open techniques are equally effective, but patients return to work an average of one week earlier with endoscopic repair.

Physical maneuvers are an essential step in diagnosing carpal tunnel syndrome. This update can help you get up to speed on diagnosis and treatment.