1. Carpal tunnel syndrome
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This article is about the medical condition. For the anatomical structure, see Carpal tunnel. For the Fall Out
Boy song, see The Carpal Tunnel of Love. For the Kid Koala album, see Carpal Tunnel Syndrome (album).
Carpal tunnel syndrome
Classification and external resources
Transverse section at the wrist. The median nerve is colored
yellow. The carpal tunnel consists of the bones and flexor
retinaculum.
ICD-10
G56.0
ICD-9
354.0
OMIM
115430
DiseasesDB
2156
MedlinePlus
000433
eMedicine
orthoped/455pmr/21emerg/83radio/135
MeSH
D002349
Carpal tunnel syndrome (CTS) is a medianentrapmentneuropathy that causes paresthesia, pain,
numbness, and other symptoms in the distribution of the median nerve. The pathophysiology is not
completely understood but can be considered compression of the median nerve travelling through the
carpal tunnel.[1] It appears to be caused by a combination of genetic and environmental factors. [2] Some of
the predisposing factors include: diabetes, obesity, pregnancy, hypothyroidism, and heavy manual work or
work with vibrating tools. There is, however, little clinical data to prove that lighter, repetitive tasks can
cause carpal tunnel syndrome. Other disorders such as bursitis and tendinitis have been associated with
repeated motions performed in the course of normal work or other activities. [3]
The main symptom of CTS is intermittent numbness of the thumb, index, long and radial half of the ring
finger.[4] The numbness often occurs at night, with the hypothesis that the wrists are held flexed during

2. sleep. Recent literature suggests that sleep positioning, such as sleeping on one's side, might be an
associated factor.[5]It can be relieved by wearing a wrist splint that prevents flexion.[6] Long-standing CTS
leads to permanent nerve damage with constant numbness, atrophy of some of the muscles of the thenar
eminence, and weakness of palmar abduction.[7]
Pain in carpal tunnel syndrome is primarily numbness that is so intense that it wakes one from sleep. Pain
in electrophysiologically verified CTS is associated with misinterpretation of nociception and depression.[8]
Conservative treatments include use of night splints and corticosteroid injection. The only scientifically
established disease modifying treatment is surgery to cut the transverse carpal ligament. [9]
Contents
1 Signs and symptoms
2 Causes
o 2.1 Work related
o 2.2 Associated conditions
3 Diagnosis
o 3.1 Differential diagnosis
4 Pathophysiology
5 Prevention
6 Treatment
o 6.1 Splints
o 6.2 Corticosteroids
o 6.3 Surgery
o 6.4 Physiotherapy
7 Prognosis
8 Epidemiology
o 8.1 Occupational
9 History
10 Notable cases
11 References
12 External links
Signs and symptoms
Untreated carpal tunnel syndrome
People with CTS experience numbness, tingling, or burning sensations in the thumb and fingers, in
particular the index, middle fingers, and radial half of the ring fingers, which are innervated by the median
nerve. Less-specific symptoms may include pain in the wrists or hands and loss of grip strength[10] (both of
which are more characteristic of painful conditions such as arthritis).

3. Some posit that median nerve symptoms can arise from compression at the level of the thoracic outlet or
the area where the median nerve passes between the two heads of the pronator teres in the forearm, [11] but
this is highly debatable. This line of thinking is an attempt to explain pain and other symptoms not
characteristic of carpal tunnel syndrome.[12] Carpal tunnel syndrome is a common diagnosis with an
objective, reliable, verifiable pathophysiology, whereas thoracic outlet syndrome and pronator syndrome
are defined by a lack of verifiable pathophysiology and are usually applied in the context of nonspecific
upper extremity pain.
Numbness and paresthesias in the median nerve distribution are the hallmark neuropathic symptoms (NS)
of carpal tunnel entrapment syndrome. Weakness and atrophy of the thenar muscles may occur if the
condition remains untreated.[13]
Causes
Carpal Tunnel Syndrome
Most cases of CTS are of unknown causes, or idiopathic.[14] Carpal Tunnel Syndrome can be associated
with any condition that causes pressure on the median nerve at the wrist. Some common conditions that can
lead to CTS include obesity, oral contraceptives, hypothyroidism, arthritis, diabetes, prediabetes (impaired
glucose tolerance), and trauma.[15] Carpal tunnel is also a feature of a form of Charcot-Marie-Tooth
syndrome type 1 called hereditary neuropathy with liability to pressure palsies.
Other causes of this condition include intrinsic factors that exert pressure within the tunnel, and extrinsic
factors (pressure exerted from outside the tunnel), which include benign tumors such as lipomas, ganglion,
and vascular malformation.[16] Carpal tunnel syndrome often is a symptom of transthyretin amyloidosisassociated polyneuropathy and prior carpal tunnel syndrome surgery is very common in individuals who
later present with transthyretin amyloid-associated cardiomyopathy, suggesting that transthyretin amyloid
deposition may cause carpal tunnel syndrome.[17][18][19][20][21][22][23]
Work related
The international debate regarding the relationship between CTS and repetitive motion in work is ongoing.
The Occupational Safety and Health Administration (OSHA) has adopted rules and regulations regarding
cumulative trauma disorders. Occupational risk factors of repetitive tasks, force, posture, and vibration
have been cited. However, the American Society for Surgery of the Hand (ASSH) has issued a statement
claiming that the current literature does not support a causal relationship between specific work activities
and the development of diseases such as CTS.[24]

4. The relationship between work and CTS is controversial; in many locations, workers diagnosed with caral
tunnel syndrome are entitled to time off and compensation. [25] In the USA, carpal tunnel syndrome results
in an average of $30,000 in lifetime costs (medical bills and lost time from work).[26]
Some speculate that carpal tunnel syndrome is provoked by repetitive movement and manipulating
activities and that the exposure can be cumulative. It has also been stated that symptoms are commonly
exacerbated by forceful and repetitive use of the hand and wrists in industrial occupations, [27] but it is
unclear as to whether this refers to pain (which may not be due to carpal tunnel syndrome) or the more
typical numbness symptoms.[28]
A review of available scientific data by the National Institute for Occupational Safety and Health (NIOSH)
indicated that job tasks that involve highly repetitive manual acts or specific wrist postures were associated
with incidents of CTS, but causation was not established, and the distinction from work-related arm pains
that are not carpal tunnel syndrome was not clear. It has been proposed that repetitive use of the arm can
affect the biomechanics of the upper limb or cause damage to tissues. It has also been proposed that
postural and spinal assessment along with ergonomic assessments should be included in the overall
determination of the condition. Addressing these factors has been found to improve comfort in some
studies.[29]
Speculation that CTS is work-related is based on claims such as CTS being found mostly in the working
adult population, though evidence is lacking for this. For instance, in one recent representative series of a
consecutive experience, most patients were older and not working. [30] Based on the claimed increased
incidence in the workplace, arm use is implicated, but the weight of evidence suggests that this is an
inherent, genetic, slowly but inevitably progressive idiopathic peripheral mononeuropathy. [31]
Associated conditions
A variety of patient factors can lead to CTS, including heredity, size of the carpal tunnel, associated local
and systematic diseases, and certain habits.[1] Non-traumatic causes generally happen over a period of time,
and are not triggered by one certain event. Many of these factors are manifestations of physiologic aging. [32]
Examples include:
Rheumatoid arthritis and other diseases that cause inflammation of the flexor tendons.
With hypothyroidism, generalized myxedema causes deposition of mucopolysaccharides within
both the perineurium of the median nerve, as well as the tendons passing through the carpal
tunnel.
During pregnancy, women experience CTS due to hormonal changes (high progesterone levels)
and water retention (which swells the synovium), which are common during pregnancy.
Previous injuries including fractures of the wrist.
Medical disorders that lead to Ramkumar fluid retention or are associated with inflammation, such
as inflammatory arthritis, Colles' fracture, amyloidosis, hypothyroidism, diabetes mellitus,
acromegaly, and use of corticosteroids and estrogens.
Carpal tunnel syndrome is also associated with repetitive activities of the hand and wrist, in
particular with a combination of forceful and repetitive activities. [15]
Acromegaly causes excessive growth hormones. This causes the soft tissues and bones around the
carpel tunnel to grow and compress the median nerve. [33]
Tumors (usually benign), such as a ganglion or a lipoma, can protrude into the carpal tunnel,
reducing the amount of space. This is exceedingly rare (less than 1%).
Obesity also increases the risk of CTS: individuals classified as obese (BMI> 29) are 2.5 times
more likely than slender individuals (BMI < 20) to be diagnosed with CTS.[34]
Double-crush syndrome is a debated hypothesis that compression or irritation of nerve branches
contributing to the median nerve in the neck, or anywhere above the wrist, increases sensitivity of
the nerve to compression in the wrist. There is little evidence, however, that this syndrome really
exists.[35]
Heterozygous mutations in the gene SH3TC2, associated with Charcot-Marie-Tooth, confer
susceptibility to neuropathy, including the carpal tunnel syndrome.[36]
Diagnosis

5. There is no consensus reference standard for the diagnosis of carpal tunnel syndrome. A combination of
described symptoms, clinical findings, and electrophysiological testing is used by a majority of hand
surgeons. Numbness in the distribution of the median nerve, nocturnal symptoms, thenar muscle
weakness/atrophy, positive Tinel's sign at the carpal tunnel, and abnormal sensory testing such as two-point
discrimination have been standardized as clinical diagnostic criteria by consensus panels of experts. [37][38] A
predominance of pain rather than numbness is unlikely to be caused by carpal tunnel syndrome no matter
what the result of electrophysiological testing.
Electrodiagnostic testing (electromyography and nerve conduction velocity) can objectively verify the
median nerve dysfunction. If these tests are normal, carpal tunnel syndrome is either absent or very, very
mild.
Clinical assessment by history taking and physical examination can support a diagnosis of CTS.
Phalen's maneuver is performed by flexing the wrist gently as far as possible, then holding this
position and awaiting symptoms.[39] A positive test is one that results in numbness in the median
nerve distribution when holding the wrist in acute flexion position within 60 seconds. The quicker
the numbness starts, the more advanced the condition. Phalen's sign is defined as pain and/or
paresthesias in the median-innervated fingers with one minute of wrist flexion. Only this test has
been shown to correlate with CTS severity when studied prospectively. [1]
Tinel's sign, a classic — though less sensitive - test is a way to detect irritated nerves. Tinel's is
performed by lightly tapping the skin over the flexor retinaculum to elicit a sensation of tingling or
"pins and needles" in the nerve distribution. Tinel's sign (pain and/or paresthesias of the medianinnervated fingers with percussion over the median nerve) is less sensitive, but slightly more
specific than Phalen's sign.[1]
Durkan test, carpal compression test, or applying firm pressure to the palm over the nerve for up
to 30 seconds to elicit symptoms has also been proposed. [40][41]
Hand elevation test The hand elevation test has higher sensitivity and specificity than Tinel's test,
Phalen's test, and carpal compression test. Chi-square statistical analysis confirms the hand
elevation test is not ineffective compared with Tinel's test, Phalen's test, and carpal compression
test.[42]
As a note, a patient with true carpal tunnel syndrome (entrapment of the median nerve within the carpal
tunnel) will not have any sensory loss over the thenar eminence (bulge of muscles in the palm of hand and
at the base of the thumb). This is because the palmar branch of the median nerve, which innervates that area
of the palm, branches off of the median nerve and passes over the carpal tunnel. [43] This feature of the
median nerve can help separate carpal tunnel syndrome from thoracic outlet syndrome, or pronator teres
syndrome.
Other conditions may also be misdiagnosed as carpal tunnel syndrome. Thus, if history and physical
examination suggest CTS, patients will sometimes be tested electrodiagnostically with nerve conduction
studies and electromyography. The goal of electrodiagnostic testing is to compare the speed of conduction
in the median nerve with conduction in other nerves supplying the hand. When the median nerve is
compressed, as in CTS, it will conduct more slowly than normal and more slowly than other nerves. There
are many electrodiagnostic tests used to make a diagnosis of CTS, but the most sensitive, specific, and
reliable test is the Combined Sensory Index (also known as Robinson index).[44] Electrodiagnosis rests upon
demonstrating impaired median nerve conduction across the carpal tunnel in context of normal conduction
elsewhere. Compression results in damage to the myelin sheath and manifests as delayed latencies and
slowed conduction velocities [1] However, normal electrodiagnostic studies do not preclude the presence of
carpal tunnel syndrome, as a threshold of nerve injury must be reached before study results become
abnormal and cut-off values for abnormality are variable.[38] Carpal tunnel syndrome with normal
electrodiagnostic tests is very, very mild at worst.
The role of MRI or ultrasound imaging in the diagnosis of carpal tunnel syndrome is unclear. [45][46][47]
Differential diagnosis
There are some who believe that carpal tunnel syndrome is simply a universal label applied to anyone
suffering from pain, numbness, swelling, and/or burning in the radial side of the hands and/or wrists. When
pain is the primary symptom, carpal tunnel syndrome is unlikely to be the source of the symptoms. [28] As a
whole, the medical community is not currently embracing or accepting trigger point theories due to lack of
scientific evidence supporting their effectiveness.

6. Pathophysiology
Main article: Carpal tunnel
The carpal tunnel is an anatomical compartment located at the base of the palm. Nine flexor tendons and
the median nerve pass through the carpal tunnel that is surrounded on three sides by the carpal bones that
form an arch. The median nerve provides feeling or sensation to the thumb, index finger, long finger, and
half of the ring finger. At the level of the wrist, the median nerve supplies the muscles at the base of the
thumb that allow it to abduct, or move away from the fingers, out of the plane of the palm. The carpal
tunnel is located at the middle third of the base of the palm, bounded by the bony prominence of the
scaphoid tubercle and trapezium at the base of the thumb, and the hamate hook that can be palpated along
the axis of the ring finger. The proximal boundary is the distal wrist skin crease, and the distal boundary is
approximated by a line known as Kaplan's cardinal line.[48] This line uses surface landmarks, and is drawn
between the apex of the skin fold between the thumb and index finger to the palpated hamate hook.[49] The
median nerve can be compressed by a decrease in the size of the canal, an increase in the size of the
contents (such as the swelling of lubrication tissue around the flexor tendons), or both. [50] Simply flexing
the wrist to 90 degrees will decrease the size of the canal.
Compression of the median nerve as it runs deep to the transverse carpal ligament (TCL) causes atrophy of
the thenar eminence, weakness of the flexor pollicis brevis, opponens pollicis, abductor pollicis brevis, as
well as sensory loss in the digits supplied by the median nerve. The superficial sensory branch of the
median nerve, which provides sensation to the base of the palm, branches proximal to the TCL and travels
superficial to it. Thus, this branch spared in carpal tunnel syndrome, and there is no loss of palmar
sensation.[51]
Prevention
Suggested healthy habits such as avoiding repetitive stress, work modification through use of ergonomic
equipment (wrist rest, mouse pad), taking proper breaks, using keyboard alternatives (digital pen, voice
recognition, and dictation), and employing early treatments such as taking turmeric (anti-inflammatory),
omega-3 fatty acids, and B vitamins have been proposed as methods to help prevent carpal tunnel
syndrome. The potential role of B-vitamins in preventing or treating carpal tunnel syndrome has not been
proven.[52][53] There is little or no data to support the concept that activity adjustment prevents carpal tunnel
syndrome.[54]
Biological factors such as genetic predisposition and anthropometrics had significantly stronger causal
association with carpal tunnel syndrome than occupational/environmental factors such as repetitive hand
use and stressful manual work.[54] This suggests that carpal tunnel syndrome might not be preventable
simply by avoiding certain activities or types of work/activities.
Treatment
Generally accepted treatments include steroids either orally or injected locally, splinting, and surgical
release of the transverse carpal ligament.[55] There is no or insufficient evidence for ultrasound, yoga,
lasers, B6, and exercise therapy.[55]
Early surgery with carpal tunnel release is indicated where there is clinical evidence of median nerve
denervation or a person elects to proceed directly to surgical treatment. [56] The treatment should be
switched when the current treatment fails to resolve the symptoms within 2 to 7 weeks. However, these
recommendations have sufficient evidence for carpal tunnel syndrome when found in association with the
following conditions: diabetes mellitus, coexistent cervical radiculopathy, hypothyroidism, polyneuropathy,
pregnancy, rheumatoid arthritis, and carpal tunnel syndrome in the workplace.[56]
Splints

7. A rigid splint can keep the wrist straight
The importance of wrist braces and splints in the carpal tunnel syndrome therapy is known, but many
people are unwilling to use braces. In 1993, The American Academy of Neurology recommend a noninvasive treatment for the CTS at the beginning (except for sensitive or motor deficit or grave report at
EMG/ENG): a therapy using splints was indicated for light and moderate pathology. [57] Current
recommendations generally don't suggest immobilizing braces, but instead activity modification and nonsteroidal anti-inflammatory drugs as initial therapy, followed by more aggressive options or specialist
referral if symptoms do not improve.[15][58]
Corticosteroids
Corticosteroid injections can be effective for temporary relief from symptoms while a person develops a
long-term strategy that fits their lifestyle.[59] This treatment is not appropriate for extended periods,
however. In general, local steroid injections are only used until other treatment options can be identified.
For most surgery is the only option that will provide permanent relief. [60]
Surgery
Main article: Carpal tunnel surgery
Scars from carpal tunnel release surgery. Two different techniques were used. The left scar is 6 weeks old,
the right scar is 2 weeks old. Also note the muscular atrophy of the thenar eminence in the left hand, a
common sign of advanced CTS

8. Carpal Tunnel Syndrome Operation
Release of the transverse carpal ligament is known as "carpal tunnel release" surgery. It is recommended
when there is static (constant, not just intermittent) numbness, muscle weakness, or atrophy, and when
night-splinting no longer controls intermittent symptoms.[61] In general, milder cases can be controlled for
months to years, but severe cases are unrelenting symptomatically and are likely to result in surgical
treatment.[62]
Physiotherapy
One review of the evidence found good evidence for splinting, ultrasound, nerve gliding exercises, carpal
bone mobilization, magnetic therapy, and yoga for people with carpal tunnel syndrome. [63] However, a
recent evidence based guideline produced by the American Academy of Orthopedic Surgeons assigned
lower grades to most of these treatments.[64]
Again, some claim that pro-active ways to reduce stress on the wrists, which alleviates wrist pain and
strain, involve adopting a more ergonomic work and life environment. For example, some have claimed
that switching from a QWERTY computer keyboard layout to a more optimised ergonomic layout such as
Dvorak was commonly cited as beneficial in early CTS studies[citation needed], however some meta-analyses of
these studies claim that the evidence that they present is limited. [65][66]
Prognosis
Most people relieved of their carpal tunnel symptoms with conservative or surgical management find
minimal residual or "nerve damage".[67] Long-term chronic carpal tunnel syndrome (typically seen in the
elderly) can result in permanent "nerve damage", i.e. irreversible numbness, muscle wasting, and weakness.
Those that undergo a carpal tunnel release are nearly twice as likely as those not having surgery to develop
trigger thumb in the months following the procedure.[68]
While outcomes are generally good, certain factors can contribute to poorer results that have little to do
with nerves, anatomy, or surgery type. One study showed that mental status parameters or alcohol use
yields much poorer overall results of treatment.[69]
Recurrence of carpal tunnel syndrome after successful surgery is rare.[70] If a person has hand pain after
surgery, it is most likely not caused by carpal tunnel syndrome. It may be the case that the illness of a
person with hand pain after carpal tunnel release was diagnosed incorrectly, such that the carpal tunnel
release has had no positive effect upon the patient's symptoms. [citation needed]
Epidemiology
Carpal tunnel syndrome can affect anyone. In the U.S., roughly 1 out of 20 people will suffer from the
effects of carpal tunnel syndrome. Caucasians have the highest risk of CTS compared with other races such
as non-white South Africans.[71] Women suffer more from CTS than men with a ratio of 3:1 between the

9. ages of 45–60 years. Only 10% of reported cases of CTS are younger than 30 years. [71] Increasing age is a
risk factor. CTS is also common in pregnancy.
Occupational
As of 2010, 8% of U.S. workers reported ever having carpal tunnel syndrome and 4% reported carpal
tunnel syndrome in the past 12 months. Prevalence rates for carpal tunnel syndrome in the past 12 months
were higher among females than among males; among workers aged 45–64 than among those aged 18–44.
Overall, 67% of current carpal tunnel syndrome cases among current/recent workers were reportedly
attributed to work by health professionals, indicating that the prevalence rate of work-related carpal tunnel
syndrome among workers was 2%, and that there were approximately 3.1 million cases of work-related
carpal tunnel syndrome among U.S. workers in 2010. Among current carpal tunnel syndrome cases
attributed to specific jobs, 24% were attributed to jobs in the manufacturing industry, a proportion 2.5 times
higher than the proportion of current/recent workers employed in the manufacturing industry, suggesting
that jobs in this industry are associated with an increased risk of work-related carpal tunnel syndrome.[72]
History
The condition known as carpal tunnel syndrome had major appearances throughout the years but it was
most commonly heard of in the years following World War II. [73] Individuals who had suffered from this
condition have been depicted in surgical literature for the mid-19th century.[73] In 1854, Sir James Paget
was the first to report median nerve compression at the wrist in a distal radius fracture. [74] Following the
early 20th century there were various cases of median nerve compression underneath the transverse carpal
ligament.[74] Carpal Tunnel Syndrome was most commonly noted in medical literature in the early 20th
century but the first use of the term was noted 1939. Physician Dr. George S. Phalen of the Cleveland
Clinic identified the pathology after working with a group of patients in the 1950s and 1960s.
Notable cases
HRH Prince Philip, husband of Queen Elizabeth II[75]
Mike Dirnt, bassist with the band Green Day[76]
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