This study examined 232 patients with symptoms of carpal tunnel syndrome and compared the results of clinical tests, nerve conduction tests, and ultrasound imaging. The study found that clinical tests like Phalen's, Tinel's, and carpal tunnel compression tests were more sensitive indicators of tenosynovitis (inflammation of the tendon sheath) than of carpal tunnel syndrome. Specifically, these clinical tests correctly identified tenosynovitis in 75-95% of cases but only correctly identified carpal tunnel syndrome in 30-47% of cases based on nerve conduction and ultrasound results. The study suggests these clinical tests may be better indicators for diagnosing and managing tenosynovitis rather than carpal tunnel syndrome.

1. Available online at www.sciencedirect.com
Joint Bone Spine 75 (2008) 451e457
http://france.elsevier.com/direct/BONSOI/
Original article
Clinical diagnosis of carpal tunnel syndrome: Old testsenew concepts
Yasser El Miedany a,*, Samia Ashour b, Sally Youssef a, Annie Mehanna c, Fatma A. Meky d
a
Rheumatology and Rehabilitation, Ain Shams University, Cairo, Egypt
b
Neurology, Ain Shams University, Cairo, Egypt
c
Radiology, Ain Shams University, Cairo, Egypt
d
Community, Environmental and Occupational Medicine, Ain Shams University, Cairo, Egypt
Accepted 27 September 2007
Available online 2 May 2008
Abstract
Background: The diagnosis of carpal tunnel syndrome (CTS) continues to be neurophysiologically and clinically controversial. Earlier data con-
cluding that the higher prevalence of persons with symptoms suggestive of CTS but without evidence of median mononeuropathy highlights the
need for a better understanding of the underlying pathophysiology and natural history of CTS to provide a less empirical foundation for diag-
nosis and clinical management.
Objective: To examine the relationship between the clinical manifestations of CTS with the outcome of the diagnostic tools (nerve conduction
tests and ultrasonography), and its implication for clinical practice.
Methods: Two-hundred and thirty-two patients (69 male and 163 female, ages ranging between 20 and 91 years) with CTS manifestations and
182 controls were included in this study. Diagnosis of CTS was based on the American Academy of Neurology clinical diagnostic criteria. All
patients and controls completed a patient oriented questionnaire, were subjected to clinical testing for provocative tests for carpal tunnel
syndrome (Tinel’s, Phalen’s, Reverse Phalen’s and carpal tunnel compression tests), blood check for secondary causes of carpal tunnel
syndrome, nerve conduction testing as well ultrasonographic assessment of the carpal tunnel and median nerve.
Results: One-hundred and seventy-seven out of 232 (76.3%) had abnormal nerve conduction studies. Forearm symptoms and tenosynovitis con-
firmed by US examination were found in 51.3% of cases. No significant difference was found on comparing anthropometric measures in the
affected hands to the control group hands. A higher prevalence of positive Phalen’s and CT compression were found in patients suffering
from tenosynovitis regardless of their nerve conduction study results. Sensitivity of Tinel’s, Phalen’s, Reverse Phalen’s and carpal tunnel com-
pression tests was higher for the diagnosis of tenosynovitis than for the diagnosis of CTS (Tinel, 46% vs. 30%; Phalen’s, 92% vs. 47%; Reverse
Phalen’s, 75% vs. 42%; carpal tunnel compression test, 95% vs. 46%). Similarly, higher specificity of these tests was found with tenosynovitis
than CTS.
Conclusion: The results of this study revealed that Tinel’s, Phalen’s, Reverse Phalen’s and carpal tunnel compression tests are more sensitive, as
well as being specific tests for the diagnosis of tenosynovitis of the flexor muscles of the hand, rather than being specific tests for carpal tunnel
syndrome and can be used as an indicator for medical management of the condition.
Ó 2008 Elsevier Masson SAS. All rights reserved.
Keywords: Carpal tunnel syndrome; Nerve conduction testing; Ultrasound; Phalen test; Tinel test; Carpal tunnel compression test
1. Introduction
Carpal tunnel syndrome (CTS) is a common clinical condi-
tion with an estimated lifetime risk of 10% and an annual
incidence of 0.1% among adults [1,2]. These estimates are
* Corresponding author. 2 Italian Hospital St., Abbassia, Cairo, 11381,
undoubtedly conservative because they are based on data col-
Egypt. Tel.: þ20 441322428425; fax: þ20 441322428415. lected prior to the substantial increase in work related cases of
E-mail address: yasser_elmiedany@yahoo.com (Y. El Miedany). CTS in the 1980s and early 1990s and the concomitant
1297-319X/$ - see front matter Ó 2008 Elsevier Masson SAS. All rights reserved.
doi:10.1016/j.jbspin.2007.09.014

2. 452 Y. El Miedany et al. / Joint Bone Spine 75 (2008) 451e457
increased awareness of this condition [3,4]. More recent esti- posture or by shaking the hand; sensory deficit or hypotrophy
mates of the prevalence of CTS in the general population of the median innervated thenar muscle.
are 0.6% in men and 5.8% in women [5]. Data from Sweden
reported by Atroshi and colleagues suggest an overall preva- 2.3. Clinical testing for CTS
lence of 2.1% [6]. Despite the large number of original re-
search studies on carpal tunnel syndrome, considerable A detailed clinical history, with thorough examination and
uncertainty and even controversy exist in the medical commu- extended musculoskeletal as well as neurophysiological eval-
nity about its extent and aetiology, the contribution of work uation were carried out. Careful consideration was paid to as-
and non-work risk factors to its development, the criteria sessing the possibility of the presence of forearm symptoms
used to diagnose it, the outcomes of various treatment methods and in particular tendonitis. Four tests were performed for
and the appropriate strategies for intervention and prevention. both hands of every subject included in this study. They
In addition, there is insufficient evidence to identify a single were considered positive when applying the test would repro-
‘‘best’’ examination-based clinical test. Certain clinical tests duce presenting symptoms of pain or numbness in digits 1, 2,
have been in use as components of a clinical diagnosis of and 3 (median nerve distribution). The tests were: Tinel’s test,
CTS, however, their sensitivity and specificity have been a mat- percussion of the median nerve at the wrist; Phalen’s test,
ter of controversy [7]. Furthermore, it is relatively difficult for complete palmer wrist flexion for 60 s; Reverse Phalen’s
the treating physician to distinguish between CTS and other test, complete dorsal wrist flexion for 60 s; carpal tunnel com-
conditions with similar symptoms such as tendonitis. There pression test, even pressure exerted by the examiner on the
is ample evidence that the accuracy of the available diagnostic space between thenar and hypothenar eminence for 30 s while
tools is not very good [8,9]. arm is supinated [22]. The patient was questioned with regard
In recent years, imaging techniques such as magnetic reso- to symptoms at 15-s intervals during the 30-s period.
nance imaging [10e13] and sonography [14e19] have been Laboratory investigations to diagnose any secondary cause
shown to be of value in the diagnosis of CTS. Both have the for CTS were done for all patients, namely full blood count,
advantage of providing insight into the possible focal causes haemoglobin A1C, thyroid functions, liver and kidney profiles.
of CTS such as localized space occupying lesions, rheumatoid Patients who underwent decompression surgery and showed no
arthritis, tenosynovitis or synovitis of the wrist [20,21]. US significant improvement in their symptoms (less than 25% im-
and MRI enabled the researchers to assess the presence of te- provement in the score of symptom severity assessed by visual
nosynovitis of the flexors of the hands or any other localized analogue scale) were included in the study (35 patients). Pa-
swelling [19]. However, no studies meeting the inclusion cri- tients with the following conditions were excluded from the
teria addressed the frequency with which forearm conditions study: (1) patients who had cervical nerve impingement as
co-exist with CTS. This study was carried out to examine proved by MRI cervical spine; (2) patients suffering from other
the relationship between the clinical manifestations of CTS neurological diseases causing motor weakness of the hands (3)
as well as the possible related forearm conditions with the out- patients suffering from diabetes mellitus or thyroid dysfunction.
come of the diagnostic tools (nerve conduction tests and ultra-
sonography), and its implications for clinical practice. 2.4. Control group
2. Methods One-hundred and eighty-two healthy, age-matched subjects
with no signs or symptoms of CTS were studied as a control
2.1. Patients group: 121 females and 61 males. The control subjects were
from the healthy subjects accompanying the patients during
Two-hundred and thirty-two patients were included in this their visits to the hospital (mostly housewives) or from the
study. They were gathered from those attending the outpatient hospital staff. They were subjected to full musculoskeletal
clinic with a history suggestive of median nerve entrapment. and neurological examination to verify their normality. All
All patients had both hands examined clinically, sonographi- patients showed negative results on the self-administered ques-
cally and electrophysiologically. The limit for age matching tionnaire. In addition, they were subjected to the same labora-
was a 5-year interval for both men and women. tory investigations as the patient group. Nerve conduction
studies and ultrasonography examination of both wrists were
2.2. Definition of cases and data collection at initial carried out for all subjects included in the control group.
evaluation
2.5. Patient-oriented data
Sociodemographic data, clinical and work related data were
obtained for every subject included in this study. Diagnosis of Each subject included in this study completed a self-
CTS was based on the American Academy of Neurology clin- administered questionnaire for clinical assessment as well as
ical diagnostic criteria (1993) [2] summarized as: paraesthesia; severity of carpal tunnel syndrome. This includes 11 questions
pain; swelling; weakness or clumsiness of the hand provoked to identify 5 main presenting symptoms: paraesthesia, nocturnal
or worsened by sleep, sustained hand or arm position; repeti- pain, diurnal pain, weakness/clumsiness and pain. Severity of all
tive action of the hand or wrist that is mitigated by changing patients’ symptoms was assessed by the carpal tunnel severity

3. Y. El Miedany et al. / Joint Bone Spine 75 (2008) 451e457 453
index [23]. The main symptoms were identified based on the Y.M.), 12 MHz linear array transducer. To ensure unbiased ex-
American Academy of Neurology clinical diagnostic criteria amination, the examiner was requested not to inquire about
[2]. symptoms and the patients were asked not to speak about their
In addition, each subject completed the modified Boston problem during the examination. Sonographic examination was
Carpal Tunnel Questionnaire (BCTQ) [24]. The mBCTQ eval- done either on the same day or within 3 days of the electrophys-
uates ‘‘functional status’’ assessed with a ten-item scale (writ- iological study. The sonographic examination was performed
ing, buttoning, holding, gripping, bathing, dressing, computer with the patient seated in a comfortable position facing the so-
work/typing and driving). The questionnaire was presented in nographer with the forearm resting on the table and the palm
multiple-choice format and scores were assigned from 1 point facing up in the neutral position. The volar wrist crease was
(mildest) to 5 points (most severe). Each score was calculated used an initial external reference point with subsequent modifi-
as the mean of the responses of the individual items. Patients cations during scanning. The median nerve was located superfi-
were divided into 5 groups according to their mean score: cial to the echogenic flexor tendons and its size, shape,
extreme (4.1e5 points), severe (3.1e4 points), moderate echogenicity and relationship to the surrounding structures
(2.1e3 points), mild (1.1e2 points) and minimal (0.1e1 and overlying retinaculum were noted. The amount of synovial
point). The patients had to answer the questions for each fluid and the presence of masses within the carpal tunnel were
hand separately. In order to avoid any influence of the physi- noted. Measurement of the anteroeposterior dimensions of
cian or the neurophysiologic data on the patient-oriented re- the carpal tunnel was also assessed at the midpoint of the carpal
sults, the mBCTQ was always completed in the waiting room. tunnel at the level of the distal margin of pisiform bone. The
main hallmark of tenosynovitis is irregularities of tendon mar-
2.6. Electrodiagnostic evaluation gins and presence of fluid in the tendon’s sheath. Doppler tech-
niques were carried out to detect flow signals within and around
Electrodiagnostic studies were carried out for all subjects in- the involved tendon(s). Colour Doppler was also used to distin-
cluded in this study according to the protocol inspired by the guish the hypoechoic pannus in patients with arthritis from the
American Association of Electrodiagnostic Medicine recom- effusion based on the presence or absence of flow signals.
mendations [8,25,26] using a Dantec Keypoint. All testing In order to assess the reliability, every seventh subject was
was done in the same room and in similar temperature condi- asked to return within 24 h for a repeat US. A total of 33 CTS
tions. When standard tests (median sensory nerve conduction patients and 26 control subjects were assessed for this purpose.
velocity in two-digit/wrist segment and median distal motor la- Inter-observer reliability was also assessed.
tency from the wrist to the thenar eminence) yielded normal re- The local protocols for the study approval were followed.
sults, further segmental tests over a short distance of 7e8 cm The nature of the work was explained to all patients and
were performed [27,28] or comparative median/ulnar studies healthy subjects included in the study. All subjects who shared
[29,30]. F-wave testing was done for all patients. Measurements in this work signed information consent written according to
performed and cut-off points or normal values used in our study the Declaration of Helsinki.
were as follows: (1) median nerve distal sensory latency, upper
limit of normal 3.6 ms; (2) difference between the median and 2.8. Statistical analysis
ulnar nerve distal sensory latencies, upper limit of normal
0.4 ms; (3) distal motor latency over the thenar, upper limit of For statistical analysis we used SPSS for windows, Release
normal 4.3 ms; (4) median motor nerve conduction velocity, 11 (statistical package for Social Sciences Inc. Chicago, IL,
lower limit of normal 49 m/s; (5) median sensory nerve conduc- USA). Chi square (c2) test was used for categorical variables.
tion velocity, lower limit of normal 49 m/s [31]. The severity of Student t-test and one-way analysis of variance (ANOVA) with
electrophysiological CTS impairment was assessed according Tukey were used for quantitative variables. Epicalc 2000 pro-
to the classification reported by Padua et al. [32]. CTS hands gram was used to calculate the confidence intervals of sensitiv-
were divided into 6 groups based on their neurophysiological ity and specificity of clinical tests. Sensitivity was calculated
findings: negative, normal findings on all tests; minimal, abnor- as the number of true positive divided by the total diseased
mal segmental or comparative tests only; mild, abnormal digit/ persons. Specificity was calculated as the number of true neg-
wrist sensory nerve conduction velocity and normal distal motor ative divided by the total disease-free persons by the golden
latency; moderate, abnormal digit/wrist sensory nerve conduc- standard test. Nerve conduction testing and ultrasonography
tion velocity and abnormal distal motor latency; severe, absence were considered the golden standard tests. The correlations be-
of sensory response and abnormal distal motor latency; ex- tween distal sensory latency and distal motor sensory latency
treme, absence of motor and sensory response. with age and score of severity of symptoms were calculated
using Pearson’s correlation coefficient. Level of significance
2.7. Sonography was set at p less than or equal to 0.05.
All patients and control subjects underwent high-resolution 3. Results
real-time sonography of the carpal tunnels of both hands using
a Diasonic Gateway machine (examination was carried out by The study included 232 patients with CTS. The patients
AM)/Mylab 50 Esoate (Italy) (examination carried out by group was 69 male and 163 female aged between 20 and

4. 454 Y. El Miedany et al. / Joint Bone Spine 75 (2008) 451e457
91 years. For patients with bilateral symptoms, the more
affected hand was used for analysis.
Tenosynovitis symptoms confirmed by US examination
(Figs. 1 and 2) were found in 54% of cases. Table 1 shows so-
cio-demographic and clinical data of the patient group in-
cluded in this study. A positive history of forearm symptoms
was given by 54.3% of the patients (126/232). The diagnosis
of tenosynovitis was confirmed by US in 94% of these patients
(119/126). No significant difference was found (Table 2) be-
tween different anthropometric measures in the affected hands
(197 patients) in comparison to the control group hands (pa-
tients with past history of carpal tunnel decompression opera-
tion were excluded). In patients with postoperative recurrence
of symptoms (35 subjects), US assessment revealed that inter-
stitial oedema was present in 9/35 patients, focal swelling in 3/
35 patients, synovitis in 4/35 patients, bifid median nerve in 1/
35 patient, and tenosynovitis in 18 patients.
Fig. 2. Transverse scan showing tenosynovitis of the flexor tendons: the
Table 3 shows the association between the positivity of the tendons appear swollen and indenting the compressed median nerve (MN).
clinical provocative tests and both socio-demographic factors
as well as the diagnostic tests applied in this study (nerve con-
duction testing and US). The prevalence of positive Tinel, Pha- Reverse Phalen’s and CT compression than those with abnor-
len’s, Reverse Phalen’s and CT compression were significantly mal conduction but with no tenosynovitis.
higher in patients in the age category 65 years in comparison The sensitivity and specificity with 95% confidence interval
to those >65 years (37.4, 69.9, 56.1 and 66.1% versus 13.1, of clinical tests for the diagnosis of carpal tunnel syndrome
13.1, 19.7 and 11.5% respectively). and tenosynovitis are shown in Table 5. Sensitivity of Tinel,
Association between tenosynovitis and clinical tests in pa- Phalen’s, Reverse Phalen’s and CT compression tests was
tients with normal and abnormal nerve conduction is described higher for the diagnosis of tenosynovitis than for the diagnosis
in Table 4. Significantly higher percentages of positive Pha- of CTS (46 vs. 30 in Tinel; 92 vs. 47 in Phalen’s; 75 vs. 42 in
len’s, Reverse Phalen’s and CT compression tests were found Reverse Phalen’s; 95 vs. 46 in carpal tunnel compression).
in patients with normal conduction but with tenosynovitis than Similarly, higher specificity of these tests was found with teno-
in those who had normal conduction without tenosynovitis. synovitis than CTS.
Similarly, patients with abnormal conduction and having teno-
synovitis had a higher prevalence of positive Tinel, Phalen’s,
Table 1
Sociodemographic and clinical history of patients with carpal tunnel syndrome
Number (%)
(N ¼ 232)
Age categories
65-years old 65 (28)
>65-years old 167 (72)
Sex
Male 69 (29.7)
Female 163 (70.3)
Forearm symptoms
No 106 (45.7)
Yes 126 (54.3)
Tenosynovitis (detected by US)
No 113 (48.7)
Yes 119 (51.3)
Nocturnal dysaesthesia
No 0 (0)
Yes 232 (100)
Diurnal pain
No 120 (51.7)
Yes 112 (48.3)
Fig. 1. Transverse scan showing tenosynovitis of the flexor policis longus: the
Improvement of symptoms on shaking the hands
tendon appears swollen and surrounded by hypoechoic hallo of oedema (ar-
No 117 (50.4)
rowheads), median nerve (MN). The tendon could be identified by asking
Yes 115 (49.6)
the patient to move the thumb during scanning.

5. Y. El Miedany et al. / Joint Bone Spine 75 (2008) 451e457 455
Table 2 Table 4
Anthropometric measures in the symptomatic hands (197 patients) in compar- Association between tenosynovitis and clinical tests in patients with normal
ison to the control group (182 patients) and abnormal nerve conduction
Affected hands Control group Significance Positive N (%) Total
mean Æ SD mean Æ SD Tinel Phalen’s Reverse Carpal N (%)
BMI 29.01 Æ 4.75 28.93 Æ 5.25 NS Phalen’s tunnel
Forearm length (cm) 19.35 Æ 1.54 19.19 Æ 1.73 NS compression
Flexor retinaculum (mm) 1.065 Æ 0.37 1.012 Æ 0.16 NS Normal nerve conduction
Antero-posterior of carpal 11.75 Æ 0.90 11.71 Æ 0.64 NS No 4 (40.0) 3 (30.0) 2 (20.0) 0 10 (20.8)
tunnel (mm) tenosynovitis
BMI, body mass index. Tenosynovitis 13 37 29 27 38
(34.2) (97.4)*** (76.3)** (71.1)*** (79.2)
Total 48
Studies for the reproducibility of the radiographic assess-
Abnormal nerve conduction
ment showed high inter-observer reproducibility (K ¼ 0.89
No 13 (12.6) 14 (13.6) 16(15.5) 6 (5.8) 103 (56)
and 0.93), whereas, kappa values for intra-observer reproduc- tenosynovitis
ibility were 0.91 and 0.93 indicating high reproducibility. Tenosynovitis 42 73 61 72 81
(51.9)*** (90.1)*** (75.3)*** (88.9)*** (44)
Total 184
4. Discussion
*p < 0.05, **p < 0.01, ***p < 0.001.
The diagnosis of carpal tunnel syndrome (CTS) continues to
be neurophysiologically and clinically controversial. Earlier compression test), the results of this study revealed that the
data highlighted the possibility of having patients with symp- prevalence of positive clinical tests in patients with CTS diag-
toms suggestive of CTS but without evidence of median mono- nosed by nerve conduction testing as the gold standard was:
neuropathy and revealed the need for a better understanding of 29.9%, 47.3%, 41.8% and 42.4% respectively. Sensitivities
the underlying pathophysiology and natural history of CTS. of the 4 test were 30%, 47%, 42% and 46% respectively,
This study was carried out to examine the relationship between whereas their specificities were 65%, 17%, 35% and 25% re-
the clinical symptoms of CTS (and the possible related forearm spectively. These figures are in agreement with the earlier data
conditions) with the outcome of assessment using the diagnostic published. Ghavanini and Haghighat [33] carried out a study to
tools (nerve conduction testing and US) in patients presenting reappraise the value of these clinical tests in CTS patients.
with carpal tunnel syndrome manifestations. They found that, in patients with CTS diagnosed by nerve con-
On examining the prevalence of the 4 clinical tests exam- duction testing as the gold standard, Tinel’s test was the most
ined (Tinel’s, Phalen’s, Reverse Phalen’s and carpal tunnel specific and the least sensitive; carpal compression test was
less sensitive and specific. There was no correlation between
Table 3 Phalen time, Reverse Phalen time, carpal compression time,
Association between clinical provocative tests and both socio-demographic and nerve conduction measurements. In another study Buch
factors as well as the diagnostic tests applied in this study (nerve conduction and Foucher [34] found that when correlation between 11 clin-
testing and US) ical signs and tests (isolated or associated) was performed in
Positive N (%) patients with CTS manifestations with nerve conduction test-
Tinel Phalen’s Reverse Carpal tunnel ing used as ‘‘standard’’, none of the signs or tests reached
Phalen’s compression an acceptable level of sensitivity, specificity or predictive
Age categories value. Furthermore, in the study carried out by Homan et al.
65-years 64 (37.4)*** 119 (69.9)*** 96 (56.1)*** 113 (66.1)*** [35] to evaluate the concordance between various clinical
>65-years 8 (13.1) 8 (13.1) 12 (19.7) 7 (11.5) screening procedures for carpal tunnel syndrome, there was
Sex
Male 18 (26.1) 32 (46.4) 29 (42.0) 32 (46.4) Table 5
Female 54 (33.1) 95 (58.4) 79 (48.5) 88 (54.0) Sensitivity and specificity and 95% confidence interval of clinical tests in di-
Diagnosis of carpel tunnel syndrome by nerve conduction test agnosis of carpal tunnel syndrome and tenosynovitis
Normal 17 (35.4) 40 (83.3) 31 (64.6) 36 (75.0) Carpal tunnel syndrome Tenosynovitis
Mild 17 (36.2) 31 (66.0)* 23 (48.9) 24 (51.1)*
Sensitivity Specificity Sensitivity Specificity
Moderate 24 (31.2) 37 (48.1)*** 40 (51.9) 37 (48.1) **
(95% CI) (95% CI) (95% CI) (95% CI)
Severe 14 (23.3) 19 (31.7)*** 14 (23.3)*** 23 (38.3)***
Tinel 30 65 46 85
Forearm symptoms
(24.3e36.4) (58.4e71.1) (40.5e53.6) (79.6e89.2)
No 16 (15.1) 11 (10.4) 13 (12.3) 0
Phalen’s 47 17 92 87
Yes 56 (44.4)*** 116 (92.1)*** 95 (75.4)*** 120 (95.2)***
(40.5e53.6) (12.5e22.6) (35.6e48.7) (81.8e90.9)
Tenosynovitis by US Reverse Phalen’s 42 35 75 85
No 16 (14.7) 14 (12.8) 16 (14.7) 3 (2.8) (35.6e48.7) (29.0e41.6) (68.8e80.3) (79.6e89.2)
Yes 56 (45.5)*** 113 (91.9)*** 92 (74.8)*** 117 (95.1)*** Carpal tunnel 46 25 95 97
compression (39.5e52.6) (19.7e31.2) (91.1e97.3) (93.7e98.7)
*p < 0.05, **p < 0.01, ***p < 0.001.

6. 456 Y. El Miedany et al. / Joint Bone Spine 75 (2008) 451e457
relatively poor overlap between the reported symptoms, the reported that most people with positive physical findings con-
physical examination findings, and the electrodiagnostic re- sistent with CTS do not have electrodiagnostic abnormalities,
sults consistent with CTS. Overall, only 23 out of 449 subjects and vice versa.
(5%) with at least 1 positive finding met all 3 criteria (symp- This work also has its therapeutic implications. A 1987 sur-
toms, physical examination findings, and electrophysiological vey of hand surgeons found that many did not have electro-
results consistent with carpal tunnel syndrome) for the domi- diagnostic studies performed for patients with suspected
nant hand. The screening procedures showed poor or no agree- CTS [8] implying that these clinicians based their diagnosis
ment with kappa values ranging between 0.00 and 0.18 for all and treatment on history and physical examination findings.
the case definitions evaluated for carpal tunnel syndrome. Jen- The results of this study suggest that some of these patients
sen et al. [36] reported that these tests represent ‘‘objective ev- might have benefited from medical therapy rather than surgical
idence’’, and have only a limited relationship with the typical option. Earlier studies revealed that short-term oral predniso-
clinical features of CTS. This situation is analogous to the lone or local steroid injections are effective treatment for car-
weak relationship between findings on magnetic resonance im- pal tunnel syndrome [40,41].
aging (MRI) of the lower back and low back pain. Further- To answer the question, why tenosynovitis has been missed
more, in agreement with our results, De Krom et al. [5] in the assessment of patients with CTS despite it being well
suggested that there is little evidence to support the notion known to be a work related disorder, the diagnosis of CTS
that provocative tests are useful for the diagnosis of CTS. has been based only on symptoms and/or signs suggestive of
More recently, Wainner et al. [37] suggested that additional the disease, but does not include in its assessment other com-
studies of provocative tests items such as the Phalen test and mon disorders such as tendonitis and cervical radiculopathy
Tinel sign, whose values have yet to be clearly demonstrated, which can give similar manifestations [2]. Second, the ques-
are likely to yield more of the same unfruitful results. They tionnaire that has been developed by Levine et al. (1999) to
recommended that future studies should assess and report assess the severity of CTS symptoms, did not include full as-
the influence of the disease spectrum on test item performance. sessment of tenosynovitis and was never designed as a diagnos-
This was one of the main targets of this study. tic tool. In fact, studies have shown insignificant correlation
The results of this work revealed that the prevalence of the 4 between the overall severity scale for all symptoms and nerve
clinical tests assessed was higher among the younger age group conduction studies [23]. Hence, it was important to assess for
of patients (<65 years). Similarly, tenosynovitis was signifi- tenosynovitis. You [42] recommended CTS symptoms be clas-
cantly more prevalent among the same group of the patients. sified into 2 groups to provide better interpretation of the
Third, in the group of patients who had normal nerve conduc- symptoms. The first group includes typical symptoms for
tion studies, but had tenosynovitis, the prevalence of positive nerve damage. The second group includes pain, and symptoms
Phalen’s, Reverse Phalen’s and carpal tunnel compression tests, suggestive of affection of body tissues including tendon, mus-
was significantly higher than the patient subgroup who had nor- cle and nerve. The results of this study are in agreement with
mal nerve conduction studies and did not suffer from tenosyn- such a hypothesis.
ovitis. Lastly, the specificity and sensitivity of these tests in The results of this study revealed that Phalen, Reverse Pha-
patients with tenosynovitis were significantly higher when com- len and carpal tunnel compression tests are more sensitive, as
pared to the specificity and sensitivity of the same tests among well as being specific tests for the diagnosis of tenosynovitis of
patients diagnosed to have CTS by the NCS as the gold stan- the flexor muscles of the hand rather than being specific tests
dard. These data give the conclusion that such provocative tests for carpal tunnel syndrome and can be used as an indicator for
are more sensitive and specific for tenosynovitis rather than medical management of the condition.
being valid clinical tests for carpal tunnel syndrome. Britz
et al. [38], correlating the clinical, electrodiagnostic, intra-
operative, and magnetic resonance imaging (MRI) findings, re- References
ported that increased signal of the median nerve was seen in 41
of 43 (95%) wrists, increased signal of the flexor tendon sheath [1] Stevens JC, Sun S, Beard CM, et al. Carpal tunnel syndrome in Roches-
ter, Minnesota, 1961 to 1980. Mayo Clin Proc 1988;38:134e8.
in 41 of 43 (95%), volar bowing of the flexor retinaculum in 39 [2] Quality standards subcommittee of the American Academy of Neurol-
of 43 (91%), increased distance between the flexor tendons in ogy. Practice parameter for carpal tunnel syndrome. Neurology
37 of 43 (86%), and abnormal nerve configuration in 28 of 43 1993;43:2406e9.
(65%). In another study Mesgarzadeh et al. [39], studying the [3] Hanrahan LP, Higgins D, Anderson H, et al. Project SENSOR: Wisconsin sur-
MRI images of patients with CTS, found CTS could be caused veillance of occupational carpal tunnel syndrome. WMJ 1991;90:82e3.
[4] Bureau of Labour Statistics. Occupational injuries and illness in the
by tendon sheath oedema in traumatic tenosynovitis, synovial United States by industry. Washington DC: US Department of Labour,
hypertrophy in rheumatoid tenosynovitis, a ganglion cyst, and Bureau of Labour Statistics; 1995.
excessive amount of fat within the carpal tunnel, a persistent [5] de Krom MC, Knipschild PG, Kester AD, et al. Carpal tunnel syndrome.
median artery, and a large adductor pollicis muscle. J Clin Epidemiol 1992;45:373e6.
In our work tenosynovitis was more prevalent among pa- [6] Atroshi I, Gummesson C, Johnsson R, et al. Diagnostic properties of
nerve conduction tests in population based carpal tunnel syndrome.
tients who had either normal nerve conduction tests or mild BMC Musculoskelet Disord 2003;4:9e16.
compression of the median nerve (Table 4). These findings [7] Fisher B, Gorsche R, Leake P. Diagnosis, causation and treatment of car-
are in agreement with the data of Homan et al. [35], who pal tunnel syndrome: an evidence based assessment, A background paper

7. Y. El Miedany et al. / Joint Bone Spine 75 (2008) 451e457 457
prepared for Medical Services Workers’ Compensation Board. Canada: [26] Padua I, Padua R, Lo Monaco M, et al. Multiperspective assessment of
Alberta; 2004. 8e11. carpal tunnel syndrome: a multicenter study. Neurology 1999;53:
[8] Seror P. Carpal tunnel syndrome in the elderly: beware of severe cases. 1654e9.
Ann Chir Main Memb Super 1991;10:217e25. [27] Rossi S, Giannini F, Passero S, et al. Sensory neural conduction of
[9] American Association of Electrodiagnostic Medicine. American median nerve from digits and palm stimulation in carpal tunnel
Academy of Neurology, American Academy of Physical Medicine and syndrome. Electroencephalogr Clin Neurophysiol 1994;93:330e4.
Rehabilitation. Literature review of the usefulness of nerve conduction [28] Padua I, Lo Monaco M, Valente EM, et al. A useful electrophysiologic
studies and electromyography for the valuation of patients with carpal parameter for diagnosis of carpal tunnel syndrome. Muscle Nerve
tunnel syndrome. Muscle Nerve 1993;16:1392e414. 1996;19:48e53.
[10] Gray RG, Gottlieb NL. Hand flexor tenosynovitis in rheumatoid arthritis [29] Gioni R, Passero SS, Parasico C, et al. Diagnostic specificity of sensory
prevalence, distribution and associated rheumatic features. Arthritis and motor nerve conduction variables in early detection of carpal tunnel
Rheum 1977;20:1003e8. syndrome. J Neurol 1989;236:208e13.
[11] Smukler NM, Patterson JR, Lorenz JJ, et al. The incidence of the carpal [30] Uncini A, Lange DJ, Solomon M, et al. Ring finger testing in carpal
tunnel syndrome in patients with rheumatoid arthritis. Arthritis Rheum tunnel syndrome: a comparative study of diagnostic utility. Muscle Nerve
1963;6:298e9. 1989;12:735e41.
[12] Barnes GG, Curry HLF. Carpal tunnel syndrome in rheumatoid arthritis. A [31] Delisa JA. Upper extremity nerves. In: Delisa JA, Lee HJ, Baron EM,
clinical and electrodiagnostic survey. Ann Rheum Dis 1967;26:226e33. Lai KS, Spieholz N, editors. Manual of nerve conduction velocity and
[13] Mesgazadch M, Schneck CD, Bonakdarpour A. Carpal tunnel: MR neurophysiology. New York: Raven Press; 1994. p. 68e71.
imaging Part 1. Normal anatomy. Radiology 1980;17:743e8. [32] Padua I, Lo Monaco M, Gregori B, et al. Neurophysiological classifica-
[14] Duncan I, Sullivan P, Lornas F. Sonography in the diagnosis of carpal tion and sensitivity in 500 carpal tunnel syndrome hands. Acta Neurol
tunnel syndrome. Am J Roentgenol 1999;173:681e4. Scand 1997;96:211e7.
[15] Sarria I, Cabada T, Cozcolluela R, et al. Carpal tunnel syndrome: [33] Ghavanini MR, Haghighat M. Carpal tunnel syndrome: reappraisal of
usefulness of sonography. Eur Radiol 2000;10:1920e5. five clinical tests. Electromyogr Clin Neurophysiol 1998;38:437e41.
[16] Buchberger Q, Judmaier W, Birbamer G, et al. Carpal tunnel syndrome: [34] Buch N, Foucher G. Validity of clinical signs and provocative tests in
diagnosis with high-resolution sonography. Am J Roentgenol carpal tunnel syndrome. Rev Chir Orthop Reparatrice Appar Mot
1992;159:793e8. 1995;80:14e21.
[17] Kanoly LP, Schrogendorger KF, Rab M, et al. The precision of [35] Homan MM, Franzblau A, Werner RA, et al. Agreement between
ultrasound imaging and its relevance for carpal tunnel syndrome. Surg symptom surveys, physical examination procedures and electrodiagnos-
Radiol Anat 2001;23:117e21. tic findings for the carpal tunnel syndrome. Scand J Work Environ Health
[18] Kotevoglu N, Gulbahce-Saglam S. Ultrasound imaging in the diagnosis
¨ 1999;25:115e24.
of carpal tunnel syndrome and its relevance to clinical evaluation. Joint [36] Jensen MC, Brandt-Zawadzki MN, Obuchowski N, et al. Magnetic reso-
Bone Spine 2005;72:142e5. nance imaging of the lumbar spine in people without back pain. N Engl J
[19] El Miedany YM, Aty SA, Ashour S. Ultrasonography versus nerve Med 1994;331:69e73.
conduction study in patients with carpal tunnel syndrome: substantive [37] Wainner RS, Fritz J, Irrgang J, et al. Development of a clinical prediction
or complementary tests? Rheumatology 2004;43:887e95. rule for the diagnosis of carpal tunnel syndrome. Arch Phys Med Rehabil
[20] Hug C, Huber H, Terrier H. Detection of flexor tenosynovitis by 2005;86:609e18.
magnetic resonance imaging: its relationship to diurnal variation of [38] Britz GW, Haynor DR, Kuntz C, et al. Carpal tunnel syndrome:
symptoms. J Rheumatol 1991;18:1055e9. correlation of magnetic resonance imaging, clinical, electrodiagnostic,
[21] Nakamichi K, Tachibana S. The use of ultrasonography in detection of and intraoperative findings. Neurosurgery 1995;37:1097e103.
synovitis in carpal tunnel syndrome. J Hand Surg Br 1993;18:176e9. [39] Mesgarzadeh M, Schneck CD, Bonakdarpour A, et al. Carpal tunnel: MR
[22] Durkan J. A new diagnostic test for carpal tunnel syndrome. J Bone Joint imaging. Part II. Carpal tunnel syndrome. Radiology 1989;171:749e54.
Surg Am 1991;13:535e8. [40] Hui ACF, Wong SM, Wong KS, et al. Oral steroid in the treatment of
[23] El Miedany YM, Youssef SS, Mehanna AN, et al. A new self- carpal tunnel syndrome. Ann Rheum Dis 2001;60:813e4.
administered questionnaire for global assessment of symptoms severity [41] Chang MH, Ger LP, Hsieh PF, et al. A randomized clinical trial of oral
and functional status of patients with carpal tunnel syndrome. Ann steroids in the treatment of carpal tunnel syndrome: a long term follow
Rheum Dis 2006;2(Suppl):259. up. J Neurol Neurosurg Psychiatry 2002;73:710e4.
[24] El Miedany Y, Ashour S, Youssef S, et al. Validation of the modified self- [42] You H. Relationships between clinical scales on severity of symptoms
administered questionnaire for assessment of functional status in patients and electrodiagnostic measures on abnormality of nerve conduction in
with carpal tunnel syndrome. Arthritis Rheum 2006;54:S650. carpal tunnel syndrome. Proceedings of the Human Factors and
[25] Padua L, Padua R, Lo Monaco M, et al. Italian multicentric study of Ergonomics Society 42nd annual meeting. Pennsylvania, PA; 1982, p.
carpal tunnel syndrome: study design. Ital J Neurol Sci 1998;19:285e9. 841e845.