Carpal Tunnel Syndrome: A Quick Guide

Carpal tunnel syndrome (CTS) is a common entrapment neuropathy that many of us see in practice. While it might seem straightforward at first glance, its diagnosis and management require careful consideration to avoid missing mimics and to ensure patients get the most appropriate treatment. Let’s walk through the essentials—from differentials to management options.

Differential Diagnoses

When faced with a patient presenting with hand numbness, tingling, or pain, keep an open mind. Consider:

• Cervical radiculopathy: Especially if symptoms extend proximally.
• Pronator teres syndrome: Can mimic CTS, with forearm discomfort.
• Thoracic outlet syndrome: When upper limb vascular or neurological signs are present.
• De Quervain’s tenosynovitis: Particularly in patients with wrist pain near the radial styloid.
• Diabetic or peripheral neuropathies: Always consider metabolic causes.
• Rheumatoid arthritis: Can involve nerve compression due to joint inflammation.

These conditions share overlapping features but require distinct management approaches, so a detailed history and exam are key.

Carpal Tunnel Syndrome

CTS occurs when the median nerve is compressed within the carpal tunnel—a narrow passage bordered by carpal bones and the transverse carpal ligament. This compression leads to:

• Sensory symptoms: Numbness, tingling, and pain (often worse at night).
• Motor involvement: In more advanced cases, weakness in the thenar muscles can lead to clumsiness or reduced grip strength.
• Etiological factors: Overuse, repetitive wrist activities, pregnancy, obesity, and systemic conditions like diabetes.

Understanding the anatomy helps clarify why patients may experience nocturnal symptoms and why provocative tests can be so revealing.

Key Considerations for Subjective Assessment

When taking a history, pay attention to:

• Symptom chronology: Duration (acute vs. chronic), frequency, and progression.
• Pain characteristics: The presence of nocturnal pain or “pins and needles.”
• Functional impact: How symptoms affect daily activities and work.
• Risk factors: A history of repetitive wrist movements, systemic illnesses (e.g. diabetes, rheumatoid arthritis), previous wrist injuries, or pregnancy.
• Patient’s own perspective: Understanding how symptoms influence quality of life can help tailor management and set realistic expectations.

A comprehensive subjective assessment helps distinguish CTS from other neuropathies and directs further investigation.

Key Considerations for Objective Assessment

Your physical exam should include:

• Provocative tests:
  • Phalen’s test: Wrist flexion to reproduce symptoms.
  • Tinel’s sign: Tapping over the median nerve to elicit tingling.

• Sensory examination: Check for deficits in the median nerve distribution.
• Motor evaluation: Assess thenar muscle strength and bulk.
• Additional assessments: Consider nerve conduction studies (NCS) and electromyography (EMG) if clinical findings are equivocal or to assess severity.

These objective tests not only support your diagnosis but also help in monitoring progression and guiding treatment choices.

Management Options

When it comes to managing CTS, the approach can be multimodal:

Conservative Management

• Do Nothing/Activity Modification:
  • Pros: Minimal risk; some patients may experience spontaneous improvement.
  • Cons: Risk of progression if irritative activities continue.
• Hand Exercises and Splints:
  • Pros: Non-invasive, low cost, and can yield improvement in as little as 4 weeks. Splints (especially overnight) help by keeping the wrist neutral.
  • Cons: Requires patient adherence; benefit may be limited in more severe cases.

• NSAIDs/Painkillers:
  • Pros: Provide short-term symptomatic relief.
  • Cons: Long-term use carries risks (e.g. gastrointestinal, renal, cardiovascular side effects).
• Corticosteroid Injections:
  • Pros: Can reduce local inflammation and offer relief within 2 weeks.
  • Cons: Potential risks include injection-site pain, temporary skin depigmentation, and a small risk of nerve damage. Repeat injections may be necessary. See our post on corticosteroid injections for more information on the risks

Surgical Management

• Carpal Tunnel Release Surgery:
  • Pros: Often leads to rapid symptom improvement, especially in severe or prolonged cases; minimal hospital stay and a high rate of patient satisfaction.
  • Cons: Recovery can take several weeks to months; potential complications include wound issues, infection, or persistent symptoms if performed too late. The decision to operate is influenced by the severity of nerve damage and functional impairment.

Key Takeaways for Primary Care

• Early Recognition Is Crucial:
  Evaluate patients with wrist pain or numbness promptly, and be mindful of the risk factors and differential diagnoses.
• Stepwise Management:
  Start with conservative measures—activity modification, splinting, and exercises—before considering more invasive options like steroid injections or surgery.
• Patient-Centered Approach:
  Involve patients in decision making. Discuss the pros and cons of each treatment, set realistic expectations, and ensure follow-up if symptoms persist or worsen.
• Referral for Specialist Assessment:
  If symptoms are severe, long-standing, or if there is evidence of nerve damage, early referral for electrophysiological studies or surgical consultation is recommended.

By integrating a thorough subjective and objective evaluation with a personalized management strategy, primary care clinicians can effectively support patients with CTS and help steer them toward optimal outcomes.

This guide is intended to serve as a quick reference for busy clinicians navigating the complexities of carpal tunnel syndrome. For further details, review the comprehensive resources available on the NICE CKS website and the NHS decision aid. Happy diagnosing!