CME

Understanding carpal tunnel syndrome

Jose Omar Garcia, MS; Derek Scott, BS; Parth Parikh, BA; Kara L. Curley, PA-C; Ali Turkmani, MD

ABSTRACT
Carpal tunnel syndrome (CTS) is an entrapment neuropathy
affecting the median nerve. Prevalence is estimated at 4% to
5% of the population. A solid understanding of the anatomy,

© PROSTOCK-STUDIO/SHUTTERSTOCK.COM
presentation, and diagnostics is key to efficient diagnosis and
appropriate referral. Both surgical and nonsurgical interven-
tions have led to improved clinical outcomes. Clinicians who
have an in-depth knowledge of CTS symptoms and treat-
ment options can prepare patients and streamline referrals for
improved patient outcomes.
Keywords: carpal tunnel syndrome, peripheral neuropathy,
median nerve, entrapment, wrist pathophysiology, carpal
tunnel release surgery

domains and have physical and economic consequences,

Learning objectives
such as absence from work, decreased neurologic function,
Describe the anatomy and pathophysiology of CTS. and high healthcare costs.3 This article describes the anat-
Review risk factors, clinical features, and examination omy and pathophysiology of CTS and its treatment options
findings that increase clinical suspicion for CTS. so clinicians can better prepare patients and streamline
Describe diagnostic imaging options for optimal workup referrals for improved outcomes.
and diagnosis.
Describe conservative and surgical treatments. ANATOMY
The carpal tunnel is a narrow space located on the palmar
surface that allows the passage of various structures such

C
arpal tunnel syndrome (CTS) is the most common as the median nerve and various flexor tendons (Figures 1
entrapment neuropathy, defined as nerve damage and 2). The borders of this tunnel include the flexor reti-
(specifically the median nerve) at narrow passage naculum (roof), carpal bones (base), the hook of the hamate,
sites.1-3 The first case reports of compression of the median pyramidal bone, pisiform bone (ulnar edge), scaphoid and
nerve were published by Paget in 1854.4 Studies by Phalen trapezoid bones, as well as the tendon of the flexor carpi
in the 1950s became the foundational principles for under- radialis (FCR) muscle forming the radial edge.11 The tendons
standing CTS.5 The condition tends to affect patients ages passing through the carpal tunnel are the four flexor digi-
40 to 60 years; prevalence is estimated between 4% and torum superficialis, the four flexor digitorum profundus,
5% of the population.6 Various studies have shown that and the flexor pollicis longus.
CTS is more common in women than men (2.2 to 5.4 The median nerve enters the hand through the carpal
women to 1.1 to 3 men per 1,000 people).7-10 Short- and tunnel and divides into six branches (Table 1). Of these,
long-term effects of these neuropathies span various the recurrent branch supplies the muscles of the thumb,
which predominantly help with opposition, including the
abductor pollicis brevis, opponens pollicis, and the super-
At the Mayo Clinic Arizona, Jose Omar Garcia, Derek Scott, and Parth
Parikh are students in the School of Medicine; Kara L. Curley prac- ficial portion of the flexor pollicis brevis.
tices in neurosurgery, is an assistant professor of neurologic surgery, The proper palmar digital nerves compose the next
and is program director of the neurosurgery PA fellowship; and Ali three branches. These are cutaneous digital branches that
Turkmani is an assistant professor. The authors have disclosed no innervate both the radial and ulnar sides of the thumb. The
potential conflicts of interest, financial or otherwise. final branch innervates the radial side of the index finger
DOI:10.1097/01.JAA.0000892708.87945.f6 along with motor innervation to the first lumbrical. The
Copyright © 2022 American Academy of PAs final two branches, the common palmar digital branches,

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 CME

A
Key points
CTS is an entrapment neuropathy characterized by
physiologic changes in the median nerve that result
from the application of external force, compressing the
nerve in the tunnel.
The mainstay of treatment involves a combination of
medications and surgical release.
Prompt recognition of symptoms and addressing
appropriate risk factors can significantly help a patient’s
quality of life.

supply innervation to the cleft between the index and B

middle finger and the cleft between the middle and ring
fingers with motor innervation to the second lumbrical.
Overall, the median nerve supplies cutaneous innervation
to the palmar side of the thumb, index, middle finger, and
the radial side of the ring finger with motor innervation to
muscles of the thenar eminence and first/second lumbricals.
A number of publications have shown variations in sensory
innervation with anastomoses of the ulnar nerve on the
palmar and dorsal surfaces.12 In addition, the Martin and
Grüber anastomosis has been documented in the forearm,
while the Riche-Cannieu anastomosis is in the hand.13

PATHOPHYSIOLOGY
C
CTS is an example of entrapment neuropathy characterized
by physiologic changes in the nerve that result from the
application of external force. These various forms include
• chronic low force application (such as typing on a key-
board for work or routinely playing a musical instrument)
• acute focal application of a large force, such as in Satur-
day night palsy, a compressive neuropathy of the radial
nerve from direct prolonged pressure on the upper medial
arm or axilla14
• repetitive application of brief larger forces (occupational
such as using a chain-saw continuously as a forestry worker,
or drilling as a stone quarry laborer).
The neuropathy also may be due to a combination of FIGURE 1. Anatomy of the wrist: Bony (A), deep (B), and arterial (C)
stretching or shearing of the nerve, leading to physiologic Illustration used with permission of the Mayo Foundation for Medical Education and
Research. All rights reserved.
change. The physiologic adaptation of the nerve to these
forces results in conduction changes of the nerve, including
slowing or complete blockage of conduction. In addition, Lundborg theory This proposed classification is based
the external forces may result in the production of ectopic on insults to the intraneural blood microcirculation, myelin
impulses that could manifest as fasciculations of the mus- sheath, axons, and supporting connective tissue.16 The
cle or paresthesias.15 early stage is characterized by intermittent symptoms
In patients with CTS, median nerve compression occurs occurring at night caused by various factors that increase
at two sites: at the most proximal portion of the carpal pressure in the carpal tunnel. One of these factors is the
tunnel where flexion and thickening of the overlying fascia tendency to flex the wrist at night, increasing pressure on
can impinge on the nerve, and at the area where the diam- the nerve. The other causes revolve around the idea that
eter of the tunnel becomes most narrow at the area of the an increase of fluid or edema in the upper limb can lead
hamate hook. Three theories about the pathophysiology to increased intraneural and endoneural pressure that
of CTS—Lundborg, double crush, and dynamic—are impairs the signal transduction of the nerves. These factors
discussed below. include a redistribution of upper limb fluid when the patient

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 Understanding carpal tunnel syndrome

FIGURE 2. Transverse cut revealing anatomy of the wrist

Illustration used with permission of the Mayo Foundation for Medical Education and Research. All rights reserved.

is supine at night, mechanical deficiencies of muscle pumps, anism of this stage is axonotmesis (a complete interruption
and an increase in arterial pressure that interferes with the of axons resulting in loss of conduction in the nerve fiber
venous return of the intraneural microcirculation, leading beyond the injury). Release of the nerve leads to variable
to metabolic effects that upset the homeostatic balance of rates of recovery that depend on proper nerve regeneration.
the nerve and its conductive capabilities. This stage is Various factors influence successful rates of regeneration
associated with intermittent symptoms due to the revers- and include age, history of polyneuropathy, and compres-
ibility of the improper drainage by repositioning of the sion severity.11
wrist and fingers. Double crush theory Upton and McComas postulated
The intermediate stage is defined by symptoms occurring that proximal compression of a nerve interrupts the axo-
both nocturnally and diurnally. The underlying mechanism plasmic transportation in anterograde and retrograde
causing these symptoms to persist is epineural and intra- fashions.17 This increases the susceptibility of symptomatic
fascicular interstitial edema, which generates a thickening neuropathy distally in the nerve due to disruption of this
of the epineurium’s connective envelope. In addition, the transport system. Various researchers later supported this
myelin sheath and nodes of Ranvier are damaged, causing theory by reporting patients who had an association of
problems with saltatory conduction of the nerve. Relief of CTS with various proximal compression syndromes such
compression leads to rapid amelioration of symptoms due as cervical radiculopathy and brachial plexus compression.
to reinstitution of the microcirculation. Intermittent symp- Understanding this mechanism can help clinicians identify
toms and electrophysiologic abnormalities may linger from the main compression site and tailor treatment to the cause
weeks to months after the resolution of the compression of the injury. When evaluating a patient’s symptoms, con-
because of the active repair of the myelin sheath. sider a differential diagnosis that involves alternative
The final or advanced stage is characterized by a persis- cervical spine or brachial plexus compression sites that
tence of sensory and motor deficits. The underlying mech- could lead to CTS symptoms.

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TABLE 1. Median nerve and what it innervates11-13

Branch of the median nerve Muscle Function
Forearm
Muscular branch Pronator teres, palmaris longus, flexor Pronation of the forearm, flexion of the wrist and small
digitorum superficialis, flexor carpi radialis joints of the hand, flexion of the medial four digits at the
proximal interphalangeal joints, some abduction of the
hand and wrist
Anterior interosseous nerve Flexor pollicus longus, radial portion of flexor Flexion of distal phalanx of thumb at interphalangeal
digitorum profundus, pronator quadratus joint, flexion of MCP and DIP of medial four digits,
pronation of radioulnar joint
Hand
Palmar cutaneous nerve Cutaneous sensation to the palm, outside of the carpal
tunnel
Palmar digital nerves Radial two lumbricals MCP joint flexion and extension of the interphalangeal
joints (PIP and DIP), cutaneous sensation
Recurrent branch Muscles of the thenar eminence–flexor Flexion, abduction, and opposition of the thumb
pollicis brevis, abductor pollicis brevis,
opponens pollicis

Dynamic A variant of CTS known as dynamic CTS occurs factors leads to a transient CTS that occurs in the presence
in patients who have no symptoms or physical examination of an increased workload.
findings during rest, but symptoms are exacerbated by
increased workload of the hands. Increased pressure inside RISK FACTORS
the carpal tunnel has been associated with repetitive motions Environmental or workplace risk factors include sustained
such as wrist extension, flexion, supination of the forearm, wrist or palm pressure, repetitive hand and wrist use,
and flexion of the fingers.18 In particular, occupations such prolonged wrist extension and flexion, and working with
as rock drilling, forestry work, repetitive assembly work, tools that vibrate. Repetitive use thickens the overlying
manufacturing, and food packing lead to increased pres- fascia and causes tendon and muscle hypertrophy that
sure inside the tunnel. These motions increase pressure and leads to median nerve compression.20-22
lead to a possible incursion of muscle bodies of both Another category of risk factors for CTS is coexisting
superficial and deep flexors.19 The combination of these conditions such as obesity, pregnancy, renal failure, hypo-
thyroidism, oral contraceptive use, menopause, and heart
failure that potentially alter the body’s fluid balance, lead-
ing to the increasing pressure on the nerve.23 In addition,
FIGURE 3. Typical symptom mapping for carpal tunnel syndrome tumors or tumorlike lesions can compress the median nerve
Illustration used with permission of the Mayo Foundation for Medical Education and
Research. All rights reserved. as can fractures of the bones near the median nerve.
A subset of factors such as diabetes, alcohol use, vitamin
excess and/or deficiencies, and exposure to toxins can have
neuropathic effects on the median nerve, predisposing patients
suffering from these conditions to potential CTS symptoms
in the future.23 For example, patients with diabetes have a
higher propensity to suffer from CTS symptoms because of
the nerve damage associated with diabetes. Some studies
also have mentioned the presence of carpal tunnel symptoms
to be initial presentations of inflammatory connective tissue
disorders, most commonly rheumatoid arthritis.24

CLINICAL FEATURES
The predominant clinical feature of CTS is pain and par-
esthesias in distributions of the median nerve (Figure 3).
These paresthesias can occur at any time but worsen at
night. As the severity of CTS increases, the paresthesias
and pain occur more frequently and last longer.25 In patients

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 Understanding carpal tunnel syndrome

TABLE 2. Provocative tests for CTS65-67

Test Technique and results Sensitivity Specificity
Tinel sign Percuss above the region of the carpal tunnel on the palmar surface of 26% to 79% 40% to 100%
the wrist. The test is positive if percussion of this region results in
paresthesia.
Phalen sign Have the patient maximally flex the palms at the wrist with the elbow 67% to 83% 47% to 100%
extended. The test is positive if it elicits paresthesias in the region of the
median nerve.
Paley/McMurphy test Apply manual pressure close to the median nerve about 1 to 2 cm 89% 45%
proximal to the wrist flexion crease. The test is positive if pressure
causes pain or paresthesia.

with severe CTS, the thenar muscles and other muscles Visualization of the median nerve on ultrasound is best
innervated by the motor branch of the median nerve are done from the site of the proximal carpal tunnel or at the
weakened, causing difficulties with daily activities such as level of the distal radius or pisiform, where maximum
opening a door and holding objects. This typically presents edema of the nerve is known to occur. The area of the
as thenar atrophy, which can readily be visually noted on median nerve in the proximal carpal tunnel, if an elliptical
clinical examination. Sensory symptoms of CTS usually shape is captured, should be at most 10 mm.29
are limited to the median nerve distribution in the hand T2-weighted MRI will show edema of the median nerve
(the first three digits and the radial half of the fourth digit). with increased signal intensity resulting from edema, myelin
At times, the sensory deficit may be variable and include sheath degeneration, or accumulation of axonal transpor-
the wrist, forearm, upper arm, and shoulder. Evidence has tation that are key indicators to watch for in the diagnosis
shown that the localization of symptoms to the first three of CTS.30-32 Sagittal MRI also allows accurate determina-
digits may be associated with more severe involvement of tion of the severity of median nerve compression at a
the median nerve; thoroughly consider symptom distribu- sensitivity of 96%; unfortunately, specificity is 33% to
tion when evaluating treatment modalities and prognosis.26 38%.29 In addition, the median-ulnar sensory latency dif-
Provocative tests for CTS are described in Table 2. ference and abnormal nerve signal found on the T2-weighted
images are useful predictors of a positive surgical outcome.33
DIAGNOSTIC TESTS AND IMAGING The results and perceived severity based on the MRI
In addition to provocative tests, diagnosis of CTS also scans do not correlate with the patients’ perceived severity
relies on electromyography/nerve conduction studies (EMG/ of CTS symptoms.33 Although the MRI shows detailed
NCS). NCS aims to confirm damage to the median nerve, anatomy, it does not provide information on impairment
quantify the severity of injury by measuring conduction in the function of the median nerve.
velocity across the nerve, and define the underlying patho-
physiology (conduction block versus demyelination versus NONSURGICAL TREATMENTS
axonal degeneration). This is done by comparing latencies All first-line treatment options should include direct patient
and conduction velocities of the median nerve across the education on the underlying pathophysiology of CTS.34 Teach
carpal tunnel segment with other nerve segments, such as patients about activity modification such as wrist bracing
the radial or ulnar nerve. A decrease in sensory conduction and reduced heavy lifting, and the use of specifically designed
velocity suggests possible nerve pathology caused by focal tools. Although these may reduce stress on the median nerve,
demyelination. A transtunnel velocity of less than 45 m/s evidence that this approach resolves CTS is limited.34 Phar-
suggests a pathologic state (a normal value is greater than macotherapy including diuretics, nonsteroidal anti-inflam-
50 m/s).27 EMG is not necessary for the diagnosis of CTS matory drugs (NSAIDs), pyridoxine (vitamin B6), and orally
in patients who have classic symptoms and a confirmatory administered corticosteroids with varying dosages per pref-
NCS. However, EMG is useful to assess severity in patients erence of the clinical provider have been used.
who may undergo surgical decompression as an option. Another nonsurgical option, low-power laser therapy,
The electrophysiologic classification of CTS in agreement exposes the transverse carpal ligament to low levels of red
with American Association of Electrodiagnostic Medicine near-infrared light.35 In the short term, laser therapy can
(AAEM) guidelines range from a negative CTS class (nor- improve function, symptoms, and conduction measures.36
mal finding on all tests) to an extreme CTS class, which Laser treatment was shown in a randomized controlled
indicates an absence of thenar motor response.28 trial to be more effective than placebo, with the greatest
Following the use of NCS, ultrasound and MRI are the evidence in patients with mild to moderate CTS.36 Another
best imaging studies to visualize the median nerve and any study compared high-intensity laser therapy with transcu-
evidence of pathology as it passes through the carpal tunnel. taneous electrical nerve stimulation (TENS).37 In this study,

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ing the effectiveness of gabapentin compared with placebo

did not show any significant improvement in reducing
paresthesias, weakness, clumsiness, pain, or nocturnal
awakenings.43
Researchers also have investigated the use of ultrasound
to mitigate the advancement of CTS and reduce inflam-
mation. Various studies have found no conclusive evidence
that ultrasound waves directed to the area of entrapment
are more effective than placebo or other nonsurgical treat-
ments for CTS.44-46

SURGICAL TREATMENT
Surgical treatment for CTS involves the release of the
contents of the carpal tunnel by transecting the transverse
carpal ligament (Figure 4). This is considered the most
effective treatment. Decompression surgery can be per-
formed by endoscopic techniques, minimally invasive short
wrist incision, or by a traditional open technique (longi-
tudinal wrist incision with direct visualization of the
transverse carpal ligament). Studies have not demonstrated
a significant difference when examining long-term func-
tional outcomes between these techniques.47-52 However,
even as both return function to a similar extent, studies
have shown that a minimally invasive approach results in
better outcomes, including fewer complications, symptom
improvement, patient satisfaction, and improvement in
FIGURE 4. Landmarks for surgical approach: superficial (A) and
deep anatomy (B). Dotted line demarcates the border of the hand. various other assessment modality results.53,54 The endo-
Illustration used with permission of the Mayo Foundation for Medical Education and Re- scopic technique shows reduced scar tenderness, shorter
search. All rights reserved.
postoperative recovery period, and earlier return to work
compared with the standard open approach.51 Although
laser therapy, rather than TENS, showed greater improve- endoscopic release does show some advantages in the length
ment in the areas of pain, paresthesia, median nerve con- of recovery, its drawbacks include cost and increased rates
duction velocity, and distal motor latency.37 of temporary nerve damage.48
Local injections of corticosteroids are commonly used Between 1% and 25% of patients have postoperative
to reduce edema in the carpal tunnel. In a randomized trial, complications.55 Of patients with complications, about
111 patients received an 80- or 40-mg methylprednisolone 0.5%, primarily those undergoing open-approach surgery,
injection into the carpal tunnel, which proved more effec- have damage to important structures such as nerves, arter-
tive than placebo in reducing symptom severity and rate ies, and tendons.56 Postoperative complications include
of subsequent surgery at the 1-year mark.38 Although the incision site tenderness, tenderness near the site of ligament
study showed effectiveness in mitigating CTS symptom release, transient loss of motor or sensory function, and
progression, 75% of the patients enrolled in the study had need for a repeat operation. One study that looked at endo-
surgery within 1 year.38 scopic carpal tunnel release in 34 hands and open technique
Another study showed that compared with the distal in 21 hands found that 32 patients required reexploration
(palmar) approach, proximal (wrist) needle insertion for and were found to have incomplete release, and five patients
corticosteroid injection produced more pain based on the required a third operation.57 Complex regional pain syn-
measurements from patients on a visual analog scale.39 No drome (CRPS) is a potentially severe complication that
difference was found between the two approaches, however, results in extreme pain, swelling, and autonomic dysfunction
on objective measures such as NCS.39 Using ultrasound- consisting of sweating and flushing in the affected limb,
guided corticosteroid injections provides improved accuracy although the incidence after CTS surgery (2.1% to 5%) is
compared with blind administration and also can reduce lower than other hand surgeries. Nevertheless, this is asso-
the time necessary for complete symptom resolution.40,41 ciated with detrimental effects on the patient’s quality of
Studies have investigated the potential of using NSAIDs life, so clinicians must recognize this complication early.58,59
to treat CTS.34,42 A study of 240 patients found that NSAIDs Although postoperative rehabilitation interventions, such
were prescribed to 38.8% of patients and alleviated symp- as wrist orthoses, dressings, exercise, and ice therapy, have
toms in 74%.42 Another randomized controlled trial assess- anecdotally helped patients, one study showed that these

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 Understanding carpal tunnel syndrome

interventions have limited and low-quality evidence for 8. Gelfman R, Melton LJ 3rd, Yawn BP, et al. Long-term trends in
carpal tunnel syndrome. Neurology. 2009;72(1):33-41.
their benefit; more high-quality trials have recommended
9. Pourmemari M-H, Heliövaara M, Viikari-Juntura E, Shiri R.
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the clinician’s expertise and patient preferences. Minimal risk factors. Muscle Nerve. 2018;58(4):497-502.
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21. Martin S. Carpal tunnel syndrome: a job-related risk. Am
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reviewing the post-test, then taking the online test at http://cme.aapa.org. 22. Nathan PA, Meadows KD, Doyle LS. Occupation as a risk
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clinical Category I (Preapproved) CME credit by the AAPA. The term of
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