QUICK RECERTIFICATION SERIES
Carpal tunnel syndrome
Sarah J. Garvick, MS, MPAS, PA-C; Suzanne Reich, PA-C, MPAS
GENERAL FEATURES
• Carpal tunnel syndrome is one of the most common
mononeuropathies seen in clinical practice
• Results from entrapment of the median nerve in the
carpal tunnel, an anatomical space formed by the
carpal bones and the transverse carpal ligament of
the wrist
• Swelling of the flexor tendons that also lie in the carpal
tunnel narrows the confined space and crowds the median
nerve
• The median nerve gives sensation to the palmar side of
the thumb, the second and third fingers, and half of the
fourth finger.
• The median nerve also gives motor control to the muscles
that control pinching and grasping between the thumb
and first finger.
HISTORY
• Chief complaints include paresthesias in the thumb and
first two fingers as well as pain in the wrist and forearm
• Many patients have a history of repetitive motion of the
wrist or hand
• Ask patients whether they are unable to perform activi-
ties of daily living (such as buttoning a shirt) and if they
feel clumsy and drop objects
• Numbness may occur only at night, especially if the
patient sleeps with a flexed wrist
• Symptoms may be transient at first, but without treatment
will turn constant and irreversible
• Other contributing factors include pregnancy, adulthood,
genetics, diabetes, and thyroid imbalance
PHYSICAL EXAMINATION
• Findings include decreased sensation along the median
nerve distribution
¡ Positive Tinel test: Reproduction of symptoms by direct
percussion over the median nerve
Sarah J. Garvick is an assistant professor of preclinical education in
the PA program at Wake Forest School of Medicine in Boone, N.C.
Suzanne Reich is an associate professor and associate program
director in the PA program at Wake Forest School of Medicine in
Winston-Salem, N.C. The authors have disclosed no potential conflicts
of interest, financial or otherwise.
Dawn Colomb-Lippa, MHS, PA-C, department editor
DOI:10.1097/01.JAA.0000491136.58273.57
Copyright © 2016 American Academy of Physician Assistants
JAAPA Journal of the American Academy of Physician Assistants
Copyright © 2016 American Academy of Physician Assistants
¡ Positive Phalen test: Reproduction of symptoms (in
less than 60 seconds) with constant forced palmar
flexion of the wrist
• Longstanding carpal tunnel also presents with thenar
atrophy and possible inability to oppose or flex the thumb
• Numbness in the entire hand should raise suspicion for
concomitant ulnar neuropathy or cervical neuropathy
DIAGNOSIS
• Order electrodiagnostic studies for definitive diagnosis,
especially if surgery is considered as a treatment option
• For the most accurate diagnosis, order a nerve conduction
study and electromyography (EMG), which should be
interpreted at the same time
• If the nerve conduction study shows delayed distal laten-
cies and slowed conduction velocities, the patient has
carpal tunnel syndrome. If the study is normal in the
presence of symptoms, suspect a polyneuropathy.
• An EMG that demonstrates impaired median nerve
conduction across the carpal tunnel is also indicative of
carpal tunnel syndrome. False-negative studies can occur
in patients with mild carpal tunnel syndrome. However,
a normal EMG can exclude conditions such as polyneu-
ropathy, plexopathy, and radiculopathy.
• A neuromuscular ultrasound at the wrist can complement
the nerve conduction study and EMG in diagnosing
carpal tunnel syndrome. Along with showing focal
enlargement of the median nerve, ultrasound can show
structural causes of symptoms, such as compressive cysts,
tumors, and vessels.
QUESTIONS
1. Carpal tunnel syndrome results from the entrapment of
which nerve?
a. median nerve
b. superficial ulnar nerve
c. radial nerve
d. deep ulnar nerve
2. Which test indicates carpal tunnel syndrome and is
performed by holding the wrist in constant forced flexion
to reproduce the patient’s symptoms?
a. Tinel test
b. Phalen test
c. carpal tunnel test
d. ulnar nerve compression test
www.JAAPA.com 49
QUICK RECERTIFICATION SERIES
TREATMENT
• Conservative therapy
¡ Activity modification: Changing patterns of hand use
to avoid positions and activities that aggravate the
symptoms may slow or stop progression of the disease
¡ Wearing cock-up wrist splints, especially at night, can
improve symptoms by keeping the wrist in a neutral
position and relieving pressure on the median nerve
¡ Oral corticosteroids at a dose of 20 mg/day for 2 to 4
weeks can significantly reduce symptoms for up to 12
months
¡ Corticosteroid injections into the carpal tunnel can
reduce symptoms for up to 3 months. Associated risks
include exacerbation of median nerve compression,
accidental injection into the median or the ulnar nerves,
and digital flexor tendon rupture.
¡ Nonsteroidal anti-inflammatory drugs have not dem-
onstrated significant long-term reduction of carpal
tunnel syndrome symptoms
• Definitive therapy
¡ Refer patients to an orthopedic provider for surgical
decompression of the median nerve if conservative
therapy fails or if the patient’s history or physical
examination reveals:
50 www.JAAPA.com
Copyright © 2016 American Academy of Physician Assistants
t Duration of symptoms greater than 10 months
t Constant paresthesias
t Positive Phalen sign in less than 30 seconds
t Prolonged motor and sensory latencies demonstrated
by electrodiagnostic testing. JAAPA
flexor retinaculum of the wrist.
performed by directly percussing the median nerve at the
can be used to diagnose carpal tunnel syndrome, it is
under the flexor retinaculum. Although the Tinel test also
a constant forced flexion to compress the median nerve
2. B. The Phalen test is performed by holding the wrist in
not affected in carpal tunnel syndrome.
the thumb and part of the hand. The deep ulnar nerve is
fingers. The radial nerve gives sensation to the dorsum of
sensation to the palmar side of half of the fourth and fifth
carpal tunnel syndrome. The superficial ulnar nerve gives
the fourth finger, which is the affected distribution of
of the thumb, the second and third fingers, and half of
1. A. The median nerve gives sensation to the palm side
Answers
Volume 29 • Number 9 • September 2016