3/10/22, 9:24 AM Carpal tunnel syndrome: Clinical manifestations and diagnosis - UpToDate

Author: Milind J Kothari, DO

Section Editor: Jeremy M Shefner, MD, PhD
Deputy Editor: Richard P Goddeau, Jr, DO, FAHA

Contributor Disclosures

All topics are updated as new evidence becomes available and our peer review process is complete.

Literature review current through: Feb 2022. | This topic last updated: Jan 07, 2022.

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INTRODUCTION

Carpal tunnel syndrome (CTS) refers to the complex of symptoms and signs brought on by
compression of the median nerve as it travels through the carpal tunnel. Patients commonly
experience pain and paresthesia, and less commonly weakness, in the median nerve distribution. CTS
is the most frequent compressive focal mononeuropathy seen in clinical practice.

This topic will review the clinical manifestations and diagnosis of CTS. Other aspects of CTS are
discussed separately.

● (See "Carpal tunnel syndrome: Pathophysiology and risk factors".)

● (See "Carpal tunnel syndrome: Treatment and prognosis".)
● (See "Surgery for carpal tunnel syndrome".)

EPIDEMIOLOGY

CTS is a common disorder. The estimated prevalence of CTS in the general population is between 1
and 5 percent. CTS is more frequent in females, with a female-to-male ratio of approximately 3 to 1.
The epidemiology of CTS is discussed in additional detail separately. (See "Carpal tunnel syndrome:
Pathophysiology and risk factors", section on 'Epidemiology'.)

CLINICAL FEATURES

The hallmark of classic CTS is pain or paresthesia (numbness and tingling) in a distribution that
includes the median nerve territory, with involvement of the first three digits and the lateral half of the
fourth digit ( figure 1).

● Signs and symptoms – Although the sensory symptoms of CTS are usually limited to the median-
innervated fingers, there can be significant variability. The pain and paresthesia may be localized
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to the wrist or it may involve the entire hand. It is not uncommon for sensory symptoms to
radiate proximally into the forearm and, less frequently, to radiate above the elbow to the
shoulder, but the neck is not affected [1].

In more severe cases of CTS, motor involvement leads to complaints of weakness or clumsiness
when using the hands, such as difficulty holding objects, turning keys or doorknobs, buttoning
clothing, or opening jar lids [1]. Clinical signs may include weakness of thumb abduction and
opposition and atrophy of the thenar eminence.

Bilateral CTS is common, reported as affecting up to 65 percent of patients [2], though clinical
experience suggests that a unilateral initial presentation of CTS is encountered more frequently.
In some cases, involvement is subclinical on one side and symptomatic on the other.

● Physical maneuvers – CTS symptoms are often provoked by activities that involve sustained
flexing or extending the wrist or raising the arms, such as driving, reading, typing, and holding a
telephone [1,3].

Some patients report temporary improvement in symptoms by shaking or wringing their hands
or by placing them under warm running water [1].

● Clinical course – The symptoms of CTS may be noted initially at night and the pain or
paresthesias may awaken patients from sleep. As they progress, symptoms may also be noted
during waking hours, especially during activities that require sustained arm positions or
repetitive movements. In some cases, there is progression from intermittent to persistent
sensory complaints and from paresthesias to sensory loss in the hand. Fixed sensory loss is
usually a late finding characterized by a distinctive clinical pattern that involves the median-
innervated fingers and spares the thenar eminence. This pattern occurs because the palmar
sensory cutaneous nerve arises proximal to the wrist and passes over, rather than through, the
carpal tunnel. (See "Carpal tunnel syndrome: Pathophysiology and risk factors", section on
'Anatomy'.)

Motor symptoms, including weakness, typically develop late and in patients with a more severe
course. However, some patients with acute CTS, such as those with symptoms due to a bone
fracture or other trauma, may report early weakness due to axonal injury.

For patients with mild symptoms, the clinical course of CTS may follow an alternating pattern
with periods of remission and exacerbation [4]. (See "Carpal tunnel syndrome: Treatment and
prognosis", section on 'Prognosis'.)

DIAGNOSIS AND EVALUATION

CTS should be suspected in patients with symptoms such as pain or paresthesia in the hand or
examination findings of sensory loss or weakness in the distribution of the median nerve ( figure 1)
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[3]. (See 'Clinical features' above.)

The diagnosis of CTS is clinical for patients with characteristic symptoms and signs. Electrodiagnostic
and other diagnostic testing can be helpful to confirm or exclude CTS when the clinical diagnosis is
uncertain [5]. Diagnostic testing is also useful for patients with moderate or severe symptoms (
table 1) to gauge the severity of nerve compression and to aid in decisions regarding surgical
intervention ( algorithm 1). Stable patients with symptoms that are mild and classic for CTS may be
followed clinically because up to two-thirds improve with nonsurgical treatment [6]. (See
'Electrodiagnostic testing' below and "Carpal tunnel syndrome: Treatment and prognosis", section on
'Nonsurgical treatment options'.)

The combination of characteristic symptoms and signs and confirmatory electrodiagnostic testing
appears to be most accurate for the diagnosis of CTS [7,8].

Clinical diagnosis — The likelihood of an accurate clinical diagnosis of CTS corresponds with the
number of characteristic symptoms and provocative or mitigating factors listed as criteria for the
diagnosis of CTS [3]. These include:

● Characteristic symptoms

• Dull, aching discomfort in the hand, forearm, or upper arm

• Paresthesia in the hand
• Weakness or clumsiness of the hand
• Occurrence of any of these symptoms in the median distribution

● Provocative factors

• Sleep
• Sustained hand or arm positions
• Repetitive actions of the hand or wrist

● Mitigating factors

• Changes in hand posture

• Shaking the hand

For patients with additional features suggestive of an alternative diagnosis and those with moderate
to severe symptoms including sensory loss or weakness, we obtain additional diagnostic testing. (See
'Differential diagnosis' below and 'Diagnostic testing for patients with moderate to severe or atypical
symptoms' below.)

Examination — Objective sensory and motor deficits corresponding to the median nerve–innervated

regions of the hand may be present, but their absence does not rule out the diagnosis of CTS.

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● Sensation should be tested in all regions of both hands, forearms, and upper arms ( figure 2).
Objective sensory deficits on testing usually occur late in the course of CTS; they involve the
median-innervated fingers but spare the thenar eminence [3]. This is a critical finding, as sensory
loss over the thenar eminence suggests a median nerve lesion proximal to the carpal tunnel. (See
"Carpal tunnel syndrome: Pathophysiology and risk factors", section on 'Anatomy'.)

● Objective weakness can occur in severe or advanced CTS and is typically limited to muscles of the
thenar eminence [3]. This manifests principally as weakness of thumb abduction and thumb
opposition. Atrophy of the thenar eminence may be present. Weakness in other hand muscles
may suggest a median or other nerve lesion proximal to the carpal tunnel.

Provocative maneuvers — Bedside tests performed as part of a clinical examination to elicit

symptoms of CTS may improve the diagnostic yield of a clinical evaluation. Provocative maneuvers
include the Phalen, Tinel, manual carpal compression, and hand elevation tests. These can be helpful
when interpreted in the proper clinical context. However, the sensitivity and specificity of these
provocative tests in isolation is moderate at best [9,10].

● The Phalen maneuver is performed by having the patient bring the dorsal surfaces of the hands
against each other to provide hyperflexion of the wrist while the elbows remain flexed (
picture 1). Alternatively, the patient fully may flex the hands at the wrist with the elbow in full
extension to provide traction on the median nerve. The flexed position is held for one minute. A
positive Phalen sign is defined as pain and/or paresthesia in the median-innervated fingers.
Meta-analyses have shown an average sensitivity of 68 percent and specificity of 73 percent for a
positive Phalen test [10]. One prospective study found that Phalen test correlated with CTS
severity [11].

● The Tinel test ( picture 2) involves firm percussion performed over the course of the median
nerve just proximal to or on top of the carpal tunnel. A positive Tinel test is defined as pain
and/or paresthesia of the median-innervated fingers that occurs with percussion over the
median nerve. A positive Tinel sign may be less sensitive (50 percent) than the Phalen sign but
has similar specificity (77 percent) [10].

● The manual carpal compression test is performed by applying pressure over the transverse
carpal ligament for 30 seconds ( picture 3). Pain or paresthesia indicates a positive result. The
average sensitivity and specificity of the manual carpal compression test are 64 and 83 percent,
respectively [10].

● The hand elevation test involves having the patient raise the hands above the head for one
minute [12]. The test is positive if it reproduces the symptoms of CTS. The sensitivity and
specificity may be similar to or slightly better than those reported for Tinel test and Phalen
maneuvers, but few reports have compared these tests directly [12,13].

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Diagnostic testing for patients with moderate to severe or atypical symptoms — We perform
electrodiagnostic testing for CTS for all patients with atypical symptoms to confirm the diagnosis and
for patients with symptoms that are moderate to severe ( table 1) or that progress despite
conservative treatment to aid in decisions regarding surgical intervention ( algorithm 1).

Imaging of the median nerve with ultrasound or magnetic resonance imaging (MRI) is typically
reserved for patients with suspected mass lesions or those with atypical symptoms not explained by
electrodiagnostic testing.

Electrodiagnostic testing — Electrodiagnostic testing with nerve conduction studies (NCS), often

supplemented with needle electromyography (EMG), has a high sensitivity and specificity for
confirming the diagnosis of CTS and for excluding other conditions in the differential diagnosis [5,14].
Electrodiagnostic testing is also useful for gauging the severity of median nerve injury because the
extent of clinical symptoms may not always correlate with the severity of the injury to the median
nerve.

The diagnosis of CTS may be confirmed by results from the NCS. Needle EMG is also performed to
identify the integrity of motor units to help select patients for surgical treatment whenever symptoms
or NCS findings are moderate to severe ( table 1) [15-22]. As examples, EMG can provide objective
evidence of persisting neuronal integrity in some severe cases when sensory and motor responses are
absent on NCS; similarly, in some cases where NCS abnormalities are modest, EMG can show evidence
of more severe active denervation.

In addition, EMG is warranted in patients with atypical symptoms to exclude other conditions such as
polyneuropathy, plexopathy, and radiculopathy [15]. (See "Carpal tunnel syndrome: Treatment and
prognosis", section on 'Surgical decompression' and 'Differential diagnosis' below.)

Nerve conduction studies — The electrodiagnosis of CTS is made by the demonstration of

impaired median nerve conduction across the carpal tunnel in the context of normal conduction
elsewhere [1,23].

The NCS evaluation for CTS involves measurement of conduction velocity across the carpal tunnel as
well as determination of the amplitude of sensory and motor responses to determine the severity of
injury to the median nerve.

● Impaired nerve conduction – Nerve compression results in damage to the myelin sheath and
manifests as delayed distal latencies and slowed conduction velocities. Mild CTS may not produce
any nerve conduction abnormalities. With increased compression of the median nerve, focal
demyelination can occur. This may result in local conduction block and/or slowing of motor and
sensory conduction across the wrist.

● Axon loss – With sustained or more severe compression, axon loss may also occur, resulting in a
reduction of the median nerve compound motor or sensory nerve action potential amplitude.

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Sensory fibers seem to be more sensitive to compression than motor fibers. As a result, sensory
fibers typically demonstrate changes on NCS earlier than do motor fibers.

Specific components of NCS to evaluate CTS include:

● Sensory conduction studies involve stimulating branches of the median nerve at the wrist and
recording sensory response from digit two or three, depending on clinical symptoms. Results are
compared with sensory responses of other nerves including the ulnar (stimulating the wrist and
recording at digit five) and radial (stimulating at the lateral radius and recording at the snuffbox)
[1].

● Motor conduction studies most often record from the abductor pollicis brevis muscle, although
other muscles can also provide diagnostic information. Results obtained are compared with age-
dependent normal values as well as with other nerves of the same hand or the contralateral
hand. Comparative motor testing typically includes the ulnar nerve (recording from the abductor
digiti minimi while stimulating at the wrist and at the elbow above and below the ulnar groove)
[1].

● Additional comparison studies should be used for patients who have normal routine NCS in the
setting of clinical findings suggestive of CTS [1]. These may include testing the second lumbrical
(median) versus interossei (ulnar) distal motor latencies, evaluating sensory latencies at digit four
by stimulating the median and ulnar nerves at the wrist individually at identical distances, and
comparing palm-to-wrist peak latencies of median and ulnar nerves, each recorded 8 cm from
the stimulating electrodes.

In a 2002 systematic review of prospective studies, the sensitivity of various NCS for CTS ranged from
56 to 85 percent, and the specificity ranged from 94 to 99 percent [5,14]. In a later study of 99 patients
without confounding neurologic disorders who met clinical criteria for CTS, NCS (including median and
ulnar palmar mixed-nerve studies) were normal in 25 percent [24].

Anomalous innervations may result in atypical findings during electrodiagnostic testing. One of the
most frequently encountered variations during evaluation of CTS is a median-to-ulnar anastomosis.
The Martin–Gruber anastomosis describes a subgroup of motor fibers that split from the median
nerve in the forearm and join the ulnar nerve to innervate the intrinsic muscles of the hand. The
Riche–Cannieu anastomosis describes a connection between the recurrent branch of the median nerve
in the hand and the deep branch of the ulnar nerve and results in ulnar innervation of the thenar hand
muscles. (See "Carpal tunnel syndrome: Pathophysiology and risk factors", section on 'Anatomy'.)

With median nerve studies in patients with CTS and median-to-ulnar anastomoses, the amplitude of
the compound muscle action potential is higher with stimulation at the proximal elbow site than with
stimulation at the wrist [25]. Median nerve conduction velocities may be surprisingly fast in the
forearm and typically slow across the wrist [25,26].

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Electromyography — EMG is a useful component of electrodiagnostic testing in CTS to exclude

other conditions, such as polyneuropathy, plexopathy, and radiculopathy, and to assess severity of CTS
if surgical decompression is being considered [1]. EMG is not necessary for patients who have classic
signs and symptoms of CTS and confirmatory findings on NCS when there is no suspicion for other
etiologies and surgery is not contemplated.

EMG assesses for evidence of pathologic changes in the muscles innervated by the median nerve.
When secondary axonal loss is present, EMG may reveal either active denervation (eg, spontaneous
activity such as fibrillation potentials, positive sharp waves, and fasciculation potentials) or chronic
changes that indicate denervation with subsequent reinnervation (eg, changes in motor unit action
potential amplitudes, durations, and recruitment). Such findings are supportive of the diagnosis of CTS
in the context of normal findings in both nonmedian-innervated muscles and proximal median nerve-
innervated muscles.

Specific components of EMG to evaluate CTS include [1]:

● Abductor pollicis brevis

● Two or more C6–C7 innervated muscles (eg, pronator teres, triceps brachii, extensor digitorum
communis) to look for evidence of cervical radiculopathy

● Additional muscles are typically evaluated if the abductor pollicis brevis is abnormal [1]. This
includes median-innervated muscles proximal to the carpal tunnel (eg, flexor carpi radialis,
pronator teres, flexor pollicis longus) to exclude a proximal median neuropathy and nonmedian-
innervated muscles (eg, first dorsal interosseous, extensor indicis proprius) to rule out brachial
plexopathy, polyneuropathy, and C8 to T1 radiculopathy.

Imaging — Imaging of the median nerve with ultrasound or MRI is typically reserved for patients
with a suspected structural abnormality of the wrist such as tumor, ganglion cyst, deformity, or other
bone or joint disease or those with atypical symptoms not explained by electrodiagnostic testing
[27,28].

● Neuromuscular ultrasound ( image 1) in patients with CTS may show increased median nerve
cross-sectional area compared with controls [29-33]. However, optimal cross-sectional area cut-
off for the diagnosis as well as the sensitivity and specificity of this technique have varied in these
reports [34,35]. In a systematic review of the literature, the four highest-quality studies used cut-
offs of 8.5 to 10 mm2 for the diagnosis [35]. The sensitivities ranged from 65 to 97 percent and
the specificities ranged from 73 to 98 percent. Caution is warranted when interpreting ultrasound
in older adults, as the sensitivity appears to be significantly lower in patients 80 years and older
compared with those younger than 65 years [36,37].

Instructional videos demonstrating proper performance of the ultrasound examination of the

wrist and related pathology can be found at the website of the American Medical Society for
Sports Medicine. Registration must be completed to access these videos, but no fee is required.
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● MRI can detect abnormalities of the median nerve, flexor tendons, vascular structures, and
transverse carpal ligament in the region of the carpal tunnel [38,39]. MRI can identify soft tissue
abnormalities and may be useful for unusual cases to rule out a mass lesion. However, the
diagnostic utility of MRI for other cases of CTS remains uncertain.

DIFFERENTIAL DIAGNOSIS

The differential diagnosis of CTS includes neurologic, musculoskeletal, and vascular conditions that
can present with pain, paresthesia, sensory loss, or weakness involving the arm or hand [1,27,40,41].

Conditions that may present with symptoms isolated to or predominating in the median nerve include
cervical spine disorders, brachial plexopathy, proximal lesions of the median nerve, and various types
of polyneuropathy.

● Cervical radiculopathy – The most common disorder than can mimic CTS is cervical
radiculopathy, particularly with C6 or C7 nerve root involvement [1]. The symptoms may include
arm pain and paresthesia that resemble those of CTS. Features that favor cervical radiculopathy
include [1,27]:

• The presence of neck pain that radiates into the shoulder and arm
• Exacerbation of symptoms with neck movement
• Reduced reflexes (ie, biceps, brachioradialis, and triceps)
• Weakness of proximal arm muscles involving elbow flexion, extension, and arm pronation
• Sensory loss in the forearm or medial palm

C8 and T1 root lesions may also mimic the symptoms or signs of CTS, predominantly involving
motor dysfunction.

Although clinical sensory loss may be present in cervical radiculopathy, the sensory nerve action
potentials remain unaffected in root lesions due to the more distal location of the sensory nerve
cell body. This is an important distinguishing feature from peripheral nerve lesions. (See
"Overview of nerve conduction studies", section on 'Sensory nerve conduction' and "Clinical
features and diagnosis of cervical radiculopathy", section on 'Electrodiagnostic studies'.)

● Median neuropathy in the forearm – Median neuropathy proximal to the carpal tunnel may
occur in the forearm where the nerve passes through the pronator teres muscle. Patients may
present with forearm pain and sensory loss involving the entire lateral palm. Features that favor
a forearm localization include the findings of sensory loss over the thenar eminence (typically
spared in CTS) and weakness of more proximal median-innervated muscles (thumb flexion, wrist
flexion, and arm pronation) [1]. However, electrodiagnostic studies are often required to localize
the site of compression appropriately.

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● Cervical spondylotic myelopathy and cervical polyradiculopathy – Cervical spine myelopathy

or polyradiculopathy may present with symptoms similar to CTS but usually involves bilateral
sensory loss and motor dysfunction in the hands and may also include dysfunction in nonmedian
nerve territories [41]. (See "Cervical spondylotic myelopathy", section on 'Clinical presentation'.)

● Brachial plexopathy – Patients with brachial plexopathies may sometimes manifest with
predominant symptoms suggestive of dysfunction to an individual nerve, such as the axillary,
long thoracic, anterior interosseous, radial, median, or a cutaneous nerve. However, the
examination findings more commonly reveal weakness, sensory loss, or diminished reflexes
outside the distribution of the median nerve and usually involve more than one spinal segment.
(See "Brachial plexus syndromes".)

Other conditions characterized by multifocal or diffuse symptoms may sometimes be included in the
differential diagnosis of CTS when presenting early with prominent median nerve symptoms. This
includes central nervous system lesions, motor neuron disease, compartment syndrome involving the
forearm or hand, fibromyalgia, osteoarthritis and inflammatory arthropathy involving the small joints
of the hand, Raynaud phenomenon, and ligamentous injury, which can present in ways similar to CTS,
although for the most part these entities are easily distinguished.

● Ischemic stroke – Small ischemic strokes restricted to the cortical region of the primary motor
cortex responsible for movement of the contralateral hand may mimic the weakness seen in CTS
[42,43]. However, patients with stroke in this "hand knob" region typically report sudden onset of
symptoms, lack pain, and have weakness of muscles innervated by median and radial and/or
ulnar nerves on examination. (See "Clinical diagnosis of stroke subtypes".)

● Motor neuron disease – Amyotrophic lateral sclerosis (ALS) or other forms of motor neuron
disease can present with asymmetric hand involvement that may predominantly involve the
thenar hand intrinsic muscles. The absence of pain argues against CTS. More importantly, ALS
essentially never presents with weakness of a single muscle. (See "Clinical features of
amyotrophic lateral sclerosis and other forms of motor neuron disease", section on 'Initial
presentation'.)

● Forearm or hand compartment syndrome – Patients with compartment syndrome can present
as pain with passive stretch and a firm compartment palpated over the forearm or hand; it may
be confused with CTS or other peripheral nerve injury if pain and sensory deficits involve the
median nerve territory. However, the distribution of pain may be more widespread with
progression of compartment syndrome when the ulnar and dorsal sensory radial nerves are also
compromised [40]. In addition, acute compartment syndrome typically occurs in the setting of
trauma, which helps differentiate it from CTS. (See "Acute compartment syndrome of the
extremities", section on 'Clinical features'.)

● Fibromyalgia – Symptoms in fibromyalgia frequently include numbness and tingling radiating

down the arm. However, the sensory symptoms may not be restricted to the median nerve and
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the chronic widespread musculoskeletal pain and fatigue that is typical of fibromyalgia is unusual
in patients with CTS. (See "Clinical manifestations and diagnosis of fibromyalgia in adults" and
"Differential diagnosis of fibromyalgia".)

● Arthritis – Patients with osteoarthritis and rheumatoid arthritis or other inflammatory

arthropathies may present with wrist pain that radiates to or involves the hand. Features
suggestive of arthritis over CTS include bilateral involvement, involvement of joints other than
the wrist, and joint swelling. (See "Clinical manifestations and diagnosis of osteoarthritis", section
on 'Hand' and "Clinical manifestations of rheumatoid arthritis", section on 'Hands'.)

Osteoarthritis and rheumatoid arthritis are also risk factors for CTS. Inflammatory changes from
these conditions may cause localized symptoms as well as CTS due to anatomic compression at
the carpal tunnel. (See "Carpal tunnel syndrome: Pathophysiology and risk factors", section on
'Arthritis'.)

● Raynaud phenomenon – The vasoconstriction that occurs with the Raynaud phenomenon (RP)
may produce digital pain and paresthesia. However, RP symptoms occur typically as episodes
provoked by cold temperatures or stress and are accompanied by skin pallor or cyanosis. (See
"Clinical manifestations and diagnosis of Raynaud phenomenon", section on 'Signs and
symptoms of Raynaud phenomenon'.)

● Pain from a ligamentous disruption – The pain that accompanies ligamentous injury of the
wrist may be similar to pain in CTS but is typically more localized and does not involve the volar
surface of the wrist or thenar region seen in CTS. (See "Evaluation of the adult with subacute or
chronic wrist pain", section on 'Differential diagnosis by regions of the wrist'.)

SOCIETY GUIDELINE LINKS

Links to society and government-sponsored guidelines from selected countries and regions around
the world are provided separately. (See "Society guideline links: Carpal tunnel syndrome".)

INFORMATION FOR PATIENTS

UpToDate offers two types of patient education materials, "The Basics" and "Beyond the Basics." The
Basics patient education pieces are written in plain language, at the 5th to 6th grade reading level, and
they answer the four or five key questions a patient might have about a given condition. These articles
are best for patients who want a general overview and who prefer short, easy-to-read materials.
Beyond the Basics patient education pieces are longer, more sophisticated, and more detailed. These
articles are written at the 10th to 12th grade reading level and are best for patients who want in-depth
information and are comfortable with some medical jargon.

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Here are the patient education articles that are relevant to this topic. We encourage you to print or
email these topics to your patients. (You can also locate patient education articles on a variety of
subjects by searching on "patient info" and the keyword(s) of interest.)

● Basics topics (see "Patient education: Carpal tunnel syndrome (The Basics)" and "Patient
education: Hand pain (The Basics)")

SUMMARY

● Clinical features – The hallmark of classic carpal tunnel syndrome (CTS) is pain or paresthesia
(numbness and tingling) in a distribution that includes the median nerve territory, with
involvement of the first three digits and the radial half of the fourth digit ( figure 1). (See
'Clinical features' above.)

• Diurnal character – The symptoms are typically worse at night and characteristically awaken
affected patients from sleep.

• Location of pain – The pain and paresthesia may be localized to the wrist, involve the entire
hand, or radiate proximally to as high as the shoulder ( figure 2).

• Provoking features – CTS symptoms are often provoked by activities that involve flexing or
extending the wrist or raising the arms.

• Severe manifestations – Fixed sensory loss is usually a late finding characterized by a

distinctive clinical pattern that involves the median-innervated fingers and spares the thenar
eminence. In severe CTS, motor involvement leads to complaints of weakness or clumsiness
when using the hands. Clinical signs may include weakness of thumb abduction and
opposition and atrophy of the thenar eminence.

● Clinical diagnosis – The clinical diagnosis of CTS is made in patients with pain or paresthesia in
the hand or examination findings of sensory loss or weakness in the distribution of the median
nerve ( figure 1). (See 'Diagnosis and evaluation' above.)

Provocative maneuvers for CTS include the Phalen, Tinel, manual carpal compression, and hand
elevation tests. These can be helpful when interpreted in the proper clinical context. However, the
sensitivity and specificity of these tests are moderate at best. (See 'Provocative maneuvers'
above.)

● Electrodiagnostic confirmation and evaluation – Electrodiagnostic testing is warranted for all

patients who have atypical symptoms to confirm the diagnosis and for patients with symptoms
that are moderate to severe ( table 1) or that progress despite conservative treatment to aid in
decisions regarding surgical intervention ( algorithm 1). (See 'Diagnostic testing for patients
with moderate to severe or atypical symptoms' above.)

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The electrodiagnosis of CTS is made by the demonstration of impaired median nerve conduction
across the carpal tunnel in the context of normal conduction elsewhere. Electromyography is
used along with nerve conduction studies to exclude other conditions, such as polyneuropathy,
plexopathy, and radiculopathy, and to assess severity CTS if surgical decompression is being
considered. (See 'Electrodiagnostic testing' above.)

● Differential diagnosis – The differential diagnosis of CTS includes neurologic, musculoskeletal,

and vascular conditions that can present with pain, paresthesia, sensory loss, or weakness
involving the arm or hand. The most common disorder than can mimic CTS is cervical
radiculopathy, particularly with C6 or C7 nerve root involvement. (See 'Differential diagnosis'
above.)

ACKNOWLEDGMENT

The UpToDate editorial staff acknowledges Kevin Scott, MD, who contributed to an earlier version of
this topic review.

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