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Carpal tunnel syndrome
Background
Overview
Definition
CTS is condition characterized by symptomatic compressive neuropathy of the median nerve at the wrist.
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Pathophysiology
CTS is caused by compression and traction of the median nerve in the carpal tunnel, either due to idiopathic causes or secondary to fibrous hypertrophy of synovial flexor sheath or due to repetitive movements of the wrist.
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Epidemiology
The prevalence and incidence of CTS in the United State are 7.8% and 2.3 per 100 person-years, respectively.
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Disease course
The combination of increased pressure in the tunnel, median nerve microcirculation injury, median nerve connective tissue compression, and synovial tissue hypertrophy results in altered function of the nerve, demyelination, and degeneration of the nerve at the site of compression and beyond. These events cause paresthesias, weakness, and loss of function in the distal distribution of median nerve (thumb, index, middle finger, and the radial side of the ring finger) and even outside the distribution of the median nerve.
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Prognosis and risk of recurrence
Carpal tunnel release is effective in 70-90% of the patients. The recurrence rate after carpal tunnel release varies from 3-25%.
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Guidelines
Key sources
The following summarized guidelines for the evaluation and management of carpal tunnel syndrome are prepared by our editorial team based on guidelines from the American Academy of Orthopaedic Surgeons (AAOS/ASSH 2025), the American Society of Interventional Pain Physicians (ASIPP/NASS/AAPM/ASRA/IPSIS 2025), the American Academy of Family Physicians (AAFP 2024,2016), the American College of Radiology (ACR 2024), the Academy of Orthopaedic Physical ...
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Screening and diagnosis
Diagnosis: as per AAOS/ASSH 2025 guidelines, consider using the CTS-6 instead of the routine use of ultrasound or nerve conduction velocity/EMG for the diagnosis of CTS.
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Carpal Tunnel Syndrome 6 (CTS-6)
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Symptoms and history
Numbness predominately or exclusively in median nerve territory sensory symptoms are mostly in the thumb, index, middle, and/or ring fingers)
Nocturnal numbness symptoms are prominent when the patient sleeps; numbness wakes the patient from sleep)
Physical examination
Thenar atrophy and/or weakness the bulk of the thenar area is reduced or manual motor testing shows strength of grade ≤ 4)
Positive Phalen test flexion of the wrist reproduces or worsens symptoms of numbness in the median nerve territory)
Loss of 2-point discrimination a failure to discriminate two points held ≤ 5 mm apart from one another, in the median nerve innervated digits, is a positive test suggestive of carpal tunnel syndrome)
Positive Tinel sign light tapping over the median nerve at the level of the carpal tunnel causing radiating paraesthesia into the median nerve innervated digits but not proximally)
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Classification and risk stratification
Diagnostic investigations
Clinical assessment, sensory function tests: as per AHUEPT/AOPT 2019 guidelines, obtain Semmes-Weinstein monofilament testing using the 2.83 or 3.22 monofilament as the threshold for normal light touch sensation and static two-point discrimination on the middle finger to help in determining the extent of nerve damage in the evaluation of patients with suspected CTS. Assess any radial finger using the 3.22 filament as the threshold for normal in patients with suspected moderate-to-severe CTS. Repeat Semmes-Weinstein monofilament testing by the same provider.
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Clinical assessment (motor function tests)
Clinical assessment (provocative tests)
Clinical assessment (patient-reported measures)
Wrist imaging
Nerve conduction studies
Evaluation for amyloidosis
Nonpharmacologic interventions
Wrist immobilization: as per AAFP 2024 guidelines, consider offering splinting for relief of mild-to-moderate carpal tunnel symptoms. Prefer neutral splints over extension splints and night-only wear over continuous wear.
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Exercise programs
Manual therapy
Therapeutic procedures
Biophysical therapies
As per AAOS/ASSH 2025 guidelines:
Recognize that heat therapy, magnet therapy, and phonophoresis do not demonstrate superiority over control or placebo.
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Recognize that laser therapy, shockwave therapy, and pulsed radiofrequency do not improve long-term patient-reported outcomes in CTS.
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Therapeutic ultrasound
Local corticosteroid injection (indications)
Local corticosteroid injection (technical considerations)
Local platelet-rich plasma injection
Therapies with no evidence for benefit
Perioperative care
Perioperative management: as per AAOS/ASSH 2025 guidelines, avoid obtaining routine preoperative testing (laboratory tests, CXR, ECG).
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Postoperative management
Surgical interventions
Specific circumstances
Patient education
Patient education
As per AHUEPT/AOPT 2019 guidelines:
Consider educating patients on CTS pathology, risk identification, symptom self-management, and postures/activities aggravating symptoms.
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Consider educating patients regarding the effects of mouse use on carpal tunnel pressure and assisting patients to develop alternative strategies, including the use of arrow keys, touch screens, or alternating the mouse hand. Consider advising the use of keyboards with reduced strike force in patients reporting pain with keyboard use.
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