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Clinical manifestations and diagnosis of carpal tunnel syndrome

Milind J Kothari, DO
Section Editor
Jeremy M Shefner, MD, PhD
Deputy Editor
John F Dashe, MD, PhD


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 "Etiology of carpal tunnel syndrome" and "Treatment of carpal tunnel syndrome".)


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 radial half of the fourth digit (figure 1). The symptoms of CTS are typically worse at night and often awaken patients from sleep. Some patients react to these symptoms by shaking or wringing their hands or by placing them under warm running water [1].

Although the sensory symptoms of CTS are usually limited to the median-innervated fingers, there is a wide range of variability. The pain and paresthesia may be localized to the wrist or 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 [1].

CTS symptoms are often provoked by activities that involve flexing or extending the wrist or raising the arms, such as driving, reading, typing, and holding a telephone [1,2].


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Literature review current through: Feb 2015. | This topic last updated: Jun 17, 2014.
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  1. Preston, DC, Shapiro, BE. Median neuropathy. In: Electromyography and neuromuscular disorders: Clinical-electrophysiologic correlations, Butterworth-Heinemann, Boston 1998. p.231.
  2. Bland JD. Carpal tunnel syndrome. BMJ 2007; 335:343.
  3. Bland JD, Rudolfer SM. Clinical surveillance of carpal tunnel syndrome in two areas of the United Kingdom, 1991-2001. J Neurol Neurosurg Psychiatry 2003; 74:1674.
  4. Muller M, Tsui D, Schnurr R, et al. Effectiveness of hand therapy interventions in primary management of carpal tunnel syndrome: a systematic review. J Hand Ther 2004; 17:210.
  5. Bland JD. Carpal tunnel syndrome. Curr Opin Neurol 2005; 18:581.
  6. Rempel D, Evanoff B, Amadio PC, et al. Consensus criteria for the classification of carpal tunnel syndrome in epidemiologic studies. Am J Public Health 1998; 88:1447.
  7. Katz JN, Larson MG, Sabra A, et al. The carpal tunnel syndrome: diagnostic utility of the history and physical examination findings. Ann Intern Med 1990; 112:321.
  8. D'Arcy CA, McGee S. The rational clinical examination. Does this patient have carpal tunnel syndrome? JAMA 2000; 283:3110.
  9. MacDermid JC, Wessel J. Clinical diagnosis of carpal tunnel syndrome: a systematic review. J Hand Ther 2004; 17:309.
  10. Priganc VW, Henry SM. The relationship among five common carpal tunnel syndrome tests and the severity of carpal tunnel syndrome. J Hand Ther 2003; 16:225.
  11. Ahn DS. Hand elevation: a new test for carpal tunnel syndrome. Ann Plast Surg 2001; 46:120.
  12. Practice parameter for carpal tunnel syndrome (summary statement). Report of the Quality Standards Subcommittee of the American Academy of Neurology. Neurology 1993; 43:2406.
  13. Jablecki CK, Andary MT, Floeter MK, et al. Practice parameter: Electrodiagnostic studies in carpal tunnel syndrome. Report of the American Association of Electrodiagnostic Medicine, American Academy of Neurology, and the American Academy of Physical Medicine and Rehabilitation. Neurology 2002; 58:1589.
  14. Jillapalli D, Shefner JM. Electrodiagnosis in common mononeuropathies and plexopathies. Semin Neurol 2005; 25:196.
  15. Witt JC, Hentz JG, Stevens JC. Carpal tunnel syndrome with normal nerve conduction studies. Muscle Nerve 2004; 29:515.
  16. Amoiridis G. Median--ulnar nerve communications and anomalous innervation of the intrinsic hand muscles: an electrophysiological study. Muscle Nerve 1992; 15:576.
  17. Rodriguez-Niedenführ M, Vazquez T, Parkin I, et al. Martin-Gruber anastomosis revisited. Clin Anat 2002; 15:129.
  18. Preston, DC, Shapiro, BE. Anomalous innervations. In: Electromyography and neuromuscular disorders: Clinical-electrophysiologic correlations, Butterworth-Heinemann, Boston 1998. p.77.
  19. Rubin DI, Dimberg EL. Martin-Gruber anastomosis and carpal tunnel syndrome: [corrected] morphologic clues to identification. Muscle Nerve 2010; 42:457.
  20. Ashraf AR, Jali R, Moghtaderi AR, Yazdani AH. The diagnostic value of ultrasonography in patients with electrophysiologicaly confirmed carpal tunnel syndrome. Electromyogr Clin Neurophysiol 2009; 49:3.
  21. Yesildag A, Kutluhan S, Sengul N, et al. The role of ultrasonographic measurements of the median nerve in the diagnosis of carpal tunnel syndrome. Clin Radiol 2004; 59:910.
  22. Visser LH, Smidt MH, Lee ML. High-resolution sonography versus EMG in the diagnosis of carpal tunnel syndrome. J Neurol Neurosurg Psychiatry 2008; 79:63.
  23. Moran L, Perez M, Esteban A, et al. Sonographic measurement of cross-sectional area of the median nerve in the diagnosis of carpal tunnel syndrome: correlation with nerve conduction studies. J Clin Ultrasound 2009; 37:125.
  24. Wiesler ER, Chloros GD, Cartwright MS, et al. The use of diagnostic ultrasound in carpal tunnel syndrome. J Hand Surg Am 2006; 31:726.
  25. Mhoon JT, Juel VC, Hobson-Webb LD. Median nerve ultrasound as a screening tool in carpal tunnel syndrome: correlation of cross-sectional area measures with electrodiagnostic abnormality. Muscle Nerve 2012; 46:871.
  26. Descatha A, Huard L, Aubert F, et al. Meta-analysis on the performance of sonography for the diagnosis of carpal tunnel syndrome. Semin Arthritis Rheum 2012; 41:914.
  27. Cartwright MS, Hobson-Webb LD, Boon AJ, et al. Evidence-based guideline: neuromuscular ultrasound for the diagnosis of carpal tunnel syndrome. Muscle Nerve 2012; 46:287.
  28. Jarvik JG, Yuen E, Haynor DR, et al. MR nerve imaging in a prospective cohort of patients with suspected carpal tunnel syndrome. Neurology 2002; 58:1597.
  29. Uchiyama S, Itsubo T, Yasutomi T, et al. Quantitative MRI of the wrist and nerve conduction studies in patients with idiopathic carpal tunnel syndrome. J Neurol Neurosurg Psychiatry 2005; 76:1103.