Carpal Tunnel Syndrome
Original Editor - Kristin Sartore
- 1 Search Strategy
- 2 Definition/Description
- 3 Clinically Revelant Anatomy
- 4 Epidemiology /Etiology
- 5 Characteristics/clinical presentation
- 6 Differential Diagnosis
- 7 Diagnostic procedures
- 8 Outcome measures
- 9 Examination
- 10 Medical Management
- 11 Physical Therapy management
- 12 Key Evidence
- 13 Resources
- 14 Clinical Bottom line
- 15 Recent Related Research
- 16 References
First we went looking in the library for useful information in anatomy books and physiotherapy books. Here we found relevant information. To add more scientific information we searched journal articles on the Internet using keywords we found in the library books. We also used some websites. We made sure that the websites we found all had references to journal articles or were written by actual doctors or physiotherapists. Pubmed was a very useful scientific database during our search.
For every individual item, our keyword existed of carpal tunnel syndrome or CTS and the name of the item we were searching information about. We only used articles of which the full text was available.
Which keywords did you use? Give some examples of successful combinations of keywords Epidemiology carpal tunnel syndrome, carpal tunnel syndrome medical, CTS, Carpal tunnel syndrome test,…
Carpal tunnel syndrome (CTS) is a condition in the wrist. It is caused by compression, traction, pinching, squeezing or irritation of the median nerve, while it runs through the transverse carpal ligament.    
Clinically Revelant Anatomy
The carpal tunnel (CT) is situated on the palmar side of the wrist. The structures that form the tunnel are the scaphoid, lunate and triquetrium bones and the flexor retinaculum. The three bones form an arch. On top of the arch, running from the pisiform bone and the hamulus of the hamate bone to the scaphoid and the trapezium bone.  
The eight carpal bones are oriented in two rows between the ulna and radius and the metacarpal bones. These form the connection between the forearm and the hand. The first row exists from lateral to medial of the scaphoid, lunate, triquetrium and pisiform bones. The second row exists from lateral to medial of the trapezium, trapezoid, capitates and hamate bones. The hamate bone has an extra bone called the hamulus. An easy way to recall the orientation of the carpal bones is the sentence: Simply Learn The Parts That The Carpus Has. 
Through the tunnel run the tendons of the flexor digitorum profundus, flexor digitorum superficialis and flexor pollicis longus muscles and the median nerve. The nerve runs in the middle of the tunnel. [gross] The median nerve runs from the forearm to the palm side of the hand. It controls sensations to the palm side of the thumb and fingers, except for the little finger. It also allows the fingers and thumb to move. 
The CT is very rigid and narrow, so a little swelling of the tendons causes a lot of compression on the median nerve. 
Table 1  describes the origin, insertion and function of the three muscles running through the CT. They are all innervated by the median nerve. The flexor digitorum profundus and the flexor pollicis longus muscles are also innervated by the ulnar nerve.
|flexor digitorum superficialis|| - Medial epicondyle of the humeral head
- Ulnar head
- Coronoid process
- Radial head
- Anterior border of the radius
|Bodies of the middle phalanx of the second to the fifth finger|| - Flexion of the middle and proximal phalanx of the second to the fifth finger|
- Flexion of the hand
|flexor digitorum profundus|| - Medial and anterior surface of proximal ¾ of ulna
- Interosseous membrane
|Anterior base of distal phalanges of the second to the fifth finger|| - Flexion of the distal phalanx of the second to the fifth finger|
- Hand flexion
|flexor pollicis longus|| - Anterior surface of the radius
- Interosseous membrane
|Palmar base of distal phalanx of the thumb||- Flexion of the distal phalanx of the thumb|
Most of the time CTS is idiopathic, so the cause is unknown. This is correlated with hypertrophy of the synovial membrane of the tendons of the flexor muscles. CTS can be related to a degeneration of the connective tissue which? Retinaculum flexorum (Fasc palm, ret. Flex…) with vascular sclerosis, edema and collagen fragments. The most predisposing factors are gender, age, genetic factors and the size of the carpal tunnel. Obesity and smoking are also involved factors. Other predisposing factors are repetitive manual activities, exposure to vibrations and cold temperatures. 
Secondary CTS can be related to abnormalities of the person with CTS. These abnormalities can be conditions to modify the wall of the tunnel, which causes compression. The shape, position, dislocation or subluxation of the carpal bones can be causal factors. Fractures or skewed consolidation of the distal radius can also be the source of the pain. The last type of cause is wrist arthrosis and inflammatory or infectious arthritis ad synovitis. Secondary CTS can also come from the content of the CT. Inflammatory or metabolic tenosynovitis, tenosynovial hypertrophy, abnormalities of fluid distribution, supernumerary muscles, arterial hypertrophy of the median nerve, intratunnel tumor, hematoma and obesity can all cause the syndrome. 
Dynamic CTS is usually caused by excessive manual work. Repetitive extension and flexion movements of the wrist combined with flexion of the fingers and supination of the forearm have been mentioned to be the cause. During this motion the pressure in the carpal tunnel increases. 
Acute CTS is caused by trauma (displacements or fractures), infection, hemorrhage, high-pressure injection, acute thrombosis of the artery and burns. 
Compression of the medial nerve in the carpal tunnel can be caused by an overuse of the musculus flexor digitorum and superficialis, injury or inflammation diseases, for example Rheumatoid Arthritis. 
The estimated prevalence of CTS is 4-5% of the population. CTS usually affects people between 40 and 60 years. In 2008 127 269 individuals, aged 20 and older, were operated of CTS in France. These represent an incidence of 1,2/1000, of which 3,6/1000 are female, 1,7/1000 male. 
There are two peak age frequencies: the first and biggest peak is between 45 and 59 years of which 75% is female. The second age peak is between 75 and 84 years, of which 64% is female. 
Because of the irritation to the median nerve, caused by the rigid confines of the carpal tunnel, there are several symptoms detectable in the thumb, the index finger, the middle finger and the lateral half of the ring finger. The carpal tunnel syndrome generally starts with tingling or numbness in the previously mentioned fingers.   
This sensation often appears while holding an object like a phone or steering wheel. It may increase from your wrist up your arm. The symptoms develop gradually and usually start off being worse at night or early in the morning.  
As the disorder progresses, the feeling of tingling or numbness may become constant and patients may complain of burning pain. 
The final symptoms are weakness and atrophy of the muscles at the base of the thumb.  
The consequences for the functions of the neural tissue are loss of sensory feedback, which causes clumsiness and weaknees, and loss of motor power. 
The differential diagnosis is complex because the diagnostic criteria of the carpal tunnel syndrome are quite subjective. 
The neurological symptoms may be caused by another nerve. In this case you need to take different pathologies in account. For example: a pinching of the nn. digitales in the palm of your hand, a pinching of the median nerve at the level of the elbow or cervicobrachial syndrome as result of a pinched nerve root. A major cause of this last pathology is a hernia nuclei pulposa. Even though the neurological symptoms of this pathology have a more segmental character, the C7-C8-radiculopathy is very similar to the carpal tunnel syndrome. This is because there are also sensibility disorders in the median and ulnar area of the hand. The force of the m. abductor pollicis longus is normally maintained. Another pathology is neuralgic amyotrophy. The symptoms start with pain in the area of the shoulder or the upper arm and sometimes neurological symptoms in the hand.
There are intracranial neoplasms. Sometimes they present tingling, weakness or loss of coordination in the hand. The pattern of weakness of hypoesthesia will not be in a distribution limited to that of the median nerve. 
A second pathology is multiple sclerosis, which can superficially be similar to the symptoms of the carpal tunnel syndrome. With the use of a neurological evaluation, it can be distinguished. There will be a reaction in multiple areas that are not typical for the carpal tunnel syndrome.  
The third one, cervical radiculopathy, is the most common neurological condition which can be confused or which can coexist with the carpal tunnel syndrome. In this case there will be weakness or numbness in proximal dermatomes, which do not compare to the symptoms of the carpal tunnel syndrome.
Cervical syringomyelia shows symptoms like weakness and numbness. The origin of the symptoms is located in the cervical spine.
The Brachial plexus injury can also be confused with the carpal tunnel syndrome.
The thoracic outlet syndrome has symptoms in the ulnar nerve distribution.
A pancoast tumor has symptoms, which may present in the hand but the neurological distribution will be rather different. 
Other pathologies are: posttraumatic dystrophy, CVA, ulnar neuropathy, radial neuropathy, churg-strauss syndrome, arthritis and median nerve contusion. 
A second type of test is the electroneuromyography (ENMG) examination. 
By using a stimulation-detection stage it is possible to examine the sensory and motor nerve conductance of the median nerve. It also highlights the elective weakening in passing through the carpal tunnel. It is considered abnormal when there is a diminished sensory conduction velocity between the wrist, the palm of the hand and the fingers. This test may be used to diagnose the condition and rule out other pathologies. 
Another test is the electromyogram (EMG) of the muscles innervated by the median nerve. It measures electrical dischargers produced in the muscles. The electrical activity of the muscles will be evaluated when they contract and when they are at rest. This test can determine if there is any muscle damage and can rule out other conditions.  
A last test is ultrasound. It can identify space-occupying lesion in and around the median nerve. The test can confirm abnormalities that can diagnose CTS and help guide steroid into the carpal tunnel.  
Sometimes an X-ray is recommended to exclude other causes of wrist pain like arthritis or a fracture. 
There are several questionnaires available to determine the outcome measures for CTS. The four questionnaires below are all supported by studies with level of evidence 2A or 2B. Only the study of Levine et al. , describing the BCTQ, has level of evidence 4. This questionnaire is, however supported by other, higher level (2A or 2B) studies as well.
1. Boston Carpal Tunnel Questionnaire (BCTQ)
The BCTQ or the Levine Scale, originally developed by Levine et al. (1993) , is the most commonly used outcome measure in the assessment of CTS patients. It can be self-, interview- or telephone-administered. The questionnaire comprises of two scales: the Symptom Severity Scale (SSS) and the Functional Status Scale (FSS).  
The SSS consist of 11 questions, scored on a five-point rating scale, for the evaluation of pain, test-retest reliability of paraesthesia, numbness, weakness, nocturnal symptoms and overall function status.  
The FSS rates 8 functional activities on difficulty level, also scored on a five-point rating scale. The overall score for both scales is calculated as the mean of the items. 
The reliability, validity and responsiveness of the BCTQ has been found to be very good by several studies, such as the report of the University of Oxford16 and the studies of Sambandam et al. , Bakhsh et al.  and Greenslade et al. .
2. Disability of Hand and Shoulder (DASH) Questionnaire
The DASH-questionnaire is a self-, interview- or telephone-administered region-specific outcome instrument developed as a measure of self-rated upper-extremity disability and symptoms. The DASH is a 30-item scale, each scored on a 5-point Likert scale and overall scored on a scale from 0 (no disability) to 100 (maximum disability). It consists of two dimensions: Physical Functioning and Symptoms. The DASH is not specific for CTS, but can detect and differentiate small and large changes in disability over time after surgery in patients with several upper extremity musculoskeletal disorders. 
The DASH questionnaire is also found to be a valid and reliable test with good responsiveness.     Bakhsh et al.  however found the DASH questionnaire to be less responsive than the BCTQ.
3. Michigan Hand Outcomes Questionnaire (MHQ)
The MHQ is a self-, interview- or telephone-administered questionnaire used to assess the outcome for various hand disorders.  It consists of 37 items, grouped into 6 domains: overall hand function, activity of daily living, pain, work performance, aesthetics and patient satisfaction with hand function. All questions are scored from 1 to 5, with high scores denoting better performance, except for the pain scale, in which a higher score means more pain. The score of each scale is converted to a score from 0 to 100.  
The MHQ is found to be a valid and reliable measurement with good responsiveness.  
4. Patient Evaluation Measures (PEM)
The PEM is a self-, interview- or telephone-administered questionnaire to measure physical health. It consists of 3 components (patient’s opinion on delivery of care, hand health profile, overall assessment) and a total of 18 items scored on a 7-point scale. Low scores indicate positive outcomes.16 17 Hobby et al.20 found this instrument to be valid and reliable and to have good responsiveness.  
Clinical prediction rules (CPR), specifically for the Carpal Tunnel Syndrome, are a reliable examination method. It consists of five tests. Wainner et al.  found that the CPR is more useful for diagnosis of CTS than any single test item. Using CPR results is posttest probability changes up to 56%.
Other than the CPR, there are several provocative tests and the thenar atrophy observation that can be used in the clinical examination of a CTS patient. In Table 2  you find the sensitivity and specificity rates of all the tests explained below.
|Sensitivity (%)||Specificity (%)||Positive Prediction Value (%)||Negative Prediction Value (%)||Accuracy (%)|
|Scratch Collapse Test||34||61||71||25||41|
|Thumb Abduction Weakness||37||73||80||28||46|
1. Phalen’s test
The patient flexes his wrist for one minute and reports any symptoms that may occur. The test is described in many different positions. As described by G. A. Phalen (1966) , the patient holds his forearm vertically and lets his wrist drop down in 90° flexion . The arm can also be held horizontally in front of the patient with the wrist hanging down.  Another common way of executing the test is to hold both wrists against each other in 90° flexion with elbows also flexed and fingers pointing in the patient’s direction.  
The Reverse Phalen’s test, where the patient holds his wrist and fingers in full extension, provokes the same symptoms as the original test, which are the symptoms that are usually experienced by patients with CTS, such as tingling, paresthesia or pain in the fingers. 
2. Tinel’s sign
The examiner taps with his fingers of with a tendon hammer on the inside of the wrist onto the medial nerve at carpal tunnel level. Patients with CTS will not feel pain, but experience a tingling sensation in their hand. 
3. Hand elevation test (Roos Stress Test)
Isn’t this a test for thoracic outlet syndrome? The Roos Stress Test is indeed an indicative test for TOS and not for CTS. The hand elevation test is however a CTs test. The link to Roos Stress Test should be removed.The patient hold his arm above his head as straight as possible and holds this position for a minimum of two minutes.  The test is positive when the patient experiences typical CTS symptoms, such as a numb or tingling feeling in the fingers or pain or stiffness in the fingers, palm or wrist. Some patients also experience soreness in the shoulder. 
This test is only considered meaningful if the results can be duplicated by other, more specific CTS tests. 
4. Scratch Collapse Test (CTS-6 Lax/Sringent)
Cheng et al.  introduced this test in 2008 as an improved method to diagnose CTS among other syndromes. The test is executed with the patient facing the examiner with his arms adducted, elbows flexed and hands outstretched with the wrists in neutral position. The patient has to resist the external rotation movement the examiner is trying to make by pushing both the patient’s forearms out. The examiner then scratches the median nerve at carpal tunnel level and the previous exercise is repeated. A brief loss of resistance against the external rotation force of the affected side after scratching the median nerve is considered a positive scratch collapse test. 
Video of the Scratch Collapse Test: https://www.youtube.com/watch?v=Uh6bM2Z1ESk
5. Durkan’s Carpal Compression Test
The examiner externally applies pressure directly over the carpal tunnel. This test is also positive when the typical CTS symptoms occur while the pressure is applied. 
Non-surgical treatment comprises oral steroids  , corticosteroid injections , NSAID , diuretics , vitamin B6  and splinting/hand brace .
Reviews show that there is moderate and strong evidence for the effectiveness for curing CTS using oral and local steroids. (LoE 2A), (LoE 1A), (LoE 1A) Huisstede et al  says that for both treatments no evidence was found for long term effectiveness. Diuretics, NSAID and vitamin B6 turn out to be ineffective . There is limited  to moderate evidence of the effectiveness of splinting in short term. Huisstede et al  claim that number of nonsurgical interventions benefit CTS in the short term, but there is sparse evidence on the midterm and long-term effectiveness of these interventions
Huistede et al (LoE 1A) can conclude that surgical treatment seems to be more effective than splinting and anti-inflammatory drugs plus hand therapy in the midterm and long term to treat CTS . However, there is no unequivocal evidence that suggests one surgical treatment is more effective than the other. They examined 25 RCT’s and 2 reviews for this review.
The two main manners to decompress the median nerve by surgery are the open carpal tunnel release (OCTR) and the endoscopic carpal tunnel release (ECTR). During the OCTR they first cut open the skin and then make an incision in the transverse carpal ligament. https://www.youtube.com/watch?v=xSnGWeN1sDE
The less invasive ECTR is an operation during which they also cut the ligament, but without opening the skin completely. During this operation the surgeon can use the single-portal technique and the two-portal technique. The first technique uses one incision, the second one two. Using a camera, surgeons can see what happens inside. https://www.youtube.com/watch?v=igQKiFpzqGA
Benson et al (LoE 3A) says that with both techniques (OCTR and ECTR) the structural complications for nerves, blood vessels or tendons are low. According to Chen et al  there are no obvious statistical differences in relief of symptoms (pain en paraesthesia), recovery of grip strength a reoperation rate. Though, two articles with moderate to strong level of evidence (3A and 1B) declares the ECTR causes a faster return to work  and a better recovery of pinch strength.
Physical Therapy management
Patients with mild to moderate symptoms do not need to be immediately operated but can be effectively treated in a primary care environment (LoE 3B) (LoE 3A).  Physical therapy can exist of modifications of activities and the work place (ergonomic modifications) , patient education, carpal bone and nerve mobilisation , nerve and tendon gliding exercises , ultrasound  and electromagnetic field therapy , but also splinting.
In these patients, splinting and medication is often considered to be the standard treatment.
The review of Page et al recites the interventions that can be used as a conservative treatment for CTS. Nerve and carpal bone mobilisation, soft tissue mobilisation (with or without instrument-assistance), nerve and tendon gliding exercises, chiropractic treatment and yoga.
More than one article  with 3A and 1B level of evidences declare the benefit of nerve and tendon gliding, but only as an adjunct to the standard treatment that mostly exists from splinting and taking corticoids. Only nerve and tendon gliding has no effect.
During the exercises shown in the figure below the neck and shoulder is in a neutral position and the elbow in supination and 90° flexion. This programme should be done 5 times a day and the patients should maintain each position for 5 seconds.
It’s important to mention that, in general, the evidence of the effectiveness of the exercise and mobilisation interventions is limited and very low in quality. The physical therapist should always inform the patient about the limited evidence of effectiveness and safety .
The effectiveness of ultrasound varies between the studies and most of the time the evidence is low. According to Page et al (LoE 2A) there’s poor and limited evidence about the effect of therapeutic ultrasound. There is insufficient evidence that therapeutic ultrasound has a greater benefit than other non-surgical treatments, such as splinting, exercises or oral drugs.
It is important to pay attention to the cause of the CTS. Physical therapists should give advice in task modification, like taking enough rest and variation of movements. Burke et al  (LoE 3A) declare that often simple obvious alterations to the working practice can be beneficial in controlling milder symptoms of CTS.
Peter et al  declare that evidence about post-operative rehabilitation is also limited. Their reviewed interventions handle physical applications, differences between kinds of immobilisation and multimodal hand therapy. None of them seems to have a prevailing benefit.
• Krom de M.C.T.F.M., MD, KnipschildP.G. Prof. Efficacy of provocative tests for diagnosis of carpal tunnel syndrome. The Lancet. 1990 Feb 17; Vol.335 Issue 8686: 393-395 
• Huisstede BM, Hoogvliet P, Randsdorp MS, Glerum S, van Middelknoop M, Koes BW. Carpal Tunnel Syndrome. Part I: Effectiveness of Nonsurgical Treatments–A Systematic Review. Archives of physical medicine and rehabilitation. 2010 Jul; 91(7):981-1004
• Piazzini DB, Aprile I, Ferrara PE, Bertolini C, Tonali P, Maggi L, Rabini A, Piantelli S, Padua L. A systematic review of conservative treatment of carpal tunnel syndrome. Clinical rehabilitation. 2007 Apr; 21(4):299-314 
• Huisstede BM, Randsdorp MS, Coert JH, Glerum S, van Middelknoop M, Koes BW. Carpal Tunnel Syndrome. Part II: Effectiveness of Surgical Treatments—A Systematic Review. Archives of physical medicine and rehabilitation. 2010 Jul; 91(7):1005-24 
• Saw NL, Jones S, Shepstone L, Meyer M, Chapman PG, Logan AM. Early outcome and cost-effectiveness of endoscopic versus open carpal tunnel release: a randomized prospective trial. Journal of hand surgery. 2003 Oct; 28(5):444-9 
• Akalin E, El O, Peker O, Senocak O, Tamci S, Gülbahar S, Cakmur R, Oncel S. Treatment of Carpal Tunnel Syndrome with Nerve and Tendon Gliding Exercises. American journal of physical medicine & rehabilitation. 2002 Feb; 81(2):108-13 
• Bardak AN, Alp M, Erhan B, Paker N, Kaya B, Onal AE. Evaluation of the Clinical Efficacy of ConservativeTreatment in the Management of Carpal Tunnel Syndrome. Advances in therapy. 2009 Jan; 26(1):107-16 
Clinical Bottom line
Carpal Tunnel Syndrome (CTS) is a condition in the wrist, caused by compression, traction, pinching, squeezing or irritation of the median nerve. The median nerve passes through the carpal tunnel, which is formed by the scaphoid, lunate and triquetrum bones and the flexor retinaculum in the palmar side of the wrist. The tendons of the flexor digitorum profundus, flexor digitorum superficialis and flexor pollicis longus muscles pass through the tunnel along with the median nerve.
CTS can be divided in idiopathic, secondary, dynamic and acute CTS. These different kinds of the condition can be caused by many different matters, such as degeneration of the connective tissue, anatomical abnormalities in the CT region, trauma, etc. Symptoms occur mostly in the thumb, index finger, middle finger and the lateral half of the ring finger, but can also spread upwards to the arm. These symptoms are tingling and numbness in those finger, which increase gradually, and in later stages also weakness and atrophy at the base of the thumb.
The same symptoms can be caused by another nerve, intracranial neoplasms, multiple sclerosis, cervical radiculopathy, cervical syringomyelia and brachial plexus injuries. Besides these most common pathologies, there are a few others that resemble the CTS diagnosis. This makes the differential diagnosis quite complex.
CTS can be objectively diagnosed by following procedures: ENMD, EMG, Ultrasound and X-ray.
Subjectively, a physical examination can also help to diagnose a patient with CTS. This is possible by using the Clinical Prediction Rules for CTS. There are also several provocative tests, of which the most reliable are the Phalen’s test, Tinel sign, the hand elevation test, the scratch collapse test and the Durkan’s carpal compression test.
To assess the outcome measures, following questionnaires can be used: BCTQ, DASH-questionnaire, MHQ and PEM.
CTS-patients can be treated non-surgically as well as surgically. Non-surgical interventions are oral steroids, corticosteroid injections, NSAID, diuretics, vitamin B6 and splinting/hand brace. The two main surgical interventions are OCTR and ECTR.
Patients with moderate symptoms can be helped with only physical treatment, which consists of modification of activities, patient education, carpal bone and nerve mobilisation, nerve and tendon gliding, exercises, electromagnetic field therapy and splinting.
Recent Related Research
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- Shiel WC. Carpal tunnel syndrome [internet]. 2008 [2013 November 13 ; 2015 April 4]. Available from : http://www.emedicinehealth.com/carpal_tunnel_syndrome/article_em.htm.
- Carpal tunnel syndrome fact sheet [internet]. Bethesda; 2012 July [2015 April 17; 2015 april 20]. Available from: http://www.ninds.nih.gov/disorders/carpal_tunnel/detail_carpal_tunnel.htm#280913049.
- Moses KP, Banks JC, Nava PB, Petersen D. Altals of clinical gross anatomy. Elsevier Mosby; 2008. Chapter 23, Wrist and hand joints; p.260-265.
- FitzGordon J. The wrist and carpal tunnel [internet]. New York; 2013 November 1. [2015; 2015 April 10]. Fig 1: anatomy of the carpal tunnel, longitudinal view and cross-section. available from: fckLRhttp://corewalking.com/wrist-carpal-tunnel/
- Chammas M, Boretto J, Burmann LM, Ramos RM, Neto FCS, Silva JB. Carpal tunnel syndrome – part 1 (anatomy, physiology, etiology and diagnosis). Revista brasileira de Ortopedia (English edition) 2014 September-October; 49 (5):429-436. LoE: 5
- Jesus Filho AG, do Nascimento BF. Comparative study between physical examination, electroneuromyography and ultrasonography in diagnosing carpal tunnel syndrome. Revista Brasileira de Ortopedia (English Edition). 2014 September–October; 49(5): 446–451. LoE: 4
- Ashworth NL, MBChB. Carpal Tunnel Syndrome Clinical Presentation [Internet]. 1994 [Updated 2014 Aug 25; cited 2015 March 20].fckLRAvailable from:fckLRhttp://emedicine.medscape.com/article/327330-clinical. LoE: 5
- Krom de M.C.T.F.M., MD, KnipschildP.G. Prof. Efficacy of provocative tests for diagnosis of carpal tunnel syndrome. The Lancet. 1990 Feb 17; Vol.335 Issue 8686: 393-395. LoE: 1B
- Amadio P. Differential Diagnosis of Carpal Tunnel Syndrome. Carpal Tunnel Syndrome. 2007. Chapter 41, Differential diagnosis of carpal Tunnel; p.89-94
- Ashworth NL, MBChB. Carpal Tunnel Syndrome Differential Diagnoses [Internet]. 1994 [Updated 2014 Aug 25; cited 2015March 20] Available from: http://emedicine.medscape.com/article/327330-differntial . LoE: 5
- Visser LH, Smidt MH, Lee ML. High-resolution sonography versus EMG in the diagnosis of carpal tunnel syndrome. J Neurol Neurosurg Psychiatry. 2008;79:63-67. LoE: 3B
- Simpson JA. Electrical signs in the diagnosis of carpal tunnel and related syndromes. J Neurol Neurosurg Psychiatry. 1956 Nov; 19(4):275-280. LoE: 3B
- Ashworth NL, MBChB. Carpal Tunnel Syndrome Workup [Internet]. 1994 [Updated 2014 Aug 25; cited 2015 March 20].fckLRAvailable from: http://emedicine.medscape.com/article/327330-workup. LoE: 5
- Levine DW, Simmons BP, Koris MJ, Daltroy LH, Hohl GG, Fossel AH, Katz JN. A self-administered questionnaire for the assessment of severity of symptoms and functional status in carpal tunnel syndrome. J Bone Surg Am. 1993 Nov; 75(11):1585-92. LoE: 4
- Hadi M, Gibbons E, Fitzpatrick R. A structured review of patient-reported outcome measures for procedures for carpal tunnel syndrome. Oxford: Departmet of Public Health (University of Oxford); 2011. 33p. LoE: 2A
- Sambandam SN, Priyanka P, Gul A, Ilango B. Critical analysis of outcome measures used in the assessment of carpal tunnel sundrome. Int Orthop. 2008 Aug; 32(4):497-504. LoE: 2A
- Bakhsh H, Ibrahim I, Khan W, Smitham P, Goddard N. Assessment of validity, reliability, responsiveness and bias of three commonly used patient-reported outcome measures in carpal tunnel syndrome. Ortop traumatol Rehabil. 2012 Jul/Aug; 14(4):335-340. LoE: 2B
- Greenslade JR, Mehta RL, Belward P, Warwick DJ. Dash and Boston questionnaire assessment of carpal tunnel syndrome outcome: what is the responsiveness of an outcome questionnaire? JHS. 2004 Apr; 29(2):159-164. LoE: 2B
- Hobby JL, Watts C, Elliot D. Validity and responsiveness of the patient evaluation measure as an outcome measure for carpal tunnel syndrome. J Hand Surg Br. 2005 Aug; 30(4):350-354. LoE: 2B
- Wainner RS, Fritz JM, Irrgang JJ, Delitto A, Allison S, Boninger ML. Development of a clinical prediction rule for the diagnosis of carpal tunnel syndrome. Archives of Physical Medicine and Rehabilitation. 2005 Apr; 86(4): 609-618. LoE: 2B
- Physiotutors. Wainner Clinical Prediction Rule (CPR) | Carpal Tunnel Syndrome (CTS). Available from: https://www.youtube.com/watch?v=h136sLsCZcc
- Makanji HS, Becker SJE, Mudgal CS, Jupiter JB, Ring D. Evaluation of the scratch collapse test for the diagnosis of carpal tunnel syndrome. JHS. 2014 Feb; 39(2):181-186. LoE: 2B
- Phalen GS. The Carpal-tunnel Syndrome: Clinical Evaluation of 598 Hands. Clinical Orthopaedics. 1972 Mar/Apr; 83:29-40. LoE: 2B
- Phalen GS. The Carpal-Tunnel Syndrome – seventeen years’ of experience in diagnosis and treatment of six hundredfifty-four hands. J Bone Joint Surg Am. 1966 Mar; 48(2):211-228. LoE: 5
- Diagnosing CTS; Provocative tests [internet]. NHS; 2010 [Updated 2011 June 11]. Available from: http://www.carpal-tunnel.net/diagnosing/provocative. LoE: 2A
- Romito K. Physical Exam for Carpal Tunnel Syndrome [internet]. Healthwise; 2005 [Updated 2012 Oct 2]. Available from: fckLRhttp://www.webmd.com/pain-management/carpal-tunnel/physical-exam-for-carpal-tunnel-syndrome. LoE: 5
- Urbano FL. Tinel’s sign and Phalen’s Maneuver: Physical Signs of Carpal Tunnel Syndrome. Hospital Physician. 2000 Jul: 39-44. LoA: 3A
- Wolgin MA. Carpal Tunnel Syndrome [internet]. Albany fckLRAvailable from: http://www.drwolgin.com/pages/carpaltunnel.aspx. LoE: 5
- How to Use a Hand Elevation Test to Detect Carpal Tunnel Syndrome [internet]. Demand Media; 1999-2015. Available from: http://www.ehow.com/how_2088359_use-hand-elevation-test-detect.html. LoE: 5
- Cheng CJ, Mackinnon-Patterson B, Beck JL, Mackinnon SE. Scratch Collapse Test for Evaluation of Carpal and Cubital Tunnel Syndrome. JHS. 2008 Nov; 33(9):1518-1524. LoE: 2B
- O’Connor D, Marshall SC, Massy-Westropp N, Pitt V. Non-surgical treatment (other than steroid injection) for carpal tunnel syndrome (Review). The Cochrane database of systematic reviews. 2012; volume (7):1-106. LoE: 2A
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