Carpal tunnel syndrome (CTS) is among the conditions that have many special tests but is challenging to diagnose.
Pathophysiology and symptoms:
Carpal tunnel syndrome is the most common form of compression neuropathy in the upper extremities. It occurs when the median nerve is entrapped within the carpal tunnel of the wrist.
Symptoms vary but may include early involvement of the sensory systems and later involvement of the motor system. Within the hand, CTS generally affects the thumb, index, and middle finger and the radial half of the ring finger. However, atypical distributions are present and can make CTS diagnosis challenging.
CTS is more common in middle aged women and may have a presentation that is worst at night during sleep or during daytime activity.
Diagnosis and special tests:
Carpal tunnel syndrome is generally considered a clinical diagnosis. This means that the signs and symptoms are the necessary criteria to consider the condition, whereas electro-diagnostic testing aids in confirming the diagnosis. Further, the condition is divided by acute and chronic CTS, with chronic CTS being the most prevalent form seen by treating clinicians. Symptoms may involve burning, pain, numbness, and tingling, and less common clumsiness and weakness of the hand. Clinicians must rule out competing conditions such as cervical myelopathy or other forms of mononeuropathy.
Certainly, the clinicians that frequently treat CTS are going to be the best at identifying the condition. Clinicians who rarely care for patients with CTS may have to rely on a good physical examination and proper special tests and measures. Although, there is a wealth of special tests for CTS, only a few provide diagnostic utility consistently across a number of studies.
The two tests that have demonstrated the best diagnostic utility are the carpal compression test (in its many forms) and Phalen’s test (which is frequently incorrectly performed). The carpal compression test involves applied compression to the carpal tunnel region for a dedicated time, with the wrist in a flexed, extended, or neutral position. The amount of time past 1 minute of compression doesn’t seem to influence the accuracy of the test, nor does the wrist positioning. Phalen’s test is a static, passive test that involves allowing the wrist to hang in flexion for 2 or more minutes.
Treatment of CTS involves both conservative and surgical approaches. Unfortunately, surgical approaches are performed too frequently and should only be considered when symptoms are severe. Accordingly, conservative treatments may include splinting, cortical steroid injections, non-steroidal anti-inflammatory drugs, B6 vitamin, diuretics, ultrasound therapy, ergonomic positioning, manual therapy intervention, lidocaine patches, and acupuncture.
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