Login
Search

Search
Search

Carpal Tunnel Syndrome (CTS)

NICE CKS Carpal tunnel syndrome. Last revised: Aug 2022.

Background Information

Entrapment neuropathy caused by the compression of the median nerve in the carpal tunnel at the wrist.

  • Activities with high hand / wrist repetition rate (wrist flexion or hand elevation)
    • Gardening
    • Assembly line work
    • Use of vibrating hand tools
    • Computer work (lack of consistent evidence)
  • Obesity
  • Pregnancy
  • Osteoarthritis of MCP joint
  • Ganglion cyst

Secondary causes:
  • Inflammatory joint disease (e.g. rheumatoid arthritis)
  • Hypothyroidism
  • Diabetes mellitus

  • Sensory symptoms in the median nerve distribution
    • Paraesthesia
    • Numbness
    • Burning pain 
  • Symptoms are often worse at night
  • Relieving factor: changing hand posture or skaking the wrist (flick sign)

Motor features (e.g. weakness, reduced hand grip, reduced hand coordination) is uncommon in early stages but usually only seen in late advanced disease.

Typical signs that are associated with late advanced disease:
  • Wasting of thena eminence muscles
  • Sensory loss in the median nerve distribution
  • Trophic ulceration at the tips of the digits (rare - indicate loss of protective sensation)

Certain hand provocation manoeuvres can be used to support the diagnosis of CTS:
  • Phalen’s test — +ve if flexing the wrist for 60 seconds reproduces symptoms
  • Tinel's test — +ve if tapping lightly over the median nerve at the volar surface of the wrist reproduces symptoms
  • Durkan's test (carpal tunnel compression test) — +ve if direct pressure over the proximal wrist crease reproduces symptoms

Guidelines

Clinical diagnosis is sufficient without referral if there are typical clinical features.

Further investigations in secondary care:
  • Blood tests if secondary causes are suspected (e.g. rheumatoid arthritis, hypothyroidism)
  • Nerve conduction studies

First attempt primary care approaches, only refer to secondary care if:

  • Persistent symptoms despite primary care management
  • Severe disease impacting daily function
  • Diagnostic uncertainty
 

Offer 6-week trial of conservative treatment
  • Lifestyle changes (e.g. avoid repetitive hand / wrist movements and take regular breaks)
  • Hand exercise and median nerve mobilisation techniques
  • Wrist splint use at night (to maintain neutral wrist position)
  • Corticosteroid injection (if appropriate expertise and experience available) - sometimes only preformed in secondary care

Main stay of management is carpal tunnel decompression (open / endoscopic technique)
  • Recurrence rate post-surgery is 0.3-12 %
  • Risks of surgey
    • Scar
    • Neurovascular damage
    • Complex regional pain syndrome

References

Author: Adams Lau
Reviewer:
Last edited: 22/07/25