Diagnosis

Diagnosis of the condition requires a clear history and examinations directed at identifying standard features and provocative factors (1).

• patients presents with a history of tingling, numbness, or pain of the fingers in the distribution of the median nerve which is often worse at night and causes wakening
• provocative tests such as Tinel’s sign, modified Phalen’s test , and Durkan’s compression test are usually positive (2)

The following criteria (described by GPs with a special interest in musculoskeletal health, from the Primary Care Rheumatology Society) followed by a decision tree will be help in diagnosing CTS:

Inquire about the following from patients who presents with hand or wrist symptoms:

• any numbness or tingling in the wrist, hand, or fingers?
• does the symptoms spare the little finger?
• are the symptoms worse at night?
• do the symptoms wake you up at night?
• any weakness in the hand e.g. – dropping thing in the hand regularly?
• shaking the hand, holding the hand or running under water improves the symptoms?
• symptoms are made worse by driving, holding a telephone, using vibrating tools, or typing?
• have splints or injections helped with the pain in the past?

Decision tree:

• if the answer to question 1 is
  • no – diagnosis of CTS is unlikely
  • yes – are ≥3 other questions answered as
    • yes – diagnosis of CTS can be made
    • no – are 2 other questions answered as
      • no – consider further investigations or an alternative diagnosis
      • yes – is Phalen’s test positive
        • yes – CTS diagnosed
        • no - consider further investigations or an alternative diagnosis (1)

Reference:

• (1) Burton C, Chesterton LS, Davenport G. Diagnosing and managing carpal tunnel syndrome in primary care. Br J Gen Pract. 2014;64(622):262-3.
• (2) Middleton SD, Anakwe RE Carpal tunnel syndrome. BMJ. 2014;349:g6437