• American Academy of Orthopaedic Surgeons clinical guideline on diagnosis of carpal tunnel syndrome. Rosemont (IL): American Academy of Orthopaedic Surgeons (AAOS); 2007. 72 p. [381 references]

This is the current release of the guideline.

Definitions of the levels of evidence (I-V) and grades of recommendation (A-C, I) and are provided at the end of the "Major Recommendations" field.

Recommendation 1.1

The physician should obtain an accurate patient history (Level V, Grade C).

Recommendation 2.1

The physician should perform a physical examination of the patient that may include:

• Personal characteristics (Level V, Grade C)
• Performing a sensory examination (Level V, Grade C)
• Performing manual muscle testing of the upper extremity (Level V, Grade C)
• Performing provocative tests (Level V, Grade C), and/or
• Performing discriminatory tests for alternative diagnoses (Level V, Grade C)

Recommendation 3.1a

The physician may obtain electrodiagnostic tests to differentiate among diagnoses. (Level V, Grade C)

Recommendation 3.1b

The physician may obtain electrodiagnostic tests in the presence of thenar atrophy and/or persistent numbness (Level V, Grade C).

Recommendation 3.1c

The physician should obtain electrodiagnostic tests if clinical and/or provocative tests are positive and surgical management is being considered (Level II and III, Grade B)

Recommendation 3.2

If the physician orders electrodiagnostic tests, the testing protocol should follow the American Academy of Neurology/American Association of Neuromuscular and Electrodiagnostic Medicine/American Academy of Physical Medicine and Rehabilitation (AAN/AANEM/AAPMR) guidelines for diagnosis of carpal tunnel syndrome (CTS) (Level IV and V, Grade C).

Recommendation 3.3

The physician should not routinely evaluate patients suspected of having carpal tunnel syndrome with new technology, such as magnetic resonance imaging (MRI), computerized axial tomography (CAT), and pressure specified sensorimotor devices (PSSD) in the wrist and hand. (Level V, Grade C).

Please note that Recommendation 3.3 is not based on a systematic literature review. An additional abbreviated review was completed following the face to face meeting of the Work Group on February 24, 2007.

Definitions:

Levels of Evidence for Primary Research Question¹

¹ A complete assessment of quality of individual studies requires critical appraisal of all aspects of the study design.
² A combination of results from two or more prior studies.
³ Studies provided consistent results.
⁴ Study was started before the first patient enrolled.
⁵ Patients treated one way (e.g., cemented hip arthroplasty) compared with a group of patients treated in another way (e.g., uncemented hip arthroplasty) at the same institution.
⁶ The study was started after the first patient enrolled.
⁷ Patients identified for the study based on their outcome, called "cases"; e.g., failed total hip arthroplasty, are compared to those who did not have outcome, called "controls"; e.g., successful total hip arthroplasty.
⁸ Patients treated one way with no comparison group of patients treated in another way.

Recommendation Grades

A: Good evidence (Level I Studies with consistent finding) for or against recommending intervention.

B: Fair evidence (Level II or III Studies with consistent findings) for or against recommending intervention.

C: Poor-quality evidence (Level IV or V) for or against recommending intervention.

I: There is insufficient or conflicting evidence not allowing a recommendation for or against intervention.

Grading Recommendations Specific to the CTS Guideline: When studies employ readers who were not blinded to each other and/or to the symptoms of the patient, we downgraded the quality of a study by one level of evidence (i.e., unblinded studies introduce the possibility of bias).

Relevant Issues:

The Committee recognized the following language in constructing the recommendations: Strong Recommendation (Must), Recommendation (Should), Option (May), or no recommendation. These definitions help clarify the intent of the Work Group by reflecting the assessment of the importance of adherence to the recommendation based on the grade level of the recommendation.

None provided

The type of supporting evidence is specifically stated for each recommendation (see the "Major Recommendations" field).

• American Academy of Orthopaedic Surgeons clinical guideline on diagnosis of carpal tunnel syndrome. Rosemont (IL): American Academy of Orthopaedic Surgeons (AAOS); 2007. 72 p. [381 references]

Not applicable: The guideline was not adapted from another source.

2007 May 19

American Academy of Orthopaedic Surgeons - Medical Specialty Society

American Academy of Orthopaedic Surgeons

American Academy of Orthopaedic Surgeons (AAOS) Carpal Tunnel Syndrome (CTS) Diagnosis Guideline Work Group

Guidelines Oversight Committee Chair: William C. Watters III, MD, Bone and Joint Clinic of Houston, P.A., Houston, TX

Work Group Members: Michael Warren Keith, MD (Chair) Professor of Orthopaedics and Biomedical Engineering, MetroHealth Medical Center, Case Western Reserve University, Cleveland, OH; Victoria Masear, MD (Co-Chair) Orthopaedic Specialists of Alabama, Birmingham, AL; Kevin Chung, MD, MS, Associate Professor of Plastic Surgery, University of Michigan Medical Center, Ann Arbor, MI; Kent Maupin, MD, Orthopaedic Surgery Representative, Grand Rapids, MI; Michael Andary, MD, MS, Physical Medicine and Rehabilitation Representative, Michigan State University, East Lansing, MI; Peter C. Amadio, MD, Mayo Clinic, Rochester, MN; Richard W. Barth, MD, BOC Representative, Washington, DC

American Academy of Orthopaedic Surgeons (AAOS) Staff: Charles M. Turkelson, PhD, Director of Research and Scientific Affairs, Rosemont, IL; Robert H. Haralson III, MD, MBA, AAOS Medical Director, Rosemont, IL; Janet L. Wies, MPH, Manager, Clinical Guidelines, Rosemont, IL; Andrew Chang, MPH, Research Associate, Rosemont, IL; Nicole Proia, MS, Research Associate, Rosemont, IL; Kevin Boyer, Research Associate, Rosemont, IL

All panel members gave full disclosure of conflicts of interest prior to voting on the recommendations contained within these guidelines. No member on the Carpal Tunnel Syndrome Diagnosis Guideline Work Group disclosed a conflict of interest.

This is the current release of the guideline.

None available

This NGC summary was completed by ECRI Institute on July 10, 2007. The information was verified by the guideline developer on July 26, 2007.

This NGC summary is based on the original guideline, which is subject to the guideline developer's copyright restrictions. For more information, please contact AAOS Department of Research and Scientific Affairs, 6300 North River Road, Rosemont, IL 60018; Phone: (847) 823-7186; Fax: (847) 823-8125.