• Work Loss Data Institute. Carpal tunnel syndrome (acute & chronic). Corpus Christi (TX): Work Loss Data Institute; 2007 Apr 24. 201 p. [275 references]

Note: This guideline has been updated. The National Guideline Clearinghouse (NGC) is working to update this summary.

Note: This guideline has been updated. The National Guideline Clearinghouse (NGC) is working to update this summary. The recommendations that follow are based on the previous version of the guideline.

Initial Diagnosis

• First visit: with Primary Care Physician MD/DO (100%)
• Determine severity: (see also Severity definitions in the Procedure Summary of the original guideline document)
  • Mild/moderate (Go to Initial Conservative Treatment):
    • Symptoms: pain/numbness in hand/wrist/forearm, below the elbow, with tingling that is primarily in thumb, index, and long finger (Katz hand diagram and hypesthesia index finger compared to little finger), with nocturnal awakening, impaired dexterity, and having to shake the hand for relief (the Flick sign has a sensitivity of 93% and specificity 96%)
    • Tests: Phalen's/Tinel's signs not always useful; also consider Semmes Weinstein monofilament test, Durkan's compression test. (See Table, "Sensitivity and Specificity of Diagnostic Tests for Carpal Tunnel Syndrome Measured Against Nerve Conduction Studies" in the original guideline document.)
    • Recommended: findings that best distinguish between patients with electrodiagnostic evidence of carpal tunnel syndrome (CTS) and patients without it are hypalgesia in the median nerve territory, classic or probable Katz hand diagram results, and weak thumb abduction strength. See Table, "Sensitivity and Specificity of Diagnostic Tests for Carpal Tunnel Syndrome Measured Against Nerve Conduction Studies" in the original guideline document.
    • Muscle atrophy: mild weakness of thenar muscles (thumb abduction)
    • History/exam, comorbidities: diabetes, hypothyroidism, rheumatoid arthritis, obesity, hypertension, depression, inactivity, age, work, and hobbies

      Carpal tunnel syndrome seems to be primarily attributable to CTS-prone personal characteristics (e.g., obesity, diabetes, female, smoking), but also possibly in combination with improper work conditions. There is sufficient evidence to conclude that CTS is associated with work, but the studies have neither proven nor disproven whether the association is causal. See "Work" in the Procedure Summary of the original guideline document.

    • Concurrent pregnancy: CTS likely to resolve on its own within 6–12 weeks after delivery
  • Severe (Go Directly to Electrodiagnostic Testing)
    • Muscle atrophy: severe weakness of thenar muscles
    • Test: 2-point discrimination over 6 mm
• Rule out diagnoses (See other treatment parameters for each of these):
  • Cervical radiculopathy (refer to the original guideline document for relevant International Classification of Diseases, Ninth Revision [ICD-9] codes for CTS and other diagnoses)
  • Tendonitis
  • Osteoarthritis
  • Thoracic outlet syndrome, brachial plexus disorders

Mild/Moderate -- Initial Conservative Treatment (70% of cases)

• Also first visit (day 1):
  • Prescribe alteration of activity (home and work), frequent breaks, stretching, night and possibly day splint, appropriate analgesia (i.e., acetaminophen) [Benchmark cost: $14], back to work--modified duty if condition caused by job, possible ergonomic evaluation of job, patient education

• Second visit (day 7 to 14--about 2 weeks after first visit, but sooner if the patient is off work)
  • Document progress.
  • If not significantly improved then may (approximately 50% of cases) prescribe physical therapy for home exercise training [Benchmark cost: $250]: Refer to Physical Therapist (50%) or Occupational Therapist (50%) for 3 visits.
• Third visit (day 20 to 30--about 1 month after first visit, but sooner if patient is off work)
  • Document progress.
  • Corticosteroid injection trial (high likelihood of relief, but may have recurrence of symptoms within several months--initial relief of symptoms good indicator for success of surgery, can assist in confirmation of diagnosis) [Benchmark cost: $276]. Should be performed by musculoskeletally trained physician because of nerve injury risk. Recommend only one injection.

• Fourth visit (day 40 to 50--about 6 weeks after first visit)
  • Refer for Electrodiagnostic Testing.

Electrodiagnostic Testing (50% of cases)
[Benchmark cost: $370]

• All severe cases, plus mild/moderate cases after Initial Conservative Treatment above; See "Protocols for electrodiagnostic studies" in the original guideline document.
• Refer to Neurologist (70%) or Physical Medicine (30%) specialists certified in electrodiagnostic medicine, for electromyography (EMG)/Nerve Conduction Studies, the "gold standard" tests for the evaluation of CTS.
• Positive test: refer for Carpal Tunnel Release depending on severity
• Note: ODG recommends that nerve conduction studies (NCS) should be done to support the diagnosis of CTS prior to surgery. If an individual has appropriate responses to treatment (i.e. injections, modification of activities, meds) but still has symptoms with normal NCS, surgery may be appropriate on a case-by-case basis and reasonable documentation by the treating physician.

Carpal Tunnel Release (35% of cases)

(See also ODG Indications for Surgery™ -- Carpal Tunnel Release in the Procedure Summary in the original guideline document)
[Benchmark cost: $3,158]

• Only after the positive diagnosis of CTS is made by history, physical examination, and electrodiagnostic studies
• Performed by Hand Surgeon: Orthopaedic Surgeon (75%), Neurosurgeon (10%), Plastic Surgeon (10%), or General Surgeon (5%)
• On an outpatient basis
• May be open or endoscopic, depending on experience of surgeon (risk of nerve injury, although slight, may be greater with endoscopic, but recovery is faster)
• If bilateral (25% of cases), schedule separate surgeries (usually)
• Expected outcome:
  • Mild/moderate cases: over 90% success with complete recovery after failure of Initial Conservative Treatment (Outcomes in workers' comp cases may not be as good as outcomes overall, but still support surgery.)
  • Severe cases: Complete recovery is unlikely, but 90% will benefit from at least partial recovery.
• Post-surgical treatment:
  • Splint - day and night: not recommended
  • Stitches out in 5 to 10 days
  • Physical/Occupational Therapy: A short course may be appropriate; if so, then post-surgical treatment of 3 to 5 visits.

• Failed Carpal Tunnel Release (4% of cases):
  • Repeat Electrodiagnostic Testing
  • Repeat Carpal Tunnel Release (by fellowship-trained Hand Surgeon)

None provided

During the comprehensive medical literature review, preference was given to high quality systematic reviews, meta-analyses, and clinical trials over the past ten years, plus existing nationally recognized treatment guidelines from the leading specialty societies.

The heart of each Work Loss Data Institute guideline is the Procedure Summary (see the original guideline document), which provides a concise synopsis of effectiveness, if any, of each treatment method based on existing medical evidence. Each summary and subsequent recommendation is hyper-linked into the studies on which they are based, in abstract form, which have been ranked, highlighted and indexed.

• Work Loss Data Institute. Carpal tunnel syndrome (acute & chronic). Corpus Christi (TX): Work Loss Data Institute; 2007 Apr 24. 201 p. [275 references]

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

2003 (revised 2007 Apr 24)

Work Loss Data Institute - Public For Profit Organization

Not stated

Not stated

There are no conflicts of interest among the guideline development members.

Note: This guideline has been updated. The National Guideline Clearinghouse (NGC) is working to update this summary.

This summary was completed by ECRI on February 2, 2004. The information was verified by the guideline developer on February 13, 2004. This NGC summary was updated by ECRI on March 24, 2005, January 3, 2006, April 11, 2006, November 9, 2006, March 28, 2007, and August 16, 2007.

This NGC summary is based on the original guideline, which is subject to the guideline developer's copyright restrictions.