Carpal tunnel syndrome
|Carpal tunnel syndrome|
|Classification and external resources|
|eMedicine||orthoped/455 pmr/21 emerg/83 radio/135|
Carpal tunnel syndrome (CTS) is a median entrapment neuropathy that causes paresthesia, pain, numbness, and other symptoms in the distribution of the median nerve due to its compression at the wrist in the carpal tunnel. The mechanism is not completely understood but can be considered compression of the median nerve traveling through the carpal tunnel. It appears to be caused by a combination of genetic and environmental factors. Some of the predisposing factors include: diabetes, obesity, pregnancy, hypothyroidism, and heavy manual work or work with vibrating tools. There is, however, little clinical data to prove that lighter, repetitive tasks can cause carpal tunnel syndrome. Other disorders such as bursitis and tendinitis have been associated with repeated motions performed in the course of normal work or other activities.
The main symptom of CTS is intermittent numbness of the thumb, index, long and radial half of the ring finger. The numbness often occurs at night, with the hypothesis that the wrists are held flexed during sleep. Recent literature suggests that sleep positioning, such as sleeping on one's side, might be an associated factor. It can be relieved by wearing a wrist splint that prevents flexion. Long-standing CTS leads to permanent nerve damage with constant numbness, atrophy of some of the muscles of the thenar eminence, and weakness of palmar abduction.
Pain in carpal tunnel syndrome is primarily numbness that is so intense that it wakes one from sleep. Pain in electrophysiologically verified CTS is associated with misinterpretation of nociception and depression.
- 1 Signs and symptoms
- 2 Causes
- 3 Diagnosis
- 4 Pathophysiology
- 5 Prevention
- 6 Treatment
- 7 Prognosis
- 8 Epidemiology
- 9 History
- 10 Notable cases
- 11 References
- 12 External links
Signs and symptoms
People with CTS experience numbness, tingling, or burning sensations in the thumb and fingers, in particular the index, middle fingers, and radial half of the ring fingers, which are innervated by the median nerve. Less-specific symptoms may include pain in the wrists or hands and loss of grip strength (both of which are more characteristic of painful conditions such as arthritis).
Some suggest that median nerve symptoms can arise from compression at the level of the thoracic outlet or the area where the median nerve passes between the two heads of the pronator teres in the forearm, but this is debatable. This line of thinking is an attempt to explain pain and other symptoms not characteristic of carpal tunnel syndrome. Carpal tunnel syndrome is a common diagnosis with an objective, reliable, verifiable pathophysiology, whereas thoracic outlet syndrome and pronator syndrome are defined by a lack of verifiable pathophysiology and are usually applied in the context of nonspecific upper extremity pain.
Numbness and paresthesias in the median nerve distribution are the hallmark neuropathic symptoms (NS) of carpal tunnel entrapment syndrome. Weakness and atrophy of the thenar muscles may occur if the condition remains untreated.
Most cases of CTS are of unknown causes, or idiopathic. Carpal Tunnel Syndrome can be associated with any condition that causes pressure on the median nerve at the wrist. Some common conditions that can lead to CTS include obesity, oral contraceptives, hypothyroidism, arthritis, diabetes, prediabetes (impaired glucose tolerance), and trauma. Carpal tunnel is also a feature of a form of Charcot-Marie-Tooth syndrome type 1 called hereditary neuropathy with liability to pressure palsies.
Other causes of this condition include intrinsic factors that exert pressure within the tunnel, and extrinsic factors (pressure exerted from outside the tunnel), which include benign tumors such as lipomas, ganglion, and vascular malformation. Carpal tunnel syndrome often is a symptom of transthyretin amyloidosis-associated polyneuropathy and prior carpal tunnel syndrome surgery is very common in individuals who later present with transthyretin amyloid-associated cardiomyopathy, suggesting that transthyretin amyloid deposition may cause carpal tunnel syndrome.
The median nerve can usually move up to 9.6 mm to allow the wrist to flex, and to a lesser extent during extension. Long-term compression of the median nerve can inhibit nerve gliding, which may lead to injury and scarring. When scarring occurs, the nerve will adhere to the tissue around it and become locked into a fixed position, so that less movement is apparent.
Normal pressure of the carpal tunnel has been defined as a range of 2–10 mm, and wrist flexion increases this pressure 8-fold, while extension increases it 10-fold. Repetitive flexion and extension in the wrist significantly increase the fluid pressure in the tunnel through thickening of the synovial tissue that lines the tendons within the carpal tunnel.
The international debate regarding the relationship between CTS and repetitive motion in work is ongoing. The Occupational Safety and Health Administration (OSHA) has adopted rules and regulations regarding cumulative trauma disorders. Occupational risk factors of repetitive tasks, force, posture, and vibration have been cited. The relationship between work and CTS is controversial; in many locations, workers diagnosed with carpal tunnel syndrome are entitled to time off and compensation.
Some speculate that carpal tunnel syndrome is provoked by repetitive movement and manipulating activities and that the exposure can be cumulative. It has also been stated that symptoms are commonly exacerbated by forceful and repetitive use of the hand and wrists in industrial occupations, but it is unclear as to whether this refers to pain (which may not be due to carpal tunnel syndrome) or the more typical numbness symptoms.
A review of available scientific data by the National Institute for Occupational Safety and Health (NIOSH) indicated that job tasks that involve highly repetitive manual acts or specific wrist postures were associated with incidents of CTS, but causation was not established, and the distinction from work-related arm pains that are not carpal tunnel syndrome was not clear. It has been proposed that repetitive use of the arm can affect the biomechanics of the upper limb or cause damage to tissues. It has also been proposed that postural and spinal assessment along with ergonomic assessments should be included in the overall determination of the condition. Addressing these factors has been found to improve comfort in some studies.
Speculation that CTS is work-related is based on claims such as CTS being found mostly in the working adult population, though evidence is lacking for this. For instance, in one recent representative series of a consecutive experience, most patients were older and not working. Based on the claimed increased incidence in the workplace, arm use is implicated, but the weight of evidence suggests that this is an inherent, genetic, slowly but inevitably progressive idiopathic peripheral mononeuropathy.
A variety of patient factors can lead to CTS, including heredity, size of the carpal tunnel, associated local and systematic diseases, and certain habits. Non-traumatic causes generally happen over a period of time, and are not triggered by one certain event. Many of these factors are manifestations of physiologic aging.
- Rheumatoid arthritis and other diseases that cause inflammation of the flexor tendons.
- With hypothyroidism, generalized myxedema causes deposition of mucopolysaccharides within both the perineurium of the median nerve, as well as the tendons passing through the carpal tunnel.
- During pregnancy women experience CTS due to hormonal changes (high progesterone levels) and water retention (which swells the synovium), which are common during pregnancy.
- Previous injuries including fractures of the wrist.
- Medical disorders that lead to fluid retention or are associated with inflammation such as: inflammatory arthritis, Colles' fracture, amyloidosis, hypothyroidism, diabetes mellitus, acromegaly, and use of corticosteroids and estrogens.
- Carpal tunnel syndrome is also associated with repetitive activities of the hand and wrist, in particular with a combination of forceful and repetitive activities
- Acromegaly causes excessive growth hormones. This causes the soft tissues and bones around the carpel tunnel to grow and compress the median nerve.
- Tumors (usually benign), such as a ganglion or a lipoma, can protrude into the carpal tunnel, reducing the amount of space. This is exceedingly rare (less than 1%).
- Obesity also increases the risk of CTS: individuals classified as obese (BMI > 29) are 2.5 times more likely than slender individuals (BMI < 20) to be diagnosed with CTS.
- Double-crush syndrome is a debated hypothesis that compression or irritation of nerve branches contributing to the median nerve in the neck, or anywhere above the wrist, increases sensitivity of the nerve to compression in the wrist. There is little evidence, however, that this syndrome really exists.
- Heterozygous mutations in the gene SH3TC2, associated with Charcot-Marie-Tooth, confer susceptibility to neuropathy, including the carpal tunnel syndrome.
There is no consensus reference standard for the diagnosis of carpal tunnel syndrome. A combination of described symptoms, clinical findings, and electrophysiological testing is used by a majority of hand surgeons. Numbness in the distribution of the median nerve, nocturnal symptoms, thenar muscle weakness/atrophy, positive Tinel's sign at the carpal tunnel, and abnormal sensory testing such as two-point discrimination have been standardized as clinical diagnostic criteria by consensus panels of experts. A predominance of pain rather than numbness is unlikely to be caused by carpal tunnel syndrome no matter what the result of electrophysiological testing.
Electrodiagnostic testing (electromyography and nerve conduction velocity) can objectively verify the median nerve dysfunction. If these tests are normal, carpal tunnel syndrome is either absent or very, very mild.
Clinical assessment by history taking and physical examination can support a diagnosis of CTS.
- Phalen's maneuver is performed by flexing the wrist gently as far as possible, then holding this position and awaiting symptoms. A positive test is one that results in numbness in the median nerve distribution when holding the wrist in acute flexion position within 60 seconds. The quicker the numbness starts, the more advanced the condition. Phalen's sign is defined as pain and/or paresthesias in the median-innervated fingers with one minute of wrist flexion. Only this test has been shown to correlate with CTS severity when studied prospectively.
- Tinel's sign, a classic — though less sensitive - test is a way to detect irritated nerves. Tinel's is performed by lightly tapping the skin over the flexor retinaculum to elicit a sensation of tingling or "pins and needles" in the nerve distribution. Tinel's sign (pain and/or paresthesias of the median-innervated fingers with percussion over the median nerve) is less sensitive, but slightly more specific than Phalen's sign.
- Durkan test, carpal compression test, or applying firm pressure to the palm over the nerve for up to 30 seconds to elicit symptoms has also been proposed.
- Hand elevation test The hand elevation test has higher sensitivity and specificity than Tinel's test, Phalen's test, and carpal compression test. Chi-square statistical analysis confirms the hand elevation test is not ineffective compared with Tinel's test, Phalen's test, and carpal compression test.
As a note, a patient with true carpal tunnel syndrome (entrapment of the median nerve within the carpal tunnel) will not have any sensory loss over the thenar eminence (bulge of muscles in the palm of hand and at the base of the thumb). This is because the palmar branch of the median nerve, which innervates that area of the palm, branches off of the median nerve and passes over the carpal tunnel. This feature of the median nerve can help separate carpal tunnel syndrome from thoracic outlet syndrome, or pronator teres syndrome.
Other conditions may also be misdiagnosed as carpal tunnel syndrome. Thus, if history and physical examination suggest CTS, patients will sometimes be tested electrodiagnostically with nerve conduction studies and electromyography. The goal of electrodiagnostic testing is to compare the speed of conduction in the median nerve with conduction in other nerves supplying the hand. When the median nerve is compressed, as in CTS, it will conduct more slowly than normal and more slowly than other nerves. There are many electrodiagnostic tests used to make a diagnosis of CTS, but the most sensitive, specific, and reliable test is the Combined Sensory Index (also known as Robinson index). Electrodiagnosis rests upon demonstrating impaired median nerve conduction across the carpal tunnel in context of normal conduction elsewhere. Compression results in damage to the myelin sheath and manifests as delayed latencies and slowed conduction velocities  However, normal electrodiagnostic studies do not preclude the presence of carpal tunnel syndrome, as a threshold of nerve injury must be reached before study results become abnormal and cut-off values for abnormality are variable. Carpal tunnel syndrome with normal electrodiagnostic tests is very, very mild at worst.
There are some[weasel words] who believe that carpal tunnel syndrome is simply a universal label applied to anyone suffering from pain, numbness, swelling, and/or burning in the radial side of the hands and/or wrists. When pain is the primary symptom, carpal tunnel syndrome is unlikely to be the source of the symptoms. As a whole, the medical community is not currently embracing or accepting trigger point theories due to lack of scientific evidence supporting their effectiveness.
The carpal tunnel is an anatomical compartment located at the base of the palm. Nine flexor tendons and the median nerve pass through the carpal tunnel that is surrounded on three sides by the carpal bones that form an arch. The median nerve provides feeling or sensation to the thumb, index finger, long finger, and half of the ring finger. At the level of the wrist, the median nerve supplies the muscles at the base of the thumb that allow it to abduct, or move away from the fingers, out of the plane of the palm. The carpal tunnel is located at the middle third of the base of the palm, bounded by the bony prominence of the scaphoid tubercle and trapezium at the base of the thumb, and the hamate hook that can be palpated along the axis of the ring finger. The proximal boundary is the distal wrist skin crease, and the distal boundary is approximated by a line known as Kaplan's cardinal line. This line uses surface landmarks, and is drawn between the apex of the skin fold between the thumb and index finger to the palpated hamate hook. The median nerve can be compressed by a decrease in the size of the canal, an increase in the size of the contents (such as the swelling of lubrication tissue around the flexor tendons), or both. Simply flexing the wrist to 90 degrees will decrease the size of the canal.
Compression of the median nerve as it runs deep to the transverse carpal ligament (TCL) causes atrophy of the thenar eminence, weakness of the flexor pollicis brevis, opponens pollicis, abductor pollicis brevis, as well as sensory loss in the digits supplied by the median nerve. The superficial sensory branch of the median nerve, which provides sensation to the base of the palm, branches proximal to the TCL and travels superficial to it. Thus, this branch spared in carpal tunnel syndrome, and there is no loss of palmar sensation.
Suggested healthy habits such as avoiding repetitive stress, work modification through use of ergonomic equipment (wrist rest, mouse pad), taking proper breaks, using keyboard alternatives (digital pen, voice recognition, and dictation), and employing early treatments such as taking turmeric (anti-inflammatory), omega-3 fatty acids, and B vitamins have been proposed as methods to help prevent carpal tunnel syndrome. The potential role of B-vitamins in preventing or treating carpal tunnel syndrome has not been proven. There is little or no data to support the concept that activity adjustment prevents carpal tunnel syndrome.
Stretches and isometric exercises will aid in prevention for persons at risk. Stretching before the activity and during breaks will aid in alleviating tension at the wrist. Place the hand firmly on a flat surface and gently pressing for a few seconds to stretch the wrist and fingers. An example for an isometric exercise of the wrist is done by clinching the fist tightly, releasing and fanning out fingers. None of these stretches or exercises should cause pain or discomfort.
Biological factors such as genetic predisposition and anthropometrics had significantly stronger causal association with carpal tunnel syndrome than occupational/environmental factors such as repetitive hand use and stressful manual work. This suggests that carpal tunnel syndrome might not be preventable simply by avoiding certain activities or types of work/activities.
Generally accepted treatments include: steroids either orally or injected locally, splinting, and surgical release of the transverse carpal ligament. There is no or insufficient evidence for ultrasound, yoga, lasers, B6, and exercise therapy.
Early surgery with carpal tunnel release is indicated where there is clinical evidence of median nerve denervation or a person elects to proceed directly to surgical treatment. The treatment should be switched when the current treatment fails to resolve the symptoms within 2 to 7 weeks. However, these recommendations have sufficient evidence for carpal tunnel syndrome when found in association with the following conditions: diabetes mellitus, coexistent cervical radiculopathy, hypothyroidism, polyneuropathy, pregnancy, rheumatoid arthritis, and carpal tunnel syndrome in the workplace.
The importance of wrist braces and splints in the carpal tunnel syndrome therapy is known, but many people are unwilling to use braces. In 1993, The American Academy of Neurology recommend a non-invasive treatment for the CTS at the beginning (except for sensitive or motor deficit or grave report at EMG/ENG): a therapy using splints was indicated for light and moderate pathology. Current recommendations generally don't suggest immobilizing braces, but instead activity modification and non-steroidal anti-inflammatory drugs as initial therapy, followed by more aggressive options or specialist referral if symptoms do not improve.
Corticosteroid injections can be effective for temporary relief from symptoms while a person develops a long-term strategy that fits their lifestyle. This treatment is not appropriate for extended periods, however. In general, local steroid injections are only used until other treatment options can be identified. For most surgery is the only option that will provide permanent relief.
Release of the transverse carpal ligament is known as "carpal tunnel release" surgery. It is recommended when there is static (constant, not just intermittent) numbness, muscle weakness, or atrophy, and when night-splinting no longer controls intermittent symptoms. In general, milder cases can be controlled for months to years, but severe cases are unrelenting symptomatically and are likely to result in surgical treatment.
One review of the evidence found good evidence for splinting, ultrasound, nerve gliding exercises, carpal bone mobilization, magnetic therapy, and yoga for people with carpal tunnel syndrome. However, a recent evidence based guideline produced by the American Academy of Orthopedic Surgeons assigned lower grades to most of these treatments.
Again, some claim that pro-active ways to reduce stress on the wrists, which alleviates wrist pain and strain, involve adopting a more ergonomic work and life environment. For example, some have claimed that switching from a QWERTY computer keyboard layout to a more optimised ergonomic layout such as Dvorak was commonly cited as beneficial in early CTS studies, however some meta-analyses of these studies claim that the evidence that they present is limited.
Most people relieved of their carpal tunnel symptoms with conservative or surgical management find minimal residual or "nerve damage". Long-term chronic carpal tunnel syndrome (typically seen in the elderly) can result in permanent "nerve damage", i.e. irreversible numbness, muscle wasting, and weakness. Those that undergo a carpal tunnel release are nearly twice as likely as those not having surgery to develop trigger thumb in the months following the procedure.
While outcomes are generally good, certain factors can contribute to poorer results that have little to do with nerves, anatomy, or surgery type. One study showed that mental status parameters or alcohol use yields much poorer overall results of treatment.
Recurrence of carpal tunnel syndrome after successful surgery is rare. If a person has hand pain after surgery, it is most likely not caused by carpal tunnel syndrome. It may be the case that the illness of a person with hand pain after carpal tunnel release was diagnosed incorrectly, such that the carpal tunnel release has had no positive effect upon the patient's symptoms.
Carpal tunnel syndrome can affect anyone. It accounts for about 90% of all nerve compression syndromes. In the U.S., roughly 1 out of 20 people will suffer from the effects of carpal tunnel syndrome. Caucasians have the highest risk of CTS compared with other races such as non-white South Africans. Women suffer more from CTS than men with a ratio of 3:1 between the ages of 45–60 years. Only 10% of reported cases of CTS are younger than 30 years. Increasing age is a risk factor. CTS is also common in pregnancy.
As of 2010, 8% of U.S. workers reported ever having carpal tunnel syndrome and 4% reported carpal tunnel syndrome in the past 12 months. Prevalence rates for carpal tunnel syndrome in the past 12 months were higher among females than among males; among workers aged 45–64 than among those aged 18–44. Overall, 67% of current carpal tunnel syndrome cases among current/recent workers were reportedly attributed to work by health professionals, indicating that the prevalence rate of work-related carpal tunnel syndrome among workers was 2%, and that there were approximately 3.1 million cases of work-related carpal tunnel syndrome among U.S. workers in 2010. Among current carpal tunnel syndrome cases attributed to specific jobs, 24% were attributed to jobs in the manufacturing industry, a proportion 2.5 times higher than the proportion of current/recent workers employed in the manufacturing industry, suggesting that jobs in this industry are associated with an increased risk of work-related carpal tunnel syndrome.
The condition known as carpal tunnel syndrome had major appearances throughout the years but it was most commonly heard of in the years following World War II. Individuals who had suffered from this condition have been depicted in surgical literature for the mid-19th century. In 1854, Sir James Paget was the first to report median nerve compression at the wrist in a distal radius fracture. Following the early 20th century there were various cases of median nerve compression underneath the transverse carpal ligament. Carpal Tunnel Syndrome was most commonly noted in medical literature in the early 20th century but the first use of the term was noted 1939. Physician Dr. George S. Phalen of the Cleveland Clinic identified the pathology after working with a group of patients in the 1950s and 1960s.
- HRH Prince Philip, husband of Queen Elizabeth II
- Mike Dirnt, bassist with the band Green Day
- Scott, Kevin R.; Kothari, Milind J. (October 5, 2009). "Treatment of carpal tunnel syndrome". UpToDate.
- McCartan, B; Ashby, E; Taylor, EJ; Haddad, FS (Apr 2012). "Carpal tunnel syndrome.". British journal of hospital medicine (London, England : 2005) 73 (4): 199–202. PMID 22585195.
- Walker, Jennie A. (2010). "Management of patients with carpal tunnel syndrome". Nursing Standard 24 (19): 44–8. doi:10.7748/ns2010.01.24.19.44.c7447. PMID 20175360.
- McCabe, SJ; Uebele, AL, Pihur, V, Rosales, RS, Atroshi, I (Sep 2007). "Epidemiologic associations of carpal tunnel syndrome and sleep position: Is there a case for causation?". Hand 2 (3): 127–34. doi:10.1007/s11552-007-9035-5. PMC 2527141. PMID 18780073.
- Shiel, William C. "Carpal Tunnel Syndrome & Tarsal Tunnel Syndrome". MedicineNet.
- Uemura T, Hidaka N, Nakamura H (October 2010). "Clinical outcome of carpal tunnel release with and without opposition transfer". The Journal of Hand Surgery, European Volume 35 (8): 632–6. doi:10.1177/1753193410369988. PMID 20427406.
- Nunez, F; Vranceanu, AM; Ring, D (2010). "Determinants of pain in patients with carpal tunnel syndrome". Clinical orthopaedics and related research 468 (12): 3328–32. doi:10.1007/s11999-010-1551-x. PMC 2974864. PMID 20811788.
- Bickel, Kyle D (January 2010). "Carpal Tunnel Syndrome". Journal of Hand Surgery 35 (1): 147–152. doi:10.1016/j.jhsa.2009.11.003. PMID 20117319. Retrieved 26 February 2011.
- Atroshi, I.; Gummesson, C; Johnsson, R; Ornstein, E; Ranstam, J; Ros�n, I (1999). "Prevalence of Carpal Tunnel Syndrome in a General Population". JAMA 282 (2): 153–158. doi:10.1001/jama.282.2.153. PMID 10411196.
- Netter, Frank (2011). Atlas of Human Anatomy (5th ed.). Philadelphia, PA: Saunders Elsevier. pp. 412, 417, 435. ISBN 978-0-8089-2423-4.
- "Carpal Tunnel Syndrome Information Page". National Institute of Neurological Disorders and Stroke. December 28, 2010.
- Lazaro, R (1997). "Neuropathic symptoms and musculoskeletal pain in carpal tunnel syndrome: Prognostic and therapeutic implications". Surgical Neurology 47 (2): 115–7; discussion 117–9. doi:10.1016/S0090-3019(95)00457-2. PMID 9040810.
- Sternbach, G (1999). "The carpal tunnel syndrome". Journal of Emergency Medicine 17 (3): 519–23. doi:10.1016/S0736-4679(99)00030-X. PMID 10338251.
- Katz, Jeffrey N.; Simmons, Barry P. (2002). "Carpal Tunnel Syndrome". New England Journal of Medicine 346 (23): 1807–12. doi:10.1056/NEJMcp013018. PMID 12050342.
- Tiong, W. H. C.; Ismael, T.; Regan, P. J. (2005). "Two rare causes of carpal tunnel syndrome". Irish Journal of Medical Science 174 (3): 70–8. doi:10.1007/BF03170208. PMID 16285343.
- Almeida, M.R., et al., Small transthyretin (TTR) ligands as possible therapeutic agents in TTR amyloidosis. Curr. Drug Targets: CNS Neurol. Disord., 2005. 4: p. 587–596.
- Izumoto, S., et al., Familial amyloidotic polyneuropathy presenting with carpal tunnel syndrome and a new transthyretin mutation, asparagine 70. Neurology, 1992. 42: p. 2094–102.
- Jacobson, D.R., et al., Transthyretin ILE20, a new variant associated with late-onset cardiac amyloidosis. Hum. Mutat., 1997. 9: p. 83–85.
- Kodaira, M., et al., Non-senile wild-type transthyretin systemic amyloidosis presenting as bilateral carpal tunnel syndrome. J Peripher Nerv Syst, 2008. 13: p. 148–50.
- Koike, H., et al., The significance of carpal tunnel syndrome in transthyretin Val30Met familial amyloid polyneuropathy. Amyloid, 2009. 16: p. 142–148.
- Sekijima, Y., et al., High prevalence of wild-type transthyretin deposition in patients with idiopathic carpal tunnel syndrome: a common cause of carpal tunnel syndrome in the elderly. Hum Pathol, 2011. 42: p. 1785–91.
- Tojo, K., et al., Upper limb neuropathy such as carpal tunnel syndrome as an initial manifestation of ATTR Val30Met familial amyloid polyneuropathy. Amyloid, 2010. 17: p. 32–35.
- "Ibrahim, I., Khan, W. S., Goddard, N., & Smitham, P. (2012). Suppl 1: Carpal Tunnel Syndrome: A Review of the Recent Literature. The Open Orthopaedics Journal, 6, 69.
- Armstrong, T., & Chaffin, D. (1979). Capral tunnel syndrome and selected personal attributes. Journal of Occupational Medicine, 21(7).
- Schuind, F., Ventura, M., & Pasteels, J. (1990). Idiopathic carpal tunnel syndrome: Histologic study of flexor tendon synovium. The Journal of Hand Surgery, 15(3).
- Work-related carpal tunnel syndrome: the facts and the myths 5 (2). 2006. pp. 353–67, viii. doi:10.1016/j.coem.2005.11.014 (inactive 2014-03-22). PMID 16647653.
- Office of Communications and Public Liaison (December 18, 2009). "National Institute of Neurological Disorders and Stroke".
- Werner, Robert A. (2006). "Evaluation of Work-Related Carpal Tunnel Syndrome". Journal of Occupational Rehabilitation 16 (2): 201. doi:10.1007/s10926-006-9026-3. PMID 16705490.
- Graham, B. (1 December 2008). "The Value Added by Electrodiagnostic Testing in the Diagnosis of Carpal Tunnel Syndrome". The Journal of Bone and Joint Surgery 90 (12): 2587–2593. doi:10.2106/JBJS.G.01362. PMID 19047703.
- Cole, Donald C.; Hogg-Johnson, Sheilah; Manno, Michael; Ibrahim, Selahadin; Wells, Richard P.; Ferrier, Sue E.; Worksite Upper Extremity Research Group (2006). "Reducing musculoskeletal burden through ergonomic program implementation in a large newspaper". International Archives of Occupational and Environmental Health 80 (2): 98–108. doi:10.1007/s00420-006-0107-6. PMID 16736193.
- LOZANOCALDERON, S; PAIVA, A; RING, D (1 March 2008). "Patient Satisfaction After Open Carpal Tunnel Release Correlates With Depression". The Journal of Hand Surgery 33 (3): 303–307. doi:10.1016/j.jhsa.2007.11.025. PMID 18343281.
- LOZANOCALDERON, S; ANTHONY, S; RING, D (1 April 2008). "The Quality and Strength of Evidence for Etiology: Example of Carpal Tunnel Syndrome". The Journal of Hand Surgery 33 (4): 525–538. doi:10.1016/j.jhsa.2008.01.004. PMID 18406957.
- Stevens JC, Beard CM, O'Fallon WM, Kurland LT (1992). "Conditions associated with carpal tunnel syndrome". Mayo Clin Proc 67 (6): 541–548. doi:10.1016/S0025-6196(12)60461-3. PMID 1434881.
- "Carpel Tunnel Syndrome in Acromegaly". Treatmentandsymptoms.com. Retrieved 2011-10-05.
- Werner, Robert A.; Albers, James W.; Franzblau, Alfred; Armstrong, Thomas J. (1994). "The relationship between body mass index and the diagnosis of carpal tunnel syndrome". Muscle & Nerve 17 (6): 632–6. doi:10.1002/mus.880170610.
- Wilbourn AJ, Gilliatt RW (1997). "Double-crush syndrome: a critical analysis". Neurology 49 (1): 21–27. doi:10.1212/WNL.49.1.21. PMID 9222165.
- Lupski, James R.; Reid, Jeffrey G.; Gonzaga-Jauregui, Claudia; Rio Deiros, David; Chen, David C.Y.; Nazareth, Lynne; Bainbridge, Matthew; Dinh, Huyen et al. (2010). "Whole-Genome Sequencing in a Patient with Charcot–Marie–Tooth Neuropathy". New England Journal of Medicine 362 (13): 1181–91. doi:10.1056/NEJMoa0908094. PMID 20220177.
- Rempel, D; Evanoff B; Amadio PC; et al (1998). "Consensus criteria for the classification of carpal tunnel syndrome in epidemiologic studies". Am J Public Health 88 (10): 1447–1451. doi:10.2105/AJPH.88.10.1447. PMC 1508472. PMID 9772842.
- Graham, B; Regehr G; Naglie G; Wright JG (2006). "Development and validation of diagnostic criteria for carpal tunnel syndrome". Journal of Hand Surgery 31A (6): 919–924.
- Cush JJ, Lipsky PE (2004). "Approach to articular and musculoskeletal disorders". Harrison's Principles of Internal Medicine (16th ed.). McGraw-Hill Professional. p. 2035. ISBN 0-07-140235-7.
- Gonzalezdelpino, J; Delgadomartinez, A; Gonzalezgonzalez, I; Lovic, A (1997). "Value of the carpal compression test in the diagnosis of carpal tunnel syndrome". The Journal of Hand Surgery: Journal of the British Society for Surgery of the Hand 22: 38–41. doi:10.1016/S0266-7681(97)80012-5.
- Durkan, JA (1991). "A new diagnostic test for carpal tunnel syndrome". The Journal of bone and joint surgery. American volume 73 (4): 535–8. PMID 1796937.
- Ma H, Kim I (November 2012). "The diagnostic assessment of hand elevation test in carpal tunnel syndrome". Journal of Korean Neurosurgical Society 52 (5): 472–5. doi:10.3340/jkns.2012.52.5.472. PMC 3539082. PMID 23323168.
- Netter, Frank (2011). Atlas of Human Anatomy (5th ed.). Philadelphia, PA: Saunders Elsevier. p. 447. ISBN 978-0-8089-2423-4.
- Robinson, L (2007). "Electrodiagnosis of Carpal Tunnel Syndrome". Physical Medicine and Rehabilitation Clinics of North America 18 (4): 733–46. doi:10.1016/j.pmr.2007.07.008. PMID 17967362.
- Wilder-Smith, Einar P; Seet, Raymond C S; Lim, Erle C H (2006). "Diagnosing carpal tunnel syndrome—clinical criteria and ancillary tests". Nature Clinical Practice Neurology 2 (7): 366–74. doi:10.1038/ncpneuro0216. PMID 16932587.
- Bland, Jeremy DP (2005). "Carpal tunnel syndrome". Current Opinion in Neurology 18 (5): 581–5. doi:10.1097/01.wco.0000173142.58068.5a. PMID 16155444.
- Jarvik, J; Yuen, E; Kliot, M (2004). "Diagnosis of carpal tunnel syndrome: electrodiagnostic and MR imaging evaluation". Neuroimaging Clinics of North America 14: 93–102, viii. doi:10.1016/j.nic.2004.02.002. PMID 15177259.
- Brooks, JJ; Schiller, JR, Allen, SD, Akelman, E (Oct 2003). "Biomechanical and anatomical consequences of carpal tunnel release.". Clinical biomechanics (Bristol, Avon) 18 (8): 685–93. doi:10.1016/S0268-0033(03)00052-4. PMID 12957554.
- Vella, JC; Hartigan, BJ, Stern, PJ (Jul–Aug 2006). "Kaplan's cardinal line.". The Journal of hand surgery 31 (6): 912–8. doi:10.1016/j.jhsa.2006.03.009. PMID 16843150.
- RH Gelberman, PT Hergenroeder, AR Hargens, GN Lundborg and WH Akeson (03/01/1981). "The carpal tunnel syndrome. A study of carpal canal pressures". The Journal of Bone and Joint Surgery 63 (3): 380–383. PMID 7204435.
- Norvell, Jeffrey G.; Steele, Mark (September 10, 2009). "Carpal Tunnel Syndrome". eMedicine.
- Spooner, GR; Desai, HB, Angel, JF, Reeder, BA, Donat, JR (Oct 1993). "Using pyridoxine to treat carpal tunnel syndrome. Randomized control trial". Canadian Family Physician 39: 2122–7. PMC 2379872. PMID 8219859.
- Scangas, G; Lozano-Calderón, S; Ring, D (Sep 2008). "Disparity between popular (Internet) and scientific illness concepts of carpal tunnel syndrome causation". The Journal of hand surgery 33 (7): 1076–80. doi:10.1016/j.jhsa.2008.03.001. PMID 18762100.
- Lozano-Calderón, Santiago; Shawn Anthony; David Ring (April 2008). "The Quality and Strength of Evidence for Etiology: Example of Carpal Tunnel Syndrome". The Journal of Hand Surgery 33 (4): 525–538. doi:10.1016/j.jhsa.2008.01.004. PMID 18406957.
- "Nadal, Roger, and Susan Lintsworth. "Getting a Hand up on Carpal Tunnel Syndrome. Tips for Beating the Malady of the Information Age." PTA Today. EBSCO Host, Apr. 2002. Web. 24 Jan. 2014. http://wnyptot.com/articles/info_education/carpal_tunnel.pdf"
- Piazzini, DB; Aprile, I; Ferrara, PE; Bertolini, C; Tonali, P; Maggi, L; Rabini, A; Piantelli, S; Padua, L (Apr 2007). "A systematic review of conservative treatment of carpal tunnel syndrome.". Clinical rehabilitation 21 (4): 299–314. doi:10.1177/0269215507077294. PMID 17613571.
- Clinical Practice Guideline on the Treatment of Carpal Tunnel Syndrome. American Academy of Orthopaedic Surgeons. September 2008.[page needed]
- . PMID 16557211. Missing or empty
- Katz, Jeffrey N.; Simmons, Barry P. (2002). "Carpal Tunnel Syndrome". New England Journal of Medicine 346 (23): 1807–1812. doi:10.1056/NEJMcp013018. PMID 12050342.
- Harris JS, ed. (1998). Occupational Medicine Practice Guidelines: evaluation and management of common health problems and functional recovery in workers. Beverly Farms, Mass.: OEM Press. ISBN 978-1-883595-26-5.[page needed]
- Premoselli, S; Sioli, P; Grossi, A; Cerri, C (2006). "Neutral wrist splinting in carpal tunnel syndrome: a 3- and 6-months clinical and neurophysiologic follow-up evaluation of night-only splint therapy". Europa medicophysica 42 (2): 121–6. PMID 16767058.
- Michlovitz, SL (2004). "Conservative interventions for carpal tunnel syndrome". The Journal of orthopaedic and sports physical therapy 34 (10): 589–600. doi:10.2519/jospt.2004.34.10.589. PMID 15552705.
- Marshall, Shawn C; Tardif, Gaetan; Ashworth, Nigel L; Marshall, Shawn C (2007). "Local corticosteroid injection for carpal tunnel syndrome". In Marshall, Shawn C. Cochrane Database of Systematic Reviews. doi:10.1002/14651858.CD001554.pub2.
- Hui, A.C.F.; Wong, S; Leung, CH; Tong, P; Mok, V; Poon, D; Li-Tsang, CW; Wong, LK; Boet, R (2005). "A randomized controlled trial of surgery vs steroid injection for carpal tunnel syndrome". Neurology 64 (12): 2074–8. doi:10.1212/01.WNL.0000169017.79374.93. PMID 15985575.
- Hui, A.C.F.; Wong, S.M.; Tang, A.; Mok, V.; Hung, L.K.; Wong, K.S. (2004). "Long-term outcome of carpal tunnel syndrome after conservative treatment". International Journal of Clinical Practice 58 (4): 337–9. doi:10.1111/j.1368-5031.2004.00028.x. PMID 15161116.
- Kouyoumdjian, JA; Morita, MP; Molina, AF; Zanetta, DM; Sato, AK; Rocha, CE; Fasanella, CC (2003). "Long-term outcomes of symptomatic electrodiagnosed carpal tunnel syndrome". Arquivos de neuro-psiquiatria 61 (2A): 194–8. doi:10.1590/S0004-282X2003000200007. PMID 12806496.
- Muller, M; Tsui, D; Schnurr, R; Biddulph-Deisroth, L; Hard, J; MacDermid, JC (2004). "Effectiveness of hand therapy interventions in primary management of carpal tunnel syndrome: a systematic review". Journal of Hand Therapy 17 (2): 210–28. doi:10.1197/j.jht.2004.02.009. PMID 15162107.
- Keith, M. W.; Masear, V., Chung, K. C., Amadio, P. C., Andary, M., Barth, R. W., Maupin, K., Graham, B., Watters, W. C., Turkelson, C. M., Haralson, R. H., Wies, J. L., McGowan, R. (4 January 2010). "American Academy of Orthopaedic Surgeons Clinical Practice Guideline on The Treatment of Carpal Tunnel Syndrome". The Journal of Bone and Joint Surgery 92 (1): 218–219. doi:10.2106/JBJS.I.00642. PMID 20048116.
- Lincoln, A; Vernick, JS; Ogaitis, S; Smith, GS; Mitchell, CS; Agnew, J (2000). "Interventions for the primary prevention of work-related carpal tunnel syndrome". American Journal of Preventive Medicine 18 (4 Suppl): 37–50. doi:10.1016/S0749-3797(00)00140-9. PMID 10793280.
- Verhagen, Arianne P; Karels, Celinde C; Bierma-Zeinstra, Sita MA; Burdorf, Lex L; Feleus, Anita; Dahaghin, Saede SD; De Vet, Henrica CW; Koes, Bart W; Verhagen, Arianne P (2006). Ergonomic and physiotherapeutic interventions for treating work-related complaints of the arm, neck or shoulder in adults. In Verhagen, Arianne P. "Cochrane Database of Systematic Reviews". Cochrane Database of Systematic Reviews 3 (3): CD003471. doi:10.1002/14651858.CD003471.pub3. PMID 16856010.
- Olsen, K. M.; Knudson, D. V. (2001). "Change in Strength and Dexterity after Open Carpal Tunnel Release". International Journal of Sports Medicine 22 (4): 301–3. doi:10.1055/s-2001-13815. PMID 11414675.
- King, Bradley A.; Stern, Peter J.; Kiefhaber, Thomas R. (2013). "The incidence of trigger finger or de Quervain's tendinitis after carpal tunnel release". Journal of Hand Surgery (European Volume) 38 (1): 82–3. doi:10.1177/1753193412453424. PMID 22791612.
- Katz, Jeffrey N.; Losina, Elena; Amick, Benjamin C.; Fossel, Anne H.; Bessette, Louis; Keller, Robert B. (2001). "Predictors of outcomes of carpal tunnel release". Arthritis & Rheumatism 44 (5): 1184–93. doi:10.1002/1529-0131(200105)44:5<1184::AID-ANR202>3.0.CO;2-A.
- Ruch, DS; Seal, CN; Bliss, MS; Smith, BP (2002). "Carpal tunnel release: efficacy and recurrence rate after a limited incision release". Journal of the Southern Orthopaedic Association 11 (3): 144–7. PMID 12539938.[unreliable medical source?]
- Ibrahim, I., Khan, W. S., Goddard, N., & Smitham, P. (2012). Suppl 1: Carpal Tunnel Syndrome: A Review of the Recent Literature. The open orthopaedics journal, 6, 69.
- Ashworth, Nigel L. (December 4, 2008). "Carpal Tunnel Syndrome". eMedicine.
- Luckhaupt SE, Dahlhamer JM, Ward BW, Sweeney MH, Sestito JP, Calvert GM (June 2013). "Prevalence and work-relatedness of carpal tunnel syndrome in the working population, United States, 2010 National Health Interview Survey". American Journal of Industrial Medicine 56 (6): 615–24. doi:10.1002/ajim.22048. PMID 22495886.
- Amadio, Peter C. (2007). "History of carpal tunnel syndrome". In Luchetti, Riccardo; Amadio, Peter C. Carpal Tunnel Syndrome. Berlin: Springer. pp. 3–9. ISBN 978-3-540-22387-0.
- Fuller, David A. (September 22, 2010). "Carpal Tunnel Syndrome". eMedicine.
- Prince Philip undergoes minor surgery on hand. BBC News. June 8, 2010.
- Rosen, Steven (Autumn 2004). "Green Day". Total Guitar: 24–30.
- Carpal Tunnel Syndrome Fact Sheet (National Institute of Neurological Disorders and Stroke)
- NHS website carpal-tunnel.net provides a free to use, validated, online self diagnosis questionnaire for CTS