Author Affiliations: University of Washington Health Sciences Center (Dr D'Arcy) and University of Washington, Seattle-Puget Sound Veterans Affairs Health Care System (Dr McGee), Seattle.
The Rational Clinical Examination Section Editors: David L. Simel, MD, MHS, Durham Veterans Affairs Medical Center and
Duke University Medical Center, Durham, NC; Drummond Rennie, MD, Deputy Editor, JAMA.
Context History taking and physical examination maneuvers, including Tinel and
Phalen signs, are widely used for the diagnosis of carpal tunnel syndrome
Objective To systematically review the precision and accuracy of history taking
and physical examination in diagnosing CTS in adults.
Data Sources English-language literature was searched using MEDLINE (January 1966-February
2000) as well as bibliographies of relevant articles.
Study Selection Studies of patients presenting to clinicians with symptoms suggestive
of CTS in which findings from clearly described physical examination maneuvers
were independently compared with electrodiagnostic testing. Twelve of 42 initially
identified articles met these criteria and were included in the review.
Data Extraction Two authors independently reviewed and abstracted data from all of the
articles and reached consensus about any discrepancies.
Data Synthesis In patients presenting with hand dysesthesias, the findings that best
distinguish between patients with electrodiagnostic evidence of CTS and patients
without it are hypalgesia in the median nerve territory (likelihood ratio
[LR], 3.1; 95% confidence interval [CI], 2.0-5.1), classic or probable Katz
hand diagram results (LR, 2.4; 95% CI, 1.6-3.5), and weak thumb abduction
strength (LR, 1.8; 95% CI, 1.4-2.3). Findings that argue against the diagnosis
of carpal tunnel syndrome are unlikely Katz hand diagram results (LR, 0.2;
95% CI, 0.0-0.7) and normal thumb abduction strength (LR, 0.5; 95% CI, 0.4-0.7).
Several traditional findings of CTS have little or no diagnostic value, including
nocturnal paresthesias; Phalen and Tinel signs; thenar atrophy; and 2-point,
vibratory, and monofilament sensory testing. Other less commonly used maneuvers,
including the square wrist sign, flick sign, and closed fist sign, require
validation by other studies before they can be recommended.
Conclusions Hand symptom diagrams, hypalgesia, and thumb abduction strength testing
are helpful in the establishing electrodiagnosis of CTS. The utility of these
results is limited, however, by problems inherent in using nerve conduction
studies as a criterion standard.
D'Arcy CA, McGee S. Does This Patient Have Carpal Tunnel Syndrome?. JAMA. 2000;283(23):3110-3117. doi:10.1001/jama.283.23.3110