Context: History taking and physical examination maneuvers, including Tinel and Phalen signs, are widely used for the diagnosis of carpal tunnel syndrome (CTS).
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.
In the following patient, the clinician would like to know which items from the patient interview and physical examination accurately predict the diagnosis of carpal tunnel syndrome (CTS):
A 55-year-old woman has difficulty sleeping because of numbness and tingling in her right hand for 6 months. On a hand diagram, she uses a pencil to locate precisely her numbness and tingling over the dorsal and palmar aspects of all 5 fingers, sparing the palm. On inspection the patient has no evidence of thenar atrophy, but thumb abduction is weak on the affected side. Sensory examination using monofilaments and a vibrating tuning fork is normal. Tinel sign is positive, and Phalen sign is negative.
Why Is the Diagnosis Important?
Carpel tunnel syndrome is an important cause of pain and functional impairment of the hand due to compression of the median nerve at the wrist ( Figure 1). Patients are usually between their third and fifth decades when diagnosed, and women are affected 3 times as often as men (2-3). About 0.5% of the general population reports being diagnosed with CTS (2). It is likely, however, that few affected patients consult clinicians because population-based studies reveal that about 3% of adults have symptomatic electrodiagnostically confirmed CTS (4)
Many conditions, including pregnancy, rheumatoid arthritis, diabetes mellitus, and previous wrist trauma, are associated with CTS, (19) although histologic sections from the carpal tunnel of most affected patients are normal (20-21). Many patients have an abnormally high tissue pressure within the carpal tunnel,(22) which presumably causes intraneural ischemia that leads to dysesthesias and abnormal results of sensory testing (23-25).
This article systematically reviews the diagnostic accuracy of bedside findings for CTS. Presentation of this information, however, first requires understanding some of the issues surrounding electrodiagnosis, the current CTS diagnostic standard.
The Diagnostic Standard for CTS
In his original definition of CTS, Phalen (26) required patients to have 1 or more of 3 bedside findings: sensory changes restricted to the median nerve distribution of the hand, a positive Tinel sign, and a positive Phalen sign ( Table 1). Though electrodiagnosis was not part of Phalen's definition, clinicians now use electrodiagnosis frequently to confirm the diagnosis, and some third-party payers require it before compensating claims (34). Consensus committees from professional societies have endorsed electrodiagnosis as the diagnostic test of choice (35-36). Diagnostic standards for nerve conduction studies in CTS have been developed, which report sensitivities of 49% to 84% and specificities of 95% to 99% (37).
Table 1.Definition of Abnormal Physical Findings
The high specificity figures in these studies are also misleading, being arbitrarily set at 2 SDs above the mean of observations of normal hands. The values of 95% to 99% are based on the assumption that nerve conduction recordings follow a standard gaussian distribution, which has been shown to be inaccurate. 43-44 False-positive test results are well documented when these test thresholds are applied to other populations (10, 45-47).
It is well documented that many hand surgeons perform carpal tunnel release successfully in patients with normal electrodiagnostic findings (15, 34, 48-50). Even in patients with positive electrodiagnostic findings who undergo surgery, symptoms usually resolve within days despite nerve conduction abnormalities that persist for months or longer (11, 17, 42, 51-52).
Nonetheless, most physicians rely on electrodiagnosis as the best available diagnostic standard. Electrodiagnostic studies may help identify other conditions that also cause hand dysesthesias, such as cervical radiculopathy, polyneuropathy, or other median nerve entrapment syndromes (41, 53-55). Furthermore, the overwhelming majority of patients in surgical studies have compatible symptoms and electrodiagnostic studies positive for CTS (10, 12, 17, 56). Electrodiagnosis may not predict recovery after carpal tunnel release, but neither does any other clinical variable with any certainty. The potential utility of computed tomography, magnetic resonance imaging, and ultrasonography is still being determined, and they remain primarily research tools (57-61). For these reasons, our review addresses the accuracy of the history and physical examination in diagnosing CTS, as confirmed by electrodiagnostic studies.
Using the MEDLINE database for articles from January 1966 to February 2000, both authors independently used the following search strategy, limited to the English language and human subjects, to retrieve all relevant publications on the diagnosis of CTS in adults: exp carpal tunnel syndrome and exp diagnosis. In addition text word searches were completed for Tinel or Tinels or Hoffman-Tinels, and Phalen or Phalens. Based on review of titles and abstracts, relevant publications were retrieved. To complete the search, the authors reviewed the bibliographies of these articles and retrieved all relevant articles.
To be included in this review, a study had to satisfy the following criteria: (1) the patients presented to a clinician for symptoms suggestive of CTS, (2) the physical examination maneuvers were clearly described, (3) there was an independent comparison with one or more electrodiagnostic parameters (which had to include at least some measurement of motor or sensory nerve conduction), and (4) the authors could extract from figures or tables in the articles the numbers needed to construct 2 × 2 tables and calculate sensitivity, specificity, and likelihood ratios (LRs).
Twelve articles met these criteria and are included (27-33, 62-66). Thirty articles were excluded: 14 because the control group was asymptomatic,(67-80) 8 because the data were incomplete,(15, 49, 57, 81-85) 4 because the subjects were identified by population surveys,(45, 86-88) 3 because the criterion standard was unacceptable (ie, electromyography alone, (89)electrodiagnosis and abnormal monofilament testing, 90 or criterion standard missing (91), and 1 because the examination maneuvers were not clearly defined (92).
Sensitivity, specificity, and LRs and their confidence intervals (CIs) were calculated using conventional definitions (93). When a cell of a 2 × 2 table was 0, 0.5 was added to all cells before summarizing the data for a particular test. Our summary measures pooled all the data using the Dersimonian and Laird random-effects model,(94) which considers both within-study variance and variability among studies. Our test for homogeneity between studies was the effectiveness score, a test of overall accuracy (95).
Likelihood ratios are the odds that a given finding would occur in a patient with CTS as opposed to one without CTS. If a particular LR, positive or negative, had a value close to 1 that outcome of the test is unhelpful in making diagnostic decisions at the bedside.
PRECISION AND ACCURACY
How to Elicit Symptoms and Signs of CTS
Table 1 summarizes how to elicit the physical examination signs of CTS analyzed in this review. When examining thumb strength, the clinician should focus on abduction of the thumb ( Figure 2), not flexion or opposition, which sometimes can be accomplished by muscles innervated by nerves other than the recurrent motor branch of the median nerve (54, 59). The Katz hand diagram is a self-administered diagram that depicts both the dorsal and palmar aspect of the patient's hands and arms ( Figure 3). Patients use this diagram to mark the specific location of their symptoms, characterizing them as pain, numbness or tingling, or other. Diagrams are then graded as classic, probable, possible, or unlikely to be CTS based on criteria that appear in Figure 3 (32, 63).
Diagnostic Accuracy of Physical Findings
Table 2 summarizes the studies addressing the diagnostic accuracy of the history and physical examination for CTS. Based on the CIs of LRs, the following findings favor the electrodiagnosis of CTS when they are present in patients who present with hand dysesthesias: decreased sensitivity to pain (hypalgesia) in the median nerve territory (LR, 3.1; 95% 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). Using a slightly different system for grading hand diagrams, another study also found that the definite or possible hand diagram argued for CTS (LR, 2.1; 95% CI, 1.5-3.0) (92). In our analysis, 2 findings argued against the electrodiagnosis of CTS: a Katz hand diagram classified as unlikely (LR, 0.2; 95% CI, 0.0-0.7; not shown in Table 2) and normal thumb abduction strength (LR, 0.5; 95% CI, 0.4-0.7).
Several studies addressed the diagnostic accuracy of combined findings,(32, 65, 90) but no combination consistently proved significantly more helpful than the individual findings themselves. One study did find that the combined finding of a positive Tinel sign and a classic or probable hand diagram was slightly more discriminating (LR, 3.6; 95% CI, 1.6-8.1) than either finding alone (LR, 1.8 for positive Tinel sign and 2.4 for classic or probable hand diagram), (32) though this result requires validation given the problems with Tinel sign in other studies.
According to our analysis, several unconventional findingsflick sign, closed fist sign, and square wrist signshow promise in diagnosing CTS. However, these maneuvers are not widely used and have been tested in only 1 or 2 studies. Two letters to the editor have suggested that the sensitivity of the flick sign is much lower (only 25%-36%) than indicated in Table 2. 84-85 Therefore, before any of these 3 findings can be recommended for clinical practice, further supportive evidence is necessary.
There are several reasons why some findings are not as helpful diagnostically as traditionally thought. Thenar atrophy is probably not useful because it occurs only in long-standing or neglected cases of CTS and can also result from lower cervical radiculopathies or polyneuropathies. Tinel intended his sign to be used in patients after blunt traumatic nerve injury to follow the course of the regenerating nerve (30, 76, 87). The idea that patients with CTS would also have a stub of continually regenerating nerve at the distal wrist crease seems unlikely, limiting the diagnostic utility of this particular test. Our analysis shows that hypalgesia in the median nerve distribution is a more useful diagnostic finding than abnormalities of other sensory modalities, in part because hypalgesia is a more specific finding. It is not clear why this should be, though it may indicate that the threshold for abnormal results when testing sensation for vibration, 2-point discrimination, and monofilaments is set too low (in one study, for example, 20% of asymptomatic hands also displayed abnormal monofilament results (76).
In our analysis, only results for Tinel sign were heterogeneous. The heterogeneity is not explained by differences in the electrodiagnostic parameters used as criterion standards in the individual studies, variations in examination technique (ie, whether the clinician tapped over the median nerve using his index finger or a reflex hammer), differences in prevalence of CTS in each of the studies (mean prevalence was 57%), differences in the age and sex composition (mean age was 50 years, 77% were women), or by an apparent workup bias. Excluding the 2 studies that account for the heterogeneity (62, 64) does not change the summary measure in any meaningful way, and therefore these studies are included in our analysis.
THE BOTTOM LINE
When evaluating patients with hand dysesthesias, the findings most helpful in predicting the electrodiagnosis of CTS are hand symptom diagrams, hypalgesia, and weak thumb abduction strength testing. The square wrist sign, flick sign, and closed fist sign also show promise, but require validation by other investigators. Many traditional findings, including Phalen and Tinel signs, have limited ability to predict the electrodiagnosis of CTS.
The main limitation of the existing literature is the lack of an ideal criterion standard, which complicates all clinical research in the field of CTS. It is also important to note that these data are derived from symptomatic patients presenting to an orthopedic surgeon, physical therapist, or an electrodiagnostic laboratory. There are no data addressing the value of physical diagnosis in patients presenting to a primary care physician with symptoms suggestive of CTS. Our analysis, therefore, is most applicable to patients with severe enough symptoms to warrant such a referral.
Returning to the case presented at the beginning of the article, the findings of a classic hand diagram and thumb abduction weakness both support the diagnosis of CTS. The findings of a normal thenar eminence, a positive Tinel sign, and negative Phalen sign do not contribute significant diagnostic information. Her clinician believed she probably had CTS and chose to manage her symptoms by splinting her wrists and recommending anti-inflammatory medications. If the patient's symptoms fail to improve, nerve conduction testing, additional empiric therapeutic modalities (eg, corticosteroid injections), or referral for surgical assessment should be considered.
The best study using doses consistent with those commonly used in clinical practice (i.e. 40mg of methylprednisilone with 10mg of lidocaine), those receiving the steroid were nearly 4 times as likely to show improvement a month later than those receiving placebo (Dammers JWHH, Veering MM, VErmeulen M. Injection with methylprednisilone proximal to the carpal tunnel: randomised double blind trial. BMJ 1999: 319: 884-886).
Acknowledgment: We thank Jaya Rao, MD, MHS, and Richard W. Tim, MD, who reviewed this article and provided many helpful comments.
1. Lum PB, Kanaklamedala R. Conduction of the palmar cutaneous branch of the median nerve. Arch Phys Med Rehabil. 1986;67:805-806. [Medline Link] [Context Link]
2. Tanaka S, Wild D, Seligman P, et al. The US prevalence of self-reported carpal tunnel syndrome: 1988 national health interview survey data. Am J Public Health. 1994;84:1846-1848. [Medline Link] [Context Link]
3. Stevens JC, Sun S, Beard CM, O'Fallon WM, Kurland L. Carpal tunnel syndrome in Rochester, Minnesota, 1961-1980. Neurology. 1988;38:134-138. [Medline Link] [Context Link]
4. Atroshi I, Gummesson C, Johnsson R, et al. Prevalence of carpal tunnel syndrome in a general population. JAMA. 1999;282:153-158. [Fulltext Link] [Medline Link] [CINAHL Link] [Context Link]
5. Green DP. Diagnostic and therapeutic value of carpal tunnel injection. J Hand Surg [Am]. 1984;9:850-854. [Medline Link] [Context Link]
6. Gelberman RH, Aronson D, Weisman MH. Carpal tunnel syndrome: results of a prospective trial of steroid injection and splinting. J Bone Joint Surg Am. 1980;62:1181-1184. [Medline Link] [Context Link]
7. Weiss AP, Sachar K, Gendreau M. Conservative management of carpal tunnel syndrome: a reexamination of steroid injection and splinting. J Hand Surg [Am]. 1994;19:410-415. [Medline Link] [Context Link]
8. Dammers JWHH, Veering MM, Vermeulen M. Injection with methylprednisolone proximal to the carpal tunnel: randomized double blind trial. BMJ. 1999;319:884-886. [Fulltext Link] [Medline Link] [Context Link]
9. Gainer JV Jr, Nugent GR. Carpal tunnel syndrome: report of 430 operations. South Med J. 1977;70:325-328. [Medline Link] [Context Link]
10. Cseuz KA, Thomas JE, Lambert EH, Love JG, Lipscomb PR. Long-term results of operation for carpal tunnel syndrome. Mayo Clin Proc. 1966;41:232-241. [Medline Link] [Context Link]
11. Bande S, De Smet L, Fabry G. The results of carpal tunnel release: open versus endoscopic technique. J Hand Surg [Br]. 1994;19:14-17. [Medline Link] [Context Link]
12. Tountas CP, Macdonald CJ, Meyerhoff JD, Bihrle DM. Carpal tunnel syndrome: a review of 507 patients. Minn Med. 1983;66:479-482. [Medline Link] [Context Link]
13. Muhlau G, Both R, Kunath H. Carpal tunnel syndromecourse and prognosis. J Neurol. 1984;231:83-86. [Medline Link] [Context Link]
14. Kendall D. Aetiology, diagnosis, and treatment of paraesthesiae in the hands. BMJ. 1960;2:1633-1640. [Context Link]
15. Phalen GS. The carpal-tunnel syndrome: seventeen years' experience in diagnosis and treatment of six hundred fifty-four hands. J Bone Joint Surg Am. 1966;48:211-228. [Medline Link] [Context Link]
16. Doyle JR, Carrol RE. The carpal tunnel syndrome: a review of 100 patients treated surgically. Calif Med. 1968;108:263-267. [Medline Link] [Context Link]
17. Brown RA, Gelberman RH, Seiler JG, et al. Carpal tunnel release: a prospective, randomized assessment of open and endoscopic methods. J Bone Joint Surg Am. 1993;75:1265-1280. [Fulltext Link] [Medline Link] [Context Link]
18. Boeckstyns MEH, Sorensen AI. Does endoscopic carpal tunnel release have a higher rate of complications than open carpal tunnel release? an analysis of published series. J Hand Surg [Br]. 1999;24:9-15. [Medline Link] [Context Link]
19. Stevens JC, Beard CM, O'Fallon WM, Kurland L. Conditions associated with carpal tunnel syndrome. Mayo Clin Proc. 1992;67:541-548. [Medline Link] [Context Link]
20. Nakamichi K, Tachibana S. Histology of the transverse carpal ligament and flexor tenosynovium in idiopathic carpal tunnel syndrome. J Hand Surg [Am]. 1998;23:1015-1024. [Medline Link] [Context Link]
21. Kerr CD, Sybert DR, Albarracin NS. An analysis of the flexor synovium in idiopathic carpal tunnel syndrome: report of 625 cases. J Hand Surg [Am]. 1992;17:1028-1030. [Medline Link] [Context Link]
22. Gelberman RH, Hergenroeder PT, Hargens AR, Lundborg GN, Akeson WH. The carpal tunnel syndrome: a study of carpal canal pressures. J Bone Joint Surg Am. 1981;63:380-383. [Medline Link] [Context Link]
23. Gelberman RH, Szabo RM, Williamson RV, Dimick MP. Sensibility testing in peripheral nerve compression syndromes: an experimental study in humans. J Bone Joint Surg Am. 1983;65:632-638. [Medline Link] [Context Link]
24. Lundborg G, Gelberman RH, Minteer-Convery M, Lee YF, Hargens AR. Median nerve compression in the carpal tunnelfunctional response to experimentally induced controlled pressure. J Hand Surg [Am]. 1982;7:252-259. [Context Link]
25. Gelberman RH, Rydevik BL, Pess GM, Szabo RM, Lundborg G. Carpal tunnel syndrome: a scientific basis for clinical care. Orthop Clin North Am. 1988;19:115-124. [Medline Link] [Context Link]
26. Phalen GS. The birth of a syndrome, or carpal tunnel revisited. J Hand Surg [Am]. 1981;6:109-110. [Medline Link] [Context Link]
27. Radecki P. A gender specific wrist ratio and the likelihood of a median nerve abnormality at the carpal tunnel. Am J Phys Med Rehabil. 1994;73:157-163. [Medline Link] [CINAHL Link] [Context Link]
28. De Smet L, Steenwerckx A, Van Den Bogaert G, Cnudde P, Fabry G. Value of clinical provocative tests in carpal tunnel syndrome. Acta Orthop Belg. 1995;61:177-182. Review. [Context Link]
29. Pryse-Phillips W. Validation of a diagnostic sign in carpal tunnel syndrome. J Neurol Neurosurg Psychiatry. 1984;47:870-872. [Context Link]
30. Kuhlman KA, Hennessey WJ. Sensitivity and specificity of carpal tunnel syndrome signs. Am J Phys Med Rehabil. 1997;76:451-457. [Fulltext Link] [Medline Link] [Context Link]
31. Buch-Jaeger N, Foucher G. Correlation of clinical signs with nerve conduction tests in the diagnosis of carpal tunnel syndrome. J Hand Surg [Br]. 1994;19:720-724. [Context Link]
32. Katz JN, Larson MG, Sabra A, et al. Carpal tunnel syndrome: diagnostic utility of history and physical examination findings. Ann Intern Med. 1990;112:321-327. [Medline Link] [Context Link]
33. Gerr F, Letz R, Harris-Abbott D, Hopkins LC. Sensitivity and specificity of vibrometry for detection of carpal tunnel syndrome. J Occup Environ Med. 1995;37:1108-1115. [Medline Link] [Context Link]
34. Concannon MJ, Gainor B, Petroski GJ, Puckett CL. The predictive value of electrodiagnostic studies in carpal tunnel syndrome. Plast Reconstr Surg. 1997;100:1452-1458. [Fulltext Link] [Medline Link] [Context Link]
35. American Academy of NeurologyAmerican Association of Electrodiagnostic MedicineAmerican Academy of Physical Medicine and Rehabilitation. Practice parameter for electrodiagnostic studies in carpal tunnel syndrome (summary statement). Neurology. 1993;43:2404-2405. [Context Link]
36. Quality Standards Subcommittee of the American Academy of Neurology. Practice parameter for carpal tunnel syndrome (summary statement). Neurology. 1993;43:2406-2409. [Context Link]
37. Jablecki CK, Andary MT, So YT, Wilkins DE, Williams FH. Literature review of the usefulness of nerve conduction studies and electromyography for the evaluation of patients with carpal tunnel syndrome. Muscle Nerve. 1993;16:1392-1414. [Medline Link] [Context Link]
38. Kimura J. The carpal tunnel syndrome: localization of conduction abnormalities within the distal segment of the median nerve. Brain. 1979;102:619-635. [Medline Link] [Context Link]
39. Nathan P, Meadow KD, Doyle LS. Sensory segmental latency values of the median nerve for a population of normal individuals. Arch Phys Med Rehabil. 1988;69:499-501. [Medline Link] [CINAHL Link] [Context Link]
40. Jackson DH, Clifford JC. Electrodiagnosis of mild carpal tunnel syndrome. Arch Phys Med Rehabil. 1989;70:199-204. [Medline Link] [CINAHL Link] [Context Link]
41. Dawson DM, Hallett M, Wilbourn AJ. Carpal tunnel syndrome. In: Entrapment Neuropathies. 3rd ed. Philadelphia, Pa: Lippincott-Raven Publishers; 1999: 20-94. [Context Link]
42. Gilliat RW, Sears TA. Sensory nerve action potentials in patients with peripheral nerve lesions. J Neurol Neurosurg Psychiatry. 1958;21:109-118. [Context Link]
43. Robinson LR, Temkin NR, Fujimoto WY, Stolov WC. Effect of statistical methodology on normal limits in nerve conduction studies. Muscle Nerve. 1991;14:1084-1090. [Medline Link] [Context Link]
44. Goodgold J. A statistical problem in diagnosis of carpal tunnel disease. Muscle Nerve. 1994;17:1490-1491. [Medline Link] [Context Link]
45. Ferry S, Silman AJ, Pritchard T, Keenan J, Croft P. The association between different patterns of hand symptoms and objective evidence of median nerve compression. Arthritis Rheum. 1998;41:720-724. [Fulltext Link] [Medline Link] [Context Link]
46. Thomas JE, Lambert EH, Cseuz KA. Electrodiagnostic aspects of the carpal tunnel syndrome. Arch Neurol. 1967;16:635-641. [Medline Link] [Context Link]
47. Redmond KD, Rivner MH. False-positive electrodiagnostic tests in carpal tunnel syndrome. Muscle Nerve. 1988;11:511-517. [Medline Link] [Context Link]
48. Grundberg AB. Carpal tunnel decompression in spite of normal electromyography. J Hand Surg [Am]. 1983;8:348-349. [Medline Link] [Context Link]
49. Phalen GS. The carpal tunnel syndrome: clinical evaluation of 598 hands. Clin Orthop. 1972;83:29-40. [Medline Link] [Context Link]
50. Mainous AG III, Nelson KR. How often are preoperative electrodiagnostic studies obtained for carpal tunnel syndrome in a Medicaid population? Muscle Nerve. 1996;19:256-257. [Medline Link] [Context Link]
51. Harris CM, Tanner E, Goldstein MN, Pettee DS. The surgical treatment of the carpal-tunnel syndrome correlated with preoperative nerve-conduction studies. J Bone Joint Surg Am. 1979;61:93-98. [Medline Link] [Context Link]
52. Patiala H, Rokkanen P, Kruuna O, et al. Carpal tunnel syndrome: anatomical and clinical investigation. Arch Orthop Trauma Surg. 1985;104:69-73. [Medline Link] [Context Link]
53. Kaufman MA. Differential diagnosis and pitfalls in electrodiagnostic studies and special tests for diagnosing compressive neuropathies. Orthop Clin North Am. 1996;27:245-252. [Medline Link] [CINAHL Link] [Context Link]
54. Spinner RJ, Bachman JW, Amadio PC. The many faces of carpal tunnel syndrome. Mayo Clin Proc. 1989;64:829-836. [Medline Link] [Context Link]
55. Haig AJ, Tzeng HM, LeBreck D. The value of electrodiagnostic consultation for patients with upper extremity nerve complaints: a prospective comparison with the history and physical examination. Arch Phys Med Rehabil. 1999;80:1273-1281. [Medline Link] [CINAHL Link] [Context Link]
56. Bessette L, Keller RB, Lew RH, et al. Prognostic value of a hand symptom diagram in surgery for carpal tunnel syndrome. J Rheumatol. 1997;24:726-734. [Medline Link] [Context Link]
57. Rosenbaum RB. The role of imaging in the diagnosis of carpal tunnel syndrome. Invest Radiol. 1993;28:1059-1062. [Medline Link] [Context Link]
58. Winn FJ, Habes DJ. Carpal tunnel area as a risk factor for carpal tunnel syndrome. Muscle Nerve. 1990;13:254-258. [Medline Link] [Context Link]
59. Cantatore FP, Dell'accio F, Lapadula G. Carpal tunnel syndrome: a review. Clin Rheumatol. 1997;16:596-603. [Medline Link] [Context Link]
60. Seyfert S, Boegner F, Hamm B, Kleindienst A, Klatt C. The value of magnetic resonance imaging in carpal tunnel syndrome. J Neurol. 1994;242:41-46. [Medline Link] [Context Link]
61. Lee D, van Holsbeeck MT, Janevski PK, et al. Diagnosis of carpal tunnel syndrome: ultrasound versus electromyography. Radiol Clin North Am. 1999;37:859-872. [Medline Link] [Context Link]
62. Gupta SK, Benstead TJ. Symptoms experienced by patients with carpal tunnel syndrome. Can J Neurol Sci. 1997;24:338-342. [Medline Link] [Context Link]
63. Katz JN, Stirrat C, Larson MG, et al. A self-administered hand symptom diagram in the diagnosis and epidemiologic study of carpal tunnel syndrome. J Rheumatol. 1990;17:1495-1498. [Medline Link] [Context Link]
64. Golding DN, Rose DM, Selvarajah K. Clinical tests for carpal tunnel syndrome: an evaluation. Br J Rheumatol. 1986;25:388-390. [Medline Link] [Context Link]
65. Heller L, Ring H, Costeff H, Solzi P. Evaluation of Tinel and Phalen signs in the diagnosis of the carpal tunnel syndrome. Eur Neurol. 1986;25:40-42. [Medline Link] [Context Link]
66. Burke DT, Burke MAM, Bell R, et al. Subjective swelling: a new sign for carpal tunnel syndrome. Am J Phys Med Rehabil. 1999;78:504-508. [Fulltext Link] [Medline Link] [Context Link]
67. Yii NW, Elliot D. A study of the dynamic relationship of the lumbrical muscles and the carpal tunnel. J Hand Surg [Br]. 1994;19:439-443. [Medline Link] [Context Link]
68. Gonzalez Del Pino J, Delgado-Martinez AD, Gonzalez I, Lovic A. Value of the carpal compression test in the diagnosis of carpal tunnel syndrome. J Hand Surg [Br]. 1997;22:38-41. [Medline Link] [Context Link]
69. Bowles AP, Asher SW, Pickett JD. Use of Tinel's sign in carpal tunnel syndrome. Ann Neurol. 1983;13:689-690. [Medline Link] [Context Link]
70. Durkan JA. A new diagnostic test for carpal tunnel syndrome. J Bone Joint Surg Am. 1991;73:535-538. [Medline Link] [Context Link]
71. Seror P. Tinel's sign in the diagnosis of carpal tunnel syndrome. J Hand Surg [Br]. 1987;12:364-365. [Medline Link] [Context Link]
72. Seror P. Phalen's test in the diagnosis of carpal tunnel syndrome. J Hand Surg [Br]. 1988;13:383-385. [Medline Link] [Context Link]
73. Tetro AM, Evanoff BA, Hollstien SB, Gelberman RH. A new provocative test for carpal tunnel syndrome: assessment of wrist flexion and nerve compression. J Bone Joint Surg Br. 1998;80:493-498. [Fulltext Link] [Medline Link] [Context Link]
74. Williams TM, Mackinnon SE, Novak CB, McCabe S, Kelly L. Verification of the pressure provocative test in carpal tunnel syndrome. Ann Plast Surg. 1992;29:8-11. [Medline Link] [Context Link]
75. Stewart JD, Eisen E. Tinel's sign and the carpal tunnel syndrome. BMJ. 1978;2:1125-1126. [Medline Link] [Context Link]
76. Gelmers HJ. The significance of Tinel's sign in the diagnosis of carpal tunnel syndrome. Acta Neurochir. 1979;49:255-258. [Medline Link] [Context Link]
77. Borg K, Lindblom U. Diagnostic value of quantitative sensory testing (QST) in carpal tunnel syndrome. Acta Neurol Scand. 1988;78:537-541. [Medline Link] [Context Link]
78. Fertl E, Wober C, Zeitlhofer J. The serial use of two provocative tests in the clinical diagnosis of carpal tunnel syndrome. Acta Neurol Scand. 1998;98:328-332. [Fulltext Link] [Medline Link] [Context Link]
79. Ghavanini MR, Haghighat M. Carpal tunnel syndrome: reappraisal of five clinical tests. Electromyogr Clin Neurophysiol. 1998;38:437-441. [Medline Link] [Context Link]
80. Koris M, Gelberman RH, Duncan K, Boublick M, Smith B. Carpal tunnel syndrome: evaluation of a quantitative provocational diagnostic test. Clin Orthop. 1990;251:157-161. [Medline Link] [Context Link]
81. Gilliatt RW, Wilson TG. A pneumatic-tourniquet test in the carpal tunnel syndrome. Lancet. 1953;256:595-597. [Context Link]
82. Spindler H, Dellon A. Nerve conduction studies and sensibility testing in carpal tunnel syndrome. J Hand Surg [Am]. 1982;7:260-263. [Medline Link] [Context Link]
83. Szabo RM, Slater RR, Farver TB, Stanton DB, Sharman WK. The value of diagnostic testing in carpal tunnel syndrome. J Hand Surg [Am]. 1999;24:704-714. [Medline Link] [Context Link]
84. Roquer J, Herraiz J. Validity of flick sign in CTS diagnosis. Acta Neurol Scand. 1988;78:351. [Medline Link] [Context Link]
85. Krendell DA, Jobsis M, Gaskell PC, Sanders DB. The flick sign in carpal tunnel syndrome. J Neurol Neurosurg Psychiatry. 1986;49:220-221. [Medline Link] [Context Link]
86. De Krom MCTFM, Knipschild PG, Kester ADM, Spaans F. Efficacy of provocative tests for diagnosis of carpal tunnel syndrome. Lancet. 1990;335:393-395. [Medline Link] [Context Link]
87. Kuschner SH, Ebramazadeh E, Johnson D, Brien WW, Sherman R. Tinel's sign and Phalen's test in carpal tunnel syndrome. Orthopedics. 1992;15:1297-1302. Review. [Context Link]
88. Homan MM, Franzblau A, Werner RA, et al. Agreement between symptom surveys, physical examination procedures and electrodiagnostic findings for the carpal tunnel syndrome. Scand J Work Environ Health. 1999;25:115-124. [Medline Link] [Context Link]
89. Mossman SS, Blau JN. Tinel's sign and the carpal tunnel syndrome. BMJ. 1987;294:680. [Medline Link] [Context Link]
90. Gellman H, Gelberman RH, Tan AM, Botte MJ. Carpal tunnel syndrome. J Bone Joint Surg Am. 1986;68:735-737. [Medline Link] [Context Link]
91. Novak CB, Mackinnon SE, Brownlee R, Kelly L. Provocative sensory testing in carpal tunnel syndrome. J Hand Surg [Br]. 1994;19:817-820. [Medline Link] [Context Link]
92. Stevens JC, Smith BE, Weaver AL, et al. Symptoms of 100 patients with electromyographically verified carpal tunnel syndrome. Muscle Nerve. 1999;22:1448-1456. [Medline Link] [Context Link]
93. Simel DL, Samsa GP, Matchar DB. Likelihood ratios with confidence: sample size estimation for diagnostic test studies. J Clin Epidemiol. 1991;44:763-770. [Medline Link] [Context Link]
94. Dersimonian R, Laird N. Meta-analysis in clinical trials. Controlled Clin Trials. 1986;7:177-188. [Medline Link] [Context Link]
95. Hasselbland V, Hedges LV. Meta-analysis of screening and diagnostic tests. Psychol Bull. 1995;117:167-178. [Context Link]
96. Marx RG, Hudak PL, Bombardier C, et al. The reliability of physical examination for carpal tunnel syndrome. J Hand Surg [Br]. 1998;23:499-502. [Medline Link] [Context Link]
Carpal Tunnel Syndrome; Clinical Competence; Diagnosis; THE RATIONAL CLINICAL EXAMINATION (Simel DL, Rennie D, eds)
Section Description 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.