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Clinical Review

Carpal tunnel syndrome

BMJ 2014; 349 doi: (Published 06 November 2014) Cite this as: BMJ 2014;349:g6437

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I read with a particular interest the review by Drs Middleton and Anakwe about carpal tunnel syndrome (CTS). Unfortunately, such as other colleagues before (including Dr Bland who wrote the previous review (1)), different aspects on diagnosis, etiology and subsequent treatment are missing and must be added.

For diagnosis, description of possible symptoms is interesting of the box 1, but patients are rarely able to clearly describe the precise distribution of the symptoms and the typical description is rare.(2) However, sensory disturbances from the palm to the fingertips (including the middle finger), with fluctuating level of symptoms with exacerbation at night
and/or partial relief of symptoms by changing hand posture or shaking the hand, and radiating to the elbow, are highly suggestive.(3) In contrast, isolated hand pain confined to the ulnar or dorsal aspect of the hand is unlikely to correspond to CTS.(4)

Imaging is not generally performed to establish the diagnosis of CTS, although MRI and X-ray can be useful in the differential diagnosis of hand pain. Ultrasound is however, now well established and can detect subtle changes in the width of the median nerve as it passes underneath the flexor retinaculum and, although these signs are not pathognomonic, they can add weight to the diagnosis in doubtful cases.(5)

Work exposure is also a significant risk factor among manual workers. Blue-collar workers involved in manufacturing, construction, meat- and fish-processing industry, and in forestry work with chain saws are mostly likely to develop CTS, together with lower-grade white-collar women working in personal service industries.(6) Forceful hand exertion and combination of high strain (high levels of hand-arm vibration, prolonged work with a flexed or extended wrist, high requirements for hand force, high repetitiveness), were consistently associated with incident CTS,(7–9) whereas keyboard and computer use are not.(10) This is important because in cases with high physical exposure tasks should be discussed with the workers (e.g. mix work patterns, change tools and postures).(11) Subjects with highly probable work-related hand pain or for whom working conditions cannot be adjusted, should be referred to an occupational health specialist.(12)


1 Bland JDP. Carpal tunnel syndrome. BMJ 2007;335:343–6.
2 Burke FD, Ellis J, McKenna H, et al. Primary care management of carpal tunnel syndrome. Postgrad Med J 2003;79:433–7.
3 Calfee RP, Dale AM, Ryan D, et al. Performance of simplified scoring systems for hand diagrams in carpal tunnel syndrome screening. J Hand Surg Am 2012;37:10–7.
4 Graham B, Regehr G, Naglie G, et al. Development and Validation ofDiagnostic CriteriaforCarpal Tunnel Syndrome. JHand Surg(USA) 2006;31:919.
5 Descatha A, Huard L, Aubert F, et al. Meta-analysis on the performance of sonography for the diagnosis of carpal tunnel syndrome. Semin Arthritis Rheum 2012;41:914–22.
6 Palmer KT, Harris EC, Coggon D. Carpal tunnel syndrome and its relation to occupation: a systematic literature review. Occup Med (Lond) 2007;57:57–66.
7 Van Rijn RM, Huisstede BM, Koes BW, et al. Associations between work-related factors and the carpal tunnel syndrome--a systematic review. ScandJ Work EnvironHealth 2009;35:19–36.
8 Spahn G, Wollny J, Hartmann B, et al. [Metaanalysis for the Evaluation of Risk Factors for Carpal Tunnel Syndrome (CTS) Part II. Occupational Risk Factors]. Z Orthop Unfall 2012;150:516–24.
9 Harris-Adamson C, Eisen EA, Kapellusch J, et al. Biomechanical risk factors for carpal tunnel syndrome: a pooled study of 2474 workers. Occup Environ Med Published Online First: 16 October 2014. doi:10.1136/oemed-2014-102378
10 Mediouni Z, de Roquemaurel A, Dumontier C, et al. Is carpal tunnel syndrome related to computer exposure at work? A review and meta-analysis. J Occup Environ Med 2014;56:204–8.
11 Palmer KT. Carpal tunnel syndrome: the role of occupational factors. Best Pract Res Clin Rheumatol 2011;25:15–29.
12 Saint-Lary O, Rébois A, Descatha A. Carpal Tunnel Syndrome in Workers. submitted

Competing interests: Editor in chief of Archives of occupational and environamental disorders (

15 November 2014
Alexis Descatha
Professor in occupational health , MD
Occupational health unit, UMS011 Inserm, Versailles university, Paris Hospital
Poincaré university hospital, Garches, Paris suburb, France