Diagnosing and assessing CTS

There is no foolproof way of establishing whether a given patient’s symptoms are due, either wholly or in part to CTS. The generally accepted, and probably reasonable, view is that it is primarily a ‘clinical diagnosis’ - meaning that an experienced doctor can recognise it from the pattern of the patient’s signs and symptoms with a fair degree of reliability. It is important to remember that clinical diagnosis depends on both the skill of the person listening to the patient's story and examining them, and the ability of the patient to give a good account of the symptoms and even the best clinicians will not always be right. Every patient’s symptoms are slightly different and some people have other medical problems in addition which obscure the overall clinical picture and make diagnosis more difficult, thus some cases will be clinically obvious and easily diagnosed by almost anyone who has encountered the condition while others will be extremely difficult to spot.

The approach to making the diagnosis can be discussed under the conventional medical headings of:

- History - the patient's account of the symptoms

- Examination - what can be seen and felt on examining the patient

- Provocative tests - a set of physical manouevers designed to provoke symptoms in patients with CTS

This much can be done in the clinic on first meeting the patient.  Although the diagnosis is usually fairly straightforward, misdiagnosis is not uncommon. Conditions which have been mistaken for CTS include, but are not limited to:

Cervical radiculopathy (pressure on the 6th, 7th and 8th cervical nerve roots in the neck)

Thoracic outlet syndrome (cervical rib and related brachial plexus lesions)

Ulnar neuropathy (at the elbow - cubital tunnel syndrome, or wrist - canal of Guyon)

Peripheral neuropathy (all forms, diabetic neuropathy is the commonest in the UK)

Syringomyelia

Multiple sclerosis

Motor neurone disease

Trigger digits (stenosing tenosynovitis)

Rheumatoid arthritis (and almost any other form of arthritis)

Raynaud's phenomenon/disease

Restless limb syndrome (Restless legs) - which can begin in the arm

De Quervain's tenosynovitis (and other tendonitides)

Writers cramp (focal dystonia of the forearm)

Lateral epicondylitis (tennis elbow)

Medial epicondylitis (golfer's elbow)

Gout

Chronic regional pain syndrome

If uncertainty remains at this point, one can fall back on:

 - Laboratory tests, either general screening tests or tests designed specifically to diagnose CTS and including both neurophysiological tests, medical imaging and quantitative sensory testing

Revision date - 28th July 2020