Carpal tunnel syndrome is the most common entrapment neuropathy in adults, caused by mechanical compression of the median nerve as it passes beneath the transverse carpal ligament at the wrist. It affects roughly 3-6% of US adults and accounts for more than 200,000 surgical releases per year in the United States alone, with women three times more affected than men and a peak incidence between ages 45 and 60.
Carpal tunnel syndrome (ICD-10: G56.0) is a focal compressive mononeuropathy of the median nerve at the wrist, where the nerve and nine flexor tendons share a narrow osseofibrous canal bounded dorsally by the carpal bones and volarly by the transverse carpal ligament (flexor retinaculum). Sustained elevation of pressure inside this canal — normally below 10 mmHg, often above 30 mmHg in symptomatic CTS — disrupts epineurial blood flow, causes intraneural edema, and over time produces segmental demyelination and ultimately axonal loss of the sensory and motor fibers supplying the radial three and a half digits and the thenar muscles. The condition is classified by severity (mild, moderate, severe) based on a combination of electrodiagnostic findings and clinical exam, and is staged from intermittent paresthesias through fixed sensory loss to thenar muscle atrophy. It sits within the broader family of upper-limb entrapment neuropathies that includes cubital tunnel syndrome (ulnar nerve at the elbow) and pronator syndrome (median nerve at the forearm), and is managed primarily by hand surgeons, orthopedic surgeons, neurologists, and physical medicine and rehabilitation physicians..
The key symptoms of Carpal Tunnel Syndrome are: Numbness, tingling, or burning paresthesias in the thumb, index, middle, and radial half of the ring finger — the classic median nerve distribution — typically worst at night and on waking., Pain that wakes the patient from sleep and is relieved by shaking, flicking, or hanging the hand over the side of the bed (the flick sign, reported by 70-90% of patients)., Daytime paresthesias provoked by sustained wrist flexion or extension — driving, holding a phone, reading a book, or gripping a steering wheel for prolonged periods., Loss of fine motor coordination in the affected hand, with patients reporting dropping small objects, difficulty buttoning shirts, and clumsiness handling coins or keys., Aching pain in the volar wrist and forearm that may radiate proximally as far as the shoulder, often misattributed to tendinitis or cervical spine disease., Reduced two-point discrimination and pinprick sensation in the median nerve distribution on neurological exam, indicating sensory fiber compromise., Weakness of thumb abduction and opposition in advanced disease, with difficulty opening jars, turning keys, or pinching small objects..
Diagnosis of carpal tunnel syndrome is clinical, supported by validated provocative tests and confirmed by electrodiagnostic studies when surgery is being considered or the picture is atypical. The 2016 American Academy of Orthopaedic Surgeons clinical practice guideline endorses a structured history, the Boston Carpal Tunnel Questionnaire (a validated symptom severity and functional status score, Levine 1993), and a focused neurological examination as the diagnostic foundation. Classic features include nocturnal paresthesias in the median nerve distribution, the flick sign on waking, symptoms reproduced by Phalen's manoeuvre (sustained wrist flexion for 60 seconds, sensitivity 70% / specificity 80%), the Tinel sign over the volar wrist (sensitivity 50% / specificity 75%), and the carpal compression test (Durkan, sensitivity 87% / specificity 90%). Two-point discrimination, monofilament testing, and thenar bulk are documented to grade severity. Electrodiagnostic testing — nerve conduction studies (NCS) and needle electromyography (EMG) — performed according to the AANEM practice parameters is considered the reference standard for confirmation, with overall sensitivity 85% and specificity 95% in clinically suspected CTS. The earliest abnormality is prolonged distal sensory latency; motor latency prolongation and reduced compound muscle action potential amplitude appear with more advanced disease. High-resolution ultrasound (median nerve cross-sectional area greater than 10-12 mm² at the inlet) and MRI are emerging alternatives that approach the accuracy of NCS in expert hands and are useful when electrodiagnostics are unavailable, intolerable, or equivocal. Differential diagnosis includes cervical radiculopathy (especially C6-C7), pronator syndrome, thoracic outlet syndrome, peripheral polyneuropathy, and multiple sclerosis — each distinguishable by the pattern of sensory loss, examination findings, and selective electrodiagnostic and imaging studies.
Prognosis depends heavily on severity at diagnosis and on whether reversible drivers (pregnancy, hypothyroidism, diabetes) are addressed. Mild-to-moderate CTS treated with splinting and steroid injection has a 50-70% chance of meaningful long-term symptom control without surgery. Surgical release for moderate-to-severe CTS produces complete symptom resolution in 75-90% of patients at 2 years and persistent benefit at 10-year follow-up in the AAOS evidence review; recurrence requiring revision is under 5%. Severe pre-operative findings — fixed sensory loss, thenar atrophy, denervation on EMG — predict slower and incomplete recovery, particularly of strength. Diabetes, smoking, and ongoing high-force occupational exposure are associated with worse outcomes regardless of treatment chosen. Untreated severe CTS progresses to permanent thumb weakness and sensory loss over years and is associated with measurable reductions in employment and self-reported function. The decisive prognostic variable is the duration of severe symptoms before decompression — patients treated within 12 months of severe symptom onset do significantly better than those who wait beyond 2 years.
A hand surgeon or orthopedic surgeon with hand fellowship training should be consulted when conservative therapy (6-12 weeks of splinting and a single steroid injection) fails to control symptoms, when severe features are present at diagnosis (thenar atrophy, fixed numbness, denervation on EMG), when CTS is bilateral and progressing rapidly, or when the diagnosis is uncertain. Neurologists or physiatrists are typically involved for electrodiagnostic confirmation and for cases overlapping with cervical radiculopathy or polyneuropathy.
Find specialists →Conservative management (splinting and injection) typically produces measurable symptom improvement within 4-6 weeks; full response is judged at 12 weeks. After open carpal tunnel release, light activities and typing usually resume within 1-2 weeks, the surgical scar tightens over 4-6 weeks, and grip strength returns to roughly 80% of baseline by 3 months and full strength by 6 months. Endoscopic release follows a slightly faster curve, with most patients returning to office work within 7-10 days. Nighttime paresthesias typically disappear within days to weeks of release; long-standing fixed numbness or thenar wasting may take 6-12 months to recover and may be incomplete in severe pre-operative cases.
Regular aerobic activity (150 minutes per week of brisk walking, cycling, or swimming) supports weight, glucose control, and overall nerve health. Specific to CTS, hand therapists prescribe median nerve gliding and tendon gliding exercises 2-3 sets of 10 repetitions twice daily, plus wrist flexor and extensor stretching. Avoid heavy gripping exercise (dead-lifts, kettlebell swings, climbing) during active symptoms or for at least 4-6 weeks after surgical release.
Look for board certification in orthopedic surgery or plastic surgery with subspecialty fellowship training in hand surgery, plus high annual carpal tunnel release volume (more than 50 cases per year is associated with better outcomes in registry data). Confirm comfort with both open and endoscopic techniques so the surgeon can choose what fits your anatomy, not their preference. Ask whether they routinely measure outcomes using the Boston Carpal Tunnel Questionnaire and what their reported satisfaction rates and complication rates are.
Medically reviewed by AIHealz Medical Editorial Board · May 12, 2026
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