We're unable to sign you in at this time. Please try again in a few minutes.
We were able to sign you in, but your subscription(s) could not be found. Please try again in a few minutes.
There may be a problem with your account. Please contact the AMA Service Center to resolve this issue.
Contact the AMA Service Center:
Telephone: 1 (800) 262-2350 or 1 (312) 670-7827  *   Email: subscriptions@jamanetwork.com
Error Message ......
The Rational Clinical Examination |

Does This Patient Have Carpal Tunnel Syndrome?

Christopher A. D'Arcy, MD; Steven McGee, MD
JAMA. 2000;283(23):3110-3117. doi:10.1001/jama.283.23.3110.
Text Size: A A A
Published online

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.

Figures in this Article

Sign in

Purchase Options

• Buy this article
• Subscribe to the journal
• Rent this article ?


Figure 1. Normal Anatomy of the Carpal Tunnel
Graphic Jump Location
The carpal tunnel consists of the median nerve and 9 flexor tendons surrounded by the rigid carpal bones and transverse carpal ligament (flexor retinaculum). The distal wrist crease marks the proximal edge of the carpal tunnel. Within the tunnel, the median nerve divides into a motor branch that innervates the thenar muscles (opponens, abductor, short flexor) and distal sensory branches that supply the thumb, index, and middle fingers, and the radial half of the ring finger. Because the sensory branches to the radial palm do not usually pass through the carpal tunnel, palm sensation is preserved in a classic case of carpal tunnel syndrome.1
Figure 2. Testing Thumb Abduction
Graphic Jump Location
The patient is instructed to raise his/her thumb perpendicular to the palm as the examiner applies downward pressure on the distal phalanx. This maneuver reliably isolates the strength of the abductor pollicis brevis, which is innervated only by the median nerve.
Figure 3. Katz Hand Diagram
Graphic Jump Location
Figure adapted with permission.64



Also Meets CME requirements for:
Browse CME for all U.S. States
Accreditation Information
The American Medical Association is accredited by the Accreditation Council for Continuing Medical Education to provide continuing medical education for physicians. The AMA designates this journal-based CME activity for a maximum of 1 AMA PRA Category 1 CreditTM per course. Physicians should claim only the credit commensurate with the extent of their participation in the activity. Physicians who complete the CME course and score at least 80% correct on the quiz are eligible for AMA PRA Category 1 CreditTM.
Note: You must get at least of the answers correct to pass this quiz.
Please click the checkbox indicating that you have read the full article in order to submit your answers.
Your answers have been saved for later.
You have not filled in all the answers to complete this quiz
The following questions were not answered:
Sorry, you have unsuccessfully completed this CME quiz with a score of
The following questions were not answered correctly:
Commitment to Change (optional):
Indicate what change(s) you will implement in your practice, if any, based on this CME course.
Your quiz results:
The filled radio buttons indicate your responses. The preferred responses are highlighted
For CME Course: A Proposed Model for Initial Assessment and Management of Acute Heart Failure Syndromes
Indicate what changes(s) you will implement in your practice, if any, based on this CME course.


Some tools below are only available to our subscribers or users with an online account.

110 Citations

Sign in

Purchase Options

• Buy this article
• Subscribe to the journal
• Rent this article ?

Related Content

Customize your page view by dragging & repositioning the boxes below.

See Also...
Articles Related By Topic
Related Collections

The Rational Clinical Examination: Evidence-Based Clinical Diagnosis
Carpal Tunnel Syndrome

The Rational Clinical Examination: Evidence-Based Clinical Diagnosis
Make the Diagnosis: Carpal Tunnel Syndrome