A variety of conditions can mimick symptoms of CTS. The following chart lists hallmarks findings for each condition to help with pattern recognition. It should be noted that some physical examination maneuvers are of unknown sensitivity and specificity. Therefore the physical exam may be insufficient to differentiation. Electrodiagnostic testing is valid and reliable for such differentiation, and should be performed when feasible in order to reach a diagnosis of CTS.
|
DDx |
History |
Inspection & Palpation |
Motor |
Sensory |
Special Tests & Investigations |
|
CTS |
Gradual onset of intermittent, bilateral hand numbness +/- pain; Nocturnal symptoms; Hand flicking sign; Symptoms are worse in dominant hand |
Atrophy of thenar muscles; Edema; +/- space-occupying lesion |
Decreased grip strength; Weak thenar muscles, especially abductor pollicis brevis; Loss of manual dexterity |
Numbness over thumb + index + middle fingers |
Positive Tinel sign at the wrist; Positive Phalen Test < 60 seconds; EMG: decreased CV, prolonged latency, denervation |
|
Hand-Arm Vibration Syndrome |
Use of hand-held rotating or percussive power tools; Hand contact with vibrating work surfaces |
Secondary Raynaud’s phenomenon (cold induced finger blanching) |
Decreased grip strength; Loss of manual dexterity |
Numbness and tingling in any or all digits |
Cold water immersion: prolonger recovery time; Abnormal plethys- mography; Abnormal current perception threshold at any of 5, 250, 2000 Hz |
|
Osteoarthritis |
Painful, stiff thumb, worse in the evening |
Swelling +/- enlarged appearance of thumb CMC; Tenderness on palpation of thumb CMC |
Crepitus of 1st CMC; Decreased AROM |
Normal |
EMG: normal |
|
Cervical Radiculopathy (C6 or C7) |
Sudden onset of severe, unilateral, radiating neck pain |
Neck held stiffly; Head tilted away from affected side; Tenderness on palpation of cervical paraspinal muscles |
Decreased neck AROM; C6: weak elbow flexion, wrist extension; C7: weak elbow extension, wrist flexion |
Numbness over dorsal aspect of thumb + index (C6) or middle (C7); Hyperesthesia |
EMG: normal median nerve studies; Needle Examination: C6 or C7 denervation; MRI: C-spine abnormality |
|
Ulnar Neuropathy (Cubital Tunnel Syndrome) |
Recent trauma; Frequent pressure applied to elbow; Symptoms worse in non-dominant hand |
Wartenberg Sign; +/- Valgus elbow deformity |
Weak abduction of little finger; Weak pincer grip |
Numbness over ulnar nerve distribution |
Positive Tinel sign at the elbow; EMG: abnormal ulnar nerve studies |
|
De Quervain tenosynovitis |
Thumb pain +/- wrist pain that worsens with activity |
Inflammation of the anatomical snuffbox; Thickening of radial styloid |
Painful thumb movement |
Paraesthesias of median nerve +/- radial nerve distributions |
Positive Finkelstein test; EMG: normal |
|
Brachial Plexus neuropathy (Thoracic Outlet Syndrome) |
Unilateral symptoms; History of overhead activities or recent trauma; Difficulty grasping objects |
Forward-head +/- rounded-shoulder postures; Atrophy of abductor pollicis brevis; Weak/absent pulse; coolness of the upper extremity; +/- Cervical rib |
Weakness of muscles of anterior compartment of forearm (except FCU and medial 1/2 of FDP), thenar muscles, and lumbricals |
Numbness and decreased sensation over ulnar nerve distribution |
Positive Adson maneuver, Wright test, and Roos stress test; EMG: widespread neuropathy |
+/-: need not be present, EMG: electromyography, CV: conduction velocity, AROM: active range of motion.