Carpal and Cubital Tunnel Syndrome
Diagnosis/Definition Pain, loss of strength or sensory changes (paresthesias) in the distribution of the median or ulnar nerves not associated with neck pain.
Initial Diagnosis and Management.
- History and physical exam (screen for associated conditions, i.e., diabetes, pregnancy, Rheumatoid Arthritis, Systemic Lupus Erythematosus (SLE).
- Assessment with provocative tests to include Tinel's and Phalen's sign tests of specific nerves.
- Plain radiographs are not required (unless there was trauma); MRI/CT are not indicated.
- For Carpal Tunnel Syndrome (CTS) symptoms prescribe a wrist splint (wrist in a neutral position) to wear at night and during the day for aggravating activities (take splint off every 2 hours and move wrist to prevent stiffness).
- For cubital tunnel syndrome, educate the patient to avoid pressure on elbow.
- For both, try work simplification techniques using ergonomic principles and activity modification to decrease symptoms.
Ongoing Management and Objectives
- Expect resolution or decreasing symptoms within two to four weeks.
- Consider confirming the diagnosis with Electromyography/Nerve Conduction Velocity (EMG/NCV), (PM&R or Neuro diagnostics) if symptoms have not resolved within 6 weeks or if there has been no response to treatment.
- Continue NSAID and splint use.
Indications for Specialty Care Referral
- For cubital tunnel syndrome refer to Occupational Therapy (OT) for night elbow splints.
- If the patient exhibits no relief of pain, sensory changes, decreases in AROM or strength to the upper extremity within 3-4 weeks, refer to OT for evaluation and treatment.
- Chronic CTS or cubital tunnel syndrome with symptoms >6months can be referred to OT for evaluation and treatment.
- If the patient has completed a full course of treatment through OT and referred back to primary care with no improvement, referral to Orthopedic Surgery is indicated.
- Orthopedic Hand Clinic referral is indicated if a sensory (2 point discrimination >5mm) or motor deficit is demonstrated in patients with CTS.
Criteria for Return to Primary Care
- Resolution of symptoms.
- Chronic condition that can be managed at primary care level with intermittent specialty care evaluation/intervention as needed.