Orthopedics - Carpal and Cubital Tunnel Syndrome

Orthopedics & Podiatry Main Menu

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.